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EMERGENCY SURGICAL CASES (JASS 2015).pdf
- 1. Puruhito Airlangga University Medical Faculty, Dept.Surgery Division Thoracic ,Cardiac and Vascular Surgery EMERGENCY SURGICAL CASES : What is the Role of General Prac==oner in Trauma Cases?
- 2. Injury: Scale of the Global Problem • 5.8 million deaths/year • 10% of worlds deaths • 32% more deaths than HIV, TB and Malaria combined Source: Global Burden of Disease, WHO, 2004 2
- 3. Epidemiology n Golden Hour = 80% of trauma deaths in first hour after injury n Rapid trauma care has greatest level of impact in these patients Immediately Hours Days/Weeks 50% 30% 20% Trimodal DistribuLon of Trauma Deaths 3 Role of GP
- 4. Trauma Assessment Ø The iniLal assessment and management of seriously injured paLents is a challenging task and requires a rapid and systema=c approach. This systemaLc approach can be pracLsed to increase speed and accuracy of the process but good clinical judgement is also required. Ø Although described in sequence, some of the steps will be taken simultaneously. (e.g : A-B-C) INTRODUCTION (1)
- 5. Trauma Assessment Ø The aim of good trauma care is to prevent early trauma mortality. Ø Early trauma deaths occur because of failure of oxygena=on of vital organs or central nervous system injury or both. INTRODUCTION (2)
- 6. Trauma Assessment Injuries causing this mortality occur in predictable paWerns and recogniLon of these paWerns led to the development of Advanced Trauma Life Support (ATLS). A standardised protocol for trauma paLent evaluaLon has been developed. The protocol celebrated its 35th anniversary in 2015. Good teaching and applicaLon of this protocol is held to be an important factor in improving the survival of trauma vicLms worldwide. INTRODUCTION (3)
- 7. TRAUMA MANAGEMENT (1) • Aims of the ini=al evalua=on of trauma pa=ents – Stabilise the pa=ent – Iden=fy life threatening condi=ons in order of risk and ini=ate suppor=ve treatment – Organise defini=ve treatments or organise transfer for defini=ve treatments • Prepara=on and coordina=on of care Assessment and management will begin out of hospital at the scene of injury and good communica=on with the receiving hospital is important.
- 8. TRAUMA MANAGEMENT (2) • The prehospital phase – Prepara=on of a resuscita=on area – Airway equipment (laryngoscopes etc accessible, tested) – Intravenous fluids (warming equipment etc) – Immediately available monitoring equipment – Methods of summoning extra medical help – Prompt laboratory and radiology backup – Transfer arrangements with trauma centre. • Guidelines on protec=on when dealing with body fluid should be followed throughout this and subsequent procedures. Role of GP
- 9. Trauma Team General Prac==oner General Prac==oner Nurse Medical helper The preparatory measures are to “set the scene”
- 10. TRAUMA MANAGEMENT (3) General principles 1. Follow the Airway, Breathing, CirculaLon, Disability, and Exposure approach (ABCDE) to assess and treat the paLent. 2. Treat life-threatening problems as they are idenLfied before moving to the next part of the assessment. 3. ConLnually re-assess starLng with Airway if there is further deterioraLon. 4. Assess the effects of any treatment given. 5. Recognise when you need extra help and call for help early. This may mean Dialling 118 for an ambulance. 6. Use all of your resources – ask members of public for help. This will allow you to do several things at once, e.g., collect emergency drugs and equipment.
- 11. TRAUMA MANAGEMENT (4) Ini=al assessment This comprises: • Primary survey • ResuscitaLon • Secondary survey • DefiniLve treatment or transfer for definiLve care Role of GP
- 12. GCS EYE VERBAL MOTOR Spontaneous 4 Oriented 5 Obeys 6 Verbal 3 Confused 4 Localizes 5 Pain 2 Words 3 Flexion 4 None 1 Sounds 2 Decorticate 3 None 1 Decerebrate 2 None 1
- 14. EDH SDH Pelvic ring asymetry ? Thoracic cage asymetry ?
- 15. TRAUMA MANAGEMENT (5) • A= Airway maintenance cervical spine protec=on • B= Breathing and ven=la=on • C= Circula=on with haemorrhage control • D= Disability: Neurological status • E= Exposure/ environmental control
- 16. Basics of Trauma Assessment n Prepara=on – Team Assembly – Equipment Check n Triage – Sort paLents by level of acuity n Primary Survey – Designed to idenLfy injuries that are immediately life threatening and to treat them as they are idenLfied n Resuscita=on – Rapid procedures and treatment to treat injuries found in primary survey before compleLng the secondary survey n Secondary Survey – Full History and Physical Exam to evaluate for other traumaLc injuries n Monitoring and Evalua=on, Secondary adjuncts n Transfer to Defini=ve Care – ICU, Ward, OperaLng Theatre, Another facility 16 Role of GP
- 17. Primary Survey nAirway and Protec=on of Spinal Cord nBreathing and Ven=la=on nCircula=on nDisability nExposure and Control of the Environment 17
- 18. Moving the pa=ent : NEVER do it alone ! ALWAYS WITH TEAM Systema=c sequence ONE COMMAND T ogether E ach A chieves M ore
- 19. Primary Survey Key Principles – When you find a problem during the primary survey, FIX IT. – If the paLent gets worse, restart from the beginning of the primary survey – Some criLcal paLents in the Emergency Department may not progress beyond the primary survey 19
- 20. TRAUMA MANAGEMENT (6) As part of the secondary survey • History: – A=Allergies – M=MedicaLon currently used – P=Past illnesses/Pregnancy – L=Last meal – E=Events/Environment related to injury
- 21. TRAUMA MANAGEMENT (7) A= Airway maintenance cervical spine protec=on • Are there signs of airway obstrucLon, foreign bodies, facial, mandibular or laryngeal fractures? • Establish a clear airway (chin lii or jaw thrust) but protect the cervical spine at all Lmes. If the paLent can talk the airway is likely to be safe but remain vigilant and recheck. GCS less than 8 requires defini=ve airway.
- 22. TRAUMA MANAGEMENT (8) B= Breathing and ven=la=on Evaluate breathing: lungs, chest wall, diaphragm. Chest examina=on with adequate exposure: watch chest movement, auscultate, percuss to detect lesions acutely impairing ven=la=on: – Tension pneumothorax – Flail chest – Haemothorax – Pneumothorax.
- 23. TRAUMA MANAGEMENT (9) C= Circula=on with haemorrhage control • Blood loss is the main preventable cause of death aher trauma. To assess blood loss rapidly observe: – Level of consciousness – Skin colour – Pulse. • Bleeding should be assessed and controlled: – Direct manual pressure should be used (not tourniquets except for traumaLc amputaLon as these cause distal ischaemia). – Transparent pneumaLc splinLng devices may control bleeding and allow visual monitoring. – Occult bleeding into the abdominal cavity and around long bone or pelvic fractures is problemaLc.
- 24. TRAUMA MANAGEMENT (10) D= Disability: Neurological status • Aier A,B and C above rapid neurological assessment is made to establish – Level of consciousness, using Glasgow Coma Scale – Pupils: size, symmetry and reacLon – Any lateralising signs – Level of any spinal cord injury (limb movements, spontaneous respiratory effort) • Note: remember oxygenaLon, venLlaLon, perfusion, drugs, alcohol and hypoglycaemia may all also affect level of consciousness.
- 25. TRAUMA MANAGEMENT (11) E= Exposure/ environmental control • Undress paLent, but prevent hypothermia Clothes may need to be cut off, but aier examinaLon aWenLon to prevenLon of heat loss with warming devices, warmed blankets etc is important, Intravenous fluids should be warmed before infusion.
- 26. Summary • Trauma is best managed by a team approach (there’s no “I” in trauma) • A thorough primary and secondary survey is key to idenLfy life threatening injuries • Once a life threatening injury is discovered, intervenLon should not be delayed • DisposiLon is determined by the paLent’s condiLon as well as available resources.