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INITIAL ASSESSMENT OF
TRAUMA PATIENTS
•PROF.DR.NIBEDITA PANI
HOD,DEPT. OF ANAESTHESIOLOGY
& CRITICAL CARE,SCBMCH,CUTTACK
•...
TRAUMA
THE NEGLECTED DISEASE
OF MODERN DEVELOPING
NATIONS!!!
One day it could be anyone of
us!someone from our
family;some loved one!!!
Then what???
Everyday we come across a story ab...
EPIDEMIOLOGY
 3242 persons die each day around the world
 50 million people are disabled or injured each year.
 India :...
 The tragedy of India :
78% of the victims – men, 20 to 44 years,
causing significant impact on productivity.
 A vehicul...
PITIABLE CONDITION OF INDIAN ROADS
PITIABLE ATTITUDE OF OUR
PEOPLE
Trimodal distribution of
death
GOLDEN HOUR
 The first hour following a trauma during which
aggressive resuscitation can improve the chances
of survival ...
PLATINUM MINUTES
 THE IMPORTANCE OF TIME IN TRAUMA IS
INCREASING AS EVIDENT FROM THE
EVOLUTION OF THE CONCEPT OF
“THE PLA...
INDIAN SCENARIO
 No proper pre-hospital care
 No trained emergency physicians
 No trained nursing/paramedical staff
 N...
National Crime Records Bureau, Ministry Of Home Affairs
 A total of 3,94,982 accidental deaths were reported
in the count...
INITIAL APPROACH TO
TRAUMA CARE
 Process that consists of
-Initial primary assessment
-Rapid resuscitation
-A more thorou...
OVERALL APPROACH
Anticipate the worst
Never make any assumptions
History and Exam have to make
sense
Don’t take short ...
Don’t get distracted with “ugly injuries”
OBJECTIVES
• SYSTEMIC APPROACH TO
POLYTRMA
• APPLY PRICIPLES OF PRIMARY,
SECONDARY AND TERTIARY
SURVEY
• CORRECTLYASSESS P...
TRAUMA TEAM
RADIOGRAPHER
AIRWAY DOCTOR
AIRWAY NURSE
CIRCULATION DOCTOR
CIRCULATION NURSE
ORTHO REGISTRAR
WARDSPERSON
SCRIB...
• ANATOMICAL
• PHYSIOLOGICAL
• MECHANISM
TRAUMA TEAM
ACTIVATION CRITERIA
TRAUMA TEAM
ACTIVATION CRITERIA
ANATOMICAL
 INJURY TO 2/ MORE BODY REGIONS
 FRACTURE 2/ MORE LONG BONES
 SPINAL CORD IN...
TRAUMA TEAM
ACTIVATION CRITERIA
PHYSIOLOGICAL
 SBP<90mm Hg/ PR- >130BPM
 RR<10/ >30 PER MIN
 DEPRESSED CONSCIOUSNESS
 ...
MECHANISM
 BIKER/ PEDESTRIAN HIT BY
VEHICLE>30KM/HR
 FALL>5 METRE
 FATALITY IN SAME VEHICLE
 MOTOR VEHICLE CRASH WITH
...
TEAM LEADER CHECKLIST
 Trauma team activation prior to arrival
 Name tags worn
 Universal precaution in place
 Lead go...
PRICIPLES OF INITIAL ASSESSMENT
RAPID PRIMARY
SURVEY
SIMULTANEOUS
MANAGEMENT OF
LIFE THREATNING
INJURIES
PRICIPLES OF INITIAL ASSESSMENT
APPLY
APPROPRIATE
MONITORING
DEVICES
PRICIPLES OF INITIAL ASSESSMENT
OBTAIN HISTORY
A-M-P-L-E
&
TETANUS STATUS
AMPLE
ALLERGY
MEDICATION
PAST HISTORY
LAST FOOD
...
PRICIPLES OF INITIAL ASSESSMENT
PERFORM DETAILED
SECONDARY
SURVEY(HEAD TO TOE)
PRICIPLES OF INITIAL ASSESSMENT
TRANSFER FOR
DEFINITIVE CARE
PRICIPLES OF INITIAL ASSESSMENT
APPLY
APPROPRIATE
MONITORING
DEVICES
OBTAIN HISTORY
A-M-P-L-E
&
TETANUS STATUS
RAPID PRIMA...
THE PATIENT ARRIVES
PRE-HOSPITAL INFORMATION AND
HANDOVER
M-I-S-T
 MECHANISM OF INJURY
 INJURIES SUSTAINED OR SUSPECTED
 SIGNS- VITALS ON S...
