POLYTRAUMA

Director &HOD
Prof.Dr. K.PRAKASAM
M.S.ORTHO,D.ORTHO,DSc(HON)

Moderator:Dr Hari

PRESENTOR:DR.THOUSEEF .A. MAJEED

 Definition

Poly-trauma means a syndrome of multiple

injuries with systemic traumatic reactions which

may lead to dysfunction or failure of remote

organs and vital systems.

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• Polytrauma needs management by a team of surgeons

and physicians.

• 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.

• World wide No.1 cause of death amongst the
younger age group (18-44 yrs).

• Third most common cause of death in all age

groups.
 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

• While in polytrauma there is involvement of more than

one system like associated head injury/ chest injury/
spinal injury/ abdominal or pelvic injury
 Death in polytrauma

• Immediate trauma death/First peak of death.

• Early trauma death /Second peak of death .

• Late death /Third peak of death .

 First peak of death/Immediate trauma death

• Severe head injury

• Brain stem injury

• High cord injury

• Heart and major vessel

injury

• Massive blood loss

 Second peak of death / Early trauma death

• Intracranial bleed

• Chest injury

• Abdominal bleeding

• Pelvic bleeding

• Multiple limb injury

 Third peak of death / Late death

• It occurs after several

days or weeks due to

– Sepsis

– Organ failure
 AIMS IN MANAGEMENT
“TO RESTORE THE PATIENT BACK TO HIS
PRE-INJURY STATUS”

HAVING FOLLOWING PRIORTIES:

• LIFE SALVAGE

• LIMB SALVAGE

• SALVAGE OF TOTAL FUNCTION IF POSSIBLE

 LIFE SALVAGE

• 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.
 TEAM OF CONSULTANTS FOR POLY TRAUMA

• Team Leader – General Surgeon

• Orthopaedic surgeon

• Neuro surgeon

• Thoracic surgeon

• Accident and emergency medical officer

• Urologist

• Anesthesiologist
 Advanced Trauma Life
Support (ATLS)

Four inter related stages

1. Rapid primary survey with simultaneous
resuscitation

2. Detailed secondary survey

3. Constant re-evaluation

4. Initiation of definitive care

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 PRE-HOSPITAL PHASE
BASIC EMERGENCY MEDICAL TECHNICIAN
SKILLS

1. Maintenance of Airway ( endotracheal intubation)

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 center
 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.
 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

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 PRIMARY SURVEY
• A – Air way maintenance with control of cervical
spine

• B – Breathing & Oxygenation

• C – Circulation & Control of bleeding

• D – Disability

• E – Exposure & avoidance

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 PRIMARY SURVEY
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

 SIGNS OF AIRWAY
OBSTRUCTION

LOOK LISTEN FEEL

SPEECH?
AGITATION
HOARSENESS.
FEEL FOR CREPITUS.
RIB RETRACTION
NOISY BREATHING TRACHEAL DEVIATION.
DEFORMITY
GURGLE. HEMATOMA.
FOREIGN MATERIAL.
STRIDOR.
 WHEN TO VENTILATE

• Apnoea • Diaphragmatic injury

• Hypoventilation • Head injury GCS<8

• Flail chest • Hypercapnea

• High spinal cord • Hypothermia

injury
 MAINTANENCE OF AIRWAY
• Mask O2

• Endo Tracheal-Intubation

• Ambu Bag

– Protection of the spine is very important while giving

airway maintanence.

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 CAUSES OF MAJOR BLEEDING
• External bleeding

• Thoracic bleeding

• Pelvic bleeding

• Intra-abdominal bleeding

• Long bones fracture bleeding

• External bleeding - Inspect and apply local pressure

• Thoracic bleeding take Chest X-ray and Intercostal

drainage (ICD) tube insertion.

• Pelvic bleeding take Pelvis X-ray and apply pelvic

binder or external fixator
• Intra-abdominal bleeding is confirmed by Clinical finding,
USG, CT scan and Doppler study

Emergency laparotomy

• Long bones fractures can be fixed or splintage can be

applied.
 Maintenance of circulation

•I.V. Fluids one above and one below the

diaphragm
(Crystaloids and colloids)

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 Classification of hemorrhage
• 70 kg male ---5 litres of blood

Class I Haemorrhage

- Loss of up to 15% of the blood volume

- does not cause a change in blood volume or

pressure.

- Treated with 1.5 litres of Ringer lactate or 1 litre of

Polygelatin (haemaccel)
 Class II Haemorrhage
- loss of 15% to 30% of blood volume

- results in increased pulse but no change in blood

pressure.

- Resuscitated with a crystalloid, but some may

require blood transfusion.

