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Initial Assessment And Management
 

Initial Assessment And Management

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Initial Assessment and management

Initial Assessment and management

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    Initial Assessment And Management Initial Assessment And Management Presentation Transcript

    • Chapter 1 Initial Assessment and management
    • OBJECTIVES
      • Identify the correct sequence of priorities in assessing the multiply injured patient
      • Apply the primary and secondary evaluation surveys to assessment of the multiply injured patient
      • Apply guidelines and techniques in the initial resuscitative and definitive--case phase
      • Anticipate the pitfalls associated with the initial assessment and management ( minimize their impact )
      • Conduct an initial assessment survey on a simulated multiply injured patient
    • CONCEPTS OF INITIAL ASSESSMENT
      • Preparation
      • Triage
      • Primary survey ( ABCDEs )
      • Resuscitation
      • Adjuncts to primary survey and resuscitation
      • Secondary survey ( head-to-toe evaluation and history )
      • Adjuncts to the secondary survey
      • Continued postresuscitation monitoring and reevaluation
      • Definitive care
      • Repeat primary and secondary survey when finding any deterioration in the patient’s status
      • Primary survey and resuscitation are done simultaneously
    • PREPARATION
      • Prehospital
        • Airway maintenance
        • Control of external bleeding & shock
        • Immobilization of the patient
        • Communication with receiving hospital & immediate transport to the closest, appropriate facility
        • History taking ( include events )
      • Inhospital
        • Advanced planning ( especially massive casualty )
        • Equipment & personnel
        • Communicable disease protection
        • Transfer agreements
    • TRIAGE
      • Sorting of patients according to ABCs and available resources
      • Triages is the responsibility of prehospital personnel
      • Not exceed the ability of the facility ==> treat life -- threatening patient first
      • Exceed the capacity of the facility ( mass casualties ) ==> Treat the greatest chance of survival, with the less time, less equipment & less personnel
    • PRIMARY SURVEY
      • Adult / Pediatric priorities same
      • Identified the life-threatening conditions and simultaneously managed
        • A: Airway maintenance with cervical spine protection
        • B: Breathing and ventilation
        • C: Circulation with hemorrhage control
        • D: Disability ( Neurologic status )
        • E: Exposure / Environmental control: Undress the patient & prevent hypothermia
    • PRIMARY SURVEY
      • Airway Maintenance with Cervical Spine Protection
        • Oral foreign bodies, facial, mandibular, or tracheal / laryngeal fractures may result in airway obstruction
        • Assume C-spine injury
          • Multisystem trauma
          • Altered level of consciousness
          • Blunt injury above clavicle
        • Pitfalls:
          • Difficult airway
          • Obesity: surgical airway cannot be performed smoothly
          • laryngeal fracture or incomplete upper airway transection
    • PRIMARY SURVEY
      • Breathing and Ventilation
        • Airway patency  adequate breathing & ventilation
        • injury that may acutely impair ventilation
          • 1. Tension pneumothorax
          • 2. Flail chest with pulmonary contusion
          • 3. Massive hemothorax
          • 4. Open pneumothorax
          • above problems need to be identified in the primary survey and managed
        • Pitfall: Differentiation of ventilation problems from airway compromise may be difficult
    • PRIMARY SURVEY
      • Circulation with Hemorrhage Control
        • Assess blood volume and cardiac output
          • level of consciousness
          • skin color
          • pulse
        • Bleeding control: direct manual pressure on the wound
        • Pitfall:
          • The response of elderly, children, athletes and others with chronic medical conditions to hypovolemia is different from normal people
    • PRIMARY SURVEY
      • Disability ( Neurologic Evaluation )
        • Level of consciousness
          • A. Alert
          • V. Response to voice
          • P. Response to pain
          • U. Unresponsive
        • Pupils
        • Pitfall:
          • Lucid interval ( talk and die ) : EDH, frequent neurologic reevaluation can minimize this problem
    • PRIMARY SURVEY
      • Exposure/Environmental Control
        • Undress patient completely
        • Protect from hypothermia
        • Pitfall:
          • early control of the hemorrhage is the best method to keep body temperature( early surgical intervention)
    • RESUSCITATION
      • Protect/Secure airway & protect C-spine
      • Breathing/Ventilation/Oxygenation
      • Vigorous shock therapy
        • At last two large - caliber IV line
        • Crystalloid solution ( Ringer’s lactate 2~3 litter)
        • Type-specific blood
        • surgical intervention
      • Protect from Hypothermia : 39 o C warm IV fluid
      • Urinary/gastric catheters unless contraindication
    • ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION
      • Monitor:
        • Ventilatory rate and ABGs/ end-tidal CO 2
        • Pitfalls: Combative patients often extubate or bite endotracheal tube
        • Pulse oximetry
        • ECG & BP monitor
        • Temperature
        • urine output
    • X-RAY AND DIAGNOSTIC STUDIES
      • Can’t delay or interrupt the primary survey and resuscitation
      • Trauma series ( portable X-ray ): CXR, C-spine/ lateral view, pelvic AP view
      • A negative or inadequate c-spine x-ray can’t exclude cervical spinal injury
      • Sonography / DPL
      • Pitfalls: obesity ( Sonography and DPL are difficult )
    • CONSIDER NEED FOR PATIENT TRANSFER
      • Referring doctor -to -receiving doctor communication
      • Closest appropriate hospital
    • BEFORE SECONDARY SURVEY
      • Complete primary survey
      • Establish resuscitation
      • Normalization of vital functions
    • SECONDARY SURVEY
      • History taking
      • Complete neurologic exam.
      • Head-to-toe evaluation
      • Roentgenograms
      • Special procedure
      • Tubes and fingers in every orifice
      • Re-evaluation
    • SECONDARY SURVEY
      • History
        • A. Allergies
        • M. Medications currently used
        • P. Past illness / pregnancy
        • L. Last meal
        • E. Events / Environment related to injury
    • HISTORY Mechanisms of injury
      • Blunt
        • Automobile collisions
          • Seat belt usage
          • Steering wheel deformation
          • Direction of impact
          • Ejection of passenger form the vehicle
      • Burns and Cold injury
        • Inhalation injury and CO. intoxication in fire field
      • Hazardous environment
      • Penetrate
        • Anatomy factors
        • Energy transfer factor
          • Velocity and caliber of bullet
          • Trajectory
          • Distance
    • SECONDARY SURVEY
      • Physical Examination
        • Head
            • entire scalp and head
            • eye:
              • pupil
              • visual acuity
              • EOM
              • foreign body ( soft contact lens….)
            • Pitfalls:
            • Severe facial swelling or unconsciousness p’t still need eye exam.
    • SECONDARY SURVEY
      • Physical Examination
        • Maxillofacial
          • No airway obstruction or massive bleeding ==> treat later
          • Midfacial fracture ==> R/O cribriform plate fracture
          • Pitfalls:
          • Some facial bone fracture is difficulty identified early ==> reassessment is crucial
    • SECONDARY SURVEY
      • Physical Examination
        • C-spine and Neck
          • Maintain immobilization
          • Complete evaluation
          • Complete radiology study
          • Cautions helmet removed
          • Penetrating injury: Not be explored in the emergency department; explored & treat in the operative room
          • Pitfalls:
          • Blunt injury to Neck: Carotid artery intima injury or dissection ( delay onset )
          • Immobilization ==> decubitus ulcer
    • SECONDARY SURVEY
      • Physical Examination
        • Chest
          • Pitfalls:
            • Poor tolerance to minor pulmonary trauma in elderly patients
            • A normal CXR can’t role out chest injury in children
    • SECONDARY SURVEY
      • Physical Examination
        • Abdomen
          • Identify a surgical abdomen is more important than doing a specific diagnosis ==> early consult surgeon
          • Close observation & frequent reevaluation of the abdomen
          • DPL, sonography, abdomen CT
          • Pitfalls:
            • Excessive manipulation of the pelvis should be avoid ==> just do pelvic x-ray
            • Retroperitoneal organs ( pancreatic & hollow organ ) are very difficult to identify
    • SECONDARY SURVEY
      • Physical Examination
        • Perineum / rectum / vagina
          • Perineum: Contusions, hematomas, urethral bleeding…….
          • Rectum: Sphincter tone, high riding prostate, blood…..
          • Vagina: Blood, laceration
          • Pitfalls:
          • Female urethral injury is difficult to detect
    • SECONDARY SURVEY
      • Physical Examination
        • Musculoskeletal
          • Extremities / pelvis: Contusion, deformity, pain crepitation, abnormal movement
          • Vascular: Assess all peripheral pulses
          • Spine: Physical findings, mechanism of injury
    • SECONDARY SURVEY
      • Physical Examination
        • Neurologic
          • Determine GCS score
          • Re-evaluate pupils
          • Sensory / motor evaluation
          • Maintain immobilization
          • Prevent secondary CNS injury ( keep stable vital signs, avoid increased ICP and treat IICP )
          • Early neurosurgical consultation
          • Pitfalls:
          • Intubation should be done expeditiously and as smoothly as possible ( Intubation will increase ICP )
    • REEVALUATION
      • New findings / deterioration / improvement
      • High index of suspicion ==> early diagnosis & management
      • Continuous monitoring
      • Pain relief
    • DEFINITIVE CARE
      • Trauma center
      • Closest appropriate hospital
    • RECORDS AND LEGAL CONSIDERATIONAS
      • Records: Concise, chronologic documentation
      • Consent for treatment
      • Forensic Evidence: preserve the evidence
    • SUMMARY
      • Initial assessment & management of multiply injured patient
      • Primary survey ( ABCDEs )
      • Resuscitation & monitor ( life-threatening problems )
      • Secondary survey ( head-to-toe, history )
      • Definitive care ( early consultation, surgical intervention or transport )