PRIMARY SURVEY
 Identify the life-threatening conditions and
manage simultaneously
–A: Airway maintenance with cervical
s...
SPECIAL GROUPS
PEDIATRIC
 Same Priorities and Approach
 Need for different amounts of
fluids and medications
 Need for ...
ELDERLY
 Diminished physiologic
reserve
 Comorbidities
– Heart disease, Diabetes, lung
disease
 Multiple medication use...
AIRWAY ASSESSMENT
AND C-SPINE CONTROL
 THE NEW A-B-C
A Airway
B Be Careful of the Airway
C Concentrate on the Airway
AIRWAY ASSESSMENT AND C-SPINE
CONTROL
PATIENT CONSCIOUS
ORIENTED
FAILS TO RESPOND
APPROPRIATELY(DROW
SY OR UNCONSCIOUS)
AS...
MILS- MANUAL IN LINE
STABILISATION
ASSUME C-SPINE INJURY UNLESS PROVEN OTHERWISE .
OBSTRUCTED AIRWAY
 PRE-INTUBATION-
– SUPPLEMENT OXYGEN
– OROPHARYNGEAL SUCTION
– JAW THRUST
– ORO-PHARYNGEAL AIRWAY
 RAP...
 ADVANCED AIRWAY TECNIQUES-
– FOB
– specialised laryngoscopes
– Bougies
– double lumen tubes
 Laryngeal injury-immediate...
BREATHING AND VENTILATION
 Do not confuse airway problem for ventilation problem
 Patent airway does not equal adequate ...
BREATHING WITH SUPPLEMENTAL
OXYGEN
 INSPECT:Equal chest rise,paradoxical chest
movements,contusion,sucking chest
wound,di...
TENSION PNEUMOTHORAX
 RESPIRATORY DISTRESS
 HYPERINFLATED CHEST
 DEVIATED TRACHEA
 DECREASED MOVEMENT
 DECREASED BREA...
MASSIVE HEMOTHORAX
 SIGNS SIMILAR TO TENSION
PNEUMOTHORAX EXCEPT DULLNESS ON
PERCUSSION
 SHOCK
 T/T- TUBE THORACOSTOMY
...
OPEN PNEUMOTHORAX
 CHEST TUBE AT SITE
SEPARATE TO DEFECT
 COVER WOUND WITH 3
SIDES GAUZE
 DEFINITIVE
DEBRIDEMENT IN OT
FLAIL CHEST
 >2 RIB FRACTURES
IN 2 OR MORE PLACES
 PARADOXICAL
CHESTWALL
MOVEMENT
 ADEQUATE
VENTILATION
 REEXPAND LUNG...
PERICARDIAL TAMPONADE
 PENETRATING INJURY
 BECKS TRIAD
 ECHO/ FAST
 EMERGENCY ROOM THORACOTOMY/
URGENT THORACOTOMY
 E...
CIRCULATION AND HEMORRHAGE
CONTROL ASSESS-
– PULSE RATE AND CHARACTER
– SKIN COLOUR AND TEMPERATURE
– CONSCIOUS LEVEL(GCS...
IDENTIFY
 External hemorrhage
– Apply direct pressure
– No tourniquets except for traumatic amputations
 Be aware of pos...
Primary Survey - Circulation
Table 251-4 Estimated Fluid and Blood Losses Based on Patient's Initial
Presentation
Class I ...
MANAGEMENT OF
CIRCULATION
 Control bleeding with direct pressure
 Splint limb fractures
 Insert 2 large bore IV cannula...
Fluid replacement:adults upto 2-3 lt
crystalloid/colloid,
Children 20 ml/kg
Blood replacement
O neg,group specific or ...
PITFALLS IN CIRCULATION
 Elderly - limited ability to increase HR
– BP often has little correlation to Cardiac output
 C...
DISABILITY AND NEUROLOGIC
STATUS
Disability assessed by AVPU scale
 A. Alert i.e.obeys commands
 V. vocalises-inappropri...
GLASGOW COMA SCALE
Variables Score
Eye opening Spontaneous
To speech
To pain
None
4
3
2
1
Verbal response Oriented
Confuse...
EXPOSE
You can’t treat what you don’t
find!
If you don’t look, you won’t see!
EXPOSURE
RESUSCITATION
 Protect/Secure airway & protect C-spine
 Breathing/Ventilation/Oxygenation
 Vigorous shock therapy
– At ...
