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ABC's of Emergency

ABC's of Emergency

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  • Current standards of care for trauma patients, whether polytrauma or only with craniomaxillofacial injuries, follow the Advanced Trauma Life Support (ATLS) protocol relating to Airway, Breathing, Circulation, Disability, and Environment in that sequence.
  • The 'ABC' method of remembering the correct protocol for CPR is almost as old as the procedure itself, and is an important part of the history of CPR. Throughout history, a variety of differing methods of resuscitation had been attempted and documented, although most yielded very poor outcomes.[3]In 1957, Peter Safar[4] wrote the book ABC of Resuscitation[1], which established the basis for mass training of CPR.[5]This new concept was distributed in a 1962 training video called "The Pulse of Life" created by James Jude,[6]Guy Knickerbocker and Peter Safar. Jude and Knickerbocker, along with William Kouwenhouen[7] developed the method of external chest compressions, while Safar worked with James Elam to prove the effectiveness of artificial respiration.[8] Their combined findings were presented at annual Maryland Medical Society meeting on September 16, 1960 in Ocean City, and gained rapid and widespread acceptance over the following decade, helped by the video and speaking tour the men undertook. The ABC system for CPR training was later adopted by the American Heart Association, which promulgated standards for CPR in 1973.History of the mnemonic
  • In the polytrauma patient, on admission a number of injuries take higher priority than the craniomaxillofacial ones. With extensive head or neck injury, life-preserving emergency procedures take precedence;Craniomaxillofacial injuries need to be diagnosed, a treatment plan established, and a sequence fitted into the total treatment plan for the patient at an early stage.
  • Developed by the Subcommittee on ATLS® to the ACS Committee on Trauma, TEAM introduces the concepts of trauma assessment and management to medical students during their clinical years. The slide/lecture presentation can be easily adapted into the medical school's curriculum. The format is flexible, with a 90-minute slide presentation and optional components that include a three-segment initial assessment video demonstration and a series of clinical trauma case scenarios for small-group, focused discussion and skills sessions.The core content is adapted from the College's successful program, Advanced Trauma Life Support® (ATLS) course. TEAM is an expanded version of the ATLS "Initial Assessment and Management" lecture, with important principles added from other ATLS course materials.The Committee on Trauma and the ATLS Subcommittee believe that the TEAM Program should satisfy the need for a standardized introductory course in the evaluation and management of trauma that can be taught to all medical students and multidisciplinary team members. The ATLS Subcommittee designed the TEAM program to be taught by ATLS instructors, because they know the philosophy, intent, and content of the program. The subcommittee strongly encourages their participation in this regard.TEAM is a very abbreviated version of the ATLS course and is not intended to replace the complete course. Individuals who take the TEAM course are not considered as having completed an ATLS course. Medical students are encouraged to take the ATLS course in their final year of medical school or after graduation.
  • What is ATLS®? The American College of Surgeons (ACS) and its Committee on Trauma (COT)has developed the Advanced Trauma Life Support (ATLS) Program for Doctors, a systematic, concise training to the early care of trauma patients. It will provide the participants with a safe, reliable method for immediate management of the injured patient and the basic knowledge necessary to: Assess the patient's condition rapidly and accurately Resuscitate and stabilize the patient according to priority Determine if the patient's needs exceed a facility's capabilities Arrange appropriately for the patient's interhospital transfer (what, who, when, and how) Assure that optimum care is provided The development of the ACS ATLS Program within Switzerland is done by the ATLS® Switzerland Committee of the Swiss Surgical Society (SGC/SSC) in accordance with the guidelines given by the American College of Surgeons (ACS).
  • The first and key part of the assessment of patients presenting with trauma is called the primary survey. During this time, life-threatening injuries are identified and simultaneously resuscitation is begun. A simple mnemonic, ABCDE, is used as a memory aid for the order in which problems should be addressed.A Airway Maintenance with Cervical Spine Protection B Breathing and Ventilation C Circulation with Hemorrhage Control D Disability (Neurologic Evaluation) E Exposure and Environment
  • A Airway Maintenance with Cervical Spine Protection B Breathing and Ventilation C Circulation with Hemorrhage Control D Disability (Neurologic Evaluation) E Exposure and Environment A - Airway Maintenance with Cervical Spine ProtectionThe first stage of the primary survey is to assess the airway. If the patient is able to talk, the airway is likely to be clear. If the patient is unconscious, he/she may not be able to maintain his/her own airway. The airway can be opened using a chin lift or jaw thrust. Airway adjuncts may be required. If the airway is blocked (e.g, by blood or vomit), the fluid must be cleaned out of the patient's mouth by the help of sucking instruments. At the same time, the cervical spine must be maintained in the neutral position to prevent secondary injuries to the spinal cord. The neck should be immobilised using a semi-rigid cervical collar, blocks and tape.
