Mph sriskantharajah arun castro

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  • 1. MPHrevision
  • 2. UNIT 6: HEALTH POLICYWhat is policy?Public policy : Thomas Dye 2001:- what governments do- or do not do- Specific proposals- Economic sanctions / taxes &- bundles- Cummulative effect of a govt’/ consecutive adminstrations’ individual decision making issues
  • 3. Health policy• Means different things to different people• Perspectives:• Economists – allocation of scarce resources , cost-effectiveness• Planners – wider determinants of health• Doctors – access to gold standard services & delivery• Others , like Walt 1994 recognise: Further political dimensions , that is: – The Politics of who influences policy makers – How policy makers exert their influences – & through what means/mechanisms
  • 4. Health policy triangleWalt & Gilson (1994) used the HPTas a model to described the interconnectedness ofContextContent+ processin the lives of the key “actors” in health policyActors being – individuals, groups and organisationswith an interest or responsibility inhealthcare, public policy or both.
  • 5. Contextual factors that affect policy (Leichter 1979)• Situational factors-• “ focusing events” that mark the flash point to bring about change – Environmental disasters – Communicable disease “disasters” – Economic disasters – Social disasters• Structural factors – Political system – Type of economy – Employment base – Demographics – Technological capabilities – GDP –national wealth• Cultural factors• International factors/exogenous factors – multinationals/multilateral cooperation – E.g. polio : WHO assistance
  • 6. Process of policy making “The stages heuristic” Sabatier & Jenkins-Smith 1993• Problem idenfication & recognition• Policy formulation• Implementation• Evaluation• Describes the general stage of the theory• But policy making is not necessarily a rational process – Due to its “iterative” nature – Due to actors’ interests• Policy process has been seen by many including Lindblom (1959) as being one in which decision makers “muddle through”
  • 7. CASE STUDY 1: GETTING TB NOTICED + DOTS POLICY FORMATION• 1970s
  • 8. UNIT 1: EPIDEMIOLOGY• Principles – Measuring frequency of outcomes – Measuring associations & impact – Interpreting associations• Epidemiological research studies – Design & data handling – 5 types of studies• Epidemiology in PH – Prevention strategies – Surveillance , monitoring , evaluation
  • 9. 1.1: principles of epidemiology• Health outcomes• Risk factors /Protective factors• Efficacy• Effectiveness• Descriptive vs. analytical studies• Sufficient causes• Component causes• Necessary causes• Exposure• Causality• Chance, bias, confounding
  • 10. 1.1 Five Epidemiological study types1. Ecological studies2. Cross sectional studies3. Cohort studies4. Case-control studies5. Intervention studies
  • 11. 1.1: 1. Ecological Studies (ES) analytical-observational studySubject: a population of individualsAim: relate total frequency of outcome xto average level of exposure yby population groupe.g. investigating relationship betweenincidence of BRCA = (x)to differences (e) EtOH consumption in pop. group
  • 12. 1.1:Cross Sectional Studies (CSS) analytical-observational studyData collected from One point at timeProvides a snapshot of the sampled time periodQuantify frequency of: outcome x and exposure ein a random sample of study subjects at time te.g. In November 2011 , from 500 GUM outpatient questionnaires, 350 data entries were randomly selected and analysed based onresponses to questions:• Did pt have HIV = outcome (Y/N)• Was the pt circumcised = (Y/N) hypothesised “exposure” e
  • 13. 1.1: cohort studies (CS) analytical-observational studyCompares frequency of outcome x betweendifferent groups that have known differences inexposure ee.g. frequency of cervical cancer ingroup A – 30y.o. females + swab +ve HPVgroup B – 30y.o. females + swab –ve HPV
  • 14. 1.1: interventional Studies (IS)1. RCT2. Non RCTInvestigate the outcome x (e.g. Pneumococcal pneumonia disease state ininfancy)Between two or more groups whereOne group Is allocated an intervention A (Pneumococcal vaccine)And other groups are given alternatives/comparators/standard practice/no-interventionAssesses strength of association betweenExposure to intervention A and outcome x
  • 15. 1.1: Ecological Studies1. Head2. Maxillofacial structures3. C spine and neck4. Chest5. Abdo6. Perineum,rectum,vagina7. Musculoskeletal exam8. Neurological exam
  • 16. 1.2: frequency of outcomes• Case definition• Prevalance• Risk• Odds• incidence
  • 17. 1.2 Prevalence =No. of cases at time point t / pop.total at timepoint tIncludes new and old cases at time point t
  • 18. 1.2 Incidence =No. of NEW cases / total pop. at time point tCan be measured in:- ecological studies (ES)- Cohort studies (CS)- Described as:- Risk- odds- Incident rates
  • 19. 1.2 Risk = (incident risk)• No. NEW cases / total no. AT RISK in pop. at the start of time period t
  • 20. 1.2 secondary attack rate =NEW cases amongst contacts / total ALL CONTACTS during time period t
  • 21. 1.2 Odds =NEW cases / Total Pop. – new cases during time period t =NEW cases / people who weren’t cases during time period t in population p.
  • 22. 1.2 Odds =(Cases/total) / ( noncases/total)=(cases/total) x (total / noncases)=Cases/noncases = oddse.g. 75 colds from 100 people in winter75/25 = 3 = odds of 3:1i.e. you’re 3x more likely to catch a cold in winter than not.
  • 23. 1.2 Incidence Rate =No. NEW cases / total person-time at risk during timeperiod tPerson-time at risk is a measure relevant fordynamic or open populations where people mayenter/exit the population at risk  - different durations of exposure to risk - at risk for different periods of time.