PRIMARY SURVEY ADJUNCTS:-
MONITOR
 VITALS
 ECG
 FOLEY’S CATHETER
 GASTRIC TUBE
 ABG
 PULSE OXIMETER
 URINE OUTPUT
PRIMARY SURVEY ADJUNCTS:- MONITOR
APPLY
APPROPRIATE
MONITORING
DEVICES
FOLEY’S CATHETER
 CONTRAINDICATED IN URETHRAL
INJURY
 SUSPECT URETHRAL NJURY
– INABILITY TO VOID
– UNSTABLE PELVIC FRACT...
GASTRIC TUBE
 RELIEVE GASTRIC DILATATION
 DECOMPRESS STOMACH BEFORE DPL
 REDUCE RISK OF ASPIRATION
 N.G TUBE – C.I. IN...
PRIMARY SURVEY ADJUNCTS:-
DIAGNOSIS
 CXR
 PELVIS AP
 LATERAL C-SPINE
 DPL
 FAST
A PATIENT BROUGHT TO E.D. WITH
M- CAR DRIVER HIT TREE ON ROAD
SIDE(UNDER INFLUENCE OF
ALCOHOL)
I- HEAD AND CHEST
S- PR- 10...
 ON PRIMARY SURVEY
– AIRWAY- CLEAR
– GCS- 7/15
– BREATHING-RR- 30/min, DECRASED BREATH
SOUNDS ON LEFT LUNG FIELD, HYPER-
...
 X-RAY PELVIS- NAD
 FAST- COLLECTION IN ALL QUADRANTS
 OT NOTIFIED FOR URGENT
LAPAROTOMY
 DISABILITY- GCS- 7/15, PUPIL...
BEFORE SECONDARY SURVEY
 Complete primary survey
 Establish resuscitation
 Normalization of vital functions
SECONDARY SURVEY
The complete
history and
physical
examination
SECONDARY SURVEY
History
Physical exam: head to toe
“Tubes OR fingers in every orifice”
Complete neurological exam
Sp...
Secondary survey
History
“AMPLE”
A:Allergies
M:Medication currently being taken by the patient
P:Past illness and operatio...
Secondary survey
HEAD
 Signs of skull base
fracture
 Pupillary size
 Hemorrhages of
conjunctiva/fundi
 Visual acuity
...
Secondary survey
MAXILLOFACIAL
 Associated with airway obstruction or major
bleeding
 Fracture cribriform plate
 No NG ...
Secondary survey
NECK
 Cervical tenderness, subcutaneous
emphysema
 Oesophageal injury
 Tracheal/laryngeal injury
 Car...
Secondary survey
CHEST
 Inspect
 Palpate
 Percuss
 Auscultate
 Obtain x-rays
Secondary survey
ABDOMEN
 Inspect
 Auscultate
 Palpate
 Percuss
 Reevaluate
 Special studies
Secondary survey
 Perineum:contusion,hematoma, laceration,urethral
blood
 Rectum:sphincter tone,high riding prostate,pel...
Secondary survey
Musculoskeletal
 Contusion, deformity
 Pain
 Perfusion
 Peripheral
neurovascular status
 X-ray
Secondary survey
Neurologic: brain
GCS Score
Lateralizing signs
Frequent reevaluation
Prevent secondary brain
injury
N...
ADJUNCTS TO SECONDARY
SURVEY
Special diagnostic tests as indicate
 CT
 Contrast x-ray studies
 Extremity x-ray
 Endosc...
DEFINITIVE CARE
 OR
 ICU
 Refer
DAMAGE CONTROL
 Multi trauma pt. triad of
coagulopathy,hypothermia,met
abolic acidosis-interfernce with
surgical mgt
 Go...
TERTIARY SURVEY
 Completed within 24 hours and documented
on designated forms
 Review of diagnostic tests and examinatio...
PAIN CONTROL
 Relief of pain is an important part of the
management of the trauma patient
 Titrate IV opiates and anxiol...
A GOOD BEGINNING ALMOST
ASSURES SUCCESS!!!
EMERGENCIES DON’T GIVE US
A SECOND CHANCE…..
Medicine is not the exact science,
I shall use my experience, knowledge
and judgement to its best,
I may go wrong or anyth...
I guarantee nothing but my honest
effort and care for you,
I am not God, but well-trained
professional wanting to take car...
