Hallo and a warm welcome to this part of the course. Today, we will be learning about the management of polytraumatised patients. If a patient is suffering from one or more life-threatening injuries at the same time, then this is referred to as polytrauma. And that is precisely what makes this such a special case. The fact that the injuries are life-threatening means that the patient’s survival depends on our doing the right things in the right order. And that is precisely what you are going to be learning to do today. Biberthaler. Kanz. We are admitting a 25-year old male patient into the trauma room wearing a pelvic restraint
who suffered a fall on a building site. Is he intubated and ventilated? Not yet according to the IVENA system. Okay. Can you let the Team know and then we’ll meet in the trauma room in five minutes? The team is already prepared. See you soon. Let’s go. 22 00:01:13,897 --> 00:01:19,732 24 00:01:25,578 --> 00:01:32,578 26 00:01:39,578 --> 00:01:47,450
All patients suffering from life-threatening injuries or illnesses undergo treatment in the trauma room. A trauma room alarm is always triggered if the patient’s survival is directly endangered, such as with gas exchange impairment or dangerously low blood pressure. What is important in determining the direct survival of our patients is not the cause which triggers their injury or illness, but the impaired function resulting from this. Let’s consider the displacement of the airway as a simple example. As far as the patient is concerned, it does not matter in the least whether this airway is closed because of a traumatic brain injury or a haemorrhage. At all costs, it has to be cleared to begin with. The basic principle of trauma room treatment emerges clearly from this. All patients are treated according to the same formula. This formula is focused on the priorities of ensuring survival. This means that that problem is dealt with first which would be the first problem leading to the death of the patient. Those problems are then dealt with which would be the secondary ones leading to death etc. This is referred to a priority-focused treatment programme or an algorithm. Such an algorithm requires good preparation, summed up here as “be prepared”, and follow-up procedure. In this follow-up procedure, the treatment steps which have been undertaken and which are recorded in the trauma room record are reviewed and subjected to scientific evaluation. Preparations include protective clothing, ports, infusions, as well as, for example, 0-negative blood samples or diagnostic devices. A minimal number of staff must also be available to treat the patient in the trauma room. This includes a specialist trauma surgeon, an anesthesiologist, a radiologist, as well as at least 2 nurses from the surgery department, one from anesthesiology and radiology. Who’ll take the minutes? I'll take the minutes. Very good. Polytrauma is applied to any patient whose injuries alone or in combination can be life-threatening. Polytrauma is often often also described as “multiple” or “major trauma”. This diagram shows the frequencies of injuries linked to polytrauma. What can be clearly seen is that traumatic brain injury and injuries to the limbs frequently occur. Approx. 32,000 patients per year suffer accidents of such a severe nature that they suffer polytrauma as a result. The average age among them is about 42. 70% of the injuries are incurred in traffic accidents, of which most occur during the late afternoon or at the weekend. On average, between six and seven individual injuries occur. Trauma is the leading cause of death among people under the age of 45. Trauma destroys more years of life than malignant illnesses and cardiovascular disorders together and the key “natural” enemies of modern mankind are road traffic, crime and leisure activities. The mortality of polytrauma mortality reveals three peaks. The first third dies within the first hour from non-survivable injuries, e.g. decapitation or complete avulsion of the aorta. The second third dies within the first 24 hours. The leading cause of death in this category is haemorrhagic shock. The final third dies after 72 hours or later in an intensive ward from multi-organ failure which is not actually affected by the primary trauma. Okay. The patient is a male 25 year old construction worker who fell from 10 m high scaffolding. The GCS was initially registered as being at 10, blood pressure was 80/40 and saturation was at 93, while the pulse was at 120. We administered 2 l Ringer’s solution as well as hydroxyrethyl starch. His condition became stabilised in response to these. He is probably suffering from a C or D problem. The pelvis was unstable to begin with. This is why he is wearing a pelvic binder. Legs could not be moved, but the arms could be freely moved. Good, so to repeat: 25 year old male patient, fall from a height of 10 m, 80/40, pulse of 120, primary pelvic injury and neurology in the legs. No indication of any external haemorrhaging and also no malalignment of the limbs. Skin cold and no perspiration. Breathing sounds on both sides can be heard upon auscultation, saturation of 93. The problem is not primarily a respiratory one. Then let’s move on directly to the CT, please. 1, 2, 3. 108 00:07:08,270 --> 00:07:09,930