  • 24. 1.3 measuring association & impact relative riskPrevalence ratioRisk ratioOdds ratioOdds ratio of exposureIncidence rate ratio
  • 25. 1.3 measuring association & impactAttributable risk = incidence in exposed – incidence inunexposedAttributable fraction =(incidence exposed – incidence unexposed) / incidence inexposureAttributable fraction = (relative risk -1) / relative riskPreventable fraction =( i unexposed – i exposed) / i unexposedPreventable fraction = 1 – relative risk
  • 26. 1.3 measuring association & impactNo. NEW cases / total person-time at risk during timeperiod tPerson-time at risk is a measure relevant fordynamic or open populations where people mayenter/exit the population at risk  - different durations of exposure to risk - at risk for different periods of time.
  • 27. 1.3 measuring association & impactNo. NEW cases / total person-time at risk during timeperiod tPerson-time at risk is a measure relevant fordynamic or open populations where people mayenter/exit the population at risk  - different durations of exposure to risk - at risk for different periods of time.
  • 28. 1.3 measuring association & impactNo. NEW cases / total person-time at risk during timeperiod tPerson-time at risk is a measure relevant fordynamic or open populations where people mayenter/exit the population at risk  - different durations of exposure to risk - at risk for different periods of time.
  • 29. 1.3 measuring association & impactNo. NEW cases / total person-time at risk during timeperiod tPerson-time at risk is a measure relevant fordynamic or open populations where people mayenter/exit the population at risk  - different durations of exposure to risk - at risk for different periods of time.
  • 30. 1.2 Incidence Rate =No. NEW cases / total person-time at risk during timeperiod tPerson-time at risk is a measure relevant fordynamic or open populations where people mayenter/exit the population at risk  - different durations of exposure to risk - at risk for different periods of time.
  • 31. 1.2 Incidence Rate =No. NEW cases / total person-time at risk during timeperiod tPerson-time at risk is a measure relevant fordynamic or open populations where people mayenter/exit the population at risk  - different durations of exposure to risk - at risk for different periods of time.
  • 32. 1.2 Incidence Rate =No. NEW cases / total person-time at risk during timeperiod tPerson-time at risk is a measure relevant fordynamic or open populations where people mayenter/exit the population at risk  - different durations of exposure to risk - at risk for different periods of time.
  • 33. secondary survey exam 2. MAXILOFACIAL trauma• First question:“Is maxfax trauma associated withAirway obstruction or haemorrhage?”• Yes definitive treatment• No  attend to more serious (life threatening) injuries, treat after stabilisation complete• Fractures of the midface can have cribriform plate fractures (thus gastric intubation via oral route)• Reassess – nasal, nondisplaced zygomatic, orbital rim fractures are difficult to identify early on
  • 34. secondary survey exam 3. C SPINE + NECK• Question:• “ Does pt have Maxfax or head trauma?”• Yes  presume pt has an “Unstable C Spine”= fracture or ligament injuryPlan:Canadian Cspine RulesImmobilise neck.Examine and XR neck.Exclude injury.NB: absence of neurodeficits does not exclude c-spine injury
  • 35. secondary survey exam 3. C SPINE + NECK (2)• Neck exam: Inspect , Palpate , Ausculate• C spine tenderness• Subcutaneous (surigical) emphysema• Tracheal deviation• Laryngeal “fracture” injury• Carotids palpate , ausc’ bruits• Echymosis• Neuro
  • 36. secondary survey exam 3. C SPINE + NECK (2)• In: duplex US/angiography – exclude cervical vascular injury• Cervical vascular injuries:• Most due to penetrating injury• Can be due to blunt forces or traction injury – shoulder harness restraints  intimal distruption, disection , thrombosis.• Care to immobise head and neck when removing helmets• Surgical opinion +/- Operative evalution if:• 1. active arterial bleed, 2. expanding haematoma, 3. arterial bruit, 4.. Airway obstruction• Neuro: Paralysis of an upper extremity should raise suspicion of cervical nerve root injury
  • 37. secondary survey exam 4. CHESTInspect(anterior + posterior)- open pneumothorax- Flail chest- Haematomas of the chest wall  ?occult injury- Distended neck veins  (in trauma): ? Cardiac tamponade , ? Tension PneumothoraxPalpate chest wall- clavicles, ribs, sternum- Trachea – deviated away (?tension pneumothorax)Auscultate:Lung fields:- Upper zones anteriorly (?pneumothorax)- Bases posteriorly( ?haemothorax)Findings:Hyperresonant (? Tension pneumothorax )Heart sounds:- distant/muffled ( ?cardiac tamponade ( assoc’ with narrow pulse pressure, distended neck veins)CXR:Can confirm haemothorax, simple pneumothoraxWide mediastineum ? Aortic ruptureTensionpneumothorax may be assoc’ with shock
  • 38. secondary survey exam 5. ABDO• Inspect, Palpate, Percuss, Auscultate• Normal initial exam doesn’t exclude injury• Re-assess• Involve surgeons early• Abdo palpation can elicit pain from pelvis or ribs• In: FAST scan, CT abdo.
  • 39. secondary survey exam 6. PERINEUM/PR/PVInspect for:• Contusions• Haematoma• Lacerations• Urethral / PV bleedPR exam – (in trauma) report on:• ? blood in bowel lumen• Rectal wall integrity• Spincter tone• Perianal sensation• High riding prostate *• ? Pelvic fractureNB: PR before catheterisationPV exam – report on:• Blood in vaginal vault• Lacerations• In: bHCG
  • 40. secondary survey exam 7. MUSCULOSKELETALInspect extremities for:• Contusions• Deformities (mal-alignment)Palpate bones:• Tenderness• Abnormal movementCheck Peripheral pulsesDon’t forget the Back!