  • B - Breathing and VentilationThe chest must be examined by inspection, palpation, percussion and auscultation. Subcutaneous emphysema and tracheal deviation must be identified if present. Life-threatening chest injuries, including tension pneumothorax, open pneumothorax, flail chest and massive haemothorax must be identified and rapidly treated. Flail chest, penetrating injuries and bruising can be recognized by inspection
  • Hemorrhage is the predominant cause of preventable post-injury deaths. Hypotension following injury must be assumed to be due to blood loss until proven otherwise. Hypovolemic shock is caused by significant blood loss. Two large-bore intravenous lines are established and crystalloid solution given. If the patient does not respond to this, type-specific blood, or O-negative if this is not available, should be given. External bleeding is controlled by direct pressure. Occult blood loss may be into the chest, abdomen, pelvis or from the long bones. Chest or pelvic bleeding may be identified on X-ray. Bleeding into the peritoneum may be diagnosed on ultrasound (FAST scan), CT (if stable) or diagnostic peritoneal lavage.
  • During the primary survey a basic neurological assessment is made, known by the mnenomic AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive). A more detailed and rapid neurological evaluation is performed at the end of the primary survey. This establishes the patient's level of consciousness, pupil size and reaction, lateralizing signs, and spinal cord injury level.The Glasgow Coma Scale is a quick method to determine the level of consciousness, and is predictive of patient outcome. If not done in the primary survey, it should be performed as part of the more detailed neurologic examination in the secondary survey. An altered level of consciousness indicates the need for immediate reevaluation of the patient's oxygenation, ventilation, and perfusion status. Hypoglycemia and drugs, including alcohol, may influence the level of consciousness. If these are excluded, changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise.
  • E - Exposure / Environmental controlThe patient should be completely undressed, usually by cutting off the garments. It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient privacy should be maintained.
  • When the primary survey is completed, resuscitation efforts are well established, and the vital signs are normalizing, the secondary survey can begin.The secondary survey is a head-to-toe evaluation of the trauma patient, including a complete history and physical examination, including the reassessment of all vital signs. Each region of the body must be fully examined. X-rays indicated by examination are obtained.If at any time during the secondary survey the patient deteriorates, another primary survey is carried out as a potential life threat may be present.The person should be removed from the hard spine board and placed on a firm mattress as soon as reasonably feasible as the spine board can rapidly cause skin breakdown and pain while a firm mattress provides equivalent stability for potential spinal fractures.
  • The more technically the lateral recumbent position, is an airway management technique for assisting people who are unconscious, or nearly so, but are still breathing. It is frequently taught alongside CPR in first aid.An unconscious person (GCS <8) cannot be trusted to maintain his or her own breathing. Many fatalities occur where the original injury or illness which caused unconsciousness is not inherently fatal, but where the unconscious person suffocates for one of these reasons. This is a common cause of death following unconsciousness due to excessive consumption of alcohol.When an unconscious person is lying face upwards, there are two main risk factors which can lead to suffocation: Fluids, possibly blood but particularly vomit, can collect in the back of the throat, causing the person to drown. When a person is lying face up, the esophagus tilts down slightly from the stomach toward the throat. This, combined with loss of muscular control, can lead to the stomach contents flowing into the throat, called passive regurgitation. Fluid which collects in the back of the throat can also flow down into the lungs; stomach acid can attack the inner lining of the lungs and cause aspiration pneumonia.It's possible to achieve limited protection of the airway by tilting the head back and lifting the jaw. An unconscious person will not remain in this position unless held constantly, and crucially it does not safeguard against risks due to fluids. In the recovery position, the force of gravity will allow any fluids to drain. The chest is also elevated from the ground, making breathing easier.
  • The recovery position is recommended for any unconscious person who does not need CPR, those who are too inebriated to assure their own continued breathing, victims of drowning, and also for victims of suspected poisoning (who are liable to become unconscious).
  • Putting a victim in the recovery positionChecking carotidian pulse in recovery position after initial assessment and while waiting for arrival of emergency services.Before using the Recovery Position, perform the preliminary first aid steps. First assess whether the scene is safe for the rescuer. If not, leave. Assess whether the person is responsive to your voice by asking something like "hey, buddy, are you OK?". If not, assess whether the person responds to painful stimulus by rubbing their sternum with your knuckles (this is not accepted practice in some countries). Assess whether the victim has an open airway, is breathing and has a pulse ("airway, breathing, and circulation" or "ABC"). If the victim is alert and an adult, obtain consent before performing first aid. For children, attempt to obtain consent from a parent, guardian, or other responsible caregiver. If the victim is not alert, and is not breathing, check for a pulse. If there is no pulse, perform cardiopulmonary resuscitation. If there is circulation, perform rescue breathing. The initial assessment should be done quickly, in a minute or less. Before you perform any of this, however, alert trained emergency medical personnel. Call the emergency telephone number or other emergency services.[edit] If no spinal or neck injury is indicatedThe correct position is called the "lateral recovery position."[1] Start with the victim lying on the back and with the legs straight out. Kneel on one side of the victim, facing the victim. Move the arm closest to you so it is perpendicular to the body, with the elbow flexed (perpendicular). Move the farthest arm across the body so that the hand is resting across the torso.Bend the leg farthest from you so the knee is elevated. Reach inside (preferably the outside of the knee, grasping clothing) the knee to pull the thigh toward you. Use the other arm to pull the shoulder that is farthest from you. Roll the body toward you. Leave the upper leg in a flexed position to stabilize the body.Victims who are left in this position for long periods may experience nerve compression. Still, that is a more desirable outcome for the victim than choking to death.[edit] If spinal or neck injuries are possibleWhen the injury is apparently the result of an accidental fall, collision or other trauma, the risk of spinal or neck injuries should be assumed. Movement of spinal-injured victims runs the risk of causing permanent paralysis or other such injuries, and is best left to trained medical personnel.[2] They should be moved to a recovery position only when it is necessary to drain vomit from the airway.In such instances, the correct position is called the "HAINES modified recovery position" (High Arm IN Endangered Spine.) In this modification, one of the patient's arms is raised above the head (in full abduction) to support the head and neck.[3][4] There is less neck movement (and less degree of lateral angulation) than when the lateral recovery position is used, and, therefore, HAINES use carries less risk of spinal-cord damage.[5]If an individual has suffered a fall or injuries that suggest damage to the spine, as a first aider the priority is to keep the airway open. If breathing, position should not be changed. If breathing has stopped, regardless of possible injury to the person, perform standard checks: DR & ABC (Danger, Response, Airway, Breathing, Circulation) and then move them into the recovery position to open the airway. If they do not start breathing, begin CPR. If they begin to breathe, keep them in that position.[edit] Pregnant victimsA pregnant woman should always rest on her left side, as lying on the right side may cause the uterus to compress the Inferior vena cava, possibly resulting in death.[edit] Victims with torso woundsA victim with torso wounds should be placed with the wounds closest to the ground to minimize the possibility of blood affecting both lungs, resulting in asphyxiation.
