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Hyper Calcaemia

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  • 1. TRAUMA
    • The `neglected disease of the modern society`
    • Commonest cause of death among people aged 1- 34 years.
    • WHO – 1 in 10 deaths worldwide due to trauma
    • More than half young adults 15-44 years, 73% males
    • Most vulnerable – pedestrians, cyclists, motorized two wheelers and passengers of public transport.
  • 2. TRAUMA - Indian scenario
    • National Crimes Records Bureau (NCRB) – 2004 –most accident prone state – Maharashtra, 2 nd Kerala.
    • 3066 deaths out of 41306 accidents in Kerala
    • 84000 die in India yearly
    • Loss of Rs.50000 crore annually.
  • 3. Trauma mortality
    • Trimodal distribution of death in trauma
    • First peak - Within seconds or minutes
    • Second peak – within hours about 30% of deaths – half of these caused by haemorrhage, the other half by CNS injuries. Can be averted by “golden hour” treatment.
    • Third peak – after 24 hrs. due to infection & Multiple Organ failure etc.
  • 4. Prevention
    • Primary prevention – Educational e.g. anti drink campaign , legislative like enforcement of speed limits.
    • Secondary prevention – Making vehicles and roads safer, wearing helmets, seatbelts etc.
    • Tertiary prevention – Better prehospital and hospital care of the injured.
  • 5. Causes of trauma
    • Blunt trauma – RTA
    • Penetrating trauma
    • Blast injuries
    • Crush injuries
    • Thermal injuries
  • 6. Initial assessment & management
    • Objectives:
    • Identify the correct sequence of priorities in assessing the polytrauma pt
    • Apply principles of primary & secondary survey
    • Apply guidelines & technique of resuscitative & definitive care
  • 7. Advanced Trauma Life Support (ATLS)
    • James Styner in 1976
    • Preparation
    • Triage
    • Primay survey
    • Resusscitation
    • Secondary survey
    • Continued monitoring & reevaluation
    • Definitive care
  • 8. Preparation
    • Prehospital phase
    • Inhospital phase
  • 9. Prehospital phase
    • Airway maintenance
    • Control of external bleeding & shock
    • Immobilization
    • Transport to the immediate appropriate facility preferably a trauma center
  • 10. Inhospital phase
    • Proper trauma care facilities should be available. E.g.Facilities for taking universal precautions, proper airway equipment, I/V fluids, monitoring facilities, lab. & Imaging facilities, communication system etc
  • 11. Triage
    • Sorting of patients based on the pts based on the need for treatment and available resources to provide that treatment
    • Also sorting of pts in the prehospital phase to transport to trauma center.
    • Based on A,B,C priorities
    • Quick assessment by monitoring vital signs viz., GCS,systolic B.P. & resp. rate
  • 12. Triage – stepwise approach at the site
    • Step 1: GCS <14/systoli BP <90mmHg/resp rate<10 or >29- take pt to major hospital
    • Step 2: Assess anatomical extent of injuries – pelvic #, flail chest, two or more long bone #, amputation proximal to wrist/ankle,burns>10%,all penetrating injuries to head, neck, thorax, and extremities proximal to elbow & knee, any neurological deficit > major hospital
  • 13. Triage – stepwise approach at the site
    • Step 3: Evaluate the mechanism of injury Death in the same passenger compartment/ pedestrian/ejection from vehicle/deformity of the vehicle: >major hospital
    • Step 4: Assess history: Age <10/>50yrs, known medical condition > major hospital
  • 14. Advanced Trauma Life Support (ATLS)
    • James Styner in 1976
    • Preparation
    • Triage
    • Primary survey
    • Resuscitation
    • Secondary survey
    • Continued monitoring & reevaluation
    • Definitive care
  • 15. Primary Survey
    • A. Airway maintenance with cervical spine protection.
    • B. Breathing & ventilation
    • C. Circulation with haemorrhage control
    • D. Disability: neurologic status
    • E. Exposure/Environment: completely undress the patient, but prevent hypothermia.
  • 16. Airway & cervical spine
    • Assessment – able to talk – unlikely to be in jeopardy immediately
    • Foreign bodies, secretions, facial, mandibular, tracheal/laryngeal #,unconscious pt > airway obstruction
    • Management – Perform a chin lift or jaw thrust maneuver, clear airway of FBs,insert oropharyngeal/nasopharyngeal airway
  • 17. Airway & cervical spine
    • Establish a definitive airway
    • 1. Orotraheal/nasotracheal intubation
    • 2. Surgical cricothyroidotomy
    • 3. Needle cricothyroidotomy – 12 – 14 venflon > jet insufflation O2 at the rate of 12 L/min. – temporary measure.
    • Maintain the cervical spine in the neutral position with manual immobilisation as necessary when establishing airway
    • Reinstate immobilisation with appropriate devices after establishing the airwy
  • 18. Breathing
    • Ventilation may be assessed by inspection &auscultation of the chest
    • Conditions that interfere with ventilation – tension pneumothorax, open pneumothorax, large flail chest with pulmonary contusion and large haemothorax.
    • Immediate decompression using I/V canula in the 2 nd I.C.space anteriorly in the case of tension pneumothorax.
