POLYTRAUMA
CASE PRESENTATION
DR FERDINAND
24/05/2022
IDENTIFIER: O.C
AGE: 73 Years
BIO DATA
GENDER: Male
PMHx: HTN/Diabetes(self
diagnosed)
HISTORY
• RTA- Pedestrian vs Tricycle on busy Highway
• C/O- ? Loss of consciousness
- Facial bruises
- Lt Chest wall Pain + diff. breathing
- Lt Shoulder/Elbow Pain
• CT brain – TBI( Acute haemorrhage)
• X-ray Chest – 3rd – 7th Ribs.
• X-ray Lt Shoulder – old Proximal left
humeral
-old ulnar .
• Abdomino-pelvic USS- normal findings.
INITIAL ASSESSMENT
• RTA Pedestran vs tricycle 2/7 ago
• Obvious injuries are – L Rib fractures 3rd -7th
- L Elbow & injury? New
- R thumb injury
- L zygomatic arch fracture
- L Lateral orbital wall
fracture
- HI (acute intra-cranial
haemorrhage)
RESUSC. PLAN
– FBC
– RBG
– EUCr
– Clotting Profile
– Urinalysis
– Continous ECG
mornitoring
– Chest
physiotherapy
– IM Dicoferac75mg
start + IV
Omeprazole 4omg
start
• IVF N/S 1L 8hrly
• Left Broad Arm
Sling
• For review by the
Ortho & Trauma
Surgeon
• Admit to the surgical
ward
TRAUMA ASSESSMENT
• A – Airway Patent /self maintenance
• B – RR 22/m and saturation 96% .
• C – HR 100/m, BP 140/78.
• D- GCS 15/15.
• Facial injury-Lt Raccoon eye.
-Lt Elbow Pain & Swelling.
- Lt Chest Wall tenderness.
• CT whole spine
• Retrieve CT head image
from clinix
• Retrieve all images
• Resume chat
• Stop diclofenac
• Review Abdo USS
• X-ray R thumb (AP/Lat)
• General surgeon to review
• D/C IVF
• Give oxygen by Cannula 2L/min
• Chase all blood results
• Chase USS report
• Hourly GCS please
TRAUMA
SERIES
IMAGING
SUMMARY OF INJURIES
• Based on these
injuries patient was
reviewed by;
• CTS
• NEUROSURGEON
• T & O SURGEON
SECONDARY SURVEY (ATLS)
ABDOMEN
For rigid and distended abdomen
• Four quadrant tap
• Diagnostic peritoneal lavage
• Ultrasound
• Laparoscopic examination
Any
Deterioration
Consider rapid surgical exploration
SECONDARY SURVEY (ATLS)
PELVIS
Clinical assessment
X-ray
Stabilize pelvis with fixator/ clamps if urethral injury is
suspected – high up in prostate PR
blood in meatus perineal haematoma
TRIAL CATHETHER WITH
GENTLE MATTNIPULATION
Ascending urethrogram
FINE CATHETHER
LOTS OF LUBRICANTS IN OT
SECONDARY SURVEY (ATLS)
SPINAL INJURY
Thorough sensory and motor
examination
• Prevent further damage in
unstable fractures
• Log rolling for full
neurological examination –5
people required
• Use a long spine board for
transportation
SECONDARY SURVEY (ATLS)
EXTREMITIES
• Full assessment of limbs for assessment of
injury
• Always look for distal pulse & neuro-status
• Carefully look for skin & soft tissue viability
• Look out for impending compartment
syndrome
SECONDARY SURVEY (ATLS)
EXTREMITIES
Mangled Extremity Severity Score (MESS)
based upon --
1. Skeletal/ Soft tissue group
2. Shock group
3. Ischemia group
4. Age group
If > 7, limb salvage is questionable
DEFINITIVE CARE PLAN (ATLS)
Multi-specialty approach
(Inter-disciplinary
management)
The most appropriate person in
charge is the General / Orthopedic
surgeon.
COMPLICATTIONS
• Tetanus
• A.R.D.S.
• Fat embolism
• D.I.C.
• Crush syndrome
• Multisystem organ
failure (M.S.O.F.)
COMPLICATIONS
A.R.D.S.
• Tachypnoea
• Dyspnoea
• Bilateral infiltrates in CXR
Treated with mechanical ventilation CPAP with
or without PEEP
Glucocorticoids
Inhaled nitric acid
COMPLICATIONS
Fat Emblolism
• Around 72 hours
• Tachycardia
• Tachypnoea
• Dyspnoea
• Chest pain
• Petechial haemorrhage
Treated with ------ mechanical ventilation
------ anticoagulants
------ fixation of fractures
COMPLICATIONS
Disseminated intravascular coagulation
• Follows severe blood loss and sepsis
• Restlessness, confusion, neurological
dysfunction, skin infercation, oligurea
• Excessive bleeding
• Prolonged PT, PTT, TT, hypofibrinogenemia
Treatment – prevention and early correction and
shock
COMPLICATIONS
Crush Syndrome
• When a limb remains compressed for many hours
• Compartment syndrome and further ischaemia
• Cardiac arrest due to metabolic changes in blood
• Renal failure
Treatment
• Prevention-ensure high urine flow during extrication
• IV Crystalloids, Forced mannitol alkaline diuresis
• Fascitomoy and excision of devitalized muscles
• Amputation
COMPLICATIONS
M.S.O.F
Progressive and sequential dysfunction of
physiological systems
Hypermetabolic state
It is invariably preceded by a condition known
as
Systemic Inflammatory Response Syndrome
(SIRS)
Characterized by two or more of the following
• Temperature > 38° C or < 36°
• Tachycardia > 90/ min
• Respiratory rate >20/min
• WBC count > 12,000/cmm or <4,000/cmm
COMPLICATIONS
M.S.O.F.
Treatment : Key word is
PREVENTION
• Prompt stabilisation of fracture
• Treatment of shock
• Prevention of hypoxia
• Excision of all dirty and dead
tissue
• Early diagnosis and treatment
of infection
• Nutritional support
CONCLUSION
High velocity trauma is aptly called
neglected stepchild of modern
civilisation being the number one
cause of death in 18 to 34 years age
group. Despite the major economic
productivity losses due to this problem
injury receives < 2% of the total
health budget allocation. Adequate
funding & legislations must be passed
to reduce the enormous impact on the
society.