  • Nearly all first aid organizations use "ABC" in some form, but some incorporate it as part of a larger initialism, ranging from the simple 'ABCD' (designed for training lay responders in defibrillation) to 'AcBCDEEEFG' (the UK ambulance service version for patient assessment).
  • DR ABCOne of the most widely used adaptations is the addition of "DR" in front of "ABC", which stands for Danger and Response.[24]This refers to the guiding principle in first aid to protect yourself before attempting to help others, and then ascertaining that the patient is unresponsive before attempting to treat them, using systems such as AVPU or the Glasgow Coma Score. As the original initialism was originally devised for in-hospital use, this was not part of the original protocol.[25]
  • DRsABCA modification to DRABC is that when there is no response from the patient, the rescuer is told to Shout for help[26][27]
  • ABCDThere are several protocols taught which add a D to the end of the simpler ABC (or DR ABC). This may stand for different things, depending on what the trainer is trying to teach, and at what level.[28] It can stand for:Defibrillation[29] — The definitive treatment step for cardiac arrestDisability or Dysfunction[2][30] — Disabilities caused by the injury, not pre-existing conditionsDeadly Bleeding[31][32](Differential) Diagnosis[33]Decompression[34]
  • ABCDEAdditionally, some protocols call for an 'E' step to patient assessment. All protocols that use 'E' steps diverge from looking after basic life support at that point, and begin looking for underlying causes.[35] In some protocols, there can be up to 3 E's used. E can stand for:Expose and Examine[2][30] — Predominantly for ambulance-level practitioners, where it is important to remove clothing and other obstructions in order to assess wounds.Environment[36][37] — only after assessing ABCD does the responder deal with environmentally-related symptoms or conditions, such as cold and lightning.Escaping Air — Checking for air escaping, such as through a sucking chest wound, which could lead to a collapsed lung.Elimination[34]Evaluate — Is the patient "time-critical" and/or does the rescuer need further assistance.
  • ABCDEFAn 'F' in the protocol can stand for:Fundus — relating to pregnancy, it is a reminder for crews to check if a female is pregnant, and if she is, how far progressed she is (the position of the fundus in relation to the bellybutton gives a ready reckoning guide)Family (in France) — indicates that rescuers must also deal with the witnesses and the family, who may be able to give precious information about the accident or the health of the patient, or may present a problem for the rescuer.Fluids[34] — A check for obvious fluids (blood, cerebro-spinal fluid (CSF) etc.)Fluid resuscitation[37]Final Steps[38] — Consulting the nearest definitive care facility
  • ABCDEFGA 'G' in the protocol can stand forGo Quickly! — A reminder to ensure all assessments and on-scene treatments are completed with speed, in order to get the patient to hospital within the Golden HourGlucose — The professional rescuer may choose to perform a blood glucose test, and this can form the 'G' or alternately, the 'DEFG' can stand for "Don't Ever Forget Glucose"[39][40]
  • AcBCSome trainers and protocols use an additional (small) 'c' in between the A and B, standing for 'cervical spine' or 'consider C-spine'.[41] This is a reminder to be aware of potential neck injuries to a patient, as opening the airway may cause further damage unless a special technique is used.
  • Once the patient has been stabilized and cleared for cervical spinal cord injuries, the physician can begin to evaluate the maxillofacial region. If possible, the history of events surrounding the injury should be obtained because it can provide clues to the type of injuries the patient could have. For example, a sharp, penetrating injury is more likely to injure nerves and major vessels than is blunt trauma, which is more likely to result in fractures of the facial skeleton.
