Strategies To Enhance Patient Care

Through Shared Management.

MANAGEMENT OF
POLYTRAUMATISED PATIENT
A Team Approach

Dr Ahmad Bin Hj Hashim

Emergency Physician
Hospital Queen Elizaberth.

OBJECTIVES
Concept of A Team Approach Patient care
a) Intradepartment
b) multidisciplinary
A collaborative and coordinated effort to achieve
similar target and outcome.ATLS? QTLS?

INTRODUCTION
Polytrauma
Clinical Syndrome Whereby Patient Sustains
Serious Injuries Involving Two Or More
Major Organs And Physiological Systems.
Features:

Physiological Instability
Exsanguinations
Major Torso Trauma
Major Tissue Destruction

e.g. Motor vehicle accident with SDH

and spleen rupture

POLYTRAUMA

METABOLIC RESPONSE TO INJURY

*
*

*
*
*
*
*

Catabolic counter regulatory hormones

Amplication of Catecholamine effect:
* Venous shunting with preservation of vital
organs e.g. heart, brain.
* Ischaemia secondary to vasoconstriction
* Renal shutdown
Insulin Resistance
Inflammatory Response
Lowered immune resistance
Elevation of free fatty acids
Altered protein metabolism

POLYTRAUMA

Metabolic Response To Injury

Cascade Of Death :

Hypotherm
ia

Deat
h
Coagulopathy

Metabol
ic
Acidosis

TRAUMA DEATH
Death from Trauma follows a
Trimodal Distribution.
- ( Trunkey DD : Sci Am 249:28-35 1983 )

Concept And Overview Of Trauma

Death - Trimodal Distribution

CONCEPT AND OVERVIEW

Death from Trauma has a Trimodal Distribution.
The First Peak of Death is within seconds to
minutes of injury.
Causes:
1. Laceration of the Brain
2. Brain Stem
3. High Spinal Cord Injury
4. Heart, Aorta and Large Vessels Lacerations
5. Etc.
* Usually Non-Salvageable.

The Second Peak of Death occurs within minutes to a

few hours after injury referred to as the
GOLDEN HOUR .
WITH RAPID ASSESSMENT AND RESUSCITATION
CARRIED OUT DURING THE SECOND PEAK ,
TRAUMA DEATH CAN BE REDUCED

Causes:
A. Subdural Extradural Haematoma
B. Haemopneumothorax
C. Ruptured spleen
D. Lacerations of the liver
E. Pelvic Fractures
F. Multiple Injuries Associated with Significant
Blood Loss.
G. Preventable salvageable condition

The Third Peak of Death occurs several

days or weeks after initial injury
Causes:
1.
2.
3.
4.
5.

Sepsis
Organ Failure
DIVC
ARDS
Fat Embolism

Main cause of delayed Trauma Death is

multiple organ system failure.

Associated complications:
1. Result of direct insult to specific organ
system.
2. In relation to interventional procedures.
3. In relation to poor initial resuscitation and
stabilization delay in initial investigation

TRAUMA DEATH
More than 35 % of total SURGICAL ADMISSIONS
are TRAUMA PATIENTS.
More than 55 % of Death in SURGICAL
DISCIPLINE is due to TRAUMA.
82 % of Trauma Death is due to HEAD INJURY.
10 % of Trauma Death is due to POLYTRAUMA.

A Seven Month Study was conducted at the Emergency

Department, HKL
(June96 - Jan97)

50% of total fatalities occurred

within 4 hours of admission
- 2nd Peak ( Preventable Death )
90% of these patients died within 1 hour
- 1st Peak ( Non Salvageable )
* Timing did not take into account of the
delay in Pre-Hospital Care Service & Pt
Transportation

Ye
ar

20
0

Death in EDHKL:
BID :
DID :
BID-Brought In Dead
DID-Dead In Department

298
242
56

Death in Dept
Total
Trauma
Medical

: 56
: 42
: 14

Trauma Death
Trauma
Head injury
Chest injury
Pelvic injury
Intraabdominal
Head injury +Others

: 42
: 13
: 7
: 4
: 3
: 15 ( POLYTRAUMA )

Number of Preventable Death in Relation to

Total No. of Death
TYPE OF
INJURIES

TOTAL NO. OF
NO. OF
DEATH
PRVENTABLE
DEATH

CHEST INJURY

PELVIC
INJURY

INTRA
ABDOMINAL
INJURY

FEATURES OF POLYTRAUMA PATIENT

REQUIRING EARLY INTERVENTION

Rapid Exsanguinating
Hemorrhage
Irreversible Syndrome
Overcompensated
Systemic Response
Iatrogenic

Contributing Factors For the Incidence of

Preventable Death :
1.
2.
3.
4.

Severity of Injury
Poor Resuscitation & Stabilization
Delay in diagnosis
Delayed Response from the relevant
Referred Dept
5. Delay in decision for Intervention and
Definitive Management
6. No Teamwork
7. Lack of Resources

HUMAN RELATED FACTOR RELATED TO

PREVENTABLE DEATH
1 Attitude of medical officer
2. Busy-too many patients. Lack of prioritization
3. Delay in investigation findings
eg CT scan, US, and blood results
4. Delay in informing specialist for decision making
5. Delay in implementation of definitive care Mx
e.g. - surgical intervention of patient
- Limited ICU beds

COMPONENTS OF COMPREHENSIVE
TRAUMA CARE
1.
2.
3.
4.
5.
6.
7.

