Published on: Mar 4, 2016
Transcripts - Poly trauma
• Outcome of any injury are: complete recovery Recovery with residual effect disability death.Outcome depends on:• Timing of hospital care• Mechanism of injury• Vital signs in field and on arrival• Outcome measures-ICU days, ventilator days
It has been suggested that trauma(commonest cause of unnatural death) follows tri-modal distribution:Immediate: severe head injury, aorta dissection. dealt only by prevention and public education.Early :epidural, subdural hematoma, hemothorax etc. Correctable injury, pre hospital coordinated care and definitive t/t can benefit these pt.Late: sepsis, consequences of initial management
Morbidity and mortality• Hypoxia• Microatelectasis• Hypovolemia• Chest injury• Head injury
• Physiological status Glasgow coma scale Revised trauma score• Anatomical scores Abbreviated injury scale Injury severity score System used to : ∞ stratify injury pattern ∞ assess injuries to predict pt. survival ∞ predict functional outcome of injuries• ∞ resource utilization
Glasgow coma scaleEye opening : spontaneously 4 verbal command 3 pain 2 no response 1Best motor response: to verbal command: obeys 6 painful stimulus: localized pain 5 withdrawal / flexion 4 abnormal flexion 3 extension decerebrate 2 none 1Best verbal response: oriented 5 disoriented 4 inappropriate words 3 incomprehensible words 2 nil 1 total 3—15
• Head injuries GCS scoreMinor 13 – 15Majority recover fullyModerate 9 – 12Severe <8degree of eventual recovery depends on initial brain injury
Revised trauma score <RTS>GCS score 13 -15 4 9 -12 3 6 -8 2 4 -5 1 3 0Systolic BP >90 4 76 -89 3 50 -75 2 1 - 49 1 o 0Respiratory rate 10 -29 4 >29 3 6 -9 2 1 -5 1 0 0 total score 0 – 12used for pre-hospital emergency room triage or forcomparative reassessmentduring and after resuscitation without need for accuratediagnosis
• As score diminishes --------- progressively probability of survival decreases• A score >4 for any variable --- survival rate of <90%• A score <4 --------------------a survival rate of just over 45%
ABBREVIATED INJURY SCALEo Developed to rate and compare injuries.o Scores based on t/t period, life threatening injuries, expected permanent impairment & energy dissipation.o Coding is done for anatomical site nature severity 1 minor 2 moderate 3 serious 4 severe 5 critical 6 fatal
Score <10: death rare in pt under age of 50Score 10-15: response to t/tScore 10-20: mortality 4-30% depending on ageScore >50: only rare survival
INJURY SEVERITY SCOREBODY IS DIVIDED INTO 6 PARTS: Head Face Chest Abdomen Extremities (including pelvis) External structuresISS=A2+B2+C2The total ISS score is calculated from the sum of the squares ofthe three worst regional valuesGenerally, multiple trauma patient are defined as patient withiss≥16.ISS<30 good prognosis, unless associated with head injury.ISS>60 usually fatal.The score gives a correlation between ISS and mortality
ISS is the most frequently used injury scoring methodology• Has major limitation i.e.• Can underestimate injury severity of patient with multiple injuries in same body region.• When used as predictor of survival ISS tends to overweigh combined non lethal injuries, like Isolated severe head injury ,AIS=5,ISS=25Liver laceration AIS=4 & femur fracture AIS=3 ,ISS=25 Despite equal ISS, mortality, short and long term complication rate, resource utilization in these 2 injuries are probably very different.
Prognostic factors in head injury• Increasing age • Diffuse B/L CT lesions• Pupil abnormalities • Multiple injuries resulting in hypovolaemia• Massive lesions • Immediate coma/lucid• Increasing ICP interval
Prognostic factors in thoracic trauma: • Mechanical ventilation • High PEEP(flial chest) • Pulmonary contusion –progressive hypoxia due to edematous lung leading to v-p mismatch. • Emergency surgery • Hemodynamic instability
Immediately life threatning conditions• Tension pneumothorax• Sucking chest wound• Flial chest• Cardiac tamponade• Massive hemothoraxEarly interventions by trained personnel (paramedics,fire fighters,police) and well equipped transport system and emergency team are likely to modify the outcomeComplications like ARDS, fat embolism syndrome, DIC, crush syndrome, multi system organ failure have less favourable outcome.
NEPAL TRAUMA INDEX (NTI) For trauma scoring in developing countries (Multifactoral scoring system)factors criteria scoreAge < 12 years of > 55 years 2 12-55 years 1Time gap after sustaining trauma and > 12 hours 3 6-12 hours 2reporting to hospital < 6 hours 1Med. t/t received elsewhere after none 2 some 1traumaPulse pulse less 3 100 – 120 per minute 2 100 per minute 1b.P not recordable 3 < 100 syst. 2 > 100 syst 1respiration cyanosis / gasping 3 tachypnoea 2 none 1Level of consciousness no response to verbal commands 3 reposed but irritable or incoherent 2 normal response 1Areas of suspected injuries - Viscera head face open arterial, associated burns long 3 bone fracture, fracture spine 2 - more than 2 long bone fractures, open or closed or 1 dislocations (no visceral injuries) - one long bone injury or dislocation or closed soft tissue injuryHb. At first sample < 8 grams % 3 8-10 grams % 2 > 10 grams % 1
• Maximum (worst score)- 25• Safest score-10 for extremes of age groups 9 for 12 – 55 years of age groups.
• Rock wood n Green`s fractures in adults, vol. 1• Appley’s system of orthopedics n fracture• Orthopedics principle and their applications Samuel L turek