Polytrauma 21 apr 20

Surg Lt Cdr Anup Maurya
Resident Orthopaedics
1

References
• Rock wood and green’s
• Campbells Operative Orthopedics
• Current concepts of polytrauma management; PF Stahel, CE Heyde, W
Ertel - European Journal of Trauma, 2005 - Springer
• Early Total Care versus Damage Control: Current Concepts in the
Orthopedic Care of Polytrauma Patients; ISRN Orthopedics Vol 2013
(http://dx.doi.org/10.1155/2013/329452)
2

CONTENTS
• Definition
• Introduction
• Pathophysiology
• Pre-Hospital Management
• In Hospital Care
• Damage Control Orthopedics
3

Definition
“A syndrome of multiple injuries exceeding a defined severity
(ISS ≥ 17)
with sequential systemic reactions
{systemic inflammatory response syndrome(SIRS)
for at least 1 day}
that may lead to
dysfunction or failure of remote organs and vital systems (MODS),
which have not themselves been directly injured.”
4

Team Effort
• Polytrauma needs management by a team of surgeons,
Physicians, Anaesthetist & Radiologist
Orthopaedic surgeon is one of the team member of
trauma unit
• Orthopaedic injuries are generally not life-threatening
unless they result in significant hemodynamic instability
• Team leader is a General Surgeon
5

Death Toll
• World wide No.1 cause of deaths amongst the younger
age group (18-44 yrs).
• Third most common cause of death in all age groups
Current concepts of polytrauma management; PF Stahel, CE Heyde, W Ertel - European
Journal of Trauma, 2005 - Springer
6

POLYTRAUMA Vs MULTIPLE
FRACTURES
• Polytrauma is not a synonym of multiple fractures.
• Multiple fractures are purely Orthopaedic problem as
there is involvement of skeletal system only.
• While in polytrauma there is involvement of more than
one system like associated head injury/ chest
injury/spinal injury/ abdominal or pelvic injury
7

Death in polytrauma
• Immediate trauma death/First peak of death.
• Early trauma death /Second peak of death .
• Late death /Third peak of death .
8

FIRST PEAK OF DEATH/IMMEDIATE TRAUMA DEATH
• Severe head injury
• Brain stem injury
• High spinal cord injury
• Heart and major vessel injury
• Massive blood loss
9

Second peak of death / Early trauma death
• Intracranial bleed
• Chest injury
• Abdominal bleeding
• Pelvic bleeding
• Multiple limb injury
10

Third peak of death / Late death
• It occurs after several days or weeks due to
– Sepsis
– Organ failure
11

Non-salvagable deaths
• 50% deaths due to trauma occurs before the patient
reaches hospital.
• 30% occurs within 4 hrs of reaching the hospital.
• 20% occurs within next 3 weeks in the hospital.
• If preventive measures are taken, 70% deaths can be
prevented meaning 30% deaths are non-salvagable
deaths.
12

PATHOPHYSIOLOGY AND IMMUNE
RESPONSE TO TRAUMA
14

Physiologic response to injury
(Earlier Hypothesis)
• 3 phases:
(a) a hypo dynamic phase (shock) where our body initially
attempts to limit the blood loss and to maintain perfusion to
the vital organs
(b) a hyper dynamic flow phase lasting for up to 2 weeks,
characterized by increased blood flow, in order to remove
waste products and to allow nutrients to reach the site of
injury for repair
(c) a recuperation phase, lasting for months, to allow the
human body to attempt to return to its pre-injury level.
15

Physiologic response to injury
(Present Theory)
• The first physiologic reaction after injury involves the
neuroendocrine system leading to an adrenocortical
response characterized by the increased release of
adrenocorticosteroids and catecholamines.
• This is involved in what is called “the general
adaptation syndrome.” This is considered as a
forerunner to the SIRS.
16