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELINES)Trauma ppt
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELINES)Trauma ppt
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELINES)Trauma ppt
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELINES)Trauma ppt
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELINES)Trauma ppt
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELINES)Trauma ppt
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELINES)Trauma ppt
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELINES)Trauma ppt
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELINES)Trauma ppt
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INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELINES)Trauma ppt

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THIS PRESENTATION WAS MADE AT IMA HOUSE IN BHUBANESWAR,ODISHA, BY DR.NIBEDITA PANI,HOD ,DEPT. OF ANAESTHESIOLOGY AND DR.PRERNA BISWAL,PG,ANAESTHESIOLOGY,SCBMCH,CUTTACK,

Published in: Healthcare

INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELINES)Trauma ppt

  1. 1. INITIAL ASSESSMENT OF TRAUMA PATIENTS •PROF.DR.NIBEDITA PANI HOD,DEPT. OF ANAESTHESIOLOGY & CRITICAL CARE,SCBMCH,CUTTACK •DR.PRERNA BISWAL,SCBMCH.
  2. 2. TRAUMA THE NEGLECTED DISEASE OF MODERN DEVELOPING NATIONS!!!
  3. 3. One day it could be anyone of us!someone from our family;some loved one!!! Then what??? Everyday we come across a story about someone’s loved one dying on the road and just ignore it focussing on our day to day life!!!
  4. 4. EPIDEMIOLOGY  3242 persons die each day around the world  50 million people are disabled or injured each year.  India : 1%of motor vehicles in the world but bears the burden of 6% of global vehicular accidents.  Unfortunately, a majority of trauma survivors are either confined to bed or wheel chair for the rest of their lives
  5. 5.  The tragedy of India : 78% of the victims – men, 20 to 44 years, causing significant impact on productivity.  A vehicular accident reported every 3 min and a death every 6 min on Indian roads
  6. 6. PITIABLE CONDITION OF INDIAN ROADS
  7. 7. PITIABLE ATTITUDE OF OUR PEOPLE
  8. 8. Trimodal distribution of death
  9. 9. GOLDEN HOUR  The first hour following a trauma during which aggressive resuscitation can improve the chances of survival and restore the normal functions.  Early pre-hospital care, early transport, aggressive resuscitation and interventions in ED, continued care in ICU have a definite and significant role in preventing deaths due to trauma.
  10. 10. PLATINUM MINUTES  THE IMPORTANCE OF TIME IN TRAUMA IS INCREASING AS EVIDENT FROM THE EVOLUTION OF THE CONCEPT OF “THE PLATINUM TEN MINUTES”
  11. 11. INDIAN SCENARIO  No proper pre-hospital care  No trained emergency physicians  No trained nursing/paramedical staff  No coordination between different specialties MOST OF THE TRAUMA REALTED DEATHS ARE PREVENTABLE AND ITS HIGH TIME TO REALISE THIS FACT!!!
  12. 12. National Crime Records Bureau, Ministry Of Home Affairs  A total of 3,94,982 accidental deaths were reported in the country during 2012  17 States/UTs have constituted high risk areas reporting higher rates of ‘accidental deaths’ than the all-India average of 32.6 deaths per one lakh of population.  Odisha has higher rate of ‘accidental deaths’ than the all-India average i.e. 33.1. ODISHAACCIDENTAL DEATHS IN COMPARISION TO NATIONAL DATA
  13. 13. INITIAL APPROACH TO TRAUMA CARE  Process that consists of -Initial primary assessment -Rapid resuscitation -A more thorough secondary assessment -Followed by diagnostic tests and disposition.
  14. 14. OVERALL APPROACH Anticipate the worst Never make any assumptions History and Exam have to make sense Don’t take short cuts Document frequently TEAMWORK
  15. 15. Don’t get distracted with “ugly injuries”