Let's recap. What has just happened? The emergency doctor has transferred the patient to the trauma room team the latter have gained an overview of the injuries by means of the “five second round”. This “five second round” is meant to provide a quite approximate prioritisation of the patient’s problems. These include consciousness, airways, breathing mechanics, external bleeding signs, deformities of the head, neck and torso and the skin colour and body temperature. Let’s move on now to the Primary Survey. To begin with, we look for an airway or breathing problem. What comes next? "Treat first what kills first". This means that those problems which will cause the patient to die first are treated first and then the problems which will then cause death next etc. etc. This concept is applied in the same way in all trauma rooms throughout the world as ATLS. All patients are treated according to a standardised, structured protocol focused on the priorities for survival. In order to ensure that this scheme can always be worked through by the doctors, even in the most stressful circumstances, the letters of the alphabet have been drawn upon. The sequence of letters in the alphabet is deeply rooted in our long-term memory and can be recalled quietly and reliably even at three in the morning despite haemorrhages gushing and relatives screaming all over the place. The A stands for Airway or air passage, B for Breathing or the respiratory mechanism, C for Circulation or all problems regarding the circulation, etc. D for Disability or neurologic problems. And E for environment or Exposure for all questions concerning environment. This involves for example body temperature. The trauma room protocol records the individual findings and forms of treatment administered to the patient for the purpose of later scientific evaluation. A section of the protocol is shown here by way of example. The items of information prompted can be clearly recognised. The timeline, shown here at upper left, is really crucial. We have learnt that bleeding represents a significant cause of death and that time plays a really important and critical role in this. The longer patients lose blood without receiving treatment, the more they die. As re-evaluation in the ATLS Scheme represents a really important measure with every deterioration, we repeat the information regarding our patient once again. He is 25 years old and fell from a 10 m high scaffolding. The GCS score was initially at 10 points. Blood pressure is currently at 80/60 mmHG and the pulse at 120 beats per minute. Saturation is at 93%. The administration of hydroxyrethyl starch and Ringer’s solution has been undertaken to date by way of treatment. We will now show you the Primary Survey, that is to say the initial examination according to the ABC rules. Hallo? Hallo! Breathing sounds are present on both sides, slightly weakened on the left. Saturation currently amounts to 93%. No indication of any thoracic instabilities and thoracic contusions are revealed in the lateral region. We have a potential B problem. Let’s move on to Circulation. First of all, the airway is examined. If this has been displaced, then this must be afforded appropriate treatment immediately. The breathing mechanism is then examined. Should breathing sounds be lacking, ethen treatment is to be administered immediately. Please order 10 RCC and 10 FFP. OK. I have to spray once again. 172 00:11:29,735 --> 00:11:37,285 Blood pressure is currently 80/40, heart rate has a rising tendency at 120, and sinus rhythm is without any extrasystoles. The cardiological ultrasound shows good filling of the heart and no cardiac tamponade at the moment. The abdomen reveals strong overlying bowel gas. Free fluid cannot be definitely ruled out. C stands for Circulation so that means blood pressure and pulse are examined under this. We always introduce 2 large volume needles and indicate an according substitution of fluids. "Shock" stands for reduced perfusion of vital organs. The various causes of shock are shown here. These include hypovolemic shock, cardiogenic shock or obstructive or distributive shock. The symptoms of shock are caused by an inadequate supply of oxygen. Thus results in the according pathophysiologic reactions of the organism. For example, in case of cerebral hypoxia agitation or lethargy are developing. The pupils are widened, the skin is pale, the pulse is weak and the blood pressure is falling. Moreoever, an azidosis and a tachypnea are present. This diagram shows the possible loss of blood derived from various injuries. For example in case of pelvic injuries up to 5 liters of blood can be lost in the periphery. he severity of shock can be categorised in various classes of shock. Here you can see the classification according to ATLS of grades 1 to 4. The treatment of shock consists in stopping bleeding by means of pressure dressing and replacing lost fluids. In addition, Catecholamines can be