• This activation of the neuroendocrine system is
responsible for the incr in HR, RR, fever and leukocytosis
observed in trauma patients after major injury
• SIRS is defined as being present when two or more of the
criteria apply
(a) body temperature: >38 or <36°C;
(b) heart rate: >90/min;
(c) RR: >20/min or PaCO2 < 32 mm Hg;
(d) white blood cell count>12,000 or <4,000/mm3 or
>10% band forms
(e) Lactate <2 mmol/L
SIRS
17

• The activation of the immune system following a traumatic
insult is necessary for
• hemostasis
• protection against invading microorganisms
• initiation of tissue repair and tissue healing.
18

GENOMIC STORM
• The analysis of the genomic response to trauma has shown a
“genomic storm” with activation of more than 5,136 genes.
• Trauma has stimulated the expression of genes involved in innate
immunity, microbial recognition, or inflammation.
• In contrast, the expression was decreased in genes for T-cell
function and antigen presentation.
• Patients with uncomplicated recovery were associated with a
down regulation of genes within 7 to 14 days after trauma
27

Interleukin-6
• Interleukin-6 (IL-6) has perhaps been the most useful
and widely employed of these mediators, partly due to
its more consistent pattern of expression and plasma
half life.
• A measurement of >500 pg/dL in combination with
early surgery has been associated with adverse
outcome.
• A cut-off value of 200 pg/dL was shown to be
significantly diagnostic of an “SIRS state.”
28

Alarmins
• The alarmins are endogenous molecules capable of activating innate
immune responses as a signal of tissue damage and cell injury.
• In this group of endogenous triggers belong molecules such as
(a) high mobility group box 1 (HMGB1),
(b) heat shock proteins (HSPs),
(c) defensins, cathelicidin, eosinophil-derived neurotoxin
• These structurally diverse proteins function as
(a) Endogenous mediators of innate immunity
(b) chemoattractants
(c) Activators of antigen presenting cells (APCs).
30

PAMPs
• In contrast to alarmins, the so-called pathogen-associated
molecular patterns (PAMPs) represent inflammatory
molecules of a microbial nature being recognised by the
immune system as foreign due to their peculiar molecular
patterns
• Both PAMPS and alarmins are currently considered to belong
to the larger family of Damage associated molecular proteins
(DAMPs)
31

simultaneous induction of pro- and anti-inflammatory genes and
suppression of adaptive immune system following trauma -A genomic storm
in critically injured humans
35

Current paradigm shows initial pro-inflammatory response associated with the development
of systemic inflammatory response syndrome and delayed immunosuppression also known
as compensatory anti-inflammatory response syndrome (CARS).
36

Multiple Organ Dysfunction
Syndrome(MODS)
• The clinical appearance of a seemingly poorly controlled
severe systemic inflammatory reaction, following a
triggering event such as infection,inflammation or
trauma.
• It represents the net result of altered host defence and
deregulation of the inflammatory response and the
immune system.
39

Physiological effects of MODS
40

PRE-HOSPITAL PHASE
• Starts soon as the EMS arrives the site of injury
• 1. Maintenance of Airway
• 2. Cardiopulmonary resuscitation
• 3. Fluid replacement with isotonic solution
• 4. Reduction and splintage of fractures
• 5. Perform primary survey of patient and report findings
to destination centre
42

TRIAGE
• Triage is usually used in a scene of an accident or
"mass-casualty incident”.
• To sort patients into those who need critical attention
and immediate transport to the hospital and those with
less serious injuries.
Priority 1 Immediate
Priority 2 Urgent
Priority 3 Delayed
Priority 4 Dead
44

Current concepts of polytrauma
management; PF Stahel, CE Heyde,
W Ertel - European Journal of
Trauma, 2005 - Springer 45

Golden Hour
• Rapid transport of severely injured patient to a trauma
center with in one hour
• Chances of survival diminishes after one hour
• Platinum 10 minutes: Only 10 minutes of the Golden hour
may be used for on-scene activities
46

PRIMARY SURVEY
• A – Air way maintenance with control of cervical spine
• B – Breathing & Oxygenation
• C – Circulation & Control of bleeding
• D - Disability Limitation (Neurological Evaluation)
• E - Exposure/ Environmental Control
47