  • 41. secondary survey exam 7. MUSCULOSKELETAL(2)Consider Pelvic fractures if:• Bruising over iliac wings, pubis, labia/scrotum• Pain on palpating pelvic ring• Mobility of pelvis (when applying gentle ant-to-post pressure over both ASIS) = pelvic ring disruption(NB- perform only once  further haemorrhage)
  • 42. secondary survey exam 7. MUSCULOSKELETAL(3)Joint instability  # , ligament ruptureIf:• Impaired sensation• Weakness/ loss of voluntary muscle contractionConsider:• Nerve injury• Ischaemia• Compartment Syndrome
  • 43. secondary survey exam 8. NEUROUL & LL M&SGCSRe-assess ( ?progression of intracranial injury)If GCS drops – re-assess A-EIf neuro injury i.e. head injury <13, or GCS drop >2contact senior + indication for Neuro-ImagingEarly consultation with neurosurgery
  • 44. Adjuncts to secondary survey• Investigations• XRs in resus room• US dopplers• US FAST scan• CT head,chest,abdo,pelvis,spine• Trans oesophageal US
  • 45. Re-evaluation (reassessment)• 15mins obs• Or repeat obs after each new intervention• Vitals• Urine output 0.5mls/kg/hr Adult• Child >1y.o 1ml/kg/hr• Serial ABGs.• End tidal CO2 (if intubated)• Reassess pain  Analgesia!
  • 46. After secondary survey  Definitive care• Definitive care – ACS COT criteria (interhosp transfer)
  • 47. Skill Station 1• Three areas 1 a,b,c.• Practice and demonstrate all that’s involved in : ATLS approach to multiple trauma.• Preparation, triage, primary survey(1a) , pri adjuncts, resus management, ? Transfer , secondary survey,(1b) secondary adjuncts, definative mx +/- transfer• Re-evaluation (1c)• demonstrate handover as referring doctor to definitive care dept: (1c)1. Hx + MOI2. Examination findings3. Management (resus)4. Response to Mx5. Diagnostic test results6. Neccessity for tranfer7. Method of transport8. Anticipated Time of Arrival (ETA)
  • 48. Skill 1a1. A&E needs to make preparations that will allow rapid assessment and resus, e.g. trauma call, equipment & staffing2. need to wear appropriate clothing to protect clinicians and patient from communicable diseases3. patient will need to be completely undressed & measures taken to prevent hypothermia
  • 49. Skill 1a : A + C-spine1. Assessment –- describe patency of airway- Assess for airway obstruction –look, feel, listen2. mx- establish a patent airway- Chin lift or jaw thrust- Clear airway of foreign bodies- Insert oropharygeal airway (Guedel)- Establish definitive airway (Endotracheal tube or surgical cricothyroidotomy)- Describe “jet insufflation of airway”
  • 50. Airway and Ventilation Mx• Quickest killer of injured pts : inadequate Oxygenated blood to vital organs• Prevent hypoxaemia by:• 1. protecting airway• 2. adequate ventilation (inc. vent support)• Early preventable deaths due to Airway problems are due to :• 1 failure to recognise need for airway intervention• 2. failure to identify incorrect airway intervention• 3.displacement of established airway• 4. failure to recognise need for ventilation• 5. aspiration pneumonia (gastric contents)
  • 51. Endotracheal intubation• Achieves:• 1. an airway• 2. allows delivery of 02• 3. supports ventilation• 4. prevents aspiration• If fails/difficult:• 1. emergency tracheostomy or surigcal cricothyroidotomy• 2. then operative repair
  • 52. Airway & ventilation Problem recognition 1:• Maxfax trauma:• Midface #  oropharyx & nasopharynx compromise• Facial #  haemorrhage , inc. secretions, loose teeth  difficulties maintaining airway patency• Mandibular # , esp. bilateral body #  loss of normal airway supporting structures – if pt is supine Obstruction can occur.
  • 53. Airway & ventilation Problem recognition 2:• Neck trauma:• Pentrating injury vascular injury  haemorrhage  displace/obstruct airway-Mx- ?surgical airway if ET impossible• Blunt/penetrating Injury  disruption of larynx or trachea  airway obstruction +/- haemorrhage into tracheobronchial tree• ? Partial obstruction• Cautious ET intubation
  • 54. Airway & ventilation Problem recognition 3:• Laryngeal trauma:• Rare•  Acute Obstruction• TRIAD:1. Hoarse2. Subcut emphysema3. Palpable fracture4.  CT can help identify site
  • 55. A:The talking patient• At this point in time has:• 1. patent uncompromised airway• Positive verbal response indicates:• Patent airway, ventilation intact, brain perfused adequately• Failure to resond/inappropriate response =1. Altered Level of Consciousness2. compromised airway & ventilation3. Or both.
  • 56. Objective signs of airway obstruction• 1. observe :• Aggitation  hypoxia• Obtundation  hypercarbia• Cyanosis  hypoxaemia• Accessory muscles• 2. listen :• Noisy, gurgling, snoring, stridor (partial obst’n)• Hoarse= Dysphonia (? Laryngeal obst’n)• abusive/rude : (? Hypoxaemic)• 3. Palpate:• Trachea central/deviated
  • 57. Airway & Ventilation: problem recognition• Ventilatory compromise due to :• 1. CNS depression• 2. mechanical ventilation problem• Breathing (ventilation) Patterns:• Shallow: chest trauma  rib #• Abnormal/ irratic  intracranial injury• Diaphragmatic  c.spinal cord injury• Abdominal + intercostal muscle paralysis  Complete Cervical cord transection sparing Phrenic Nerves C3&4.