administered and by means of physical measures the bleeding can be reduced. These include either positioning or physical compression measures, as for example a pelvic binder. I would now like to demonstrate to you an ultrasound examination of the abdomen in a trauma situation. We call this examination FAST, which stands for Focussed Assessment Sonographic Trauma, and due to its high level of sensitivity for free fluids, such as haemorrhages, it has almost completely replaced peritoneal lavage. The first step is on the right side in the posterior axillary line between the 11th and 12th rib and we visualise what is referred to as Morison’s pouch by means of the ultrasound. What we want to depict in this way is the space between the liver, which you can see here, and the kidney. This pocket is called Morison’s pouch. If the patient now had free fluid, such as blood, in the abdomen, then we would see a dark margin here. The second standardised step takes place on the left side. Here as well, the ultrasound also comes in the posterior axillary line between the 10th and 11th rib. The aim here is to visualise the spleen. You can see the kidney again here, and here, above the kidney, the spleen can be visualised. The spleen is a capsular organ which is relatively susceptible to suffering trauma nd if the capsule tears, then a lot of blood flows into the abdomen and the patient is placed in acute danger. This is why, with this setting, we can decide very quickly whether the spleen has been destroyed or not. This means that if we had any haemorrhages in this area, we would immediately see a fluid margin here. The third setting is suprapubic and depicts what is referred to as the pouch of Douglas. Here is the bladder, here is the prostate and here is the rectum. SThe abdomen can be pictured as a bathtub, with the blood flowing to the lowest point in the lesser pelvis. We call this point the pouch of Douglas and this can be depicted here using the transducer head. A dark margin would then be shown here far below, indicating to us that blood is to be found there. The fourth section moves in the direction of the pericardium, below the xiphoid, here, at 45° upwards, and you can see here the movements of the heart and of the pericardial sac. If fluid is now found between the pericardial sac and the heart, then we would see this here as a black stripe and would know that a pericardial effusion is occurring. This in turn would then indicate to us the need for immediate intervention. This FAST examination has proven to be extraordinarily sensitive and effective. Using this method, we can conclude with a very high degree of certainty whether a haemorrhage is to be found in the abdomen or not. It is not so specific, meaning we do not know precisely where the haemorrhage is located, but we can ascertain that using the computerised tomogram. The abdomen reveals strong overlying bowel gas. Free fluid cannot be definitely ruled out. Blood pressure is falling and is now at 60/30, the frequency is tending to rise ever higher. I would now initiate catecholamines and volume. We have a C problem. The patient may be suffering from an abdominal haemorrhage. We have the fractured pelvis. We have no external haemorrhage. Let’s move on to Disability. Hallo? Hallo! Pupils react equally on both sides, but somewhat sluggishly. Glasgow Coma Scale currently at 10. D is for Disability. Neurological status is examined to this end and the Glasgow Coma Scale established. Here are 3 basic, neurological qualities examined. The eye opening, the verbal reaction and the motor function. This table shows in detail the scoring of Glasgow Coma Scale. For the reaction of the eyes there are a total of 4 points. For spontaneous eye opening 4, on request 3, on pain stimulus 2, and if there is no reaction, there is only 1 point. The verbal reaction is rated with a total of 5 points. An oriented patient gets 5 points, a disoriented 4 points, incoherent words get 3 points, incomprehensible sounds 2 and no reaction 1 point. The motor reaction leads to a total of 6 points. With correct compliance with prompts the patient receives 6 points. With targeted defense against pain stimulus 5 points, with untargeted defense 4 points. In case of flexor synergies on pain stimulus the patient receives 3 points, with extension synergies 2 and with no reaction, the patient gets 1 point. It becomes clear that the lowest score is 3, and the highest is 15. E is for Environment or Exposure. This means the patient is completely undressed once, turned over and the surrounding conditions, such as body temperature, are taken into account. Temperature 36.3. Markedly visible abrasions are to be recognised on the surface of the body. We do not have any E problems, but we still have a D problem. The patient is not sufficiently advanced according to the Glasgow Coma Scale. We now have to carry out protective intubation. 293 00:19:37,976 --> 00:19:46,700