• Life threatening conditions are identified and
management is instituted simultaneously
• Airway obstruction
• Tension pneumothorax
• Haemothorax
• Open thoracic injury and flail chest
• Cardiac tamponade
• Massive internal or external hemorrhage
48

SIGNS OF AIRWAY OBSTRUCTION
• LOOK
• AGITATION
• RIB RETRACTION
• DEFORMITY
• FOREIGN MATERIAL.
• LISTEN
• SPEECH?
• HOARSENESS.
• NOISY BREATHING
• GURGLE.
• STRIDOR.
• FEEL
• CREPITUS
• TRACHEAL DEVIATION
• HEMATOMA
49

MAINTANENCE OF AIRWAY
• Mask O2
• Endo Tracheal-Intubation
• Ambu Bag
– Protection of the spine is very important while giving
airway maintanence.
50

CAUSES OF MAJOR BLEEDING
• External bleeding(Inspect and apply local pressure)
• Thoracic bleeding
• Pelvic bleeding
• Intra-abdominal bleeding
• Long bones fracture bleeding (Splintage and transport)
51

Trauma scoring systems
• Used to quantify the injuries in consideration with other parameters like
comorbidities, age, and mechanism of injury
• based on conversion of many independent factors into a one-dimensional numeric
value that ideally represents the patient’s degree of critical illness.
58

RTSc - 0.9368 GCS + 0.208 RR +0.7326 SBP
60

Injury Severity Score
• AIS codes are allotted and grouped into six ISS-body regions: head and neck,
face, chest,abdomen, extremities and pelvis, and external
• The ISS is the sum of the squared AIS scores from the three most severely
injured ISS-body regions.
• It can take values from 1 to 75
• If AIS is 6 in any of the body region ISS becomes 75 independent of any other
injuries
61

NISS
• Osler et al described NISS in 1997
• Calculated as the sum of highest three AIS severity scores
regardless of the ISS body regions
• Disadvantage - requires an accurate injury diagnosis
before a precise calculation can be made
63

TRISS
• The TRISS uses both the ISS and the RTS as well as the
patient’s age to predict survival
Ps = 1/(1 + e-b)
where e is a constant (approximately 2.718282) and
b = b0 + b1(RTS) + b2(ISS) + b3(age factor)
b constant is derived from MOTS database
• Scores range from 0 to 1
• Its predictive value of survival or death approximates75% to 90%
64

Staging of the Patient’s Physiologic
Status
66

Staging of Patient Management
Periods
• Acute “Reanimation” period - 1-3hrs
• Primary “stabilisation” period- 1-48hrs
• Secondary “regeneration” period - 2-10 days
• Tertiary “reconstruction and rehabilitation” period
(weeks)
67

Imaging
• Conventional Radiography
• Chest Xray AP View
• Cervical spine lateral view
• Xray pelvis AP view
• USG- eFAST
To be done bedside with a mobile
Xray machine
68

• CT Scan
• Gold standard for head, spinal, chest and abdomen
imaging
• Angiography
• Best method for detecting traumatic vascular
injuries
• Especially useful in intra pelvic and abdominal solid
organ injuries
69

Priorities for life saving Surgeries
• Hemothorax
• Mediastinal Hemorrhage and thoracic Aortic injuries
• Abdominal Trauma vs expanding ICH
• Pelvic Trauma
70

Priorities for life saving Surgeries
• Hemothorax
• Mediastinal Hemorrhage and thoracic Aortic injuries
• Abdominal Trauma vs expanding ICH
• Pelvic Trauma
71

Damage Control Orthopedics
• Early stabilisation of the femoral fractures reduces the
incidence of Fat embolism, ARDS and post op
complications
• In 1980s the rationale of Early Total Care was
developed. Surgeries were done within 24hrs of
admission
72

• Early rapid containment and stabilisation of orthopedic
injuries without worsening the patient general
condition
76

• Early rapid containment and stabilisation of orthopedic
injuries without worsening the patient general
condition
77

Polytrauma 21 apr 20

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