Polytrauma

Question 1

RTA patient hemodynamically unstable
Management of airway and breathing and circulation as per ATLS
Disability and exposure

Answer 1

According to ATLS, I will start with airway and cervical spine control.
• If the patient is speaking, the airway is patent.
• If not, I will assess for obstruction by looking in the mouth and face for injuries, listening for stridor or hoarseness, and feeling for breath.
• Airway can be secured with maneuvers like jaw thrust (avoiding head tilt due to possible cervical injury), followed by adjuncts such as oropharyngeal or nasopharyngeal airway. If needed, I will proceed to definitive airway with endotracheal intubation, and surgical airway if that fails. The cervical spine will be protected throughout with hard collar sand bag and tape (triple fixation)

For breathing, I will inspect for chest injuries, count respiratory rate and look for use of accessory muscles of breathing , and assess chest wall movement. I will palpate for tracheal deviation or surgical emphysema, and percuss and auscultate for hemothorax or pneumothorax.
• Management includes giving high-flow oxygen via non-rebreather mask, placing an occlusive dressing on open pneumothorax, performing immediate needle decompression for tension pneumothorax followed by chest tube insertion, and chest drain for massive hemothorax.”

For circulation, I will first assess the pulse rate and character, measure the blood pressure, and classify the patient according to the class of hemorrhagic shock. I will also look for signs of external bleeding and assess capillary refill and skin perfusion
• Stop any obvious source of bleeding
• Gain venous access by 2 large bore cannulae
• Take blood for FBC, glucose, U&E
• Cross match for 4 units of blood
• Commence IV fluid resuscitation with 1L of crystalloids
• Consider blood transfusion if no response to fluids

D - Disability

• As soon as the patient’s cardiopulmonary status is managed, perform a rapid, focused neurological examination.

This consists primarily of determining the patient’s
o GCS score o Pupillary light response o Focal neurological deficit.

E - Exposure
• Logroll maneuver is performed to evaluate the patient’s spine and any posterior chest injuries One person is assigned to restrict motion of the head and neck. Other individuals positioned on the same side of the patient’s torso manually prevent segmental rotation, flexion, extension, lateral bending, or sagging of the chest or abdomen while transferring the patient. Another person is responsible for moving the patient’s legs, and a fourth person removes the spine board and examines the back

Question 2

Define and classify shock
Difference between spinal and neurogenic shock
Agents used in neurogenic shock

Answer 2

Types of shock / classify shock?
• Distributive
o Septic shock o Systemic inflammatory response syndrome (SIRS) o Neurogenic shock o Anaphylactic shock o Drug and toxin-induced shock o Endocrine shock

• Cardiogenic
o Cardiomyopathic o Arrhythmic o Mechanical

• Hypovolemic
o Hemorrhagic o Non-hemorrhagic

• Obstructive
o Pulmonary embolism cardiac temponade hemothorax pneumothorax

Spinal shock is the immediate temporary loss of motor, sensory, and reflex activity below the level of injury, while neurogenic shock is the sudden loss of sympathetic outflow, usually with lesions above T6.

Blood pressure: In spinal shock, BP depends on injury severity; in neurogenic shock, there is always hypotension.
Pulse: Spinal shock doesn’t necessarily affect pulse, but neurogenic shock gives bradycardia.
Reflexes: Bulbocavernosus reflex is absent in spinal shock but variable in neurogenic shock.
Motor: Flaccid paralysis in spinal shock; variable weakness in neurogenic shock.
Duration: Spinal shock lasts 48–72 hours or longer; neurogenic shock lasts hours to days.
Mechanism: Spinal shock is due to temporary loss of excitability of neurons below injury, while neurogenic shock is due to loss of sympathetic tone and vasodilation.

Phenylephrine hydrochloride, dopamine, or norepinephrine (Vasopressors

Question 3

Spinal cord syndromes?

Answer 3

1. Anterior Cord Syndrome
   • Cause: Anterior spinal artery infarction, trauma, compression.
   • Findings:
   • BL Loss of motor function below lesion (corticospinal tract)
   • BL Loss of pain & temperature sensation (spinothalamic tract)
   • Preserved vibration & proprioception (dorsal columns)

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2. Posterior Cord Syndrome
   • Cause: Rare; trauma, vitamin B12 deficiency, tabes dorsalis.
   • Findings:
   • Loss of vibration & proprioception (dorsal columns)
   • Motor function preserved
   • Pain & temperature preserved

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3. Central Cord Syndrome
   • Cause: Hyperextension injury in cervical spine (often older patients with spondylosis).
   • Findings:
   • Weakness more pronounced in upper limbs than lower limbs
   • Variable sensory loss (pain/temp more than vibration/proprioception)
   • Bladder dysfunction may occur

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4. Brown-Séquard Syndrome (Hemisection)
   • Cause: Penetrating trauma, tumor.
   • Findings (ipsilateral vs contralateral):
   • Ipsilateral: Motor loss + vibration/proprioception loss
   • Contralateral: Pain & temperature loss (1–2 levels below lesion)

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5. Conus Medullaris Syndrome
   • Cause: Lesion of sacral spinal cord/conus.
   • Findings:
   • Bilateral lower limb weakness
   • Early sphincter dysfunction (urinary/fecal retention)
   • Saddle anesthesia

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6. Cauda Equina Syndrome
   • Cause: Compression of lumbar/sacral nerve roots (disk herniation, tumor).
   • Findings:
   • Lower motor neuron signs: flaccid paralysis, absent reflexes
   • Asymmetric leg weakness
   • Severe radicular pain
   • Bowel/bladder dysfunction (late)

Question 4

What are the types of pelvic fracture?

contraindications to Foley’s catheterization?

How will you manage and who will you involve?

What other types of urinary catheters do you know?

Answer 4

The four patterns of force leading to pelvic fractures include
• AP compression
• Lateral compression
• Vertical shear
• Complex (combination) pattern.

• Pelvic fracture.
• Blood on the meatus (Urethral trauma)
• Perineal hematoma.
• Bleeding tendency.
• Pre-existing infection around the glans or the meatus.
• High riding prostate on DRE.
• Meatal stenosis.

Urologist for suprapubic catheterization.

• Condom catheter.
• Straight catheter.
• Coudé tip catheter.
• Silicon catheter
• 3-way catheter for continuous bladder irrigation.
• Suprapubic catheter.
• Nélaton’s catheter for irrigation of clots.

Question 5

Advantages and disadvantages of whole-body CT Advantages

Cause of narrow pulse pressure?

Answer 5

• Polytrauma patients o Early diagnosis o Improves survival rates

• Rule out or determine extent of/location of disease, trauma or other medical condition Disadvantages

• High radiation exposure

• Not cost effective

Pulse pressure = Systolic - Diastolic In hypovolemia, decrease in circulating blood volume will increase SVR to maintain BP (COP×SVR). Increase in vasomotor tone will raise diastolic pressure.

So Systolic is decreased due to volume loss and diastolic is increased due to high SVR Net result… narrow pulse pressure

Question 6

Management of pelvic fractures

Answer 6

• Suspected bleeding»_space; pelvic binder initially
• IV Tranexamic Acid
• bleeding not responding to resuscitation»_space; surgical packing of the pelvis or interventional radiology with selective embolization
• Early definitive surgery can not be performed»_space; External fixation or traction
• bladder or urethra injury»_space; refer to urologist
• open fracture with abdominal wound or anus or rectum»_space; consultant general or colorectal surgeon + wound debridement.
• after stabilization go for reconstruction of the pelvic ring.