Initial Assessment And Management

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Initial Assessment and management

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Initial Assessment And Management

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

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