MANAGEMENT OF

POLYTRAUMATISED PATIENT

 A Team Approac h 

“Strategies To Enhance Patient Care

Through Share Manage!ent"#

Dr Ah!a $in %& %ashi!

E!ergenc' Ph'sician

%os(ita) *ueen E)i+a,erth"

 

O$-ECTI.ES

• Concept of A Team Approach Patient care  a) Intradepartment  b) multidisciplinary

•  A collaborative and coordinated effort to achievesimilar target and outcome….ATL! "TL!

 

  INTRODUCTION

Po)'trau!a

Clinical yndrome #hereby Patient ustains

erious In$uries Involving T%o &r 'ore

'a$or &rgans And Physiological ystems.

(eaturesPhysiological Instability*+sanguinations'a$or Torso Trauma'a$or Tissue ,estruction

e.g. 'otor vehicle accident %ith ,-and spleen rupture

 

POLYTRAUMA

META$OLIC RESPONSE TO IN-URY

/ Catabolic counter regulatory hormones

Amplication of Catecholamine effect

* Venous shunting with preservation of vital 

organs e.g. heart, brain.

* Ischaemia secondary to vasoconstriction

* Renal shutdown

Insulin /esistance

Inflammatory /esponse

Lo%ered immune resistance

*levation of free fatty acids

Altered protein metabolism

 

POLYTRAUMA

Meta,o)ic Res(onse To In&ur'

  Cascae O0 Death 1

Deat

h

Metabolic

Acidosis

Coagulopathy 

Hypothermia

 

TRAUMA DEAT%

Death 0ro! Trau!a 0o))o2s a

Tri!oa) Distri,ution"

  3 4 Trun5e' DD 1 Sci A! 6781693:; <89: = 

 

Conce(t An O>er>ie2 O0 Trau!a

Death 3 Tri!oa) Distri,ution

 

  CONCEPT AND O.ER.IE?

Death 0ro! Trau!a has a Tri!oa) Distri,ution"

The First Pea5 o0 Death is 2ithin secons to

!inutes o0 in&ur'"

  Causes1<" Laceration o0 the $rain6" $rain Ste!:" %igh S(ina) Cor In&ur'7" %eart@ Aorta an Large .esse)s Lacerations;" Etc"

/ Usua))' Non3Sa)>agea,)e" 

 

?IT% RAPID ASSESSMENT AND RESUSCITATION

CARRIED OUT DURING T%E SECOND PEA @

TRAUMA DEAT% CAN $E REDUCED

Causes1

A" Su,ura) EBtraura) %ae!ato!a

$" %ae!o(neu!othoraB

C" Ru(ture s()een

D" Lacerations o0 the )i>er 

E" Pe)>ic Fractures

F" Mu)ti()e In&uries Associate 2ith Signi0icant$)oo Loss"

G" Pre>enta,)e sa)>agea,)e conition

The Secon Pea5 o0 Death occurs 2ithin !inutes to a

0e2 hours a0ter in&ur' re0erre to as the

“ GOLDEN %OUR #"

 

The Third Pea0 of ,eath occurs several

days or %ee0s after initial in$ury

Causes1

  <" Se(sis

6" Organ Fai)ure

  :" DI.C

  7" ARDS

  ;" Fat E!,o)is!

 

Main cause o0 e)a'e Trau!a Death is

!u)ti()e organ s'ste! 0ai)ure"

Associate co!()ications1

<" Resu)t o0 irect insu)t to s(eci0ic organ

s'ste!"

6" In re)ation to inter>entiona) (roceures"

:" In re)ation to (oor initia) resuscitation an

  sta,i)i+ation e)a' in initia) in>estigation

 

TRAUMA DEATH

• More than :; o0 tota) SURGICAL ADMISSIONS

are TRAUMA PATIENTS"

• More than ;; o0 Death in SURGICAL

DISCIPLINE is ue to TRAUMA"

• 96 o0 Trau!a Death is ue to %EAD IN-URY"

• < o0 Trau!a Death is ue to POLYTRAUMA.