In summary, the vital parameters are recorded in the Primary Survey. Pulse oxymeter and blood gases can be established via adjuncts and an indwelling catheter can be inserted if required. The diagnostic investigation of the Primary Survey provides for the physical examination of A to E as well as FAST and FACTT examinations. I am now going to talk about mask ventilation and intubation. I have brought a few things with me in this regard. First of all, we of course need a mask for mask ventilation and, in addition, an Ambu bag. The latter can be fitted to the mask and air can then be pumped in. We need a laryngoscopy for the actual intubation. When this is unfolded, a light source is available at the front and the spatula here. In addition, of course, we still need a tube. This is an endotracheal tube, which in this case is equipped with a guidance rod. We also need a blocker syringe for the tube. This is a quite normal 10 ml syringe. This can be fitted and air then air pumped in, so that the cuff here at the front fills with air. This bolster of air is intended to enable us to have a secured airway, i.e. so that no fluids can run into the air pipes meaning that no aspiration occurs and also that no air can flow from the bottom upwards, enabling us to ventilate the patient with adequate air and volume. In order to unblock, the syringe is fitted again and the air is extracted. OK. I’ll now show you how everything fits together with the use of a model. To be precise, this is a model representing if the patient is lying in front of you here; that is the lower jaw, the tongue; if the tongue is pushed to one side a little, then the epiglottis is revealed and the air pipes with the glotis behind the epiglottis. Right at the back, the oesophagus is also suggested, which we naturally do not want to enter with the tube. This is how things now look: In order to insert the tube, the laryngoscope is gripped in the left hand, inserted via the right corner of the mouth, the tongue is moved to the left side, that is to say, the laryngoscope is inserted here, it passes between the tongue and epiglottis and the epiglottis is so to say shown by pulling on the lower jaw in the direction of the patient’s feet. This then means that the air tubes can be seen behind into which it is intended to insert the tube. The tube is actually to be inserted into the air tubes here at the back behind the epiglottis. behind the epiglottis. It is, course, now here positioned inside the glottis. If any problems are encountered during mask ventilation, then various aids are available. I am going to present one of these today. It is an oropharyngeal airway. This oropharyngeal airway is to be positioned within the patient in such a way and it serves to keep the airways free, i.e. the tongue is kept out of the way at the front. I will now show how to carry out mask ventilation on the model. To do this, you take the mask, place it on the nose and mouth of the patient, and make what is termed a C grip, that is, with the thumb above on the mask, Zthe index finger below, little finger in the jaw angle and both the other fingers placed on the lower jaw. The Ambu bag can then be used to ventilate the model. You can now see nicely how both the lungs rise. Ws has been mentioned, if any problems are encountered in this regard or the airway needs to be kept free, he oropharyngeal airway can be used. It is inserted as follows, rotated and the ventilation mask can then simply be placed on top and mask ventilation also be undertaken with it. Good. I now would like to demonstrate how intubation is carried out. The laryngoscope is used for this. It has to be opened to turn the light source on. Take hold of it in your left hand and hold the head facing backwards with the right hand. You can also feel in the mouth and keep the mouth open. I will now demonstrate this with the head. You can control the head a little whilst doing this. Care must, of course, be exercised in the case of overflexion. This must not be undertaken with patients suffering from any cervical spine injuries. Overflexion means the larynx and the air tubes are not included in the visual axis for intubating any more. If nothing can still be seen yet, then the head can be elevated a little - enhanced Jackson Position - meaning everything is positioned more in an axial situation. The laryngoscope is then inserted into the right corner of the mouth and the tongue is pushed away to the left. The epiglottis is seen, insertion is made between the tongue and epiglottis, the lower jaw is pulled down in the direction of the patient’s feet, the tube is grasped in the right hand, the air tubes are in sight and the tube is simply inserted there. The laryngoscope is then carefully retracted. Do not come into contact with the teeth. In an emergency, the tube is always blocked first in order to ensure that protection of aspiration is present. Air therefore enters in this way. UThe guidance rod can then be retracted and ventilation undertaken with the Ambu bag. If the patient has been intubated, a check on position must of course also be carried out, that means auscultation of the patient is conducted. The first step is auscultation of the stomach so as to exclude any wrong intubation and then to conduct auscultation of the thorax on both sides, to be precise once at the top and also on the side on the thorax. If equal breathing sounds are heard on both sides, then that means we are satisfied with the position of the tube. It can also happen that the tube slips too deep. In such cases, it normally slips into the right bronchus, meaning we would have a stronger breathing sound above the right lung than over the left one. That was a brief summary regarding mask ventilation and intubation. What do we need to do next? Whenever a new aspect occurs, the patient deteriorates or anything else unforeseen happens, re-evaluate the patient. 387 00:25:56,228 --> 00:26:05,090
If a GCS score of 8 points or below is registered, the patient should be intubated. FACTT means focused assessment with computed tomography in trauma. Computerised tomography has proven to be a quick and effective method of being able to capture the injury pattern of the patient in as optimal a way as possible. The computerised tomogram images for our patient now follow. Here is the thoracic CT. Clearly visible is the pneumothorax on the right side. Air enclosures are visible as black areas. As a secondary finding, the tube is correctly positioned in the trachea. This sequence shows the fracture of the ribs. The rip fracture can be observed in the ventral part of the thorax on the right side. The pulmonary contusion on the left side can be recognised in these images. The lung contusion is visible as a bright area in the basal parts of the left lung. This CT reconstruction shows the severely fractured pelvis. Clearly recognizable is the pronounced dislocation of the fragments. This lower leg fracture can be seen in the layers of the limbs. The spinal image shows this vertebral body comminuted fracture. No evidence of any intracranial haemorrhaging, no indication of raised pressure on the brain. No fracture can be seen in the region of the cranial vault. The tube is correctly positioned. Fractures of a series of ribs can be seen on the left side and pneumothorax on the left. No indication of any tension pneumothorax. Some free fluid in the lesser pelvis. We can see a severe Type C fractured pelvis and then we can also see an L3 burst fracture. We now insert the thoracic drainage. And after that, we will proceed to conduct the operation. Good. Has the blood been ordered? The blood has been ordered. 420 00:28:01,623 --> 00:28:07,224
This illustration shows both positions for the insertion of a thoracic drainage. The Monaldi drainage is placed in the second ICR in the medioclavicular line. The Bülau drainage in the 4th or 5th ICR in the anterior axillary line. For an emergency situation the Bülau position is very well suited. The Secondary Survey only commences once the Primary Survey has been completed and no acute threats to the life of the patient are posed. Beginning with a more precise history, the patient is once again examined from head to toe so as to ensure that no injury is overlooked. So as not to overlook anything in this regard either, use of the AMPLE Scheme is to be recommended: A for allergies, M for Medications. P stands for Past Illness or Pregnancy. The L stands for last meal and the E for special Events/Environment surrounding. In the Secondary Survey examination, the patient is examined once again from top to toe so as not to oversee any injuries. Secondary Survey for a 25-year old male patient, who fell 10 m off scaffolding. Palpation of the cranial vault reveals this to be intact. Pupilloscope. Pupils narrow on both sides. Status of teeth intact with tube inserted. The examination of head and neck provides for the following
points being investigated: The inspection of eye, nose, ears and mouth, the pupillary reaction, the mouth closure, potential bone crepitations, airway obstruction, hematoma or stridor. Clavicle does not reveal tenderness to pressure. No crepitation. Crepitation on the right side in the region of the fracture of the series of ribs and of the haematoma. Thorax not unstable. Costal arch intact. These points are recorded at the thorax: Haematoma, abrasions etc. Care is taken to see if emphysema or an unstable thorax is present. The patient is again auscultated and X-ray diagnostics taken into account. Abdomen soft, no indurations and resistances are palpable. Right renal area normal, left renal area normal. These points are recorded at the abdomen. The abdomen is auscultated again and appropriate radiological examinations considered. Pelvic belt adjoining pelvic C fracture. Is not touched any further. The examination of the pelvis contains instability, haemorrhages and haematomae. If a test has already been conducted for instability by the doctor providing the initial treatment, and this has been confirmed, then a pelvis stabilisation system, such as a pelvic restraint as in this case, will then have been subsequently fitted and this is to be left in place for the time being, as there is the danger of the pelvis suffering from a further loss of blood due to every fresh mobilisation. No injury to the penis, no injury in the testicular region, no blood in the rectal area. These examinations are conducted in the anal and genital region. There attention has to be paid on hematomas or bleeding as well as on the sphincter tone. The right thigh has a graze covering an extensive area on the outside, but the thigh is, however, soft and without any crepitation. No signs of injury on the left thigh, supple, no crepitation. Here once again is the investigation of the limbs: Right shoulder has abrasions covering a large surface area, but can be freely moved, no dislocation. Elbows can be freely moved. No injuries to the hands are visible. Shoulders can likewise be moved freely; elbows free, no external signs of injury, fingers can be freely moved. Limbs - right knee joint: graze covering a wide surface, lower leg suffering from crepitation, suspected lower leg fracture. Please insert the brace. I’ll tension it. Brace underneath. Okay. Opposite side: Graze on the inner side of the knee joint, but the latter can be freely moved, lower leg without inflammation, no crepitation, no injury to the toes. Examination of the extremities focuses on hematomas, Deformities, on the perfusion, Sensitivity and flexibility. Let’s carry out a log roll, please. Secure grip, with the head responding, please. 3, 2, 1. No conspicuous injuries on the back and the shoulder blades and spine intact as far as can be assessed, reverse sides of the thigh intact. Log roll back. The spinal examination is conducted under log-roll conditions. In case of potential fractures that could cause damage to the spinal cord. Therefore, this rotation is completed via Log Roll, with four helpers stabilizing the patient’s spine and turn on its side. These points are examined by the detailed recording of the outcomes of the neurological investigations: GCS, the pupil size, potential lateralisation sign, muscle tone, reflexes or pyramidal tract signs. In addition, bleeding from nose, mouth or ears are considered. The Secondary Survey has just been concluded. The patient has a graze on his chin, a graze on his right upper arm, a series of ribs on the right side, not requiring intervention, a pelvic fracture due to pelvic C injuries, multiple grazes on the right and left thigh and lower leg, an unstable lower leg fracture on the right, to which a brace has been applied in the meantime as well as an L1 fracture which is shown in the CT as being stable. The patient has been administered 1.5 g of Cefuroxim. A tetanus boost has been administered. Tetanus protection must be checked whenever an open wound is encountered and, if necessary, a booster administered and recorded. Polytraumatized patients receive a tetanus boost. The important thing is that the danger of Tetanus infection not necessarily depends on the size of the open wounds. Antibiotics prophylaxis is undertaken with Cefuroxim 1.5 g i.v. for all open injuries. I would now ask you to insert an indwelling catheter and the patient can go to the OR. Damage Control. Damage Control describes the surgical concept of polytrauma treatment. In the course of this, the life-threatening haemorrhages are terminated nd injuries to the limbs treated by means of an external fixator. We are having a Team Time Out. The case involves a 25 year old male patient with a pelvic C injury and a fractured lower leg. We will conduct an operation on him in order to attach a fixateur externe to the pelvis in order to stabilise the bleeding and a fixateur externe onto the lower leg. Accompanying me in conducting the operation will be Dr. Huber-Wagner, and Dr. von Matthey. My name is Biberthaler and Larissa will be acting as our instruments nurse. The duration of the operation will be between 2 and 2½ hours. The greatest risk stems from haemorrhaging. 539 00:35:51,611 --> 00:35:58,409 541 00:36:05,218 --> 00:36:12,735 543 00:36:20,252 --> 00:36:28,090 Patients are classified according to scoring systems in order to assess the degree of severity of the polytrauma and for scientific evaluation purposes. The most wide-spread one in use is the Abbreviated Injury Scale. The three highest AIS points are squared and then added together. From this is derived the Injury Severity Score which is very wide-spread in the international literature. Here, we have a 25 year old male patient He was referred to us via the trauma room three weeks ago as a polytrauma case with unstable fractured pelvis, pneumothorax and lower leg fracture. Following initial fixation of the pelvis by means of pelvic clamps, of the lower leg by means of fixateur externe, he was then transferred to the intensive care ward. He has been back with us on the normal treatment ward since the day before yesterday. Today is the eighth postoperative day following treatment of the lower leg and the twelfth postoperative day following treatment of the pelvis. Great, many thanks. My warm congratulations. This patient survived. We have learnt today how a standardised, structured algorithm can be used to solve complex, life-threatening problems in small, solvable units in such a way that the patient survives. I now wish you every success in your future professional activities. 568 00:38:12,355 --> 00:38:20,352 570 00:38:28,362 --> 00:38:37,664