  • 58. Is Ventilation adequate?• 1. look :• Symmetrical rise & fall of chest• Good expansion• Asymmetry  ? Flail chest . ? Splinting of ribs• Laboured  imminent threat to ventilation• 2. Listen:• Decreased / absent sounds  ? Thoracic injury• Rate
  • 59. Pulse Oximetry Saturations• Provides info re:• O2 sats• Peripheral perfusion status• Not adequacy of ventilation
  • 60. Airway Mx: Helmet Removal• (in pts requiring airway mx)• keep head & neck in neutral position• 2 person job• 1. inline manual immobilisation from below• 2. 2nd clinician laterally expands helmet then removes it from above• 3. re-establish inline manual immobilisation from above• 4. secure head and neck : bolsters + collar• 5. reassessing airway patency , rigid suction available• 6. high flow o2• Can use a cast cutter to minimise movement
  • 61. Airway maintenance techniques• Chin lift*• Jaw thrust** Take care to avoid hyperextension• Oropharyngeal airway – guedel – incisors to angle of mandible – not if conscious – If tolerates , high chance of needing definative airway – Tongue depressor pref, or rotating 180’ approach• Nasopharyngeal airway – Lubricate – Nostril must appear unobstructed – Midface injuries contraindicate use• Laryngeal Mask Airway• If ET or bag mask vent fails• inserted with out direct visualisation• Not a definitive airway• If inserted on arrival to A&E must plan for definitive airway• Others:• Multi lumen oesophageal airway• Laryngeal tube airway – not a definitive airway,• inserted with out direct visualisation
  • 62. Other airway adjuncts• GEB Gum elastic bougie• When vocal cords cant be visualised on direct laryngoscopy• Generally has been investigated in OR conditions rather than ED situations
  • 63. Indications for Definitive airway• 3 types : orotracheal, nasotracheal, surgicalCriteria:1. Apnea2. Unable to maintain patent airway3. Need to protect against aspirating blood/vomit4. Impending/potential for compromise5. GCS <8 :Closed head injury requiring assisted ventilation6. Facemask fails to maintain adequate sats
  • 64. Intubation & Cspine issues• Placement of a definitive airway must not be delayed by obtaining Cspine XRs• GCS <8 needs prompt intubation• If immediate definative airway not needed then can do Cspine XRs• Orotracheal vs. nasotracheal def.intubation both safe and effective. Dependant on user experience.
  • 65. Intubation- ET• Orotracheal route:• 2 person technique- inline c-spine immob.• Direct larygoscopy for insert of ET tube• Cricoid pressure – to occlude oesophagus to prevent aspiration• Laryngeal manipulation – aid visualisation of vocal cords : – BURP – backwards,upward, rightward pressure. – inserted with out direct visualisation• Inflate Cuff• Being assisted ventilation
  • 66. Checking ET placement• Breath sounds bilat.• Check no “borborygmi” (gurgling) in epigastrium• CO2 detector – e.g capnograph• CXR
  • 67. Nasotracheal tubes• Blind nasotrach tubes requre spontaneous breathing• Contraindicated with apnaeic patients• Relative contraindications:• - facial #• Frontal sinus #• Basilar skull #• Cribriform plate #• Signs of theses injury are:• Nasal fracture• Raccoon eyes – bilat periorbital ecchymosis• Battle sign – post auricular ecchymosis• CSF- rhino/otorhea
  • 68. LEMON• Predicting difficult airways• Look• Evaluate 3,3,2• Malampati• Obstruction• Neck mobility
  • 69. 12 Skills Stations• I initial assessment ()• II Airway & Ventilation mx (9)• III cricothyroidotomy• IV shock assessment & mx• V venous cutdown• VI Thoracic Injury XRs• VII Chest trauma mx• VIII diagnostic peritoneal lavage• IX Head & neck trauma assessment & mx• X Spinal Injury XRs• XI Spinal cord injury assessment & mx• XII musculoskeletal trauma assessment & Mx
  • 70. Skill 1: initial assessment & mx• 1a• 1b• 1c• 1d
  • 71. Skill II- a• Oropharyngeal airway insertion (guedal airway adjunct)• unconscious patients• For tempory ventilation• when preparing for intubation1. size : corner of mouth to external ear canal2. open mouth:chin lift or “scissors technique”3. Depress tongue w’ tongue blade care . re: gag4. insert airway posteriorly, flange rest on lips5. remove tongue blade6. ventilate pt with bag-mask device
  • 72. Skill II b: Nasopharyngeal airway insert• If gagging on oropharyngeal airway1. Assess nasal passage obstructions - Polyps , #, haemorrhage2. Size to pass thru nostril3. Lubricate4. Insert tip into nostril posterior towards ear5. Insert with slight rotation til flange nostril6. Ventilate with bag-mask device
  • 73. II-c – bag mask vent. 2 person technique• Size mask• O2 tube to bag mask device 12l/ming• Ensure airway patent + secured• First person applies mask - check seal with both hands2nd person squeezes bag with both hands – toventilateAssess adequacy of ventilation by observing chestwall movementVentilate every 5seconds approx.
