Post on 03-Oct-2015
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Initial Assessment and Management
Initial Assessment and Management
Warren M. Roraldo M.D.,MHPEd,FPSGS,FPCS,FACS
ATLS INSTRUCTOR
Objectives
Differentiate the different mechanisms of trauma
Discuss the initial assessment and management of the trauma patient at the Emergency Room
Discuss the management of life threatening injuries at the Emergency room
Given a hypothetical situation the student should be able to apply the principles outlined in the primary and secondary surveys to the assessment and management of a multiply injured.
3 Mechanisms of Injury:
Penetrating- stab wound, gunshot or any penetrating objects to the body
Blunt- any blunt object. Example: fall, vehicular accidentBlast injury- there may be blunt because of the force there can also be penetrating because of sharp object
The goals of the primary survey are to identify and treat conditions that constitute an immediate threat to life. ATLS CONCEPT
1. ABCDE approach to evaluation and treatment
Airway
Breathing
Circulation
Deficit neurologic status
Exposure/Environmental control
-You have to undress the patient, look for possible missed injuries but you have to cover her/him with blanket after to prevent hypothermia
Why airway first?
Without oxygen patient will die. Accdg to Doc:
"Sinong mas mauunang mamatay? Yung hindi humihingi o yung nagblebleed?"
2. Treat greatest threat to life first
3. Definitive diagnosis not immediately important
4. Time is of the essence (First hour is important)
2 causes of death:
(1) on site (2) after complications
How can we decrease the incidence of death due to complications? Managing correctly the patient in the ER so that we can decrease mortality because of complications
5. Do no further harm
GOALS
Rapid and accurate assessment
Resuscitate and stabilize by priority
Determine needs and capabilities of your hospital Arrange for transfer to definitive care
Ensure optimum care
The primary survey should be repeated frequently to identify any deterioration in the patient's status that indicates the need for additional intervention.
Kunwari okay ung airaway, okay din ung B, okay din ung C, then biglang nahirapan huminga ang pasyente? Go back to A! You don't need to proceed hangga't may problema pa.
PROTECTIVE GEARS
Cap
Gown
Gloves
Mask
Shoe covers
Protective eyewear / face shield
Prepare you ER room
Primary Survey- ABCDE
Resuscitation- goal of primary survey is to assess and treat
What is a quick, simple way to assess a patient in 10 seconds?Ask the patient his or her name (if the patient answer, the airway is patent!)
Ask the patient what happened
A Patent airway
B Sufficient air reserve to permit speech
C Sufficient perfusion
D Clear sensorium
PRIMARY SURVEY
Airway with c-spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neuro status
Exposure / Environmental controlGoal of Primary Survey: Identify and treat life-threatening injury
AIRWAY
Establish patent airway and protect c-spine
Make sure that the airway is patent and put a collar if blunt injury (in fall and vehicular accident, it is mandatory to put collar). There is no need to put collar if the injury is penetrating in mechanism.PITFALLS
Occult airway injury
Progressive loss of airway
Equipment failure
Inability to intubate
How do I manage the airway of a trauma patient?
Supplemental oxygenRoute in giving oxygen?
Nasal cannula (up to 4%, FiO2=28%)
Face mask (more is being delivered, 45%)
If more than 45% required= need for intubation
Basic techniques- Jaw thrust chin lift goal: para yung airway mas diretsoBasic adjuncts
Short of intubating, short of putting a tracheostomy (endotracheal tube muna!)
TIP: Kapag hindi mo nakita ang tracheostomy and cricothyroidotomy, adjuncts lahat yan!
Definitive airway
Intubation with tube
Cricothyroidotomy with tube
A cricothyrotomy (also called thyrocricotomy, cricothyroidotomy, inferior laryngotomy, intercricothyrotomy, coniotomy oremergency airway puncture) is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma. Tracheostomy
BREATHINGAssess and ensure adequate oxygenation and ventilation
Respiratory rate (Normal RR= 12-20)Chest movement (Normal: symmetrical)Air entry (Normal: equal)Oxygen saturation
During the primary survey, you are allowed to put O2 Sat machine)
General rule: You don't do diagnostic exam on an unstable patient
Pulse ox is an adjunct for primary survey
How to treat?
a. Thoracentesis
Where to insert the needle?
Pneumothorax- 2nd ICS (below the clavicle)
Put the needle superior to rib
Put the needle inferior to ICS
b. Tube thoracostomy- 5th ICS just anterior to the mid-axillary line
c. 3 sided taped gauze- in patients with Open Pneumothorax
Hindi lahat ng sides, it may cause Tension pneumothorax
d. Mechanical Ventilator
PITFALLS
Airway versus ventilation problem?
