Managing Polytrauma

Managing Polytrauma can be a complex form of emergency care in the hospital, but with the right approach and team work, it can be done timely and efficiently to save an accident victim’s life. We shall hereby consider our patient, John.

After a fatal car accident, John a 30-year-old man was rushed to the Emergency unit. He is conscious but finds it hard to speak. According to  passers-by, the man was brought out of a car after a severe car collision on the motorway. He was conscious for 5 minutes but then later fell unconscious and unresponsive to command. The emergency service was called to the scene and was then rushed to the hospital.

At the Emergency department, He regains consciousness and   complains of chest pain, difficulty breathing, nausea, headache, dizziness and can’t remember events leading up to the accident.  

Vital signs: HR100, BP86/66mmHg, RR-28, SPO2-90%.   

On physical examination there is silent breathing with weak vesicular sound on lung auscultation. You observe muffled heart sound, a distended jugular vein and a high pulse rate.  Scalp examination reveals laceration with a GCS scale-15. Other examinations are normal.

John was immediately given oxygen through an oxygen mask with instrumental and laboratory investigations ordered for proper evaluation. Diagnosis was confirmed and his condition managed accordingly in the surgical room before being referred to the intensive care unit for further monitoring and treatment.

First choice investigation? 1. ECG 2. FAST with transthoracic echocardiography (Focused assessment with sonography in Trauma), Head CT scan, Chest CT-scan, FBC.

In appropriately managing polytrauma we do: Intravenous fluid infusion, vasopressors (if required?) Surgical drainage of hemopericardium, conservative management of mild traumatic brain injury and pulmonary contusion. 

Surgical drainage of hemopericardium: a) Traditional surgical approach (subxiphoid pericardial window)  b) Video-assisted thoracoscopic pericardial window approach c) Balloon pericardiotomy

Conservative management of mild traumatic brain injury and pulmonary contusion: Osmotic diuretics (e.g. Mannitol) and opioid analgesics (e.g. Morphine hydrochloride).

Investigations with possible findings:

1. ECG:  electrical alternans
2. FAST: Hemopericardium with collapse of the right ventricle.
3. Head CT scan: Convex or lenticular shape lesion that does not cross suture line.
4. Chest CT-scan: Little to no changes on the parenchymal chest wall.

After a continuous close observation of John at the ICU for 7 days, his general and hemodynamic conditions stabilized. Control investigations before discharge were carried out with all reporting normal.

                 Possible complications? Cardiac arrest and organ hypoperfusion

                 Prognosis? Better outcome with lower mortality with timely and appropriate intervention

For Further reading?

1. Anatomy and physiology of the pericardium
2. The role of vasopressors in hypotensive accident patients as a last resort
3. What is electrical alternans?
4. Types of intravenous/crystalloid fluids?

References:

1. Clinical cases from the Emergency and Critical Care Department of Imermedi Hospital, Terjola, Georgia.
2. Evidence-based Information from the BMJ Best Practice.
3. Treatment and Management options from Medscape