 

A Se>en Month Stu' 2as conucte at the E!ergenc'

De(art!ent@ %L

 4-une8 3 -an8H=

• ; o0 tota) 0ata)ities occurre

2ithin 7 hours o0 a!ission

3 6n Pea5 4 Pre>enta,)e Death =

• 8 o0 these (atients ie 2ithin < hour 

3 <st Pea5 4 Non Sa)>agea,)e =

* Ti!ing i not ta5e into account o0 thee)a' in Pre3%os(ita) Care Ser>ice PtTrans(ortation

 

Death in ED%L1 689

  $ID 1 676

  DID 1 ;

$ID3$rought In Dea

DID3Dea In De(art!ent    Y   e   a

   r     6    E    E    :

 

Tota) 1 ;

Trau!a 1 76

Meica) 1 <7

Death in Dept

 

Trau!a 1 76

%ea in&ur' 1 <:

Chest in&ur' 1 H

Pe)>ic in&ur' 1 7

Intraa,o!ina) 1 :

%ea in&ur' JOthers 1 <; 4 POLYTRAUMA =

Trauma Death

 

TYPE OFTYPE OFIN-URIESIN-URIES

TOTAL NO" OFTOTAL NO" OFDEAT%DEAT%

NO" OFNO" OFPR.ENTA$LEPR.ENTA$LE

DEAT%DEAT%

C%EST IN-URYC%EST IN-URY HH 66

PEL.ICPEL.ICIN-URYIN-URY

77 66

INTRAINTRAA$DOMINALA$DOMINAL

IN-URYIN-URY

:: <<

Nu!,er o0 Pre>enta,)e Death in Re)ation to

Tota) No" o0 Death

 

FEATURES OF POLYTRAUMA PATIENT

RE*UIRING EARLY INTER.ENTION

• Ra(i EBsanguinating

%e!orrhage

• Irre>ersi,)e S'nro!e

• O>erco!(ensate

S'ste!ic Res(onse

• Iatrogenic

 

Contri,uting Factors For the Incience o0

Pre>enta,)e Death 1

<" everity of In$ury

1. Poor /esuscitation 2 tabili3ation

4. ,elay in diagnosis

5. ,elayed /esponse from the relevant

/eferred ,ept

6. ,elay in decision for Intervention and

,efinitive 'anagement

7. 8o Team%or0

9. Lac0 of /esources

 

 < Attitue o0 !eica) o00icer 

6" $us'3too !an' (atients" Lack of prioritization

:" De)a' in in>estigation 0inings

eg CT scan@ US@ an ,)oo resu)ts

7" De)a' in in0or!ing s(ecia)ist 0or ecision !a5ing

;" De)a' in i!()e!entation o0 e0initi>e care MB

e"g" 3 surgica) inter>ention o0 (atient

  3 Li!ite ICU ,es

%UMAN RELATED FACTOR RELATED TO

PRE.ENTA$LE DEAT%

 

COMPONENTS OF COMPRE%ENSI.E

TRAUMA CARE

:. Triage

1. Primary urvey

4. /esuscitation And tabili3ation

5. econdary urvey

6. /eevaluation

7. ,efinitive Care

9. /ehabilitation

 

TRIAGETRIAGE

A D'na!ic Process O0 Sorting Out

Patients Accoring To Their

Priorit' O0 Treat!ent

 All Polytrauma Patients Are Triaged According To The

Protocol & Guidelines For Admission To The Red

Zonecritical Zone!

 

T-* (I/T P*/&8 T& **

T-* PATI*8T CA8 A((*CT T-*

(I8AL &;TC&'*.<<

:= survey and resuscitation of vital

functions are done

simultaneously… .. A Team

 Approach

"//// F<

P&L>T/A;'A

 

PRIMARY SUR.EY1

,efinition

The preliminary assessment of a patient %hich is

conducted in a systematic manner %ith the ob$ective

of identifying life threatening conditions and

managing them as soon as they are found.

 

A&uncts to Pri!ar' Sur>e'

AD-UNCTS

?ital signs

;rinary@gastric cathetersunless contraindicated

Pulseo+imeter and C&1

 Trauma X-ray•Lateral cervical•CXR•Pelvis

*C ABs

ATLS

 

TRAUMA TEAM

,efinition

A group of s0illful and e+periencepersonnels %or0 together at the sametime managing a polytrauma patient byrapidD efficient and effective teamEmultidiscipline).

The team include all level personnelfrom specialist to attendants.