    • Ventilation by Ambu bag / ventilator
  • 19. Circulation
    • In a trauma pt, shock is assumed to be due to hypovolemia
    • Diagnsis: tachycardia, skin color, mental status, capillary refill and hypotension.
    • Management: Volume replacement after inserting two large bore I/V canula and infusing 2L of ringer lactate fast long with arresting any external bleeding .
    • Monitoring, O2 and splinting of long bone # and tackling of internal bleeding urgently.
  • 20. Disability
    • A brief neurological examination
    • A Alert
    • V Response to verbal command
    • P ,, pain - GCS 8
    • U Unresponsive - GCS 3
    • +
    • Status of the pupil
  • 21. Expose & Environment
    • Completely expose to examine from head to foot
    • Avoid hypothermia
  • 22. Adjuncts to primary survey & Resuscitation
    • Obtain arterial blood gas analysis & ventilatory rate
    • Monitor the pt`s exhaled CO2 with an appropriate device
    • Attach ECG monitor
    • Insert urinary catheter & N/G tube (CI – urethral rupture, basal skull#
    • X-rays – Cervical spine – lateral, X-ray chest - A-P, Pelvis- A-P
    • ? Abd. USG/ DPL
  • 23. Secondary survey
    • History: AMPLE
    • A = Allergies
    • M = Medications
    • P = Past illness
    • L = Last meal
    • E = Events leading to the episode
  • 24. Secondary survey
    • Head to foot evaluation
    • Head & Maxillofacial:
    • a.Glascow Coma Scale(GCS)- record
    • b. Pupils
    • c. Neurological deficit
    • d. Scalp & face – lacerations, contusions, fractures and burns
    • e. Eyes- hemorrhage, penetrating injury, visual acuity, dislocation of lens & presence of contact lens
    • f. Ears & nose for CSF leakage
    • g. Inspect mouth for evidence of bleeding, CSF,soft tissue lacerations, and loose tooth
  • 25. Management
    • Maintain airway, continue ventilation and oxygenation as indicated.
    • Control haemorrhage
    • Prevent secondary brain injury
    • Remove contact lenses
  • 26. Cervical spine & Neck
    • Inspect > signs of blunt/ penetrating injury, tracheal deviation, use of accessory muscles of aspiration.
    • Palpate> tenderness, deformity, swelling, subcut. Emphysema, tracheal deviation, & symmetry of pulse
    • Auscultator > bruits.
    • Obtain a lateral cross table cervical spine X- ray.
    • Management: adequate immobilization & protection of cervical spine
  • 27. Chest
    • Inspect: Ant., Lat., and post chest wall for signs of blunt and penetrating injury, use of accessory breathing muscles, and bilat. Resp excursions
    • Auscultate the ant chest wall and post bases for bilat breath sounds and heart sounds.
    • Palpate the entire chest wall for blunt & penetrating injury, subcut emphysema, tenderness and crepitations.
    • Percuss for evidence of hyper resonance & dullness.
  • 28. Management
    • Needle decompression / tube thoracostomy & underwater seal drainage.
    • Open wound to be dressed
    • Pericardiocentesis as indicated
    • Transfer the pt. to the operating theatre if indicated
  • 29. Abdomen
    • Inspect: ant. & post. Abdomen – signs of blunt and penetrating injuries.
    • Auscultate: presence/ absence of bowel sounds.
    • Percuss: rebound tenderness.
    • Palpate: tenderness/ involuntary muscle guard/ gravid uterus
    • Pelvic X- ray/ USG / DPL/ CT
    • Transfer to O.T. if required
  • 30. Perineum/Rectum/Vagina
    • Perineum: contusions, haematomas, lacerations, urethral bleeding.
    • Rectum: rectal blood,anal shincter tone, bowel integrity, bony fragments, prostate position.
    • Vagina: Presence of blood in the vaginal vault, vaginal lacerations.
  • 31. Musculoskeletal
    • Inspect: Contusions/ lacerations/ deformity.
    • Palpate: tenderness/ crepitation/ abnormal mobility.
    • Peripheral pulses
    • Pelvis – #/ haemorrhage.
    • Thoracic & lumbar spine – contusion/laceration/tendernes/deformity/sensation
    • X – ray pelvis/ other suspected regions.
  • 32. Management
    • Apply/Readjust appropriate splinting devices for extremity #s.
    • Maintain immobilisation of thoracic & lumbar spines.
    • Administer tetanus immunisation.
    • Appropriate medications like antibiotics.
    • Consider the possibility of compartment syndrome.
    • Complete neuro vascular exam. of extremities.
  • 33. Neurologic
    • Reevaluate pupils/level of consciousness.
    • Determine GCS score.
    • Evaluate extremities for motor & sensory functions.
    • Observe lateralizing signs.
    • Management: continue ventilation & oxygenation/ maintain adequate immobilization of the entire pt.
  • 34. Adjuncts to IIry survey
    • As the condition permits,
    • Additional X – rays,
    • CTs
    • Contrast studies
    • Angiography
    • Bronchoscopy,esophagoscopy etc.
    • Pt. reevaluation.
    • Transfer to definitive care.