Hyper Calcaemia


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Hyper Calcaemia

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