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Polytrauma and wound

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Information about Polytrauma and wound
Education

Published on March 12, 2014

Author: magician10k

Source: slideshare.net

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Trauma 1  Leading cause of death ages 1-40  Third leading cause in all age groups  Co-Morbid Factors  Extremes ofAge  Underlying Disease & Poor General Health  Pregnancy  Environmental Extremes  Protective Devices

When Trauma Deaths Occur <1 hour 1-3 hours 4 to 6 weeks Temple College EMSP 2 “The Trimodal Distribution”

Immediate Deaths (seconds to minutes) unpreventable Temple College EMSP3 Loss of Airway Brain Stem Laceration High Cx-Spine Lesion Aortic/Heart Rupture

Early Deaths (few minutes to hours ) Temple College EMSP4  Epidural Hematoma  Subdural Hematoma  Hemo/Pneumothorax  Intra-abdominal Bleeding  Pelvic Fractures  Femur Fractures  Multiple Long Bone Fractures

Late (days to week ) Temple College EMSP5 Sepsis Multiple Organ System Failure(MODS- MOSF-MOFS). Complications due to surgery or initial injury .

Initial Assessment and Management of Trauma

 Sorting of patients in mass casualty.  Their ranking according to both their clinical need and the available resources to provide treatment. Based on the ABCDE priority  Three categories of patient

Initial Assessment (Primary Survey) Find life threats If life threat present, CORRECT IT! If life threat can’t be corrected Support ABCs TRANSPORT!!

ATLS

PRIMARY SURVEY  Identify and treat what can kill the patient . Airway( patent and protected ) with Cervical spine protection Breathing (adequate bilateral air entry +no life threatening chest conditions) and ventilation Circulation with hemorrhage control Disability:(AVPU assessment ) Neurologic status Exposure/ Environmental control(keep the patient warm )

Airway with Cervical spine

Management:  Ascertain patency  Rapidly assess for airway obstruction  Chin lift / jaw thrust maneuver (the mandible is gripped and lifted forward whilst the neck is extended)  Clear the airway of FB  Insert an oro- / naso-pharyngeal airway.  Establish a definitive airway  Orotracheal / nasotracheal intubation  Surgical cricothyroidotomy( failed intubation due to edema of the glottis +laryngeal fractures +severe oral Hge)  Jet insufflations.

Cervical spine Maintain the cervical spine in a neutral position with manual immobilization as necessary when establishing an airway Immobilization of the cx-spine with appropriate devices after establishing an airway (neck collar)

Breathing and Ventilation Injuries that should be identified in the Primary survey : 1.Tension pneumothorax 2. Massive hemothorax 3. Open pneumothorax 4. Flail chest

Circulation with Hemorrhage Control  Assessment:  Pulse / skin color, capillary refill / Blood pressure  Identify source of external hemorrhage  Identify potential source(s) of internal hemorrhage  Management:  Apply direct pressure to external bleeding site.  Internal hemorrhage ? Need for surgical intervention ?  Establish IV access / central line  Fluid resuscitation / blood replacement  Cardiac tamponade

Disability Assessment of Level of consciousness  AVPU scale Alert Voice = response Pain = response Unresponsive  GCS  Pupils size, equality and reaction Management  Intubation and allow mild hyperventilation  Administer IV mannitol ( 1.5-2.0g/kg )  Arrange for brain CT

GCS - BEST!!! (3 – 15) Eye Verbal Motor 6 Obeys 5 Normal Localizes 4 Spontaneous Confused Withdraws 3 Voice Inappropriate abN flexion 2 Pain Incomprehensible Extension 1 Nil Nil Nil

 Mild H.I. GCS 13 – 15  Moderate GCS 8 – 12  Severe GCS < 8

 CT is contraindicated when the patient is hemodynamically unstable  A decrease in the level of consciousness may due to: Decreased cerebral oxygenation (A,B) Decreased cerebral perfusion (C) Direct cerebral injury (D) Drugs orAlcohol Always rule out hypoxemia and hypovolemia first.  Reevaluation

Exposure / Environment Control  Completely undress the patient.  Prevent hypothermia Pain relieve

Jaw thrust/chin lift Suction Intubations Cricothyroidotomy Airway ( with protection of C-spine ) Oxygenation Needle decompression Tube thoracostomy Supplemental oxygen Seal open pneumothorax Breathing/Ventilation Hemorrhage control IV line/ central line Venous cut down Fluid resuscitation/Blood transfusion Pericardiocentesis for cardiac tamponade Circulation IV mannitol Hypervntilation Surgery Disability

Radiological and laboratory Assessment ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION  CXR  pelvis  C-spine  Abdominal ultrasonography (FAST)

Medical history (AMPLE)  A =allergies  M=medications  P=past medical history  L=last meal  E=events leading to injury

Secondary SURVEY  The secondary survey does not begin until: The primary survey is completed, Resuscitation efforts are well established, The patient is demonstrating normalization of vital functions.  Complete history and Examination  Head-to-toe evaluation  Reassessment of all vital signs.  Complete Neurological Examination .  Indicated x-rays ,CTS, US are obtained.

Fingers and tubes in every orifice:  PR  PV  CHECK ENT  NG tube if no skull fracture .  URINARY CATHETER if no evidence of genitourinary trauma

Wound

Factor influencing wound healing  Local factors Tissue trauma Hematoma - associated with higher infection rate Blood supply Temperature Infection Technique and suture materials  General factors Systemic effect of steroids Nutrition Uncontrolled DM Chemotherapy Chronic illness

Type of wounds and their treatment  Cut wound  Abrasion  Contusion  Laceration  Avulsion  Puncture wound

Management of the clean wound  Goal - close wound as soon as possible to prevent infection, fibrosis and secondary deformity.  General principles: 1 -Immunization 2- Pre-anesthetic medication if needs 3- Local anesthesia – use epinephrine adjuvant unless contraindicated, eg., digit , tip of penis 4-Tourniquet 5- Cleaning of surrounding skin – do NOT use strong antiseptic in the wound itself 6- Debridement: Remove clot and debris, necrotic tissue ;Copious irrigation good adjunct to sharp debridement 7- Closure - atraumatic technique to approx. dermis Consider undermining of wound edges to relieve tension. 8- Dressing – must provide absorption,protection,immobilization, even compression, and be aesthetically acceptable.

Types of sutures

Wound dressings  1- Protect the wound from trauma  2 -Provide environment for healing  3 -Antibacterial medication provide moisture and control microorganism.  4- Splinting – casting : For immobilization to promote healing Do not splint too long – may promote joint stiffness  5- Pressure dressings May be useful to prevent dead space, seroma,hematoma Do NOT compress flaps tightly  6- Do NOT leave dressing too long before changing

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