Airway- kapag nakapagsalita, patent ang airway, horaseness= (+) obstructionIatrogenic pneumothorax or tension pneumothorax?
You don't need an X-ray to diagnose tension pneumothorax
CIRCULATION
Assess for organ perfusion
Level of consciousness
Skin color and temperature
Pulse rate and character
Palpable radial pulse= the patient's BP is at least 80mmHg
If wala, go to femoral pulse= 70mmHg, then carotid= 60mmHg
Sites of bleeding???
External (laceration)
Chest- hindi mo agad makikita
Abdomen
Pelvic fracture- retroperitoneal hematoma (massive bleeding)
Long bone fracture- massive bleeding (minsan hindi life threatening)
Chest, abdomen and retroperitoneum- LIFE THREATENING!!!
In trauma patients, kapag nasa C (circulation) ka na, lagyan mo agad ng IV fluid= 1L bolus, fast drip! (ATLS Concept)
750 mL Blood Volume Loss (15%)Slightly anxious
Normal blood pressure
Heart rate < 100 / min
Respirations 14-20 / min
Urinary output 30 mL / hour
Crystalloids
*Normal vital signs
*In trauma, signs of hypoperfusion is considered hypovolemic until proven otherwise750-1500 mL Blood Volume Loss (15-30%)Anxious
Normal blood pressure
Heart rate > 100 / min
Decreased pulse pressure
Respirations 20-30 / min
Urinary output 20-30 mL / hour
Crystalloids
* dito nagstart tumaas ang HR (patient is TACHYCARDIC)
1500-2000 mL Blood Volume Loss (30-40%)
Confused, anxious
Decreased blood pressure
Heart rate > 120 / min
Decreased pulse pressure
Respirations 30-40 / min
Urinary output 5-15 mL / hour
Crystalloid, blood components, definitive control of bleeding
*look for the source of bleeding> 2000 mL Blood Volume Loss (> 40%)Confused, lethargic
Hypotension
Heart rate > 140 / min
Decreased pulse pressure
Respirations > 35 / min
Urinary output negligible
Blood components, definitive control of bleeding
How to treat?
Control hemorrhage
Restore volume
You put a line, fast drip 1L then reassess
Reassess patient
ATLS Concept: Any doctor can man the emergency room.
PITFALLS
Elderly- sometimes naka beta blockers or antuhypertensive
Children- iba iba ang normal values, kapag bumaba ng 7yo iba na normal
Athletes- bradycardic, compensation for blood loss maganda akala mo okay pa sila yun pala
may blood loss na
Medications
Pregnant- seemingly normal kahit may blood loss since maganda ang compensation nila
DISABILITY
Baseline neurologic evaluation
Glasgow Coma Scale score
Universal determination of neurologic status (you have to memorize the GCS)
Lowest score=3
Do mandatory intubation if the GCS is 8 and below
Pupillary response
Dilate? There is impending uncal herniation
PITFALLS
Observe for neurologic deterioration
EXPOSURE
Completely undress the patient
Prevent hypothermia
Missed injuries
Do your secondary survey when:
If you're done with primary survey
Patient is becoming stable
RESUSCITATION
Protect and secure airway
Ventilate and oxygenate
Stop the bleeding!
Crystalloid / blood resuscitation
Protect from hypothermia
ADJUNCTS
ABGs
PULSE OXIMETER/ CO2
GASTRIC & URINARY CATHETER
ECG
X-ray portable- acceptable diagnostic exam during primary survey, sa B (breathing)
Pelvic X-ray portable (important sa C-circulation, hemorrhage)
Focused Assesment Sonography in trauma
Component: Pericardium, Right and Left gutter and PelvisDPL
Consider Early Transfer
Use time before transfer for resuscitation
Do not delay transfer for diagnostic tests
Which patients do I transfer to a higher level of care?
Those whose injuries exceed institutional capabilities
When do I start the secondary survey?
After Primary survey is completed
ABCDEs are reassessed
Vital functions are returning to normal
The priorities are the same for all patients.
Immediate threat to life due to inadequate ventilation
tension pneumothorax
open pneumothorax
flail chest with underlying pulmonary contusion
(other than these 3 hindi siya life threatening sa B-Breathing)LIFE THREATENING INJURIES due to inadequate circulation
massive hemothorax
cardiac tamponade
massive hemoperitoneum
mechanically unstable pelvic fractures.