- 1.5 Litres of Ringer lactate+ 1 Litre Haemaccel.

 Class III-haemorrhage
• Loss of 30% to 40% of circulating blood (2 litres)

- Tachycardia and loss of Systolic blood pressure and

decreased mental status.
• Patients are given 2 litres of saline over 20 min.
• Blood pressure should be maintained with crystalloid until
blood is ready.

• Recurrent hypotension- 2liters of crystalloid + type-specific

or non–cross-matched universal-donor (i.e., group O neg)
blood is given.
 Class IV-Haemorrhage

• Loss of more than 40% of blood volume.

• Marked tachycardia, significantly decreased systolic

blood pressure, cold and pale skin, severely
decreased mental status,negligible urine output.

• Consider 2-3 units of FFP and a six pack of platelets

for every 5 liter of volume replacement.
 DISABILITY
(NEUROLOGICAL EVALUATION)
• 50% of trauma deaths are due to head injuries

• To describe the level of consciousness

– A : Alert

– V : Responds to vocal stimuli

– P : Responds to painful stimuli

– U : Unresponsiveness' to all stimuli

 GLASGOW COMA SCORE

• Normal – 15/15

• If GCS <10 CT brain is

indicated
 STRATEGY IN PATIENTS WITH HEAD INJURY

Beware of the fact that cerebral auto regulation goes off

following head injury.

Extensive sympathetic block due to regional anaesthesia

may hamper Cerebral Blood Flow

Severe head injury → only life saving procedures

 STRATEGY IN PATIENTS WITH CHEST INJURY
Rib fracture or lung contusion

Monitoring with pulse

oximeter or ABG

Incidence of Acute
Respiratory Distress

Severe chest injury →only life

saving procedures
ADJUNCT TO PRIMARY SURVEY & RESUSCITATION

• ELECTRO-CARDIOGRAPHIC MONITORING

• URINARY CATHETER & RYLES TUBE if necessary

• X-RAY

– C-Spine lateral, Chest X Ray, Pelvic film (trauma series)

– Essential X-ray’s should not be avoided in pregnant

patient.
 SECONDARY SURVEY

• Patients shows normal vital sign after primary survey and

resuscitation

• Head to toe evaluation & reassessment of all vital signs

• A complete neurological examination is performed

including Glasgow Coma Score.
 MANAGEMENT OF LIFE
THREATENING ORTHOPAEDIC
INJURIES
 ZERO HOUR FIXATION

• All poly trauma patients with injuries of other organs like

spleen, Liver, Kidney

• Major blood vessel tear

• Depressed skull fractures

• Pelvic fractures
 TRANSPORT

• All Fracture sites - should be splinted.

• Back board (or) scoop stretcher used.

• Log - Rolling method to be avoided.

• Board traction devices available.

 SPINAL INJURIES
• Suspected patients of spinal

injury - immobilised

• Cervical collar

• Spine board
• In all patients with spinal injury, maintain spinal precautions
until thorough clinical and radiographic evaluation of spine
is completed.

• Spine is no more called as no man’s area.

• Stabilization of spine is mandatory.

 Prevention of bed sore.

 Early mobilization &Rehabilitation.

 PELVIC INJURIES

• Pelvic injury is one of the major cause for death

• Pelvic injuries are assessed during secondary survey

• Pelvis X-Ray is mandatory in polytrauma patient

• Can lead to life threatening hemorrahge – 50% mortality

• Urethral injury – transurethral or suprapubic catheter can be

used.
 IMMEDIATE MANAGEMENT OF SEVERE PELVIC
BLEEDING

1 Pelvic binders, MAST (Military anti shock

trousers),Pneumatic anti shock garment

2 External fixator

3 Pelvic packing

4 Angiographic Embolisation
 BINDERS/MAST
• Reduce the pelvic volume

• Allows clot formation

• Allow for auto transfusion

Disadvantages:

• Compartment syndrome and skin necrosis.

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 PELVIC PACKING

• Done during laparotomy.

• In uncontrolled pelvic bleeding associated with abdominal

injuries .

• During packing always stabilise the pelvis with external

fixators.
 ANGIOGRAPHIC EMBOLISATION
• Success rate reported in the > 95%

• Most arterial injuries involve the internal iliac artery.

• Multiple bleeding sites in 40% of patients.

• Most common branches : superior gluteal, lareal

sacral,internal pudendal, inferior gluteal, obturator.
• Complication rate: 0- 6%.