  • 74. II-d : Adult Orotracheal (ET) Intubation (+/- Gum-Elastic Bougie Device)1. Ensure adequate ventilation & oxygenation2. Have suction equip.3. Inflate cuff check for leaks. deflate4. Assemble laryngoscope , check bulb5. Assess airway (Look-false teeth,fillingd, E332(positioning) Mallampati organic Obstructions Neck- mobility)6. Assistant to manually immobilise, nb:position7. Laryngoscope insert right side mouth , displace tongue left8. Visualise epiglottis + vocal cords9. ET insert avoid pressure on teeth or oral tissues10. Inflate cuff to make seal (don’t over inflate11. Check ET placement by bagmask-to tube ventilation12. Check chest expansion,13. auscultate14. Secure tube. Reassess each time pt moved15. If ET fail in seconds stop, use bag mask device , try with GEB16. CXR position tube- although cant r/o oesopahgeal placement17. Co2 detector to confirm position18. Pulse oximeter
  • 75. Skill II e:LMA – laryngeal mask insertion
  • 76. Skill II f:LTA – laryngeal tube airway insertion
  • 77. Skill II g:infant ET intubation
  • 78. Skill II h:pulse oximetry monitoring
  • 79. Skill II I:Co2 detection
  • 80. Skill IV a: peripheral venous access- obvious
  • 81. Skill IV b: Femoral Venipuncture – Seldinger technique• Sterile technique• Supine position • Risks• Clean site , drape • DVT• Palpate femoral artery • Infection• Femoral vein is medial to artery ( NAVYfronts)• Keep finger on artery to avoid it • AV fistula• Ultrasound • Art/Nerve injury• Local anaesthetic over site 0.5% lidocaine bleb• Large calibre needle att’ to 12ml syringe cont’ 1ml saline• Needle into skin directly over vein then advance towards head• Hold needle parallel to frontal plane• Advance needle while withdrawing plunger• When blood appears remove syringe , occlude needle (air emboli)• Insert guidewire , remove needle, connect to IV tubing• Fix catheter with suture• Apply topical abx , dress• Tape IV tubing• Cxr + Axr to confirm placement + position• Change cather as soon as is practical
  • 82. Skill III c:
  • 83. Skill III d:
  • 84. Skill III e: Intraosseous puncture infusion- Sterile techique prox tibial route Risks: 1. Infection- <6yrs 2. Penetration through whole- Circulatory collapse / 2 failed cannulae bone- Discontinue once other access gained 3. Subcut or subperiosteal infiltriaon1. Supine position 4. Pressure necrosis2. Padding under knee (uninjured side) 5. Physeal plate injury3. 30 degrees knee flexion 6. haematoma4. 1 to 3 cm below tib-tub5. Clean skin + drape6. Local anaethetic if awake7. 90 degree angle introduce 18gauge needle – towards foot away froom growth plate8. After reaching bone – 45-60 degrees away from growth plate, twist, advance thru cortex to marrow9. Remove stylet , attach needle 12ml syringe, draw up10. If marrow aspirated = in medullary cavity11. Abx ointment12. Secure needle & tubing13. Reevaluate if moved
  • 85. Ch 3 : SHOCK• Haemorrhagic• Cardiogenic• Tensionpneumothorax• Neurogenic• Septic
  • 86. Ch 3 shock• Profound circulatory shock = evidence of haemodynamic compromise(collapse) with inadequate perfusion of organs (inc. skin)• Pulse rate• Resp rate• Skin circulation , capillary refil time• Pulse pressure = systolic – diastolic• Tachycardia and vasoconstriction are the early responses to volume loss• NB: any injured pt who is COOL + tachycardic should be considered to be in SHOCK unless proven otherwise
  • 87. Haemorrhage• Acute loss of circulating blood volume• Blood vol = 7% of body weight• 70kg male  5L circulating vol.• Children : 80mls/kg weight• 4 classifications of Haemorrhage• I-IV
  • 88. Factors affecting haemodynamic response to trauma• Age• Severity – anatomical site + type of injury• Time lapse between injury and rx• Prehospital fluid rx• Pneumatic antishock garments PASGs• Medications for chronic diseases
  • 89. CH3: Classes of Haemorrhage• Class 1 :• 15% blood loss• 750mls• HR <100• BP NORMAL• Pulse pressure (SBP-DBP) = normal /1ncreased• RR normal• u/o >30mls/hr• CNS – slightly anxious• FLUID REPLACEMENT : CRYSTALLOID
  • 90. CH3: Classes of Haemorrhage• Class 2 :• 15-30% blood loss• 750-1500mls• HR 100 to 120• BP NORMAL• Pulse pressure (SBP-DBP) decreased• DBP increases due to initial release of catecholamines (vasoconstriction- increased vascular tone + resistance)• RR tachyp. 20-30• u/o 5-15mls/hr• CNS – anxious , confused• FLUID REPLACEMENT : CRYSTALLOID
  • 91. CH3: Classes of Haemorrhage• Class 3 :• 30-40% blood loss• 1.5-2L• HR 120-140• BP HYPOTENSIVE• Pulse pressure (SBP-DBP) decreased• DBP increases due to initial release of catecholamines (vasoconstriction- increased vascular tone + resistance)• RR 30-40 tachyp.• u/o 20 to 30mls/hr• CNS –anxious• FLUID REPLACEMENT : CRYSTALLOID + BLOOD
  • 92. CH3: Classes of Haemorrhage• Class 4 :• >40% blood loss• >2L• HR 140• BP HYPOTENSIVE• Pulse pressure (SBP-DBP) decreased• DBP increases due to initial release of catecholamines (vasoconstriction- increased vascular tone + resistance)• RR >35• u/o <5mls/hr• CNS – confused and lethargic• FLUID REPLACEMENT : CRYSTALLOID +BLOOD