  16. 16. OBJECTIVES • SYSTEMIC APPROACH TO POLYTRMA • APPLY PRICIPLES OF PRIMARY, SECONDARY AND TERTIARY SURVEY • CORRECTLYASSESS PRIORITIES IN MANAGEMENT OF POLYTRAUMA
  17. 17. TRAUMA TEAM RADIOGRAPHER AIRWAY DOCTOR AIRWAY NURSE CIRCULATION DOCTOR CIRCULATION NURSE ORTHO REGISTRAR WARDSPERSON SCRIBE NURSETEAM LEADERSOCIAL WORKER
  18. 18. • ANATOMICAL • PHYSIOLOGICAL • MECHANISM TRAUMA TEAM ACTIVATION CRITERIA
  19. 19. TRAUMA TEAM ACTIVATION CRITERIA ANATOMICAL  INJURY TO 2/ MORE BODY REGIONS  FRACTURE 2/ MORE LONG BONES  SPINAL CORD INJURY  AMPUTATION OF LIMB  PENETRATING INJURY TO HEAD, NECK TORSO/ PROX. LIMB  BURNS> 15% IN ADULTS, >10% IN CHILDREN, AIRWAY BURNS  AIRWAY OBSTRUCTION
  20. 20. TRAUMA TEAM ACTIVATION CRITERIA PHYSIOLOGICAL  SBP<90mm Hg/ PR- >130BPM  RR<10/ >30 PER MIN  DEPRESSED CONSCIOUSNESS  AGE>70YR WITH CHEST INJURY  PREGNANCY>24 WEEKS WITH TORSO INJURY
  21. 21. MECHANISM  BIKER/ PEDESTRIAN HIT BY VEHICLE>30KM/HR  FALL>5 METRE  FATALITY IN SAME VEHICLE  MOTOR VEHICLE CRASH WITH EJECTION TRAUMA TEAM ACTIVATION CRITERIA
  22. 22. TEAM LEADER CHECKLIST  Trauma team activation prior to arrival  Name tags worn  Universal precaution in place  Lead gowns in place  X-ray cassette in place  Warmed i.v fluids hanging  O-neg blood ready, blood warmer and rapid infuser ready  Trauma surgeon notified if SBP<90mm Hg  Theatre notified  Radiology notified
  23. 23. PRICIPLES OF INITIAL ASSESSMENT RAPID PRIMARY SURVEY SIMULTANEOUS MANAGEMENT OF LIFE THREATNING INJURIES
  24. 24. PRICIPLES OF INITIAL ASSESSMENT APPLY APPROPRIATE MONITORING DEVICES
  25. 25. PRICIPLES OF INITIAL ASSESSMENT OBTAIN HISTORY A-M-P-L-E & TETANUS STATUS AMPLE ALLERGY MEDICATION PAST HISTORY LAST FOOD EVENTS
  26. 26. PRICIPLES OF INITIAL ASSESSMENT PERFORM DETAILED SECONDARY SURVEY(HEAD TO TOE)
  27. 27. PRICIPLES OF INITIAL ASSESSMENT TRANSFER FOR DEFINITIVE CARE
  28. 28. PRICIPLES OF INITIAL ASSESSMENT APPLY APPROPRIATE MONITORING DEVICES OBTAIN HISTORY A-M-P-L-E & TETANUS STATUS RAPID PRIMARY SURVEY SIMULTANEOUS MANAGEMENT OF LIFE THREATNING INJURIES PERFORM DETAILED SECONDARY SURVEY(HEAD TO TOE) TRANSFER FOR DEFINITIVE CARE
  29. 29. THE PATIENT ARRIVES
  30. 30. PRE-HOSPITAL INFORMATION AND HANDOVER M-I-S-T  MECHANISM OF INJURY  INJURIES SUSTAINED OR SUSPECTED  SIGNS- VITALS ON SCENE AND DURING TRANSPORT  TREATMENT INITIATED
  31. 31. PRIMARY SURVEY  Identify the life-threatening conditions and manage simultaneously –A: Airway maintenance with cervical spine protection –B: Breathing and ventilation –C: Circulation with hemorrhage control –D: Disability ( Neurologic status ) –E: Exposure ( Undress the patient &
  32. 32. SPECIAL GROUPS PEDIATRIC  Same Priorities and Approach  Need for different amounts of fluids and medications  Need for equipment of varying sizes PREGNANT WOMEN  Same Priorities and approach  Anatomic and physiologic changes  Potential two patients not one  “TREAT THE MOTHER TO TREAT THE FETUS”
  33. 33. ELDERLY  Diminished physiologic reserve  Comorbidities – Heart disease, Diabetes, lung disease  Multiple medication use  Increased risk of death for any given injury compared to younger patient
  34. 34. AIRWAY ASSESSMENT AND C-SPINE CONTROL  THE NEW A-B-C A Airway B Be Careful of the Airway C Concentrate on the Airway
  35. 35. AIRWAY ASSESSMENT AND C-SPINE CONTROL PATIENT CONSCIOUS ORIENTED FAILS TO RESPOND APPROPRIATELY(DROW SY OR UNCONSCIOUS) ASK TO COUGH C/I- EYE INJ., PULM. BAROTRAUMA, TBI, SPINAL INJ ASK TO TAKE DEEP BREATHS ASSESS UPPER AIRWAY, CHEST EXPANSION YES (VOCALISES NORMALLY) THREATENED AIRWAY MANDATORY INTUBATION 1. GCS<9 2. SEVERE FACIAL INJURY OR BLEED 3. SEVERE FACIAL OR NECK BURNS CONSIDER INTUBATION 1. COMBATIVE PATIENTS 2. GCS -9-12 3. FACIAL OR NECK INJURY WITH IMPENDING AIRWAY COMPROMISE(PENETRATING INJURY) NAD SUPPLEMENTAL O2 CERVICAL COLLAR
  36. 36. MILS- MANUAL IN LINE STABILISATION ASSUME C-SPINE INJURY UNLESS PROVEN OTHERWISE .
