Polytrauma

Question 1

Management of airway and breathing according to ATLS protocol (primary survey)

Answer 1

A. Airway and cervical spine control:

SCENARIO: RTA

Assessment:

• Speaking to the patient if can speak → secure airway

• If cannot speak:

o (look): in the mouth for FB or in the face for maxillofacial injuries o (feel): the breath on your cheek o (listen): to abnormal breath sounds stridor or hoarseness

Management:

• Chin lift or jaw thrust

• Remove any FB in the mouth

• Oro/nasopharyngeal airway

• Cricothyroidotomy

• Tracheostomy

• Endotracheal intubation

• Immobilize the cervical spine by hard collar or sandbag or tape

B. Breathing:

Assessment:

• Inspection:

o Any obvious chest injuries o Open wounds, flail segment o Count R.R o Symmetrical chest wall movement

• Palpation:

o Central trachea o Surgical emphysema

• Percussion and auscultation:

o For obvious hemo or pneumothorax Management:

• High flow O 2 via non-rebreather mask

• Needle thoracostomy or chest tube

• Occlusive dressing for open pneumothorax

Question 2

Comment on this CXR?

Answer 2

Pneumothorax + rib fracture + surgical emphysema

Question 3

How will you manage this?

Answer 3

Urgent needle thoracostomy in the 4 th or 5th intercostal space anterior to the midaxillary line* , then chest tube insertion * ATLS 10 th Edition

Question 4

Now, patient is shocked, how will you manage the circulation?

Answer 4

Assessment:

• Pulse rate and character

• Blood pressure

• Class of hemorrhagic shock

Management:

• Stop any obvious source of bleeding

• Gain venous access by 2 large bore cannulae

• Take blood for FBC, glucose, U&E

• Cross match for 4 units of blood

• Commence IV fluid resuscitation with 1L of crystalloids

• Consider blood transfusion if no response to fluids

Question 5

How will you monitor the response?

Answer 5

• Heart rate

• Blood pressure

• Capillary refill time

• Urine output

• Mental status

Question 6

Management of liver tear?

Answer 6

Conservative:

• Blood transfusion, monitoring of the hemodynamic status of the patient Surgical

• Damage control: perihepatic packing

• Repair

• Resection

Question 7

Was CT a good investigation of this patient?

Answer 7

No, patient is hemodynamically unstable, FAST was the investigation of choice The four classic areas that are examined for free fluid are the perihepatic space (also called Morison’s pouch or the hepatorenal recess), perisplenic space, pericardium, and the pelvis.

Question 8

Grades of liver tear?

Answer 8

AAST (American Association for the Surgery of Trauma) liver injury scale

• hematoma: subcapsular, 10-50% surface area

• hematoma: intraparenchymal <10 cm diameter

• laceration: capsular tear 1-3 cm parenchymal depth, <10 cm length

Grade III

• hematoma: subcapsular, >50% surface area of ruptured subcapsular or parenchymal hematoma

• hematoma: intraparenchymal >10 cm or expanding

• laceration: capsular tear >3 cm parenchymal depth

Grade IV

• laceration: parenchymal disruption involving 25-75% hepatic lobe or involves 1-3 Couinaud segments

Grade V

• laceration: parenchymal disruption involving >75% of hepatic lobe or involves >3 Couinaud segments (within one lobe)

• vascular: juxtahepatic venous injuries (retrohepatic vena cava / central major hepatic veins)

Grade VI

• vascular: hepatic avulsion