MANAGEMENT OF MULTIPLE TRAUMA.

DR. D. V. KANISHKA KAMAL

Where should we start ? ?

DEATH FOLLOWING INJURY

SHOWS A DISTINCT TRIMODAL PATTERN. DR. DONALD TRUNKEY CHAIRMAN OF DEPT. OF SURGERY

OREGAN, USA.

IMMEDIATE DEATHS - 50% - within minutesEARLY DEATHS - 30% - 1-3 hoursLATE DEATHS - 20% - 2-4 weeks

* CONCEPT OF GOLDEN HOURS OF TRAUMA !

HISTORY

1970- DR. JAMES STYNERAMERICAN ORTHOPAEDIC SURGEON

INTRODUCED A STRUCTURED TRAUMA MANAGEMENT TRAINING PROGRAMME

AMERICAN COLLEGE OF SURGEONS DEVELOPED ATLS EDUCATIONAL PACKAGE.

.

PHILOSOPHY

TREAT LETHAL INJURY FIRST,

THEN REASSESS,

AND TREAT AGAIN !

ATLS COMPONENT STEPS

1. PRIMARY SURVEY - IDENTIFY WHAT IS KILLING THE PATIENT.

2. RESUSCITATION - TREAT WHAT IS KILLING THE PATIENT.

3. SECONDARY SURVEY - PROCEED TO IDENTIFY ALL OTHR INJURIES.

4. DEFINITIVE CARE - DEVELOP A DEFINITIVE MANAGEMENT

PLAN.

PRIMARY SURVEY

1. AIRWAY WITH CERVICAL SPINAL CONTROL

2. BREATHING AND VENTILATION

3. CIRCULATION WITH CONTROL OF HAEMORRHAGE

4. DYSFUNCTION OF THE CNS

5. EXPOSURE IN A CONTROLLED ENVIRONMENT

SURVEY OF….

SECURING AIRWAY WITH CERVICAL SPINAL CONTROL

CONTROL CERVICAL SPINEMANUAL INLINE CONTROLCOLLAR/ SAND BAG/ HEAD TAPE

ASSESS AIRWAY

AIRWAY MANAGEMENT

AIRWAY OBSTRUCTION KILLS IMMEDIATELY !

AIRWAY MANAGEMENT

1. CONTROL CERVICAL SPINEMANUAL INLINE CONTROL

COLLAR/ SAND BAG/ HEAD TAPE

2. CLEAR AIRWAYTWO FINGER SWEEPSUCTION

3. MAINTAIN AIRWAYCHIN LIFT / JAW THRUST

4. PROVIDE AIRWAYAIRWAY DEVICESCRICOTHYROIDOTOMY

5. O2 – 14 L / MINUTE

BREATHING AND VENTILATION

ASSESS - TO IDENTIFY IMMEDIATELY LIFE THREATENING

CONDITIONS

1. TENSION PNEUMOTHORAX2. MASSIVE HAEMOTHORAX3. OPEN PNEUMOTHORAX4. FLAIL CHEST

Open pneumothorax

Tension pneumothorax

Haemothorax

Flail chest

PROBLEMS IN CIRCULATION

SHOCK.

Hypovolaemic, cardiogenic

Cardiac tamponade leading to shock.

CIRCULATION AND CONTROL OF HAEMORRHAGE

ASSESSMENT FOR SIGNS OF SHOCK

CAUSE OF SHOCK

ASSESS THE DEGREE OF BLOOD LOSSCLASS I, II, III, IV

SITE OF BLOOD LOSS“ Blood on the floor and four more “

MANAGEMNT OF A PATIENT IN SHOCK

VASCULAR ACCESSPERIPHERAL VENOUS CANNULATIONVENOUS CUTDOWNINTRAOSSEOUS TRANSFUSION

DRAW BLOOD FOR GROUPING & DT AT THE SAME TIME,

RESUSCITATIONTRANSFUSE 2L OF HARTMAAN SOLN.

ASSESS RESPONSEIMMEDIATE AND SUSTAINEDTRANSIENT & LATER DETERIORATIONNO RESPONSE

DYSFUNCTION OF THE CNS

ASSESSMENT OF NEUROLOGICAL STATUSAVPU – ALERT

RESPONDS TO VOICE RESPONDS TO PAIN UNRESPONSIVE

MONITORING

PULSE OXYMETERBLOOD PRESSURE & HEART RATEECGURINE OUTPUTTEMPERATURE

INVESTIGATIONS DURING INITIAL STAGE

XRAY CERVICAL SPINE – LATERAL FILMXRAY CHEST – SUPINE PAXRAY PELVIS - AP

HISTORY

1. ALLERGIES

2. MEDICATIONS

3. PAST MEDICAL HISTORY

4. LAST MEAL

5. EVENT LEADING TO THE INJURY

EXPOSURE OF THE PATIENT

EXPOSE IN A CONTROLLED ENVIRONMENT!

FURTHER DECISION MAKING

RESPONSE TO PRIMARY SURVEY AND RESUSCITATION INFLUENCES FURTHER DECISION MAKING

1. NO LIFE THREATENING CONDITION2. SUSTAINED RESPONSE3. TRANSIENT RESPONSE4. NO RESPONSE

SECONDARY SURVEY

HEAD TO TOE EXAMINATIONHEAD, FACE, NECK, THORAX , ABDOMEN, PELVIS, SPINAL INJURIES,EXTREMITIES

VITAL SIGNS MONITORING DEVICES ARE IN SITU

DETAILED RADIOGRAPHIC PROCEDURES

POTENTIALLY LIFE THREATNING INJURIES

- SECONDARY SURVEY

1. PULMONARY CONTUSION2. MYOCARDIAL CONTUSIONS3. AORTIC TEAR4. DIAPHRAGMATIC TEAR5. OESOPHAGEAL TEAR6. TRACHEOBRONCHIAL TEAR

DEFINITIVE CARE PLAN

DECISION ON OWNERSHIP

ATTENTION OF THE OTHER SPECIALISTS

THANK YOU !