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MANAGEMENT OF SEVERLY INJURED PATIENTS

DR TAJ UDDIN

FCPS FRCS

Shock and trauma

•Penetrating vs. blunt trauma

•Airway and ventilation

•Shock

•Delayed problems

•Damage control

•Case scenarios

Airway and ventilation in Blunt trauma

•Cervical spine

•Maxillo-facial injuries

•Laryngeal or tracheal injuries

•Burns

•Associated chest or abdominal injuries

•Level of consciousness

Indications for intubation (Absolute)

•Acute airway obstruction

•Apnoea

•Hypoxia

•Penetrating neck trauma with expanding haematoma

•Cranio-facial injury with GCS<8

•Severe shock

Other indications for intubation

•Non responding shock

•Thoracic injury with disrupted breathing mechanics. Flail chest lung contusion

•Combative trauma patients with possible life threatening injuries

•Maxillo-facial trauma

•Pulmonary contusion

Shock- A short History

•WW I – “short, deft operations”

•WW II – plasma and blood transfusion

•Korea – “irreversible shock “

•Vietnam – Post op complications

•Since – renal, pulmonary, coagulation failure and septic complications

Pathophysiology of shock

•O2 demand by mitochondria – mitochondria don’t work without O2

•Intravenous volume depletion

•Neurogenic shock

•Cardiogenic shock

•Compression cardiac shock

•Septic shock

•Adrenal insufficiency

Pathophysiology of shock

•O2 availability falls

•Mitochodria unable to turn ADP into ATP

•Do it by anaerobic glycolysis

•Pyruvate into lactate

•Metabolic acidosis (normal BE )

•Corresponds to outcome

 

 

Management of shock

• Crystalloids vs. colloids

•Crystalloids vs. crystalloids

•Crystalloids vs. blood

 

•”without a surgical procedure to control haemorrhage attempted restoration of BP to normal is futile”

 

Management of shock

• identify source of bleeding

• if bleeding and shock needs operation (or rarely embolisation)

• if shock and not bleeding

– Cardiogenic

– Neurogenic

– Compression cardiac

Management of shock

•Venous access

•CVP monitoring – optimise filling

•Arterial monitoring and ABGs

•Prevent hypothermia

Delayed problems

• Multi organ dysfunction, SIRS

• Renal failure

• ARDS

• Fat embolism

• Nutrition, immobility, secondary sepsis

• Missed injuries

• Idea of “second hit”

 

 

Things to be done in first 60 seconds

•Oxygen mask on 100%

•Stabilise the neck

•Cut clothes to expose chest, abdo and upper limbs

•Attach monitoring

•Obtain rapid !st set of obs and shout out

Airway and cervical spine

Assess                             Think about

 

Airway                              ?ventilation

?positioning                     ? Intubation

?suction

?adjuncts

Breathing

Assess                     Think about

 

RR, depth effort       Oxygen requirements

Trachea                   ?needle decompression

Neck veins                      

Bruising and crepitus ?chest drains

Air entry in axillae    

 

Circulation

Assess                             Think about

 

Skin colour and temp        How much fluid

                                        ?O neg blood

Pulses (R, B, F C)            ?Theatre

BP correlate with pulse

? Manual BP

Is the patient bleeding to death

• Scalp                     - Close

• Limbs                     - Pressure and splint

• Chest                     - X- Ray, Drain(s), surgery

• Pelvis                    - X- Ray, sandbags,                                         blanket tie, external fix or                           embolisation

• Abdomen                - Clinical exams, Holes,                                    exclusion, US or DPL,                                      ?straight to theatre

 

Neurological

Assess                             Think about

 

Pupils                               ?Intubation

GCS (above clavicle)       ?Spinal injury

Limb movements              ?ICP

Glucose

Temperature

At the end of 60 seconds-
Is the patient going to require

• Intubation

•Chest drain(s)

•Surgeons called

•Seniors called

•Anaesthetist called

•O negative blood, cross match

•Operating theatre informed?

 

New perspectives

• Some patients with trauma cannot be stabilised

•Viscous cycle

– Hypothermia (T< 35C)

–Acidosis (pH<7.2 or H+>55)

–Coagulopathy (including transfusion >10units)

•Standard surgical approach will result in patients death

•Salvage – Stabilise – Delayed definitive surgery

Damage control - indications

• Inability to achieve haemostasis

• Inaccessible major venous injury

• Management of extra-abdominal injury

•Prolonged resuscitation

• multiple bleeding penetrating injuries

 

Damage control - techniques

Packing to achieve haemostasis in the liver retroperitonium or pelvis.

Staple closure of gastrointestinal tract perforations, or totally isolating segments of damaged intestines,

Catheter drainage of urinary tract biliary tract or intestinal tracts

Occlusion of major arteries using temporary ligation or stapling

Temporary use of intravascular arterial or venous shunt

Quick temporary laparotomy wound closure using towel clips or plastic bags

Summary and questions

• Blunt trauma is complicated

• Not all shock is bleeding but if bleeding, do something about it

• Optimise non operating things

• Damage control may be required to save patient

 

CHOLECYSTECTOMY

BREAST CANCER

INGUINAL HERNIA

KIDNEY SURGERY

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