  37. 37. OBSTRUCTED AIRWAY  PRE-INTUBATION- – SUPPLEMENT OXYGEN – OROPHARYNGEAL SUCTION – JAW THRUST – ORO-PHARYNGEAL AIRWAY  RAPID SEQUENCE INDUCTION AND ENDO-TRACHEAL INTUBATION  DIFFICULT AIRWAY ANTICIPATED- – AIRWAY INJURY – HEAD AND NECK INJURY – SHORT NECK – REDUCED MOUTH OPENING – UNDERSLUNG JAW  SURGICAL AIRWAY – CAN’T INTUBATE – DISTORTED ANATOMY  IN FAILED INTUBATION – LMA AS BRIDGE
  38. 38.  ADVANCED AIRWAY TECNIQUES- – FOB – specialised laryngoscopes – Bougies – double lumen tubes  Laryngeal injury-immediate tracheostomy  Atleast 3 assistants required FOR INTUBATION-  MILS  cricoid pressure  DRUGS
  39. 39. BREATHING AND VENTILATION  Do not confuse airway problem for ventilation problem  Patent airway does not equal adequate ventilation.  Need good gas exchange – Oxygen in – CO2 out Rapid assessment of  RR  SPO2  TRACHEA  CHEST EXPANSION  PERCUSSION  AUSCULTATION
  40. 40. BREATHING WITH SUPPLEMENTAL OXYGEN  INSPECT:Equal chest rise,paradoxical chest movements,contusion,sucking chest wound,distended neck veins  AUSCULTATE: equal breath sounds,absence of breath sounds  PALPATE:Trachea,chest wall tenderness,subcutaneous emphysema,sternal and rib fracture  PERCUSS:dullness,hyperresonance  If you think about giving oxygen, GIVE IT!!!!!
  41. 41. TENSION PNEUMOTHORAX  RESPIRATORY DISTRESS  HYPERINFLATED CHEST  DEVIATED TRACHEA  DECREASED MOVEMENT  DECREASED BREATHSOUND  TACHYCARDIA  HYPOTENSIONNEEDLE THORACOSTOMY VIA 2ND ICS IN MCL FOLLOWED BY DEFINITIVE CHEST TUBE (4TH- 5TH ICS JUST ANTERIOR TO MAL CONNECTED TO WATER UNDER SEAL DRAIN)
  42. 42. MASSIVE HEMOTHORAX  SIGNS SIMILAR TO TENSION PNEUMOTHORAX EXCEPT DULLNESS ON PERCUSSION  SHOCK  T/T- TUBE THORACOSTOMY – THORACOTOMY IN  >1500ml DRAIN IMMEDIATELY  >200ml/hr FOR 4 HOURS – CONTACT CTVS EARLY.
  43. 43. OPEN PNEUMOTHORAX  CHEST TUBE AT SITE SEPARATE TO DEFECT  COVER WOUND WITH 3 SIDES GAUZE  DEFINITIVE DEBRIDEMENT IN OT
  44. 44. FLAIL CHEST  >2 RIB FRACTURES IN 2 OR MORE PLACES  PARADOXICAL CHESTWALL MOVEMENT  ADEQUATE VENTILATION  REEXPAND LUNGS: INTUBATION, IPPV, CTVS CONSULTATION
  45. 45. PERICARDIAL TAMPONADE  PENETRATING INJURY  BECKS TRIAD  ECHO/ FAST  EMERGENCY ROOM THORACOTOMY/ URGENT THORACOTOMY  ER THORACOTOMY IS CONTRAINDICATED IN MOST CARDIAC ARRESTS TO BLUNT TRAUMA HYPOTENSION DISTENDED NECK VEINS MUFFLED HEART SOUND
  46. 46. CIRCULATION AND HEMORRHAGE CONTROL ASSESS- – PULSE RATE AND CHARACTER – SKIN COLOUR AND TEMPERATURE – CONSCIOUS LEVEL(GCS) – CAPILLARY REFILL TIME – DECREASED URINE OUTPUT – HYPOTENSION-A LATE SIGN WHEN≥ 30% BLOOD VOLUME LOST.  Stopping the bleeding:most important priority
  47. 47. IDENTIFY  External hemorrhage – Apply direct pressure – No tourniquets except for traumatic amputations  Be aware of possible sources of internal bleeding both from blunt and penetrating trauma – Chest – Abdomen – Pelvic Fractures – Long Bone Fractures
  48. 48. Primary Survey - Circulation Table 251-4 Estimated Fluid and Blood Losses Based on Patient's Initial Presentation Class I Class II Class III Class IV Blood loss (mL)* Up to 750 750–1500 1500–2000 >2000 Blood loss (percent blood volume) Up to 15 15–30 30–40 40 Pulse rate <100 100–120 120–140 >140 Blood pressure Normal Normal Decreased Decreased Pulse pressure (mm Hg) Normal or increased Decreased Decreased Decreased *Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.