 

TRAUMA TEAM CONCEPT

HOLISTIC AND QUALITY

CARE

 

TRAUMA TEAM

Man' stuies in e>e)o(ing countries

ha>e sho2n that K : o0 tota) hos(ita)

eath is ue to trau!a"

A 2e)) integrate trau!a s'ste! ,ase

u(on TEAM?OR an PARTNERING can

reuce the !orta)it' rate to )ess than

<"

 

TRAUMA TEAM

/ Match (atient nee 2ith resourceuti)isation

/ Ensure ear)' senior c)inicianin>o)>e!ent in ecision !a5ing

/ Pro>ie a coorinate a((roach toear)' trau!a care

/ Mini!i+e e)a' in the E!ergenc'e(art!ent

 

FEATURES OF TRAUMA TEAM

:. -ori3ontal Tas0 ,istribution

1. *rgonomics arrangements

4. Clinically 2 Therapeutically determined

arrangement of staff based upon intervention

reFuired

5. Tas0 is distributed into small manageable

pac0age unit bet%een the Trauma Team

'embers

6. 8ot Team Leader dependant

7. Goint decision ma0ing process

 

FEATURES OF %ORIONTAL TEAM

ORGANISATION

•  All members carry out individual tas0s

simultaneously.

• 8ot focused on any particular team

member or team leader.

•  *nhance Team Performance and

Improved &utcome.

•  'ost efficient organi3ation

 

Features o0 an e00icient tea!2or5

:. pecifically allocated to individual

members.

1. Tas0 evenly divided among Team

'embers.

4. Tas0 carried out I';LTA8*&;L>.

 

POLYTRAUMA CARE TEAM

• Resuscitation Trau!a Tea! H The group that resuscitated and stabili3ed

the patient

 H *mergency department team %ith otherrelevance dept.

• De0initi>e care tea! H InvestigationalD interventional and intensive

care team.

 

P&L>T/A;'A CA/* T*A'

• The resuscitation team %ill manage thepatient rapid and systematicallystabili3ation and of need be interventional

• The definitive care team ';T response%ith immediate decision ma0ing specialist involvement

• Investigation must be automatic and resultimmediately obtainable.

 

P&L>T/A;'A CA/* T*A'

• Intensive care anesthesiology servicemust be available immediately .

•  All interventional and surgical proceduresmust be done %ithout delay.

•  All facilities reFuired eg +rayD ;D CT mustbe made available immediately toenhance care.

 

 

P&L>T/A;'A CA/* T*A'

Critical uccess (actor

• pecialist and consultant must be involved early.

• ,ecision must made immediately.

• 'anagement plan must be determined

immediately together.

• -ospital authority must enforce this policy

strictly.

•  All mortality polytrauma in a $oin mortality or

census meeting

 

POLYTRAUMA CARE TEAM

The strength of the team is as strong its

%ea0est lin0

• Patient focus Jcommitment must be

observed…….K

 

STRUCTURAL LAYOUT OF

RESUSCITATION ONE

•  A ,edicated (acility and 1nd 8ature /efle+

environment to enhance performance of the

Trauma Team.

• Jolf %ingK *rgonomics.

•  tandardi3ation 2 'odulari3ed

/esuscitation Bay

 

RESUSCITATION $AY FLOOR PLAN

AIRWAY EQUIPMENT'&8IT&/I8

>T*' ,/;

P/&C*,;/*

T/&LL*>

T*A' L*A,*/

,&CT&/ 4

8;/* 4

,&CT&/ :

8;/* :

,&CT&/ 1

8;/* 1

 

GOLF S?ING ERGONOMIC COCPIT ARRANGEMENTGOLF S?ING ERGONOMIC COCPIT ARRANGEMENT

SECOND NATURE REPONSESECOND NATURE REPONSE

 

RESUSCITATION $AY

 

CeillingMounted

 

 LTRA S!"# $AC%L%T%&S

 

Trauma Team should be managed as

smoothly and as efficiently as a

PIT T&P 

in a

(&/';LA &8* /AC*

Al'ays %n (Pole Position)

(Ready To Roll)

 

Su!!ar' o0 Po)'trau!a Tea!

Functions

• Accurate C)inica) -ug!ent

• E00ecti>e Resuscitation Sta,i)i+ation

• Accurate Ra(i Decision Ma5ing

• A((ro(riate Ra(i De0initi>e CareInter>ention

• Co))ecti>e Co))a,orati>e ecision!a5ing ,ase u(on Patientsconition

 

CONCLUSIONS:. mooth 2 efficient management of trauma victim.

1. Preserve the principles of Trauma Team despite varying

resourcesD manpo%er 2 infrastructure.

4. Change of attitude to%ards Trauma Care 2 Inculcate spirit

of team%or0..

6. ;pgrade 0no%ledge 2 s0ill in 'odern Concept of

Trauma Care.

7. Importance of integrated Trauma ystem.

9. /educe morbidity and mortality.

 

*L&A#&RSH%P+

(Leadership is li,ting a persons visionto higher sights the raising o, personper,ormance to higher standard the

building o, a person)s personalitybeyond its normal limitations)

Peter #ruc.er

 

T%AN YOU