  • 93. CH3 : shock• What can I do about shock – initial Rx• Stop the bleeding and replace vol.lost• Physical assessment ABC…to U• A&B- airway maintainance + suplementary O2• C-haemorrhage control- IV access , assess tissue perfusion, direct pressure, PASG – for pelvic/lower limb fracture• D- assess level , follow the evolution of neurological disability , it informs re: future recovery predictor• Urine output• Exposure• Gastric dilatation- decompression- often occurs in trauma pts, may cuas unexplained hypotension, can cause dysrhythmias, bradyc from excessive vagal stim. Reduces risk of aspiration pneu.• Surgery• Adequacy of tissue perfusion dictates amount of fluid resus required
  • 94. Response to Initial Resus- 2L- 20mls/kg child• Rapid response• Transient response• Minimal/no response
  • 95. Ch 3 Shock Response to Resus• RAPID RESPONSE• Obs - return to normal• Est. blood loss = 10-20%• LOW need for more crystalloid• LOW need for blood• TYPE AND CROSSMATCH BLOOD PREP• Possible need for operative intervention• Surgical Review
  • 96. Ch 3 Shock Response to Resus• TRANSIENT RESPONSE• Obs - transient improvement• Est. blood loss = 20-40%• HIGH need for more crystalloid• Moderate/HIGH need for blood• TYPE SPECIFIC BLOOD PREP• Likely need for operative intervention• Surgical Review
  • 97. Ch 3 Shock Response to Resus• MINIMAL/NO RESPONSE• Obs - abnomal• Est. blood loss = >40%• HIGH need for more crystalloid• IMMEDIATE need for blood• USE EMEGENCY BLOOD STOCK• V.LIKELY need for operative intervention• Surgical Review
  • 98. CH3- special considerations for shock• Blood pressure & cardiac output• Blood pressure = cardiac output x Systemic vascular resistance• (ohm’s law V = I x R)• If theres no change to cardiac output there will be no improvemnet to tissue perfusion or oxygenation, e.g if vasopressors are given BP may rise due to increased peripheral vascular resistance but C/O doesnot necessarily improve.
  • 99. CH3- special considerations for shock• Old age• Athletes• Pregnancy – for the tissue hypoperfusion & fetal perfusion effects of a hypovolaemic state require comparatively bigger vols of blood loss in comparison to non-pregnant.(greater circulating volume)• Medications – B-adrenergic blockers, Ca2+ antagonists, change response to haemorrhage• NSAIDS- platelet function• Diuretics – K+ hypoK-thiazides, spironolactone K+sparing• Hypothermia- coagulopathy. Think etoh –vasodilation.• Pacemakers – CVP monitoring to guide fluid rx
  • 100. Ch 3 shock mx• Reassessment• Complications• Fluid overload• Cvp monitoring
  • 101. Ch 4 thoracic trauma• Primary survey• 6 LIFE THREATENING INJURIES• Identifiable on examination:1. Airway obstruction2. Tension pneumothorax3. Open pneumothorax4. Flail chest & pulmonary contusion5. Massive haemothorax6. Cardiac tamponade
  • 102. Ch 4 thoracic trauma• Secondary survey : 8 LETHAL INJURIES• diagnoses that are not obvious from physical exam• require clinical suspicion + adjuncts1. Simple (Open) pneumothorax2. Massive haemothorax3. pulmonary contusion (+/-inc .Flail chest)4. Blunt cardiac trauma5. Tracheobronchial tree injury6. Traumatic aortic disruption7. Traumatic diaphragmatic injury8. Blunt eosophageal injury
  • 103. Ch 4 thoracic trauma • Back to the PRIMARY SURVEY • + 6 LIFE THREATENING CONDITIONSAirway obstruction. Tension pneumothorax. Open pneumothorax. Flail chest & pul. contusion.Massive haemothorax. cardiac tamponade
  • 104. CH 4: Thoracic Trauma:Primary survey : life treatening condition Flail chest & pulmonary contusion • Segment of chest wall has no bony continuity with the rest of the thoracic cage • Trauma causing Multiple rib fractures • >2 ribs # in >2 places • Serious hypoxia due to underlying pulmonary contusion • Paradoxical chest wall movement (instability) • Hypoxia – pain reducing insp. Effort + contusion • May splint chest • Inspect: Assymetrical unco-ordinated chest movement • Palp- abnormal expansion + crepitus • XR- may suggest rib # but may not show costochondral separation. • ABGAirway obstruction. Tension pneumothorax. Open pneumothorax. Flail chest & pul. contusion.Massive haemothorax. cardiac tamponade
  • 105. CH 4: Thoracic Trauma:Primary survey : life treatening condition no1.: Flail chest (2) • Initial rx – o2 humidified, fluid resus, avoid overhydration • Definitive rx- ensure o2 maximised, fluid, analgesia • Opiods iv • Or local anaesthetics • Intermittend intercostal nerve blocks • Intrapleural anaesthetic • Epidural anaestheticAirway obstruction. Tension pneumothorax. Open pneumothorax. Flail chest & pul. contusion.Massive haemothorax. cardiac tamponade