  49. 49. MANAGEMENT OF CIRCULATION  Control bleeding with direct pressure  Splint limb fractures  Insert 2 large bore IV cannulas in adults or cut down on long saphenous v  Send off blood-cross match,coagulation screen,Hb, hct,biochemistry,blood alcohol level if req  Intraosseous needle in children upto 10 yrs
  50. 50. Fluid replacement:adults upto 2-3 lt crystalloid/colloid, Children 20 ml/kg Blood replacement O neg,group specific or fully cross matched packed cells Remember other blood product requirements: ffp, cryoppt, platelets
  51. 51. PITFALLS IN CIRCULATION  Elderly - limited ability to increase HR – BP often has little correlation to Cardiac output  Children - abundant reserve, appear stable then crash  Medication use (Beta Blockers)  Have an attitude of skepticism regarding a patient’s “normal” blood pressure.
  52. 52. DISABILITY AND NEUROLOGIC STATUS Disability assessed by AVPU scale  A. Alert i.e.obeys commands  V. vocalises-inappropriate or incomprehensible  P. Responsds to pain  U. Unresponsive NEUROLOGIC ASSESSMENT-GCS SCALE,pupil reaction to light,limb movement – Consider possible injuries-depressed skull fractures, EDH, SDH, SAH, DAI, spinal injury – Clearing the cervical spine-no spinal tenderness,normal conscious state,normal neurlogical examination,no major distracting injury,..collar may be removed and no further investigation required
  53. 53. GLASGOW COMA SCALE Variables Score Eye opening Spontaneous To speech To pain None 4 3 2 1 Verbal response Oriented Confused conversation Inappropriate words Incomprehensible sounds None 5 4 3 2 1 Best motor response Obeys commands Localizes pain Normal flexion Abnormal flexion Extension None 6 5 4 3 2 1
  54. 54. EXPOSE You can’t treat what you don’t find! If you don’t look, you won’t see!
  55. 55. EXPOSURE
  56. 56. RESUSCITATION  Protect/Secure airway & protect C-spine  Breathing/Ventilation/Oxygenation  Vigorous shock therapy – At last two large - caliber IV line – Crystalloid solution ( Ringer’s lactate 2~3 litter) – Type-specific blood – surgical intervention  Protect from Hypothermia : 39oC warm IV fluid  Urinary/gastric catheters unless contraindication
  57. 57. PRIMARY SURVEY ADJUNCTS:- MONITOR  VITALS  ECG  FOLEY’S CATHETER  GASTRIC TUBE  ABG  PULSE OXIMETER  URINE OUTPUT
  58. 58. PRIMARY SURVEY ADJUNCTS:- MONITOR APPLY APPROPRIATE MONITORING DEVICES
  59. 59. FOLEY’S CATHETER  CONTRAINDICATED IN URETHRAL INJURY  SUSPECT URETHRAL NJURY – INABILITY TO VOID – UNSTABLE PELVIC FRACTURE – BLOOD AT MEATUS – SCROTAL HEMATOMA – PERINEAL ECCHYMOSIS – HIGH RIDING PROSTATE
  60. 60. GASTRIC TUBE  RELIEVE GASTRIC DILATATION  DECOMPRESS STOMACH BEFORE DPL  REDUCE RISK OF ASPIRATION  N.G TUBE – C.I. IN BASILAR SKULL #
  61. 61. PRIMARY SURVEY ADJUNCTS:- DIAGNOSIS  CXR  PELVIS AP  LATERAL C-SPINE  DPL  FAST
  62. 62. A PATIENT BROUGHT TO E.D. WITH M- CAR DRIVER HIT TREE ON ROAD SIDE(UNDER INFLUENCE OF ALCOHOL) I- HEAD AND CHEST S- PR- 100/MIN; BP-90/60mm Hg; RR- 30/ min T- 20 Gz i.v. line- 2 pints NS; O2 inhalation Case Study
  63. 63.  ON PRIMARY SURVEY – AIRWAY- CLEAR – GCS- 7/15 – BREATHING-RR- 30/min, DECRASED BREATH SOUNDS ON LEFT LUNG FIELD, HYPER- RESONANT – SpO2- 84% – CXR- LEFT PNEUMOTHORAX INTUBATE WITH MILS ICTD- 5TH ICS CIRCULATION-MEANWHILE BP IS 84/62mm Hg DESPITE 1.5 L FLUID NO VISIBLE SOURCE OF BLOOD LOSS P/A RIGIDITY MORE IN RUQ, ABDOMINAL DISTENSION, B.S.- PRESENT.