Complications:

• Liver necrosis

• Skin necrosis

• Nerve damage

• Femoral head necrosis

• Bladder necrosis

• Sexual dysfunction.
“DAMAGE CONTROL
ORTHOPAEDICS”
 DAMAGE CONTROL SURGERY
• Rapid emergency surgery to save life or limb
• Not involving complex reconstructive surgery
– Control bleeding
– Decompress cranium, pericardium, thorax, abdomen and
limbs
– Decontaminate wounds and ruptured viscera
– Splint fractures
• Cast, traction, pelvic binder, ex-fix
 THE ‘FIRST HIT’

Threshold DEATH: from multiorgan failure or adult

for fatal respiratory distress syndrome
inflammator
y response
inflammatory
response

The ‘natural’ systemic

inflammatory response

time

1st Hit: the trauma

 THE ‘SECOND HIT’ (2-5 DAYS)
• Severe trauma can result in a life threatening inflammatory
response (SIRS)

DEATH: from multiorgan failure or adult

Threshold for
respiratory distress syndrome
fatal
inflammatory
response
inflammatory

The exaggerated
response

response brought
about by the 2nd hit of
surgery

time
2nd Hit: the surgery
1st Hit: the trauma
 THE ‘SECOND HIT’ (2-5 DAYS)
• Severe trauma can result in a life threatening inflammatory
response (SIRS)

Threshold for DEATH: from multiorgan failure or adult

fatal respiratory distress syndrome
inflammatory
response
inflammatory response

In some individuals the lengthy surgery

of early total care exacerbates the the
systemic inflammatory response
resulting in death

time
2nd Hit: the surgery
1st Hit: the trauma
Patients For Damage Control
Surgery

• Stable

• Borderline

• Unstable

• Extreme
 Damage Control Surgery Patients

STABLE No life threatening injuries, Early total care

haemodynamically stable
BORDERLINE Initially respond to resuscitation Wait for
but can detoriate improvement

UNSTABLE Remain hemodynamically Damage control

unstable despite initial surgery
resuscitation
EXTREME Close to death uncontrollable Damage control
blood loss surgery or ITU
 SERUM LACTATE LEVELS
• Initial lactate:
– < 2.5 mg/dL-Chance of mortality is 5.4%

– 2.5 mg/dL to 4.0 mg/dL---6.4% Mortality

– >=4.0 mg/dL---18.8% Mortality

 Lactate controlled early total care
• Often high in 1st few hours but will drop if resuscitation is
adequate

• 2.5 magic number!

– < 2.5 Early Total Care.

– 2.5 – Look at TREND( Trauma related Neuronal

dysfunction)

– > 3 Damage Control Surgery

 EARLY TOTAL CARE

• Definitive fracture treatment within 24hr

• Only in stable patients, lactate < 2.5

• Avoid in thoracic injuries, hemorrhagic shock and

head injury

• Advantage – pain relief, less infection early

mobilisation and prevention of thromboembolism.
Priorities in surgical management of
musculoskeletal injury
– Save life

– Save limb

– Save joints

– Restore function

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 PRIORITIES IN FRACTURE CARE

• Pelvis

• Spine

• Femur

• Tibia

• Upper extremity
 Aims for fracture management

– Control of sources of contaminations

– Removal of dead issue

– Prevention of ischemia

– Pain relief

– Facilitation of intensive care

 FAT EMBOLISM IN POLYTRAUMA

• Fat embolism incidence in a polytrauma -30-90%

• If surgery is performed following polytrauma,

will reaming further increase the incidence of

Fat Embolism .
 Prevention of Fat embolism syndrome

• Avoid increase in Intra-Medullary pressure

• Medullary channel depletion

• Venting the medullary channel

• Uncemented prosthesis
 Facilities Necessary
• A full range of implants and instruments must be
available

• It is the responsibility of the surgeon to ensure that

his/her team knows what is going to happen.

• All those involved in the provision of surgical care for

trauma patients must have regular training.

• Care of the patient does not stop once the surgery is

completed.
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 MEDULLARY REAMING

• Normal Intra Medulary pressure - 30 – 50mm of Hg.

• Violent force in the bone – Intra Medulary pressure
↑many fold.
• Reaming increases Intra Medulary pressure up to 400-
600 mm of Hg.
 NEGATIVE EFFECTS OF DELAYED
FIXATION

• Prolonged immobilisation

• Pneumonia, bedsore, renal failure, inadequate

nutrition, vascular abnormalities

• Poor results
 TIMING OF SURGERY

• Day 1: Early total care- stable patients

• Day 2-5: Avoid surgery
SIRS
2nd hit is common

• Day 5-10: WINDOW OF OPPORTUNITY

• After Day 10- high infection rate.

 SUMMARY

• Polytrauma must be considered as a systemic surgical

disease

• Primary objective is survival of patients

• Early fixation of major fractures – performed with right

concept has proved to be an important tool to obtain this
primary objective.

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 THANK YOU
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