  • Do you see " double"? The presence of binocular diplopia can indicate internal or periorbital fractures. It should be considered a nonspecific symptom, however, because it can also be caused by other things, most commonly periorbital edema. The presence of monocular diplopia might indicate an injury to the globe, for which ophthalmologic consultation is necessary.
  • Are there any areas of numbness on your face? Any neurosensory deficit usually indicates a skeletal fracture has occurred surrounding the bony canals/grooves/foramina, through which the branches of the trigeminal nerves exit.
  • Does your bite feel " normal"? Most mandibular and/or maxillary fractures are associated with the subjective feeling that the bite is not "normal." The location of premature contact of the teeth can help to direct the clinician to the site of fracture.
  • Which areas on your face hurt? Although this question seems basic, one could find a patient who points to a location that is not swollen or bruised, such as the preauricular area, in the case of a condylar process fracture of the mandible.
  • Does it hurt when you open your mouth? Where? The presence of pain when one attempts functional movements of the mandible can indicate that skeletal fractures have occurred, although contusions of the temporomandibular joint can also produce pain in the absence of skeletal fractures. If pain is present, however, its location helps to determine underlying fractures. For instance, preauricular tenderness with mandibular movement could indicate a condylar process fracture. Pain at the angle of the mandible could indicate a fracture in that location. Pain in the cheek region when one attempts to open the mouth could signify a zygomaticomaxillary complex fracture
  • The clinical evaluation of the maxillofacial region must be organized and sequential and should be performed prior to ordering radiographs and other images. The head and neck examination must be methodical, or significant injuries can be missed. The maxillofacial examination must include the following components: Soft tissues NervesSkeletonDentition
  • One approach organizes the examination from "inside out and bottom up." Following this recommendation, the oral cavity is inspected first for lacerations or penetrating injuries. The tongue is frequently lacerated and can produce profuse bleeding. Soft tissue injuries should be explored for tooth fragments and other foreign bodies. Areas of soft tissue swelling and ecchymosis are noted because they can indicate underlying skeletal fractures. Lacerations of the attached gingiva around the teeth or palate also can indicate an underlying fracture.
  • An examination of the maxillofacial skeleton involves inspection and palpation. Injuries in the maxillofacial area can be associated with massive edema, which makes evaluation of the underlying skeleton difficult; however, bony contours should be palpated for irregularities and tenderness (discussed in their specific regions). One should always inspect carefully any fluid exiting the nose in case it could be cerebrospinal fluid (CSF). The presence of CSF rhinorrhea indicates disruption of the anterior cranial base, most commonly at the cribriform plate of the ethmoid bone associated with naso-orbitoethmoid fractures, or from disruption of the posterior wall of the frontal sinus. Areas of "numbness" on the face should make one suspect disruption of the sensory branch of the trigeminal nerve from skeletal fractures
  • Emergency medical services exists to fulfill the basic principles of first aid, which are to Preserve Life, Prevent Further Injury, and Promote Recovery.This common theme in medicine is demonstrated by the "star of life". The Star of Life shown here, where each of the 'arms' to the star represent one of the 6 points. These 6 points are used to represent the six stages of high quality pre-hospital care, which are:[41]Early Detection[41] - Members of the public, or another agency, find the incident and understand the problemEarly Reporting[41] - The first persons on scene make a call to the emergency medical services and provide details to enable a response to be mountedEarly Response[41] - The first professional (EMS) rescuers arrive on scene as quickly as possible, enabling care to beginGood On Scene Care[41] - The emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incidentCare in Transit[41] - the emergency medical service load the patient in to suitable transport and continue to provide appropriate medical care throughout the journeyTransfer to Definitive Care[41] - the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians

Transcript

  • 1. Polytrauma
    Frederick Mars Untalan MD
  • 2. standard of care
    Advanced Trauma Life Support (ATLS) protocol
    Airway
    Breathing
    Circulation
    Disability
    Environment
  • 3. History of the mnemonic
    1957, Peter Safar[4] wrote the book ABC of Resuscitationwhich established the basis for mass training of CPR.
    1962 training video called "The Pulse of Life" created by James Jude,[6]Guy Knickerbocker and Peter Safar. Jude and Knickerbocker, along with William Kouwenhouen[7] developed the method of external chest compressions, while Safar worked with James Elam to prove the effectiveness of artificial respiration.[8]
    Their combined findings were presented at annual Maryland Medical Society meeting on September 16, 1960 in Ocean City, and gained rapid and widespread acceptance over the following decade, helped by the video and speaking tour the men undertook.
    The ABC system for CPR training was later adopted by the American Heart Association, which promulgated standards for CPR in 1973.
  • 4. First things First
    In the polytrauma patient, a number of injuries take higher priority than the craniomaxillofacial ones.
    life-preserving emergency procedures take precedence in extensive head or neck injury
    Craniomaxillofacial injuries need to be diagnosed, a treatment plan established, and a sequence fitted into the total treatment plan for the patient at an early stage.
  • 5. TEAM (Trauma Evaluation And Management)
    TEAM introduces the concepts of trauma assessment and management to medical students during their clinical years.
    TEAM Program should satisfy the need for a standardized introductory course in the evaluation and management of trauma that can be taught to all medical students and multidisciplinary team members.