Triage
Primary Survey
Resuscitation And Stabilization
Secondary Survey
Reevaluation
Definitive Care
Rehabilitation

TRIAGE
A Dynamic Process Of Sorting Out
Patients According To Their
Priority Of Treatment

All Polytrauma Patients Are Triaged According To The

Protocol & Guidelines For Admission To The Red
Zone(critical Zone)

POLYTRAUMA
THE FIRST PERSON TO SEE
THE PATIENT CAN AFFECT THE
FINAL OUTCOME.!!

1 survey and resuscitation of vital

functions are done
simultaneously .. A Team
Approach
.**** F1

PRIMARY SURVEY:
Definition:
The preliminary assessment of a patient which is
conducted in a systematic manner with the objective
of identifying life threatening conditions and
managing them as soon as they are found.

Adjuncts to Primary Survey

ECG
Trauma Xray

Lateral cervical
CXR
Pelvis

Vital signs

ADJUNCTS

ABGs
Pulse
oximeter
and CO2

Urinary/gastric catheters
unless contraindicated
ATLS

TRAUMA TEAM
Definition:
* A group of skillful and experience
personnel's work together at the same
time managing a polytrauma patient by
rapid, efficient and effective team
(multidiscipline).
* The team include all level personnel
from specialist to attendants.

TRAUMA TEAM CONCEPT

HOLISTIC AND QUALITY
CARE

TRAUMA TEAM
Many studies in developing countries
have shown that > 30% of total hospital
death is due to trauma.
A well integrated trauma system based
upon TEAMWORK and PARTNERING can
reduce the mortality rate to less than
10%.

TRAUMA TEAM
* Match patient need with resource
utilisation
* Ensure early senior clinician
involvement in decision making
* Provide a coordinated approach to
early trauma care
* Minimize delay in the Emergency
department

FEATURES OF TRAUMA TEAM

1. Horizontal Task Distribution
2. Ergonomics arrangements
3. Clinically & Therapeutically determined
arrangement of staff based upon intervention
required
4. Task is distributed into small manageable
package unit between the Trauma Team
Members
5. Not Team Leader dependant
6. Joint decision making process

FEATURES OF HORIZONTAL TEAM

ORGANISATION
All members carry out individual tasks
simultaneously.
Not focused on any particular team
member or team leader.
Enhance Team Performance and
Improved Outcome.
Most efficient organization

Features of an efficient teamwork

1. Specifically allocated to individual
members.
2. Task evenly divided among Team
Members.
3. Task carried out SIMULTANEOUSLY.

POLYTRAUMA CARE TEAM

Resuscitation Trauma Team

The group that resuscitated and stabilized

the patient
Emergency department team with other
relevance dept.

Definitive care team

Investigational, interventional and intensive

care team.

POLYTRAUMA CARE TEAM

The resuscitation team will manage the
patient rapid and systematicallystabilization and of need be interventional
The definitive care team MUST response
with immediate decision making specialist involvement
Investigation must be automatic and result
immediately obtainable.

POLYTRAUMA CARE TEAM

Intensive care anesthesiology service
must be available immediately .
All interventional and surgical procedures
must be done without delay.
All facilities required eg xray, US, CT must
be made available immediately to
enhance care.

POLYTRAUMA CARE TEAM

Critical Success Factor
Specialist and consultant must be involved early.
Decision must made immediately.
Management plan must be determined
immediately together.
Hospital authority must enforce this policy
strictly.
All mortality polytrauma in a join mortality or
census meeting

POLYTRAUMA CARE TEAM

* The strength of the team is as strong its
weakest link*
Patient focus commitment must be
observed.

STRUCTURAL LAYOUT OF
RESUSCITATION ZONE
A Dedicated Facility and 2nd Nature Reflex
environment to enhance performance of the
Trauma Team.
Golf Swing Ergonomics.
Standardization & Modularized
Resuscitation Bay

RESUSCITATION BAY FLOOR PLAN

MONITORING
SYSTEM

AIRWAY EQUIPMENT
DRUGS

DOCTOR 1
NURSE 1

DOCTOR 2
NURSE 2

DOCTOR 3
NURSE 3

PROCEDURE
TROLLEYS

TEAM LEADER

GOLF SWING ERGONOMIC & COCKPIT ARRANGEMENT

SECOND NATURE REPONSE

RESUSCITATION BAY

Ceilling
Mounted

ULTRA SOUND FACILITIES

Trauma Team should be managed as

smoothly and as efficiently as a

PIT STOP
in a

FORMULA ONE RACE

Always In Pole Position
Ready To Roll

Summary of Polytrauma Team

Functions
Accurate Clinical Judgment
Effective Resuscitation &
Stabilization
Accurate & Rapid Decision Making
Appropriate & Rapid Definitive Care
Intervention
Collective & Collaborative decision
making based upon Patients
condition

CONCLUSIONS
1. Smooth & efficient management of trauma victim.
2. Preserve the principles of Trauma Team despite varying
resources, manpower & infrastructure.
3. Change of attitude towards Trauma Care & Inculcate spirit
of team-work..
5. Upgrade knowledge & skill in Modern Concept of
Trauma Care.
6. Importance of integrated Trauma System.
7. Reduce morbidity and mortality.

LEADERSHIP
Leadership is lifting a persons vision
to higher sights, the raising of person
performance to higher standard, the
building of a persons personality
beyond its normal limitations
Peter Drucker

THANK YOU