  • 106. CH 4: Thoracic Trauma:Primary survey : life treatening condition No 2: Massive Haemothorax • Accumulation of blood + fluid in lung • Compromises resp efforts , compresses lung and hinders ventilation 1) Decreased breath sounds 2) Dullness to percussion 3) + SHOCK • 1.5L blood in lung • >1/3rd blood volume in chest cavity • Penetrating wounds or blunt • Systemic or hilar vessel disruptionAirway obstruction. Tension pneumothorax. Open pneumothorax. Flail chest & pul. contusion.Massive haemothorax. cardiac tamponade
  • 107. Ch 4: thorax: Massive Haemothorax • Rx: • Iv crystaloid • Blood type specific transfusion • Decompress chest cavity with – - one chest tube 38 French anterior to midaxillary line 5th ICS • Autotransfusion setup • If >1.5L immediately evacuated – likely need for thoracotomy • Thoracotomy indications: • - physiology – repeated transfusions – • Chest wound medial to nipple + medial to scapula  thoracotomyAirway obstruction. Tension pneumothorax. Open pneumothorax. Flail chest & pul. contusion.Massive haemothorax. cardiac tamponade
  • 108. CH 4 : thorax : tamponade • Penetrating injury • Becks triad- 1 – distended neck veins - inc venous pressure 2 – reduced arterial pressure 3- muffled heart tonesAirway obstruction. Tension pneumothorax. Open pneumothorax. Flail chest & pul. contusion.Massive haemothorax. cardiac tamponade
  • 109. Ch 4 : thorax : circulation • PEA – in cardiac tamponade, tension pneumothorax, hypovolaeamia and cardiac ruptureAirway obstruction. Tension pneumothorax. Open pneumothorax. Flail chest & pul. contusion.Massive haemothorax. cardiac tamponade
  • 110. CH 4 : thorax : 2ndry S & adjunctsPROBLEM: Adjunct/Rx1. Simple pneumothorax 1. Upright expiratory CXR 2. Chest drain 5th ICS ant.mid axillary line2. Haemothorax 1. 36 F chest drain 2. Blood + resus (drain >200mls/hr in 2-4hr)3. Pulmonary contusion (+/- rib #) 1.Intubate & vent 2. o2 sats, abg, ecg,4. Tracheobronchial tree injury 1. Surgeon 2. Bronchoscopy 3. Multiple chest tubes 4. Intubation
  • 111. CH 4 : thorax : 2ndry S & adjunctsPROBLEM: Adjunct/Rx5. Blunt cardiac injury 1. FAST(NB TROP HAS NO ROLE) 2. ECG 3. ECHO 4. 24HR TELE 5. DIRECT INSPECTION OF MYOCARDIUM6. TRAUMATIC AORTIC DISRUPTION 1. CXR 2. CONTRAST CT 3. ANGIOGRAM 4. TRANS OESOPH. ECHO 5. SURGEON 6. ? ENDOVASCULAR REPAIR7. Traumatic diaphragm injury 1. (left) NG 2. scopes 3. Direct repair8. Blunt oesophageal injury
  • 112. CH 4: thorax: 2ndry survey : lethal injury: Traumatic aortic disruption• XR adjunct signs:1) Widened mediastinum2) Obliterated aortic knob3) Tracheal deviation to RIGHT4) Depressed left mainstem bronchus5) Elevated Right mainstem bronchus6) Obliteration of space between pulmonary artery and aorta (aortopulmonary window)7) Deviation of oesophagus to the right8) Widened paratracheal stripe9) Widened paraspinal interfaces10) Pleural /apical cap11) Left haemothorax12) Fractures to 1st/2nd/scapula
  • 113. Ch 5 Abdo & Pelvic Trauma• Blunt trauma• Penetrating trauma• Indications for laparotomy• Diaphragm injury• Duodenal injury• Pancreatic injury• GU injury• Small bowel injury• Solid organ injury• Pelvic fracture + associated problems
  • 114. Ch 5 – abdo pelvic anatomy• Peritoneal cavity• Retroperitoneal space• Pelvic cavity
  • 115. Ch 5 : abdo pelvis Indications for Laparotomy• Blunt abdo trauma + hypotensive + postive FAST scan OR• Clinical evidence of intraperitoneal bleed• Blunt Abdo trauma + positive DPL• Hypotension + penetrating abdo wound• Guns hot• Evisceration• GI/GU bleeds in trauma• Peritonitis• Free air/ ruptured hemidiaphragm after blunt injury• CT demonstrating intrabdo injury
  • 116. CH 6 : HEAD & NECK TRAUMA
  • 117. Ch 7 Spine & spinal cord• Neurogenic shock- Impairement of descending sympathetic pathway in CERVICAL or UPPER THORACIC CORD- Loss of vasomotor tone – vasodilation & pooling at viscera & lower extremities low BP- Loss of sympathetic innervation to heart: - bradycardia - failure to inc.rate in hypovol state -Vasopressors after moderate fluid replacement -Atropine for bradycardias
  • 118. Ch 7 Spine & spinal cord• Spinal shock after Spinal cord injury- Loss of muscle tone ( flaccidity)- Loss of reflexes- “shock” – injured cord may appear completely nonfunctional . However all areas may not be destroyed completely.- Duration can be variable
  • 119. CH 7 : spine & spinal cord• Spinal injury1. Level - = segment at which normal sensory & motorfunction is retained2. Severity of deficit3. Spinal cord syndrome4. Morphology : fracture, fracture-dislocation orSCIWoRA, + pentrating injuries
  • 120. CH 7 : spinal cord syndromes• Central cord syndrome –• Hx – fall forward onto face causing hyperextension• Pathology- anterior spinal artery compromise• o/e : loss of motor power – Upper limbs worse than lower limbs• Recovery – lower limb, then bladder then proximal upper limb, then hands last
  • 121. CH 7 : spinal cord syndromes• Anterior cord syndrome–• Hx –• Pathology- infarct anterior spinal artery• Affects anterior cord• Preserved posterior (Dorsal)column – (vib&proprio)• o/e :• loss of motor (CST)• Loss of STT(pain and temp)• Poorest prognosis of all “incomplete” cord injuries