  • 6. What is ATLS®?
    a systematic, concise training to the early care of trauma patients.
    It will provide the participants with a safe, reliable method for immediate management of the injured patient and the basic knowledge necessary to:
    Assess the patient's condition rapidly and accurately
    Resuscitate and stabilize the patient according to priority
    Determine if the patient's needs exceed a facility's capabilities
    Arrange appropriately for the patient's interhospital transfer (what, who, when, and how)
    Assure that optimum care is provided
  • 7. Advanced Trauma Life Support
    a training program for doctors and Advanced Practice/Critical Care Paramedics in the management of acute trauma cases, developed by the American College of Surgeons. The program has been adopted worldwide in over 40 countries,[1] sometimes under the name of Early Management of Severe Trauma (EMST), especially outside North America. Its goal is to teach a simplified and standardized approach to trauma patients. Originally designed for emergency situations where only one doctor and one nurse are present, ATLS is now widely accepted as the standard of care for initial assessment and treatment in trauma centers. The premise of the ATLS program is to treat the greatest threat to life first. It also advocates that the lack of a definitive diagnosis and a detailed history should not slow the application of indicated treatment for life-threatening injury, with the most time-critical interventions performed early. However, there is mixed evidence to show that ATLS improves patient outcomes.
    Bouillon, B., Kanz, K.G., Lackner, C.K., Mutschler, W., & Sturm, J. The importance of Advanced Trauma Life Support (ATLS) in the emergency room [Article in German]. Unfallchirurg, 107(10), 844-850.
  • 8. ABCDE of ENT Emergency
    A – Airway & Breathing
    B – Bleeding & Circulation
    C – Call
    D – D
    E - ENT
  • 9. Primary Survey
    life-threatening injuries are identified
    simultaneously resuscitation is begun
    ABCDE
    A Airway Maintenance w/ Cervical Spine Protection
    BBreathing and Ventilation
    C Circulation with Hemorrhage Control
    D Disability (Neurologic Evaluation)
    E Exposure and Environment
  • 10. Primary Survey
    A - Airway Maintenance with Cervical Spine Protection
    assess the airway.
    chin lift or jaw thrust.
    patient's mouth should be cleaned
    cervical spine -immobilised
  • 11. Simple application for CPR
    A — Airway
    Unconscious patients
    In the unconscious patient, the priority is airway management, to avoid a preventable cause of hypoxia. Common problems with the airway of patient with a seriously reduced level of consciousness involve blockage of the pharynx by the tongue, a foreign body, or vomit.
    At a basic level, opening of the airway is achieved through manual movement of the head using various techniques, with the most widely taught and used being the "head tilt — chin lift", although other methods such as the "modified jaw thrust" can be used, especially where spinal injury is suspected,[16] although in some countries, its use is not recommended for lay rescuers for safety reasons.[15]
    Higher level practitioners such as emergency medical service personnel may use more advanced techniques, from oropharyngeal airways to intubation, as deemed necessary.[17]
    Conscious patients
    In the conscious patient, other signs of airway obstruction that may be considered by the rescuer include paradoxical chest movements, use of accessory muscles for breathing, tracheal deviation, noisy air entry or exit, and cyanosis.[18]
  • 12. Primary Survey
    B - Breathing and Ventilation
    chest must be examined
    tracheal deviation must be identified
    Life-threatening chest injuries tension
    pneumothorax,
    open pneumothorax
    flail chest
    hemothorax
  • 13. Simple application for CPR
    B — Breathing
    [edit] Unconscious patients
    In the unconscious patient, after the airway is opened the next area to assess is the patient's breathing,[15] primarily to find if the patient is making normal respiratory efforts. Normal breathing rates are between 12 and 30 breaths per minute,[18] and if a patient is breathing below the minimum rate, then in current ILCOR basic life support protocols, CPR should be considered, although professional rescuers may have their own protocols to follow, such as artificial respiration.
    Rescuers are often warned against mistaking agonal breathing, which is a series of noisy gasps occurring in around 40% of cardiac arrest victims, for normal breathing.[15]
    If a patient is breathing, then the rescuer will continue with the treatment indicated for an unconscious but breathing patient, which may include interventions such as the recovery position and summoning an ambulance.[19]
    [edit] Conscious or breathing patients
    In a conscious patient, or where a pulse and breathing are clearly present, the care provider will initially be looking to diagnose immediately life-threatening conditions such as severe asthma, pulmonary oedema or haemothorax.[18] Depending on skill level of the rescuer, this may involve steps such as:[18]
    Checking for general respiratory distress, such as use of accessory muscles to breathe, abdominal breathing, position of the patient, sweating, or cyanosis
    Checking the respiratory rate, depth and rhythm - Normal breathing is between 12 and 20 in a healthy patient, with a regular pattern and depth. If any of these deviate from normal, this may indicate an underlying problem (such as with Cheyne-Stokes respiration)
    Chest deformity and movement - The chest should rise and fall equally on both sides, and should be free of deformity. Clinicians may be able to get a working diagnosis from abnormal movement or shape of the chest in cases such as pneumothorax or haemothorax
    Listening to external breath sounds a short distance from the patient can reveal dysfunction such as a rattling noise (indicative of secretions in the airway) or stridor (which indicates airway obstruction)
    Checking for surgical emphysema which is air in the subcutaneous layer which is suggestive of a pneumothorax
    Auscultation and percussion of the chest by using a stethoscope to listen for normal chest sounds or any abnormalities
    Pulse oximetry may be useful in assessing the amount of oxygen present in the blood, and by inference the effectiveness of the breathing
  • 14. Primary Survey
    C - Circulation with Hemorrhage Control
    Hemorrhage
    Hypotension
    Hypotension
    Hypovolemic shock
    crystalloid solution
    type-specific blood, or O-negative if this is not available
    External bleeding is controlled by direct pressure.
    Occult blood loss may be into the chest, abdomen, pelvis or from the long bones.
    Chest or pelvic bleeding may be identified on X-ray.
    Bleeding into the peritoneum may be diagnosed on ultrasound (FAST scan),
    CT (if stable) or
    diagnostic peritoneal lavage.
  • 15. Simple application for CPR
    C — Circulation
    Once oxygen can be delivered to the lungs by a clear airway and efficient breathing, there needs to be a circulation to deliver it to the rest of the body.
    [edit] Non-breathing patients
    Circulation is the original meaning of the 'C' as laid down by Jude, Knickerbocker & Safar, and was intended to suggest assessing the presence or absence of circulation, usually by taking a carotidpulse, before taking any further treatment steps.
    In modern protocols for lay persons, this step is omitted as it has been proven that lay rescuers may have difficulty in accurately determining the presence or absence of a pulse, and that, in any case, there is less risk of harm by performing chest compressions on a beating heart than failing to perform them when the heart is not beating.[20] For this reason, lay rescuers proceed directly to cardiopulmonary resuscitation, starting with chest compressions, which is effectively artificial circulation. In order to simplify the teaching of this to some groups, especially at a basic first aid level, the C for 'Circulation' is changed for meaning 'CPR' or 'Compressions'.[21][22][23]
    It should be remembered, however, that health care professionals will often still include a pulse check in their ABC check, and may involve additional steps such as an immediate ECG when cardiac arrest is suspected, in order to assess heart rhythm.
    [edit] Breathing patients
    In patients who are breathing, there is the opportunity to undertake further diagnosis and, depending on the skill level of the attending rescuer, a number of assessment options are available, including:
    Observation of colour and temperature of hands and fingers where cold, blue, pink, pale, or mottled extremities can be indicative of poor circulation
    Capillary refill is an assessment of the effective working of the capillaries, and involves applying cutaneous pressure to an area of skin to force blood from the area, and counting the time until return of blood. This can be performed peripherally, usually on a fingernail bed, or centrally, usually on the sternum or forehead
    Pulse checks, both centrally and peripherally, assessing rate (normally 60-80 beats per minute in a resting adult), regularity, strength, and equality between different pulses
    Blood pressure measurements can be taken to assess for signs of shock
    Auscultation of the heart can be undertaken by medical professionals
    Observation for secondary signs of circulatory failure such as oedema or frothing from the mouth (indicative of congestive heart failure)
    ECG monitoring will allow the healthcare professional to help diagnose underlying heart conditions, including myocardial infarctions
  • 16. Primary Survey
    D - Disability (Neurologic Evaluation)
    AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive).
    A more detailed and rapid neurological evaluation is performed at the end of the primary survey.
    level of consciousness, pupil size and reaction, lateralizing signs & SCI.
    Glasgow Coma Scale a quick method to determine the level of consciousness, and is predictive of patient outcome.
  • 17. Primary Survey
    E - Exposure / Environmental control
    The patient should be completely undressed
    Hypothermia in the emergency department.
    Warm Intravenous fluids
    warm environment
    Maintain Patient privacy
  • 18. Secondary Survey
    head-to-toe evaluation
    complete history and physical examination
    reassessment of all vital signs.
    Each region of the body must be fully examined. X-rays indicated by examination
    AmalMattu; DeepiGoyal; Barrett, Jeffrey W.; Joshua Broder; DeAngelis, Michael; Peter Deblieux; Gus M. Garmel; Richard Harrigan; David Karras; Anita L'Italien; David Manthey (2007). Emergency medicine: avoiding the pitfalls and improving the outcomes. Malden, Mass: Blackwell Pub./BMJ Books. pp. 60. ISBN 1-4051-4166-2
  • 19. recovery position
    an airway management technique for assisting people who are unconscious, or nearly so, but are still breathing. It is frequently taught alongside CPR in first aid.
    An unconscious person (GCS <8) cannot be trusted to maintain his or her own breathing. Many fatalities occur where the original injury or illness which caused unconsciousness is not inherently fatal, but where the unconscious person suffocates for one of these reasons. This is a common cause of death following unconsciousness due to excessive consumption of alcohol.
    When an unconscious person is lying face upwards, there are two main risk factors which can lead to suffocation: Fluids, possibly blood but particularly vomit, can collect in the back of the throat, causing the person to drown. When a person is lying face up, the esophagus tilts down slightly from the stomach toward the throat. This, combined with loss of muscular control, can lead to the stomach contents flowing into the throat, called passive regurgitation. Fluid which collects in the back of the throat can also flow down into the lungs; stomach acid can attack the inner lining of the lungs and cause aspiration pneumonia.
    It's possible to achieve limited protection of the airway by tilting the head back and lifting the jaw. An unconscious person will not remain in this position unless held constantly, and crucially it does not safeguard against risks due to fluids. In the recovery position, the force of gravity will allow any fluids to drain. The chest is also elevated from the ground, making breathing easier.
    lateral recumbent position
  • 20. When to use the recovery position
    unconscious person who does not need CPR
    those who are too inebriated to assure their own continued breathing
    victims of drowning
    victims of suspected poisoning (who are liable to become unconscious).
  • 21. Putting a victim in the recovery position / lateral recovery position."[
    Checking carotid pulse
    If spinal or neck injuries are possible
    They should be moved to a recovery position only when it is necessary to drain vomit from the airway.
    "HAINES modified recovery position" (High Arm IN Endangered Spine.)
    one of the patient's arms is raised above the head (in full abduction) to support the head and neck.
    Less neck movement (and less degree of lateral angulation) than when the lateral recovery position is used, and, therefore, HAINES use carries less risk of spinal-cord damage.
    Pregnant victims
    always rest on her left side
    Victims with torso wounds
    wounds closest to the ground to minimize the possibility of blood affecting both lungs, resulting in asphyxiation.
  • 22. Variations
    Nearly all first aid organizations use "ABC" in some form
    'ABCD' (designed for training lay responders in defibrillation)
    'AcBCDEEEFG' (the UK ambulance service version for patient assessment).
  • 23. Variations DR ABC
    One of the most widely used adaptations is the addition of "DR" in front of "ABC", which stands for Danger and Response
    “protect yourself before attempting to help others”
    then ascertaining that the patient is unresponsive before attempting to treat them, using systems such as AVPU or the Glasgow Coma Score
    "The primary survey" St John Ambulance. http://www.sja.org.uk/sja/first-aid-advice/lifesaving-procedures/primary-survey.aspx
  • 24. Variations DRsABC
    A modification to DRABC is that when there is no response from the patient, the rescuer is told to Shout for help
    "Cardio Pulmonary Resuscitation"Centre for Excellence in Teaching and Learning. http://www.cetl.org.uk/learning/print/cpr-print.pdf
  • 25. Variations ABCD
    Defibrillation— The definitive treatment step for cardiac arrest
    Disability or Dysfunction[— Disabilities caused by the injury, not pre-existing conditions
    Deadly Bleeding
    (Differential) Diagnosis
    Decompression
    Cayley, William E, Jr (2006-05-01). "Practice guidelines: 2005 AHA guidelines for CPR and Emergency Cardiac Care“.American Family Physician. http://www.aafp.org/afp/20060501/practice.html
    Primary Trauma Care. Primary Trauma Care Foundation. 2000. ISBN 0-95-39411-08 http://av.rds.yahoo.com/www.primarytraumacare.org/PTCMain/Training/pfd/PTC_ENG.pdfRetrieved 2008-12-20.
    "Emergency First Aid with Level C CPR". Western Canada Fire & First Aid Inc. http://www.wcff.ca/crs-emrgfirstaid.htm. Retrieved 2008-12-20.
    "Cardiac Arrest associated with Pregnancy“ Circulation 112: 150–153. 2005-11-28. http://www.comtf.es/doc/RCP/CIRCULATIONPregnancy.pdf. Retrieved 2008-12-20.
    "Resuscitation. Revival should be the first priority". Postgraduation Medical Journal 89 (1): 117–20. January 1991. ISSN 0032-5481
  • 26. Variations ABCDE
    Expose and Examine
    Environment
    Escaping Air — Checking for air escaping, such as through a sucking chest wound, which could lead to a collapsed lung.
    Elimination
    Evaluate
    Primary Trauma Care. Primary Trauma Care Foundation. 2000. ISBN 0-95-39411-0-8 http//www.primarytraumacare.org/PTCMain/Training/pfd/PTC_ENG.pdf. Retrieved 2008-12-20
    Accident Compensation Corporation (June 2007). Management of burns and scalds in primary care. New Zealand Guidelines Group. http://ngc.gov/summary/summary.aspx?view_id=1&doc_id=11509
    "Resuscitation. Revival should be the first priority". Postgraduation Medical Journal 89 (1): 117–20. January 1991. ISSN 0032-5481
  • 27. Variations ABCDEF
    Fundus — pregnancy
    Family (in France) — indicates that rescuers must also deal with the witnesses and the family, who may be able to give precious information about the accident or the health of the patient, or may present a problem for the rescuer.
    Fluids — A check for obvious fluids (blood, cerebro-spinal fluid (CSF) etc.)