*long bone fracture is not included
TENSION PNEUMOTHORAX
Decreased breath sounds- ipsilateral
Tracheal shift- contralateral
Hyperresonant- ipsilateral
In tension pneumothorax, which is the direct cause of hypotension? DECREASED CARDIAC OUTPUT
Initiating factor? MEDIASTINAL SHIFT
In any penetrating injury inside the cardiac box (superior border: clavicle, inferior border: subcostal, midclavicular line lateral to the left and to the right), always consider the possibility of cardiac tamponade kahit hindi pa hypotensive ang patient initially, like stab wound at the back
Given for example, stab wound at the :
6th ICS anterior axillary line, would you consider cardiac injury? NO!
Right 5th ICS midclavicular line? YES!
SECONDARY SURVEY
Allergies
Medications
Past illnesses / Pregnancy
Last meal
Events / Environment / Mechanism
Detailed Head to foot examination
Radiologic examination
Definitive Care
Admit
Transfer
Operating room
BLOOD VOLUME LOSS*
750 ml Blood Volume Loss (15%)750-1500 ml Blood Volume Loss (15-30%)1500-2000 ml Blood Volume Loss (30-40%)> 2000 ml Blood Volume Loss (> 40%)
Slightly anxious
Normal blood pressure
Heart rate < 100 / min
Respirations 14-20 / min
Urinary output 30 mL / hour
Crystalloids
*Normal vital signs
Anxious
Normal blood pressure
Heart rate > 100 / min
Decreased pulse pressure
Respirations 20-30 / min
Urinary output 20-30 mL / hour
Crystalloids
* dito nagstart tumaas ang HR (patient is TACHYCARDIC)Confused, anxious
Decreased blood pressure
Heart rate > 120 / min
Decreased pulse pressure
Respirations 30-40 / min
Urinary output 5-15 mL / hour
Crystalloid, blood components, definitive control of bleeding
*look for the source of bleedingConfused, lethargic
Hypotension
Heart rate > 140 / min
Decreased pulse pressure
Respirations > 35 / min
Urinary output negligible
Blood components, definitive control of bleeding
MUST KNOWS!!! Isaksak mo sa isip mo! Pwede din naman sa puso mong bigo! :)
What is the Glascow Coma Scale that it is mandatory to intubate the patient? 8 AND BELOW! 7 means severe head injuryWhat differentiates simple pneumothorax to a tension pneumothorax? Tension pneumothorax= PNEUMOTHORAX + HYPOTENSIONTIP: Kapag hindi mo nakita ang tracheostomy and cricothyroidotomy, adjuncts lahat yan!In trauma patients, kapag nasa C (circulation) ka na, lagyan mo agad ng IV fluid= 1L bolus, fast drip! (ATLS Concept)
Sites of bleeding: Chest, abdomen and retroperitoneum- LIFE THREATENING!!!
In tension pneumothorax, which is the direct cause of hypotension? DECREASED CARDIAC OUTPUTImmediate threat to life due to inadequate ventilation
tension pneumothorax
open pneumothorax
flail chest with underlying pulmonary contusion
(other than these 3 hindi siya life threatening sa B-Breathing)LIFE THREATENING INJURIES due to inadequate circulation
massive hemothorax
cardiac tamponade
massive hemoperitoneum
mechanically unstable pelvic fractures.
*long bone fracture is not included
Total Blood Volume= 8% of total body weight (7% for pediatrics) !!!
For example, in a 50kg male, the total blood volume is 4L (50kg x 0.08)A 50kg male, tachycardic, how much blood volume ang nawawala sa kanya?
30% of 4L= 1.2L
If the weight is given, you remember the percent!
END OF TRANSCRIPTIONS! (sabi sayo walang forever e!)
MUST KNOW!!!
What is the Glascow Coma Scale that it is mandatory to intubate the patient?
8 AND BELOW! 7 means severe head injury
What differentiates simple pneumothorax to a tension pneumothorax?
Tension pneumothorax= PNEUMOTHORAX + HYPOTENSION
From Doc:
Dyspneic ang patient, nagkakamali kasi intubate agad. Ooops! Check mo muna yung B (Breathing). Kapag okay ka sa B, then you can intubate the patient. Malay mo tension pneumothorax, na-aggravate mo pa kasi kapag nag-intubate ka you need to pre-oxygenate the patient.
How do you determine the Total Blood Volume of a patient?
60% of TBW= water
40% intracellular fluid
20% ECF
15% intertitial
5% plasma
+3% blood components
8% of total body weight (7% for pediatrics) !!!
For example, in a 50kg male, the total blood volume is 4L (50kg x 0.08)
A 50kg male, tachycardic, how much blood volume ang nawawala sa kanya?
30% of 4L= 1.2L
If the weight is given, you remember the percent!
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