  64. 64.  X-RAY PELVIS- NAD  FAST- COLLECTION IN ALL QUADRANTS  OT NOTIFIED FOR URGENT LAPAROTOMY  DISABILITY- GCS- 7/15, PUPIL- B/L NSERL  EXPOSURE PRIOR TO OT- RULE-OUT HIDDEN INJURIES  DAMAGE CONTROL LAPAROTOMY  PATIENT SHIFTED TO ICU FOR OBSERVATION AND FURTHER MANAGEMENT.
  65. 65. BEFORE SECONDARY SURVEY  Complete primary survey  Establish resuscitation  Normalization of vital functions
  66. 66. SECONDARY SURVEY The complete history and physical examination
  67. 67. SECONDARY SURVEY History Physical exam: head to toe “Tubes OR fingers in every orifice” Complete neurological exam Special diagnosis tests Re-evaluation
  68. 68. Secondary survey History “AMPLE” A:Allergies M:Medication currently being taken by the patient P:Past illness and operations,pregnancy L:Last meal E:Event/Environment related to the injury
  69. 69. Secondary survey HEAD  Signs of skull base fracture  Pupillary size  Hemorrhages of conjunctiva/fundi  Visual acuity  Penetrating injury  Contact lens  Dislocation of lens  Hyphaema  Ocular movement  Posterior scalp laceration
  70. 70. Secondary survey MAXILLOFACIAL  Associated with airway obstruction or major bleeding  Fracture cribriform plate  No NG tube [performed oral route]
  71. 71. Secondary survey NECK  Cervical tenderness, subcutaneous emphysema  Oesophageal injury  Tracheal/laryngeal injury  Carotid injury (penetrating/blunt)
  72. 72. Secondary survey CHEST  Inspect  Palpate  Percuss  Auscultate  Obtain x-rays
  73. 73. Secondary survey ABDOMEN  Inspect  Auscultate  Palpate  Percuss  Reevaluate  Special studies
  74. 74. Secondary survey  Perineum:contusion,hematoma, laceration,urethral blood  Rectum:sphincter tone,high riding prostate,pelvic fracture,rectal wall integrity,blood  Vagina:blood,laceration
  75. 75. Secondary survey Musculoskeletal  Contusion, deformity  Pain  Perfusion  Peripheral neurovascular status  X-ray
  76. 76. Secondary survey Neurologic: brain GCS Score Lateralizing signs Frequent reevaluation Prevent secondary brain injury Neurologic: spine and cord Complete motor and sensory exams Imaging as indicated Reflexes
  77. 77. ADJUNCTS TO SECONDARY SURVEY Special diagnostic tests as indicate  CT  Contrast x-ray studies  Extremity x-ray  Endoscopy  Ultrasound
  78. 78. DEFINITIVE CARE  OR  ICU  Refer
  79. 79. DAMAGE CONTROL  Multi trauma pt. triad of coagulopathy,hypothermia,met abolic acidosis-interfernce with surgical mgt  Goal- 1.control hmg 2. prevent contamination 3. protect pt. from further injury  Proceed to definitive surgery once pt stabilises  Clear communication between surgeon,anesthesiologist and intensivist
  80. 80. TERTIARY SURVEY  Completed within 24 hours and documented on designated forms  Review of diagnostic tests and examination of pt to ensure all injuries have been idntified
  81. 81. PAIN CONTROL  Relief of pain is an important part of the management of the trauma patient  Titrate IV opiates and anxiolytics  Be aware that these agents can hypotension and respiratory depression
  82. 82. A GOOD BEGINNING ALMOST ASSURES SUCCESS!!! EMERGENCIES DON’T GIVE US A SECOND CHANCE…..
  83. 83. Medicine is not the exact science, I shall use my experience, knowledge and judgement to its best, I may go wrong or anything with patient may go wrong anytime
  84. 84. I guarantee nothing but my honest effort and care for you, I am not God, but well-trained professional wanting to take care of patients

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