  • 122. CH 7 : spinal cord syndromes• Brown-Sequard syndrome• Ipsilateral motor loss CST• Ipsilateral JPS – dorsal columns• Contralateral CST (1-2 levels lower) – due to decussation
  • 123. CH 8 : musculoskeletal common joint dislocation deformitiesJoint Direction DeformityShoulder ANTERIOR Ant:“squared off” POSTERIOR Post: locked in Internal Rotation.Elbow Posterior Olecranon is prominent posteriorlyHip Anterior Flexed, abducted, external rotated Posterior Flexed abducted internal rotatedKnee Anteroposterior Loss of normal contour ExtendedAnkle Lateral Externally rotated prominent medial
  • 124. CH 8 : musculoskeltal Crush syndrome (traumatic Rhabdomyolysis)• Crush injury• Hx – thigh , calf common• Muscle ischaemia cell death  myoglobin release• CK raised• ARF• DIC
  • 125. Ch 8 : crush syndrome• Investigations:• Myoglobin urine assay• Rhabdomyolysis  – hypovolaemia – Metabolic acidosis – HYPERKalaemia – HypoCalciaemia – DIC
  • 126. Ch 8 : crush syndrome• management:• Early + aggressive fluid resus• Sodium bicarbonate Alkalisation of urine  reduces intratubular precipitation ofmyoglobin• Maintain U/o of 100mls/hr until myoglobinuria cleared
  • 127. Ch 8 : musculoskeletal : limb threatening injuries• Open fractures-problems with – infection, healing & function• Rx – – Immobilise – Resus – Debride – Stabilise fracture – Distal pulse checks – Tetanus – abx
  • 128. Ch 8 : musculoskeletal : limb threatening injuries (2)• Vascular Injuries + Traumatic Amputation• Consider if : – Vascular insufficiency – mechanisms – blunt, crushing, pentrating• Assessment: cool , CRT>2, periph.pulses diminished, ABPI. Pale , pulseless, perishingly cold• Mx-• Acutely avascular extremities – recognise + Rx• Torniquet may be lifesaving +/or limb saving in the presences of onggoing haemorrhage that is uncontrolled by first line direct pressure.
  • 129. Ch 8: musculosketal: compartment syndrome• High risk situations: – tibial + forearm fractures – Injuries under Tight dressings and casts – Severe crush injuries to muscle – Prolonged ,localised pressure to an extremity – Inc. capillary permaebility 2ndry to reperfusion of ischaemic muscle – Burns – Excessive exercise
  • 130. Ch 8: musculosketal: compartment syndrome• Signs & symptoms1. Pain greater than(out of proportion to) expected for stimulus/injury2. Palpable tense compartment3. Asymmetry4. Pain on passive movement5. Altered sensation6. Absent distal pulse – uncommon7. weakness, paralysis & pulselessness : LATE signts
  • 131. Ch 8: musculosketal: compartment syndrome• In:• Intracompartment pressures• 30 – 45 mmHG – decreased cap.flow.•  anoxia  muscle & nerve damage• NB : consider intracompartment pressure in the context of the Systemic BP.• Mx-• Surgeon• dressings/casts/splints off extremity• 30-60mins reassess• ….Fasciotomy
  • 132. CH 9 : THERMAL INJURIES Depth of burns• 1st degree : (sunburn) – erythema, pain, no blisters.• 2nd degree – Partial thickness – Red /mottled – Swelling + blisters – Weeping , wet, – Painfully hypersensitive (even to air)• 3rd degree : FULL thickness• Dark• Leathery• Or waxy white/translucent• Painless• Dry• Nonblanching
  • 133. Ch 9 : thermal injuries• Frostnip – pain pallor numb ,- reversible on rewarming, no tissue loss- over years –fat pad loss + atrophy• Frostbite –• Freezing tissue• intracellular ice crystal formations• Microvascular occlusion• Tissue anoxia
  • 134. Ch9: Frostbite• severity: degree• 1st :• Hyperaemia, oedema without skin necrosis• 2nd: large clear vesicle formation, hyperaemia, odema, partial thickness necrosis• 3rd: full thickness & subcut tissue necrosis, haemorrhage vesicle formation• 4th : full thickness necrosis, muscle and bone gangrene.
  • 135. CH12:TRAUMA IN WOMEN- Anatomical & physiological variations of pregnancy  effects on rx- Common mechanisms of injury- Treatment priorities, assessment of mother + fetus- Operative interventions in pregnancy- Isoimmunisation , IG Rx- Patterns of domestic violence
  • 136. Ch12:• The best initial rx for the fetus is provision of optimal resus of mother and early assessment of fetus• If xr indicated during critical rx it should not be withheld due to pregnancy alone• Get a surgeon and Obs in early to evaluate pregnant trauma
  • 137. Ch 12:• Changes in pregnancy:• Uterus is intrapelvic 12wk• 20wk- at umbilicus• 34-36 costal margins• Bowels lie in upper abdo• Thus fetus ,uterus and placenta are vunerable• Upper abdo pentrating injury late on  bowel injury• Amniotic fluid  embolism , DIC if fluids enter maternal intravascular space
  • 138. Ch 12: trauma in women assessment & treatment mother & fetus- Mother:- Ensure patent airway, adequate ventilation, oxygenation, effective circulatory volumes- Intubate if appropriate-
  • 139. Skill II e: