This document provides guidelines for the initial assessment and management of trauma patients, outlining the primary survey using the ABCDE approach to identify and treat life-threatening injuries, ensure adequate breathing and ventilation, establish intravenous access for fluid resuscitation, and conduct a full secondary survey to identify all injuries. It describes mechanisms of blunt and penetrating trauma, preparation of the trauma team, and interventions for airway management and spinal immobilization during the primary survey.
GEMC - Musculoskeletal Emergencies - for NursesOpen.Michigan
This is a lecture by Katherine A Perry from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This document defines and describes head injuries, including types of injuries such as closed and open head injuries. It discusses mechanisms of primary and secondary brain injuries. It also outlines signs and symptoms, diagnosis including imaging tests, and treatment for both the acute and chronic stages. Treatment in the acute stage focuses on the ABCDE approach, increasing ICP management, and surgery if needed. Long term complications and prevention methods are also mentioned.
This document defines and describes head injuries and their mechanisms and treatment. It begins by defining head injury and traumatic brain injury. It then describes different types of head injuries like open or closed injuries. It outlines primary and secondary brain injuries and different types of brain hematomas and edema that can occur. The document discusses signs, symptoms, assessments like the Glasgow Coma Scale, treatments like managing increased intracranial pressure, and expected outcomes for patients with head injuries.
Este documento proporciona información sobre la pericardiocentesis, un procedimiento médico para drenar el exceso de líquido del pericardio. Explica que la pericardiocentesis se usa para tratar derrames pericárdicos y taponamientos cardíacos, e incluye detalles sobre cómo realizar el procedimiento de manera segura a través de la vía subxifoidea u otras vías de acceso. También describe los posibles riesgos como la punción miocárdica y las infecciones.
El documento habla sobre el diagnóstico y tratamiento del trauma abdominal, que representa el 15% de las muertes traumáticas. Explica que el trauma abdominal se divide en dos tipos dependiendo de su mecanismo de acción, y que las pruebas de diagnóstico dependen de la estabilidad hemodinámica del paciente. También menciona que la gravedad de las lesiones depende de factores como la fuerza del impacto, la región afectada y el estado de conciencia del paciente.
Este documento describe las principales enfermedades del pericardio, incluyendo la pericarditis aguda, el derrame pericárdico, el taponamiento cardíaco y la pericarditis constrictiva. Se detalla la anatomía, fisiopatología, síntomas, signos, diagnóstico y tratamiento de cada una de estas afecciones. Adicionalmente, se explica el procedimiento de la pericardiocentesis.
1. Abdominal trauma is commonly encountered in emergency departments and can be life-threatening. Blunt and penetrating injuries can cause damage to solid organs like the spleen, liver, and pancreas.
2. A thorough primary and secondary survey is essential to identify injuries. Diagnostic tools like FAST ultrasound, CT scans, and laparoscopy help evaluate injuries. Conservative management is appropriate for many mild organ injuries.
3. Splenic injuries require close monitoring or surgery depending on grade. Liver injuries often stop bleeding spontaneously but may require packing or resection. Pancreatic injuries are difficult to diagnose and usually repaired surgically. Proper identification and treatment of abdominal injuries is critical for patient outcomes.
El documento describe diferentes tipos de lesiones traumáticas en la cabeza incluyendo hematomas epidurales, hematomas subdurales y fracturas de cráneo. Explica la etiología, clasificación, síntomas y tratamiento de cada lesión.
GEMC - Musculoskeletal Emergencies - for NursesOpen.Michigan
This is a lecture by Katherine A Perry from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This document defines and describes head injuries, including types of injuries such as closed and open head injuries. It discusses mechanisms of primary and secondary brain injuries. It also outlines signs and symptoms, diagnosis including imaging tests, and treatment for both the acute and chronic stages. Treatment in the acute stage focuses on the ABCDE approach, increasing ICP management, and surgery if needed. Long term complications and prevention methods are also mentioned.
This document defines and describes head injuries and their mechanisms and treatment. It begins by defining head injury and traumatic brain injury. It then describes different types of head injuries like open or closed injuries. It outlines primary and secondary brain injuries and different types of brain hematomas and edema that can occur. The document discusses signs, symptoms, assessments like the Glasgow Coma Scale, treatments like managing increased intracranial pressure, and expected outcomes for patients with head injuries.
Este documento proporciona información sobre la pericardiocentesis, un procedimiento médico para drenar el exceso de líquido del pericardio. Explica que la pericardiocentesis se usa para tratar derrames pericárdicos y taponamientos cardíacos, e incluye detalles sobre cómo realizar el procedimiento de manera segura a través de la vía subxifoidea u otras vías de acceso. También describe los posibles riesgos como la punción miocárdica y las infecciones.
El documento habla sobre el diagnóstico y tratamiento del trauma abdominal, que representa el 15% de las muertes traumáticas. Explica que el trauma abdominal se divide en dos tipos dependiendo de su mecanismo de acción, y que las pruebas de diagnóstico dependen de la estabilidad hemodinámica del paciente. También menciona que la gravedad de las lesiones depende de factores como la fuerza del impacto, la región afectada y el estado de conciencia del paciente.
Este documento describe las principales enfermedades del pericardio, incluyendo la pericarditis aguda, el derrame pericárdico, el taponamiento cardíaco y la pericarditis constrictiva. Se detalla la anatomía, fisiopatología, síntomas, signos, diagnóstico y tratamiento de cada una de estas afecciones. Adicionalmente, se explica el procedimiento de la pericardiocentesis.
1. Abdominal trauma is commonly encountered in emergency departments and can be life-threatening. Blunt and penetrating injuries can cause damage to solid organs like the spleen, liver, and pancreas.
2. A thorough primary and secondary survey is essential to identify injuries. Diagnostic tools like FAST ultrasound, CT scans, and laparoscopy help evaluate injuries. Conservative management is appropriate for many mild organ injuries.
3. Splenic injuries require close monitoring or surgery depending on grade. Liver injuries often stop bleeding spontaneously but may require packing or resection. Pancreatic injuries are difficult to diagnose and usually repaired surgically. Proper identification and treatment of abdominal injuries is critical for patient outcomes.
El documento describe diferentes tipos de lesiones traumáticas en la cabeza incluyendo hematomas epidurales, hematomas subdurales y fracturas de cráneo. Explica la etiología, clasificación, síntomas y tratamiento de cada lesión.
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This is a lecture by Dr. Patrick Carter from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
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This is a lecture from the Ghana Emergency Medicine Collaborative (GEMC). To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Tim Maxim from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
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Pediatric trauma requires special considerations due to anatomical and physiological differences in children compared to adults. The general approach of primary and secondary surveys still applies, but equipment, dosing, and techniques must be tailored based on a child's age and size. Airway management poses unique challenges in children due to their smaller and more easily obstructed airways. Proper preparation with appropriately sized equipment is critical for pediatric trauma resuscitation.
1. The document discusses pediatric orthopedic emergencies, focusing on the unique aspects of pediatric musculoskeletal injuries compared to adults.
2. Key differences include the pediatric skeleton being less dense, more porous, and still growing, making children more prone to certain injury patterns like plastic deformity fractures.
3. The document reviews mechanisms of injury, uniquely pediatric fractures, and the initial approach to pediatric orthopedic trauma, emphasizing immobilization and careful evaluation for other injuries.
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This document provides an overview of resources for disaster health information. It describes a training session that covers locating peer-reviewed literature, grey literature, surveillance data and tools from organizations like NLM, CDC and WHO. The document discusses classifying disaster-related topics in subject headings and evaluating sources. It also demonstrates NLM's WISER, REMM and CHEMM applications for hazardous materials, radiation and chemical incidents. Finally, it explores using social media, apps and alerts to stay updated on disaster health issues.
This lecture discusses how health information technology can help facilitate error reporting and analysis to improve patient safety. It presents three key HIT mechanisms: automated surveillance systems, online event reporting systems, and predictive analytics/data modeling. The lecture also emphasizes the importance of a culture of safety that encourages open discussion and learning from mistakes without blame. Error reports are analyzed using a risk assessment model to distinguish near misses from events that cause patient harm.
Sustainability Risk Management: Where Local and Global Perspectives MeetDallas College
I. UNT is a leader in sustainability initiatives in Texas and among universities nationally, with many current and planned projects focused on reducing energy usage and waste.
II. Sustainability risk management involves identifying and addressing economic, environmental and social risks and opportunities to maximize benefits for all three areas.
III. At UNT, this includes projects focused on renewable energy, green building, alternative transportation, and waste reduction that can save money while protecting the environment and human health.
A lecture on uncertainty by Dr. Rajesh Mangrulkar, M.D. This lecture was taught as a part of the University of Michigan Medical School's M1 - Patients and Populations Sequence.
View the course materials:
http://open.umich.edu/education/med/m1/patientspop-decisionmaking/2010/materials
Creative Commons Attribution-Non Commercial-Share Alike 3.0 License
http://creativecommons.org/licenses/by-nc-sa/3.0/
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This document provides an overview of the M2 Musculoskeletal Sequence curriculum at the University of Michigan Medical School in Fall 2009. The goals are to learn the musculoskeletal exam, common musculoskeletal disorders and treatments, forms of arthritis, autoimmune disorders, and metabolic bone diseases. The curriculum includes lectures, pathology labs, physical exam sessions, case discussions and is graded based on exams, participation and practice sessions. The overall aim is to improve musculoskeletal education and prepare students for managing related conditions.
The document discusses using systems science and computational social science approaches to improve community resilience for health, from everyday situations to disasters. It proposes moving beyond emergency preparedness to address the full spectrum of health issues through approaches that are scalable, adoptable, and encompassing. Key areas discussed include injury prevention, decision support tools, simulation, sensor networks, and addressing social and behavioral factors.
Sociotechnical Aspects: Clinicians and Technology_ lecture 1_slidesZakCooper1
This lecture focused on medical errors and patient safety. It distinguished between individual "slips" and "mistakes" as well as system errors. Several types of medical errors were examined like medication errors and wrong site surgeries. Efforts to improve patient safety through initiatives like medication reconciliation were also discussed. The lecture concluded by reviewing organizations driving improvements in patient safety and quality of care.
GEMC: The Management of Acute Ischemic Stroke & TIAOpen.Michigan
This is a lecture from the Ghana Emergency Medicine Collaborative (GEMC) To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc.
Instrumentation Writing Assignment
Word Limit: 2000
Unit Learning Outcomes assessed:
1. Explain and assess the basic design and practical working conditions of alternate imaging instruments employing radiation for appropriate use in regard to maximising clinical utilisation and minimising radiation and electromechanical risks
2. Critically assess the safe working conditions of specialised instruments in regard to radiation protection, electromechanical safety, appropriate regulations or standards
3. Implement and evaluate a basic quality assurance program on specialised x-ray imaging equipment to ensure accurate and safe outcomes
The purpose of this writing assignment is to encourage students to apply the knowledge of safe operation of specialised X-ray imaging equipment learnt from the unit into the clinical workplace. The safe operation of equipment encompasses the aspects of radiation protection, electromechanical safety and clinical utilisation in compliance with appropriate regulations and standards. Awareness and practice of safe operation are crucial in imaging practice. Infringement may lead to serious issues such as injury and even death. Quality Assurance (Q A) program is one way to minimize the likelihood of occurrence of such issues (Option 1). Another preventive measure is education to increase practitioners’ awareness and knowledge (Option 2).
Some students may have difficulties to get access to specialised X-ray imaging equipment during clinical placement / semester. In this situation, you can select Option 2. In this option, students are required to identify a particular X-ray imaging system (e.g. manufacturer A – model YYY mobile X-ray machine) through different manufacturers’ websites (some examples are given below) and develop a safe operation guide for it. The identified system must be within the ranges of systems for portable / mobile radiography, tomography, fluoroscopy, mammography and angiography. The main purpose of this guide is to educate practitioners the safe operation principles of a particular system. The following is the list of required contents for Option 2.
1. Introduction
• Provide relevant details (e.g. manufacturer, model, type, etc.) of the chosen system (only one is required)
• Suggest necessity of a safe operation guide for the chosen system
• N.B.: You can obtain relevant details of an imaging system from its manufacturer’s website, for example:
Carestream Health (http://www.carestreamhealth.com)
Fujifilm Corporation (http://www.fujifilm.com/products/medical/)
GE Healthcare (http://www.gehealthcare.com)
Gendex Dental Systems (http://www.gendex.com)
Koninklijke Philips Electronics N.V. (http://medical.philips.com)
Siemens AG. (http://www.medical.siemens.com)
Toshiba Corporation (http://www.medical.toshiba.com)
2. Safe Operation Details
• Provide necessary radiation protection measures in relation to the features of the chosen system
• Provide necessary measures for safeguarding elect.
Sociotechnical Aspects: Clinicians and Technology Lecture 2_slidesZakCooper1
This document discusses patient safety and the sociotechnical aspects of clinicians using technology. It describes how agencies like The Joint Commission promote patient safety through standards and regulations. Organizations work to improve safety through methods like emphasizing hand hygiene, properly using antibiotics, and identifying infectious patients. Technology enhances safety when coupled with improvements in work processes, though adapting work to technology is challenging.
This document summarizes a presentation given at a patient safety conference about implementing a "just culture" approach at Tawam Hospital in the United Arab Emirates. It discusses adopting the Comprehensive Unit-based Safety Program (CUSP) to assess safety culture, educate staff, and improve communication and teamwork. Initial surveys found room for improvement in safety attitudes. CUSP was expanded to more units over time and subsequent surveys showed increases in positive safety culture scores. Infection rates like CLABSI declined as well. The presentation highlights challenges faced and lessons learned from the culture change journey.
This document discusses the role of epidemiology in disasters. It defines disasters and lists different types, including natural disasters and terrorism. It notes that from 1994-2004 there were over a million natural disasters worldwide. Factors like population growth, poverty, and environmental degradation increase disaster severity. The document emphasizes that epidemiology is important for assessing needs, injuries, and diseases after disasters, as well as evaluating response efforts. It outlines challenges for epidemiologists in disaster settings like infrastructure losses and time pressures. Overall, the document promotes standardized disaster health information and evidence-based responses.
Krish Sankaranarayanan has over 24 years of experience in healthcare and holds multiple degrees including an MS in Patient Safety Leadership. He discussed the historical context of patient safety including figures like Florence Nightingale and Dr. Codman who helped establish standards. High reliability organizations have zero tolerance for errors, unlike healthcare which has error rates comparable to less safe industries. Common causes of medical errors include miscommunication and lack of standardized processes. The presentation provided tools and techniques to improve safety including accreditation, checklists, and focusing on system design rather than individual blame.
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
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This is a lecture by Dr. Patrick Carter from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
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Pediatric trauma requires special considerations due to anatomical and physiological differences in children compared to adults. The general approach of primary and secondary surveys still applies, but equipment, dosing, and techniques must be tailored based on a child's age and size. Airway management poses unique challenges in children due to their smaller and more easily obstructed airways. Proper preparation with appropriately sized equipment is critical for pediatric trauma resuscitation.
1. The document discusses pediatric orthopedic emergencies, focusing on the unique aspects of pediatric musculoskeletal injuries compared to adults.
2. Key differences include the pediatric skeleton being less dense, more porous, and still growing, making children more prone to certain injury patterns like plastic deformity fractures.
3. The document reviews mechanisms of injury, uniquely pediatric fractures, and the initial approach to pediatric orthopedic trauma, emphasizing immobilization and careful evaluation for other injuries.
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This document provides an overview of resources for disaster health information. It describes a training session that covers locating peer-reviewed literature, grey literature, surveillance data and tools from organizations like NLM, CDC and WHO. The document discusses classifying disaster-related topics in subject headings and evaluating sources. It also demonstrates NLM's WISER, REMM and CHEMM applications for hazardous materials, radiation and chemical incidents. Finally, it explores using social media, apps and alerts to stay updated on disaster health issues.
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I. UNT is a leader in sustainability initiatives in Texas and among universities nationally, with many current and planned projects focused on reducing energy usage and waste.
II. Sustainability risk management involves identifying and addressing economic, environmental and social risks and opportunities to maximize benefits for all three areas.
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View the course materials:
http://open.umich.edu/education/med/m1/patientspop-decisionmaking/2010/materials
Creative Commons Attribution-Non Commercial-Share Alike 3.0 License
http://creativecommons.org/licenses/by-nc-sa/3.0/
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This document provides an overview of the M2 Musculoskeletal Sequence curriculum at the University of Michigan Medical School in Fall 2009. The goals are to learn the musculoskeletal exam, common musculoskeletal disorders and treatments, forms of arthritis, autoimmune disorders, and metabolic bone diseases. The curriculum includes lectures, pathology labs, physical exam sessions, case discussions and is graded based on exams, participation and practice sessions. The overall aim is to improve musculoskeletal education and prepare students for managing related conditions.
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This lecture focused on medical errors and patient safety. It distinguished between individual "slips" and "mistakes" as well as system errors. Several types of medical errors were examined like medication errors and wrong site surgeries. Efforts to improve patient safety through initiatives like medication reconciliation were also discussed. The lecture concluded by reviewing organizations driving improvements in patient safety and quality of care.
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Instrumentation Writing Assignment
Word Limit: 2000
Unit Learning Outcomes assessed:
1. Explain and assess the basic design and practical working conditions of alternate imaging instruments employing radiation for appropriate use in regard to maximising clinical utilisation and minimising radiation and electromechanical risks
2. Critically assess the safe working conditions of specialised instruments in regard to radiation protection, electromechanical safety, appropriate regulations or standards
3. Implement and evaluate a basic quality assurance program on specialised x-ray imaging equipment to ensure accurate and safe outcomes
The purpose of this writing assignment is to encourage students to apply the knowledge of safe operation of specialised X-ray imaging equipment learnt from the unit into the clinical workplace. The safe operation of equipment encompasses the aspects of radiation protection, electromechanical safety and clinical utilisation in compliance with appropriate regulations and standards. Awareness and practice of safe operation are crucial in imaging practice. Infringement may lead to serious issues such as injury and even death. Quality Assurance (Q A) program is one way to minimize the likelihood of occurrence of such issues (Option 1). Another preventive measure is education to increase practitioners’ awareness and knowledge (Option 2).
Some students may have difficulties to get access to specialised X-ray imaging equipment during clinical placement / semester. In this situation, you can select Option 2. In this option, students are required to identify a particular X-ray imaging system (e.g. manufacturer A – model YYY mobile X-ray machine) through different manufacturers’ websites (some examples are given below) and develop a safe operation guide for it. The identified system must be within the ranges of systems for portable / mobile radiography, tomography, fluoroscopy, mammography and angiography. The main purpose of this guide is to educate practitioners the safe operation principles of a particular system. The following is the list of required contents for Option 2.
1. Introduction
• Provide relevant details (e.g. manufacturer, model, type, etc.) of the chosen system (only one is required)
• Suggest necessity of a safe operation guide for the chosen system
• N.B.: You can obtain relevant details of an imaging system from its manufacturer’s website, for example:
Carestream Health (http://www.carestreamhealth.com)
Fujifilm Corporation (http://www.fujifilm.com/products/medical/)
GE Healthcare (http://www.gehealthcare.com)
Gendex Dental Systems (http://www.gendex.com)
Koninklijke Philips Electronics N.V. (http://medical.philips.com)
Siemens AG. (http://www.medical.siemens.com)
Toshiba Corporation (http://www.medical.toshiba.com)
2. Safe Operation Details
• Provide necessary radiation protection measures in relation to the features of the chosen system
• Provide necessary measures for safeguarding elect.
Sociotechnical Aspects: Clinicians and Technology Lecture 2_slidesZakCooper1
This document discusses patient safety and the sociotechnical aspects of clinicians using technology. It describes how agencies like The Joint Commission promote patient safety through standards and regulations. Organizations work to improve safety through methods like emphasizing hand hygiene, properly using antibiotics, and identifying infectious patients. Technology enhances safety when coupled with improvements in work processes, though adapting work to technology is challenging.
This document summarizes a presentation given at a patient safety conference about implementing a "just culture" approach at Tawam Hospital in the United Arab Emirates. It discusses adopting the Comprehensive Unit-based Safety Program (CUSP) to assess safety culture, educate staff, and improve communication and teamwork. Initial surveys found room for improvement in safety attitudes. CUSP was expanded to more units over time and subsequent surveys showed increases in positive safety culture scores. Infection rates like CLABSI declined as well. The presentation highlights challenges faced and lessons learned from the culture change journey.
This document discusses the role of epidemiology in disasters. It defines disasters and lists different types, including natural disasters and terrorism. It notes that from 1994-2004 there were over a million natural disasters worldwide. Factors like population growth, poverty, and environmental degradation increase disaster severity. The document emphasizes that epidemiology is important for assessing needs, injuries, and diseases after disasters, as well as evaluating response efforts. It outlines challenges for epidemiologists in disaster settings like infrastructure losses and time pressures. Overall, the document promotes standardized disaster health information and evidence-based responses.
Krish Sankaranarayanan has over 24 years of experience in healthcare and holds multiple degrees including an MS in Patient Safety Leadership. He discussed the historical context of patient safety including figures like Florence Nightingale and Dr. Codman who helped establish standards. High reliability organizations have zero tolerance for errors, unlike healthcare which has error rates comparable to less safe industries. Common causes of medical errors include miscommunication and lack of standardized processes. The presentation provided tools and techniques to improve safety including accreditation, checklists, and focusing on system design rather than individual blame.
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1. Project: Ghana Emergency Medicine Collaborative
Document Title: Initial Assessment and Management of Trauma Patients
Author(s): Patrick Carter (University of Michigan), MD 2012
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3. Objectives
Epidemiology of Trauma Care
History of Development of Trauma Care
Mechanisms of Injury
Basics of Trauma Management
–
–
–
–
–
Primary Survey
Resuscitation
Secondary Survey
ABCDE Format
Cervical Spinal Immobilization
Specific Case Examples
3
5. Epidemiology
Road Traffic Accidents are major cause of long term morbidity and
mortality in developing nations
– In the first quarter of 2009, 372 deaths in Ghana from Road Traffic
Accidents
– 25% increase from previous year
WHO predicts that by 2020, Road Traffic Accidents will be second
leading cause of loss of life for world’s population
High Morbidity = Loss of income to society
Challenges in Developing Countries
– Technological Advances in Trauma Care
– Lack of Infrastructure for Trauma Management
EMS
Pre-hospital notification
MD/RN Training in trauma care
5
6. • 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
Injury: Scale of the Global Problem
6
7. Injury: Scale of the Global Problem
Source: World Report on Road Traffic Injury Prevention 2004
World Health Organization, who.int
7
8. Epidemiology
Trimodal Distribution of Trauma Deaths
Golden Hour = 80% of trauma deaths
in first hour after injury
Rapid trauma care has greatest level
of impact in these patients
50%
30%
20%
Immediately
Hours
Days/Weeks
8
9. History of Trauma System Development
Standardized Trauma Assessment
– Nebraska Cornfield, 1976
– Orthopedic Surgeon
– Lead to development of ATLS
Trauma Systems Development
– First developed my military in wartime
i.e. MASH Units
Otisarchives1 (flickr)
– Expanded in US to Level 1, 2, 3 Trauma Centers
Urban Systems
Statewide networks of systems
Level 1 – Highest level of care, Leaders in research, clinical
care and education
Level 2 – Provides definitive care in wide range of complex
traumatic patients
Level 3 – Provides initial stabilization and treatment. May
care for uncomplicated trauma patients
Level 4 – Provides initial stabilization and transfers all
trauma patients for definitive care
9
10. Mechanisms of Injury
Blunt Trauma
– Compression Forces
Cells in tissues are compressed and crushed
E.g. Spleen
– Shear Forces
Acceleration/Deceleration Injury
E.g. Aorta
– Shearing force = Spectrum from Full thickness tear
(Exsanguination) to Partial tear (Pseudoaneurysm)
– Overpressure
Body cavity compressed at a rate faster than the tissue
around it, resulting in rupture of the closed space
E.g. Plastic bag
E.g. in trauma = diaphragmatic rupture, bladder injury
10
11. Mechanisms of Injury
Frontal Impact Collisions
Lateral Impact Collisions (T bone)
Rear Impact Collisions
Rollover Mechanism
Open Vehicle or Motorcycle/Moped
Pedestrian Vs. Car
Penetrating Injury (Guns vs. Knives)
Nico.se (flickr)
Vincent J Brown (flickr)
Juicyrai (flickr)
Knockhill (flickr)
Nxtiak (flickr)
11
12. Basics of Trauma Assessment
Preparation
– Team Assembly
– Equipment Check
Triage
– Sort patients by level of acuity (SATS)
Primary Survey
– Designed to identify injuries that are immediately life threatening and to treat
them as they are identified
Resuscitation
– Rapid procedures and treatment to treat injuries found in primary survey
before completing the secondary survey
Secondary Survey
– Full History and Physical Exam to evaluate for other traumatic injuries
Monitoring and Evaluation, Secondary adjuncts
Transfer to Definitive Care
– ICU, Ward, Operating Theatre, Another facility
12
13. Preparation for Patient Arrival
Organize Trauma
Response Team
Top and bottom images:
http://www.trauma.org/archive/resus/traumateam.html
13
14. Primary Survey
Airway and Protection of Spinal Cord
Breathing and Ventilation
Circulation
Disability
Exposure and Control of the Environment
14
15. Primary Survey
Key Principles
– When you find a problem during the
primary survey, FIX IT.
– If the patient gets worse, restart from the
beginning of the primary survey
– Some critical patients in the Emergency
Department may not progress beyond
the primary survey
15
16. Airway and Protection of Spinal Cord
Why first in the algorithm?
– Loss of airway can result in death in < 3 minutes
– Prolonged hypoxia = Inadequate perfusion, End-organ damage
Airway Assessment
–
–
–
–
–
Vital Signs = RR, O2 sat
Mental Status = Agitation, Somnolent, Coma
Airway Patency = Secretions, Stridor, Obstruction
Traumatic Injury above the clavicles
Ventilation Status = Accessory muscle use, Retractions, Wheezing
Clinical Pearls
– Patients who are speaking normally generally do not have a need
for immediate airway management
– Hoarse or weak voice may indicate a subtle tracheal or laryngeal
injury
– Noisy respirations frequently indicates an obstructed respiratory
pattern
16
17. Airway Interventions
Maintenance of Airway Patency
– Suction of Secretions
– Chin Lift/Jaw thrust
– Nasopharyngeal Airway
– Definitive Airway
Dept. of the Army, Wikimedia Commons
Airway Support
– Oxygen
– NRBM (100%)
– Bag Valve Mask
– Definitive Airway
Ignis, Wikimedia Commons
Definitive Airway
– Endotracheal Intubation
In-line cervical stabilization
– Surgical Crichothyroidotomy
U.S. Navy photo by Photographer's
Mate 2nd Class Timothy Smith,
Wikimedia Commons
17
18. Protection of Spinal Cord
General Principle: Protect the entire spinal cord until injury has been
excluded by radiography or clinical physical exam in patients with
potential spinal cord injury.
Spinal Protection
– Rigid Cervical Spinal Collar = Cervical Spine
– Long rigid spinal board or immobilization on flat surface such as
stretcher = T/L Spine
Etiology of Spinal Cord Injury (U.S.)
– Road Traffic Accidents (47%)
– High energy falls (23%)
Clinical Pearls
–
–
–
–
–
Treatment (Immobilization) before diagnosis
Return head to neutral position
Do not apply traction
Diagnosis of spinal cord injury should not precede resuscitation
Motor vehicle crashes and falls are most commonly associated with
spinal cord injuries
– Main focus = Prevention of further injury
18
19. C-spine Immobilization
Return head to neutral position
Maintain in-line stabilization
Correct size collar application
Blocks/tape
Sandbags
James Heilman, MD, Wikimedia Commons
Paladinsf
(flickr)
19
20. Breathing and Ventilation
General Principle: Adequate gas exchange is required to
maximize patient oxygenation and carbon dioxide elimination
Breathing/Ventilation Assessment:
– Exposure of chest
– General Inspection
Tracheal Deviation
Accessory Muscle Use
Retractions
Absence of spontaneous breathing
Paradoxical chest wall movement
– Auscultation to assess for gas exchange
Equal Bilaterally
Diminished or Absent breath sounds
– Palpation
Deviated Trachea
Broken ribs
Injuries to chest wall
20
21. Breathing and Ventilation
Identify Life Threatening Injuries
Delldot (wikimedia)
– Tension Pneumothorax
Air trapping in the pleural space
between the lung and chest wall
Sufficient pressure builds up and
pressure to compress the lungs and
shift the mediastinum
Physical exam
–
–
–
–
Absent breath sounds
Air hunger
Distended neck veins
Tracheal shift
Treatment
– Needle Decompression
2nd Intercostal space, Midclavicular line
– Tube Thoracostomy
5th Intercostal space, Anterior axillary
Author unknown,
line
www.meddean.luc.edu/lumenMedEd/medicine/pulmonar/cxr/pneumo1.ht
m
21
22. Breathing and Ventilation
Hemothorax
– Blood collecting in the pleural space and is
common after penetrating and blunt chest
trauma
– Source of bleeding = Lung, Chest wall
(intercostal arteries), heart, great vessels
(Aorta), Diaphragm
– Physical Exam
Author unknown,
http://www.trauma.org/index.php/mai
n/images/C11/
Absent or diminished breath sounds
Dullness to percussion over chest
Hemodynamic instability
– Treatment = Large Caliber Tube Thoracostomy
10-20% of cases will require Thoracostomy for control of bleeding
22
23. Breathing and Ventilation
Flail Chest
http://images1.clinicaltools.com/images/trauma
/flail_chest_wounded.gif
– Direct injury to the chest resulting in an
unstable segment of the chest wall that moves
separately from remainder of thoracic cage
– Typically results from two or more fractures on
2 or more ribs
– Typically accompanied by a pulmonary
contusion
– Physical exam = paradoxical movement of chest
segment
– Treatment = improve abnormalities in gas
exchange
Early intubation for patients with respiratory
distress
Avoidance of overaggressive fluid resuscitation
Author unknown, http://www.surgicaltutor.org.uk/defaulthome.htm?specialities/cardiothoracic/chest_trauma
23
24. Breathing and Ventilation
Open Pneumothorax
– Sucking Chest Wound
– Large defect of chest wall
Author unknown,
http://www.trauma.org/index.php/main/image/
902/
Leads to rapid equilibration of
atmospheric and intrathoracic pressure
Impairs oxygenation and ventilation
– Initial Treatment
Three sided occlusive dressing
Provides a flutter valve effect
Chest tube placement remote to site of
wound
Avoid complete dressing, will create a
tension pneumothorax
Middle and bottom images:
Author unknown,
http://www.brooksidepress.org/Products/Ope
rationalMedicine/DATA/operationalmed/Pro
cedures/TreataSuckingChestWound.htm
24
25. Needle Thoracostomy
Needle Thoracostomy
– Midclavicular line
– 14 gauge angiocath
– Over the 2nd rib
– Rush of air is heard
Author unknown,
www.trauma.org/index.php/main/article
/199/index.php?main/image/95/
25
26. Tube Thoracostomy
Insertion site
–
–
5th intercostal space,
Anterior axillary line
Sterile prep, anesthesia with lidocaine
2-3 cm incision along rib margin with #10 blade
Dissect through subcutaneous tissues to rib margin
Puncture the pleura over the rib
Advance chest tube with clamp and direct posteriorly and
apically
Observe for fogging of chest tube, blood output
Suture the tube in place
Complications of Chest Tube Placement
–
–
Author unknown,
http://www.trauma.org/images/image_lib –
–
rary/chest0051a.jpg
–
–
Injury to intercostal nerve, artery, vein
Injury to lung
Injury to mediastinum
Infection
Allergic reaction to lidocaine
Inappropriate placement of chest tube
26
27. Shock
Circulation
– Impaired tissue perfusion
– Tissue oxygenation is inadequate to meet metabolic demand
– Prolonged shock state leads to multi-organ system failure and cell
death
Clinical Signs of Shock
– Altered mental status
– Tachycardia (HR > 100) = Most common sign
– Arterial Hypotension (SBP < 120)
Femoral Pulse – SBP > 80
Radial Pulse – SBP > 90
Carotid Pulse – SBP > 60
– Inadequate Tissue Perfusion
Pale skin color
Cool clammy skin
Delayed cap refill (> 3 seconds)
Altered LOC
Decreased Urine Output (UOP < 0.5 mL/kg/hr)
27
28. Circulation
Types of Shock in Trauma
– Hemorrhagic
Assume hemorrhagic shock in all trauma patients until proven
otherwise
Results from Internal or External Bleeding
– Obstructive
Cardiac Tamponade
Tension Pneumothorax
– Neurogenic
Spinal Cord injury
Sources of Bleeding
– Chest
– Abdomen
– Pelvis
– Bilateral Femur Fractures
28
29. Circulation
Emergency Nursing Treatment
– Two Large IV Lines
– Cardiac Monitor
– Blood Pressure Monitoring
General Treatment Principles
– Stop the bleeding
Apply direct pressure
Temporarily close scalp lacerations
– Close open-book pelvic fractures
Abdominal pelvic binder/bed sheet
– Restore circulating volume
Crystalloid Resuscitation (2L)
Administer Blood Products
– Immobilize fractures
Responders vs. Nonresponders
– Transient response to volume resuscitation = sign of ongoing blood loss
– Non-responders = consider other source for shock state or operating room
for control of massive hemorrhage
29
30. Circulation
Pericardial Tamponade
Pericardium
Blood
– Pericardium or sac around heart fills with
blood due to penetrating or blunt injury to
chest
– Beck’s Triad
Distended jugular veins
Hypotension
Muffled heart sounds
– Treatment
Epicardium
Aceofhearts1968(Wikimedia)
Rapid evacuation of pericardial space
Performed through a pericardiocentesis
(temporizing measure)
Open thoracotomy
30
31. Pericardiocentesis
Puncture the skin 1-2 cm inferior to xiphoid process
45/45/45 degree angle
Advance needle to tip of left scapula
Withdraw on needle during advance of needle
Preferable under ultrasound guidance or EKG lead V
attachment
Complications
Author unknown,
http://www.trauma.org/images/image_library/ch
est0054_thumb.jpg
– Aspiration of ventricular blood
– Laceration of coronary arteries, veins,
epicardium/myocardium
– Cardiac arrhythmia
– Pneumothorax
– Puncture of esophagus
– Puncture of peritoneum
Author unknown,
www.brooksidepress.org/ProductsTrauma_Surgery?M=A
31
32. Circulation
A word about cardiac arrest . . .
– Care of the trauma patient in
cardiac arrest
CPR
Bilateral Tube Thoracostomy
Pericardiocentesis
Volume Resuscitation
– Traumatic cardiac arrest due to
blunt injury has very low survival
rate (< 1%)
No point for emergency thoracotomy
Author unknown,
http://www.trauma.org/images/image_library/chest0
046.jpg
– Selected cases of cardiac arrest due
to penetrating traumatic injury may
benefit from emergent
thoracotomy
Pericardial tamponade
Cross clamp aorta
32
33. Disability
Baseline Neurologic Exam
– Pupillary Exam
Dilated pupil – suggests transtentorial herniation on ipsilateral side
– AVPU Scale
Alert
Responds to verbal stimulation
Responds to pain
Unresponsive
– Gross Neurological Exam – Extremity Movement
Equal and symmetric
Normal gross sensation
– Glasgow Coma Scale: 3-15
– Rectal Exam
Normal Rectal Tone
Note: If intubation prior to neuro assessment, consider quick
neuro assessment to determine degree of injury
33
34. Glasgow Coma Scale
Disability
GCS ≤ 8
Intubate
– Eye
Spontaneously opens
To verbal command
To pain
No response
4
3
2
1
– Best Motor Response
Obeys verbal commands
Localizes to pain
5
Withdraws from pain
Flexion to pain (Decorticate Posturing)
Extension to pain (Decerebrate Posturing)
No response
6
4
3
2
1
– Verbal Response
Oriented/Conversant
Disoriented/Confused
Inappropriate words
Incomprehensible words
No response
5
4
3
2
1
34
35. Disability
Key Principles
– Precise diagnosis is not necessary at this point in
evaluation
– Prevention of further injury and identification of
neurologic injury is the goal
– Decreased level of consciousness = Head injury until
proven otherwise
– Maintenance of adequate cerebral perfusion is key
to prevention of further brain injury
Adequate oxygenation
Avoid hypotension
– Involve neurosurgeon early for clear intracranial
lesions
35
36. Disability
Cervical Spinal Clearance
– Patients must be alert and oriented to person,
place and time
– No neurological deficits
– Not clinically intoxicated with alcohol or drugs
– Non-tender at all spinous processes
– No distracting injuries
– Painless range of motion of neck
36
37. Exposure
Remove all clothing
– Examine for other signs of injury
– Injuries cannot be diagnosed until seen by provider
Logroll the patient to examine patient’s back
– Maintain cervical spinal immobilization
– Palpate along thoracic and lumbar spine
– Minimum of 3 people, often more providers required
Avoid hypothermia
– Apply warm blankets after removing clothes
– Hypothermia = Coagulopathy
Increases risk of hemorrhage
37
40. Trauma Logroll
One person =
Cervical spine
Two people =
Roll main
body
One person =
Inspect back
and palpate
spine
Cdang, Wikimedia Commons
40
41. Secondary Survey
Secondary Survey is completed after primary
survey is completed and patient has been
adequately resuscitated.
No patient with abnormal vital signs should
proceed through a secondary survey
Secondary Survey includes a brief history
and complete physical exam
41
46. Physical Exam
Battle Sign
Raccoon's Eyes
Cullen’s Sign
http://sfghed.ucsf.edu/Education/Cli
nicImages/Battle's%20sign.jpg
Accessed 9/20/09 – Yahoo Images
http://healthpictures.com/eye/PeriorbitalEcchymosis.htm
Accessed 9/20/09 – Yahoo Images
Grey-Turner’s Sign
H. L. Fred and H.A. van
Dijk (Wikimedia)
H. L. Fred and H.A. van Dijk
(Wikimedia)
46
47. Adjuncts to Secondary Survey
Radiology
– Standard emergent films
C-spine, CXR, Pelvis
– Focused Abdominal Sonography in Trauma
(FAST)
– Additional films
Cat scan imaging
Angiography
Foley Catheter
– Blood at urethral meatus = No Foley catheter
Pain Control
Tetanus Status
Antibiotics for open fractures
47
48. FAST Exam
• Focused Abdominal Sonography in Trauma
• 4 views of the abdomen to look for fluid.
– RUQ/Morrison’s pouch
– Sub-xiphoid – view of heart
– LUQ – view of spleno-renal junction
– Bladder – view of pelvis
48
49. FAST
• Has largely replaced deep peritoneal lavage
(DPL)
• Bedside ultrasound looking for blood
collection in an unstable patient.
• If the patient is unstable and a blood
collection is found, proceed emergently to
the operating theater.
49
50. FAST
• Sensitivity of 94.6%
• Specificity of 95.1%
• Overall accuracy of 94.9% in identifying the
presence of intra-abdominal injuries.
– Yoshil: J Trauma 1998; 45
50
51. FAST
Right Upper Quadrant - Morrison’s Pouch
• Between the liver and kidney in RUQ.
• First place that fluid collects in supine
patient.
51
52. FAST Exam - RUQ
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ult
rasoundfast.htm
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ult
rasoundfast.htm
52
53. FAST – Sub-xiphoid
• Evaluate for pericardial fluid
• View through liver
– Transhepatic or Parasternal
• Searches for fluid between heart and
pericardium
53
54. FAST – Sub-xiphoid
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ultrasoundfa
st.htm
University of Louisville ED.
www.louisville.edu/medschool/emergmed/ultrasoundfa
st.htm
54
55. FAST – Left Upper Quadrant
• View between the spleen and kidney
• Another dependent place that fluid collects
• Also see diaphragm in this view
55
56. FAST - LUQ
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ultraso
undfast.htm
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ultraso
undfast.htm
56
57. FAST – Bladder View
• Evaluates for fluid in the pouch of Douglas
– Posterior to bladder
• Dependent potential space
57
58. FAST – Bladder View
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ultrasoundfast.h
tm
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ultrasoundfas
tm
58
59. Interpret this FAST Image:
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ultrasoundfast.htm
59
60. Trauma in Special Populations
Pregnancy
– Supine Hypotensive Syndrome
After 20 weeks, enlarged uterus with fetus and
amniotic fluid compresses inferior vena cava
Decreases venous return and decrease cardiac
output
Keep pregnant patients in left lateral decubitus
position to avoid excessive hypotension
– Optimal maternal and fetal outcome is
determined by adequate resuscitation of mother
– Fetal Monitoring
60
61. Trauma in Special Populations
Pediatric Trauma Resuscitation
– Differences in head to body ratio
and relative size and location of
anatomic features make children
more susceptible to head injury,
abdominal injury
– Underdeveloped anatomy leads to
chest pliability and less protection of
thoracic cage
– Cardiac Arrest
Typically result from respiratory
arrest degrading into cardiac
arrest
– Resuscitation
Broselow Tape
ABCDE
Author unknown,
http://dukehealth1.org/images/deps_tape4_sm.gif
61
67. Definitive Care
Secondary Survey followed by radiographic
evaluation
– CatScan
– Consultation
Neurosurgery
Orthopedic Surgery
Vascular Surgery
Transfer to Definitive Care
– Operating Room
– ICU
– Higher level facility
67
68. Case Example
Mr. Jones – 45 y/o male involved in
a rollover road traffic accident and
was ejected from the vehicle.
Patient was unrestrained. Patient
was not ambulatory on scene of
accident and is brought into
trauma bay for evaluation.
Pete Prodoehl (flickr)
– What concerns you about story?
– First steps of evaluation and
management
68
69. Case Example
Exam
– Awake, diaphoretic
– Pulse = 120
– BP = 90/60
– RR = 18
– O2 sat = 94%
What do you want to do next?
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70. Case Example
Preparation
Primary Survey
– Awake, alert, talking to provider
– Breathing
Absent breath sounds on left
What do you want to do next?
– Circulation
Vital Signs?
Access?
Resuscitation?
– IV/O2/Monitor
– Disability
GCS = 14
– Exposure
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71. Case Example
Chest tube placed
– Rush of air heard consistent with pneumothorax
Repeat Vital Signs
– Pulse 120
– BP 80/40
– RR = 15
– O2 sat = 99% NRBM
What do you want to do next?
– Patient complaining of abdominal pain
– Ecchymosis noted over left flank
– Resuscitation?
71
72. Case Example
Blood Product Administration
Transfer to definitive care = Operating Theatre
Bonemesh (flickr)
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73. Conclusion
Assessment of the trauma patient is a standard
algorithm designed to ensure life threatening injuries
do not get missed
Primary Survey + Resuscitation
– Airway
– Breathing
– Circulation
– Disability
– Exposure
Secondary Survey
Definitive Care
73
75. References
American College of Surgeons. Advanced Trauma Life
Support. 6th Edition. 1997.
Feliciano, David et al. Trauma. 6th Edition. McGraw Hill.
New York. 2008.
Hockberger, Robert et al. Rosen’s Emergency Medicine:
Concepts and Clinical Practice. 6th Edition. Mosby. 2006.
Tintinalli et al. Tintinalli’s Emergency Medicine: A
Comprehensive Study Guide. 6th Edition. McGraw Hill.
2003.
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