64. Polytraumas. Combined traumas

Question 1

Polytraumas - definition

Answer 1

Injury to several (>1) physical regions or organ systems, where at least one injury or the combination of several injuries is life threatening with the severity of injury being >16 on the injury severity score

• With possibility of one or more causative agents i.e. mechanic and/or chemical and/or biological

Question 2

Polytraumas - worst injury of 6 body system

Answer 2

1. Head and neck
2. Face
3. Chest
4. Abdomen
5. Extremities (including pelvis)
6. External

Question 3

Polytraumas - worst injury of 6 body system - values

Answer 3

• Max = 75
• Minor = 1-8
• Moderate = 9-15
• Serious = 16-24
• Severe = 25-49
• Critical = 50-74
• Un-survivable = 75

Question 4

Classification of Polytrauma:

Answer 4

1. 2 major systems injury + 1 major limb injury
2. 1 major system injury + 2 major limb injury
3. 1 major system injury + 1 open grade III skeletal injury
4. Unstable pelvis fracture with associated visceral injury

Question 5

Polytrauma - most common injuries

Answer 5

Traumatic brain injury frequently occurs in Polytrauma.

• Others injuries inc. amputations, burns, spinal cord injury, post-traumatic stress disorder
• Most often associated with motor vehicles, blast injuries

Question 6

Polytraumas - Trauma mortality periods

Answer 6

1. Most deaths occur during 1st hour
2. 1-4 hr (golden hour) common cause of death = hypovolemic shock
3. Several wks later pt dies of late complications + organ failure

Question 7

Polytraumas - Physiological response to Polytrauma

Answer 7

• Tissue damage
• Hypovolemia
• Changes in CVS
• Inflam reactions
  o Systemic inflam response syn (SIRS)
  o Acute respiratory distress synd (ARDS

Question 8

Polytraumas - Treatment

Answer 8

• On admission = X-ray = cervical spine, chest, pelvis

- Primary evaluation
o ABCD (disability – neurological status)

o Urinary/gastric catheters inserted

o ECG + O2 sat

o If severe blood loss = blood transfusion

o Full lab studies

• Secondary evaluation:

o Head-toe examination

o CT, extremity x-rays

o Endoscopy, US

Question 9

Blast trauma definition

Answer 9

Is a Multi-dimensional injury – combines blast, penetrating, blunt and burn mechanisms

Question 10

Primary blast injury - Clinical presentation

Answer 10

1. Primary blast injury:eardrum perforation – usually heal spontaneously or result in hearing loss in 25%
   a. Disrupts alveolar capillary intersurface = mild contusion with intralveolar hemorrhage to severe + rapidly evolving acute respiratory distress synd
   i. Pneumothorax actively sort
   ii. CF: hypoxia + bilateral diffuse infiltrates
   iii. Tx: emergency endotracheal intubation + ventilatory support

Question 11

Secondary blast injury:

Answer 11

Penetrating trauma from fragments of bomb.

Penetrating trauma = deep soft tissue wounds = profuse bleeding thus before taking pt to OR – pack wound with gauze before surgery

a. CF: profuse bleeding, superficial skin laceration to lethal visceral wounds
b. DX: X-ray, CT, physical examination to determine depth of penetration
c. TX: debridement of wound + removal of embedded foreign fragments

Question 12

Tertiary blast injury:

Answer 12

Combined with other types of trauma caused by blast. Complicates clinical picture – dilemma in priority tx

Question 13

Quaternary blast injury

Answer 13

Mostly burns + crush injuries sometimes in conjunction with inhalation injuries

Question 14

Blast Trauma types

Answer 14

Primary

Secondary

Tertiary

Quaternary

Question 15

Primary blast injury : clinical presentation

Answer 15

Hypoxia + bilateral diffuse infiltrates

Question 16

Primary blast injury treatment

Answer 16

Emergency endotracheal intubation + ventilatory support