    Fluid resuscitation
    Final Steps — Consulting the nearest definitive care facility
    "Resuscitation. Revival should be the first priority". Postgraduation Medical Journal 89 (1): 117–20. January 1991. ISSN 0032-5481
    Accident Compensation Corporation (June 2007). Management of burns and scalds in primary care. New Zealand Guidelines Group. http://ngc.gov/summary/summary.aspx?view_id=1&doc_id=11509
    "Pediatric clinical practice guidelines for nurses in primary care". Health Canada. http://www.hc-sc.gc.ca/fniah-spnia/pubs/services/_nursing-infirm/2001_ped_guide/chap_10c-eng.php. Retrieved 2008-12-21
  • 28. Variations ABCDEFG
    Go Quickly! — A reminder to ensure all assessments and on-scene treatments are completed with speed, in order to get the patient to hospital within the Golden Hour
    Glucose — The professional rescuer may choose to perform a blood glucose test, and this can form the 'G' or alternately, the 'DEFG' can stand for "Don't Ever Forget Glucose"
  • 29. Variations AcBC
    additional (small) 'c' in between the A and B, standing for 'cervical spine' or 'consider C-spine'.
    potential neck injuries to a patient, as opening the airway may cause further damage unless a special technique is used.
    Occupational First Aid. Level 5. Further Education and Training Awards Council. July 2008. http://www.safetyireland.com/occupational_first_aid_fetac.pdf. Retrieved 2008-12-21
  • 30. Examination of the Maxillofacial Region
    Once the patient has been stabilized and cleared for cervical spinal cord injuries, the physician can begin to evaluate the maxillofacial region.
    If possible, the history of events surrounding the injury should be obtained because it can provide clues to the type of injuries the patient could have.
    For example, a sharp, penetrating injury is more likely to injure nerves and major vessels than is blunt trauma, which is more likely to result in fractures of the facial skeleton.
    Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center
    Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000
  • 31. Examination of the Maxillofacial Region
    Do you see " double"?
    binocular diplopia can indicate internal or periorbital fractures.
    It should be considered a nonspecific symptom, however, because it can also be caused by other things, most commonly periorbital edema.
    monocular diplopia might indicate an injury to the globe, for which ophthalmologic consultation is necessary.
    Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center
    Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000
  • 32. Examination of the Maxillofacial Region
    Are there any areas of numbness on your face?
    Any neurosensory deficit usually indicates a skeletal fracture has occurred surrounding the bony canals/grooves/foramina, through which the branches of the trigeminal nerves exit.
    Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center
    Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000
  • 33. Examination of the Maxillofacial Region
    Does your bite feel " normal"?
    Most mandibular and/or maxillary fractures are associated with the subjective feeling that the bite is not "normal."
    The location of premature contact of the teeth can help to direct the clinician to the site of fracture.
    Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center
    Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000
  • 34. Examination of the Maxillofacial Region
    Which areas on your face hurt? Although this question seems basic, one could find a patient who points to a location that is not swollen or bruised, such as the preauricular area, in the case of a condylar process fracture of the mandible.
    Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center
    Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000
  • 35. Examination of the Maxillofacial Region
    Does it hurt when you open your mouth? Where?
    The presence of pain when one attempts functional movements of the mandible can indicate that skeletal fractures have occurred, although contusions of the temporomandibular joint can also produce pain in the absence of skeletal fractures.
    If pain is present, however, its location helps to determine underlying fractures.
    For instance, preauricular tenderness with mandibular movement could indicate a condylar process fracture.
    Pain at the angle of the mandible could indicate a fracture in that location.
    Pain in the cheek region when one attempts to open the mouth could signify a zygomaticomaxillary complex fracture
    Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center
    Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000
  • 36. The clinical evaluation of the maxillofacial region must be organized and sequential and should be performed prior to ordering radiographs and other images. The head and neck examination must be methodical, or significant injuries can be missed. The maxillofacial examination must include the following components:
    Soft tissues
    Nerves
    Skeleton
    Dentition
    Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center
    Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000
  • 37. "inside out and bottom up."
    One approach organizes the examination from "inside out and bottom up."
    Following this recommendation, the oral cavity is inspected first for lacerations or penetrating injuries. The tongue is frequently lacerated and can produce profuse bleeding.
    Soft tissue injuries should be explored for tooth fragments and other foreign bodies.
    Areas of soft tissue swelling and ecchymosis are noted because they can indicate underlying skeletal fractures.
    Lacerations of the attached gingiva around the teeth or palate also can indicate an underlying fracture.
    Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center
    Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000
  • 38. An examination of the maxillofacial skeleton involves inspection and palpation.
    Injuries in the maxillofacial area can be associated with massive edema, which makes evaluation of the underlying skeleton difficult; however, bony contours should be palpated for irregularities and tenderness (discussed in their specific regions).
    One should always inspect carefully any fluid exiting the nose in case it could be cerebrospinal fluid (CSF).
    The presence of CSF rhinorrhea indicates disruption of the anterior cranial base, most commonly at the cribriform plate of the ethmoid bone associated with naso-orbitoethmoid fractures, or from disruption of the posterior wall of the frontal sinus.
    Areas of "numbness" on the face should make one suspect disruption of the sensory branch of the trigeminal nerve from skeletal fractures
    Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center
    Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000
  • 39. Star of Life
    Preserve Life
    Prevent Further Injury
    Promote Recovery.
    6 stages of high quality pre-hospital care:
    Early Detection
    Early Reporting
    Early Response
    Good On Scene Care
    Care in Transit
    Transfer to Definitive Care[
  • 40. Polytrauma
    Frederick Mars Untalan MD