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Author(s): Patrick Carter, Daniel Wachter, Rockefeller Oteng, CarlSeger, 2009-2010.
License: Unless otherwise note, this !aterial is !ae a"aila#le$ner the ter!s of the Creative Commons Attribution 3.0License%htt&%''creati"eco!!ons.org'licenses'#(').0'We have reviewed this material in accorance with U.S. Co&(right *aw and have tried tomaximize your ability to use share and ada!t it. +he citation ke( on the following slie&ro"ies infor!ation a#o$t how (o$ !a( share an aa&t this !aterial.
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se *hare Ada!t
+a,e -our wn Assessment
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Advanced Emergency
Trauma Course
8hana >!ergenc( =eicine
@ntro$ction an Co$rse O"er"iew
@nitial /ssess!ent an=anage!ent
Presenter% Patrick Carter, =D
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Objectives @ntro$ction to />+C Co$rse
Co$rse C$rric$l$! >&ie!iolog( of +ra$!a Care Aistor( of De"elo&!ent of +ra$!a Care =echanis!s of @n5$r( Basics of +ra$!a =anage!ent
Pri!ar( S$r"e(
Res$scitation
Seconar( S$r"e( /BCD> or!at
Cer"ical S&inal @!!o#iliation S&ecic Case >7a!&les
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AETC Course /"ance >!ergenc( +ra$!a Co$rse De"elo&e #( Uni"ersit( of =ichigan an
Uni"ersit( of Utah >!ergenc( =eicine ac$lt( 8eneral O"er"iew of +ra$!a =anage!ent
U.S. #ase >= C$rric$l$! /+*S C$rric$l$!
a( co$rse
20 ho$rs of iactic teaching Skill Stations for "ital tra$!a &roce$res
Re"iew an testing on a(
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AETC Course
>"al$ation +ools Pre'Post +est of +ra$!a Enowlege Pre'Post Skill Station >"al$ations
Post Co$rse S$r"e(
F =onth Post Co$rse S$r"e(
Research St$( Gol$ntar( @n"ol"e!ent
Co$rse $tilies new teaching techni$es O&en e$cational Reso$rce =aterial *ow +echnological Si!$lation +ools
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AETC Course Schedule
1hana 7mer"ency +edicineCollaborative
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AETC Skill Stations
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Initial Assessment and
Management of the Trauma
Patient
Ghana Emergency MedicineGhana Emergency MedicineCollaborativeCollaborative
Advanced Emergency Trauma CourseAdvanced Emergency Trauma Course
So$rce% www.aic.c$hk.e$.hk'we#Htoc.ht!/ccesse 9'20'09 I Jahoo i!ages "ia Creati"eCo!!ons
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Eidemiology
Roa +raKc /ccients are !a5or ca$se of long ter!!or#iit( an !ortalit( in e"elo&ing nations
@n the rst $arter of 2009, )2 eaths in 8hana fro!Roa +raKc /ccients
2L increase fro! &re"io$s (ear
WAO &reicts that #( 2020, Roa +raKc /ccients will #esecon leaing ca$se of loss of life for worlMs &o&$lation Aigh =or#iit( N *oss of inco!e to societ( Challenges in De"elo&ing Co$ntries
+echnological /"ances in +ra$!a Care
*ack of @nfrastr$ct$re for +ra$!a =anage!ent >=S Pre-hos&ital notication =D'R +raining in tra$!a care
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Eidemiology
@!!eiatel( Ao$rs Da(s'Weeks
0L
)0L
20L
+ri!oal Distri#$tion of +ra$!a Deaths
8olen Ao$r N H0L of tra$!aeaths in rst ho$r after in5$r(
Ra&i tra$!a care has greatestle"el of i!&act in these &atients
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!istory of Trauma System "eveloment Stanarie +ra$!a /ssess!ent
e#raska Cornel, 19F Ortho&eic S$rgeon *ea to e"elo&!ent of /+*S
+ra$!a S(ste!s De"elo&!ent irst e"elo&e !( !ilitar( in warti!e
i.e. =/SA Units
>7&ane in US to *e"el 1, 2, ) +ra$!aCenters Ur#an S(ste!s Statewie networks of s(ste!s Level 9 I Aighest le"el of care, *eaers in
research, clinical care an e$cation
Level I Pro"ies eniti"e care in wie range ofco!&le7 tra$!atic &atients
Level 3 I Pro"ies initial sta#iliation antreat!ent. =a( care for $nco!&licate tra$!a&atients
Level ; I Pro"ies initial sta#iliation antransfers all tra$!a &atients for eniti"e care
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Mechanisms of Injury Bl$nt +ra$!a
Co!&ression orces Cells in tiss$es are co!&resse an cr$she >.g. S&leen
Shear orces
/cceleration'Deceleration @n5$r( >.g. /orta
Shearing force N S&ectr$! fro! $ll thickness tear>7sang$ination3 to Partial tear Pse$oane$r(s!3
O"er&ress$re Bo( ca"it( co!&resse at a rate faster than the
tiss$e aro$n it, res$lting in r$&t$re of the closes&ace
>.g. Plastic #ag >.g. in tra$!a N ia&hrag!atic r$&t$re, #laer
in5$r(
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Mechanisms of Injury rontal @!&act Collisions
*ateral @!&act Collisions + #one3 Rear @!&act Collisions
Rollo"er =echanis! O&en Gehicle or =otorc(cle'=o&e
Peestrian Gs. Car
Penetrating @n5$r( 8$ns "s. Eni"es3
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#asics of Trauma Assessment Pre&aration
+ea! /sse!#l(
>$i&!ent Check +riage
Sort &atients #( le"el of ac$it( S/+S3
Pri!ar( S$r"e(
Designe to ientif( in5$ries that are i!!eiatel( life threatening an
to treat the! as the( are ientie Res$scitation
Ra&i &roce$res an treat!ent to treat in5$ries fo$n in &ri!ar(s$r"e( #efore co!&leting the seconar( s$r"e(
Seconar( S$r"e(
$ll Aistor( an Ph(sical >7a! to e"al$ate for other tra$!atic in5$ries =onitoring an >"al$ation, Seconar( a5$ncts +ransfer to Deniti"e Care
@CU, War, O&erating +heatre, /nother facilit(
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Prearation $ $ $ Coming Attractions
Organie +ra$!aRes&onse +ea!
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htt&%''www.tra$!a.org'archi"e'res$s'tra$!atea!.ht!l
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Primary Survey
Airwa( an Protection of S&inal Corn"iron!ent
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Primary Survey
Ee( Princi&les When (o$ n a &ro#le! $ring the
&ri!ar( s$r"e(, 26= 68.
@f the &atient gets worse, restart fro!the #eginning of the &ri!ar( s$r"e(
So!e critical &atients in the>!ergenc( De&art!ent !a( not
&rogress #e(on the &ri!ar( s$r"e(
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Air%ay and Protection of Sinal Cord
Wh( rst in the algorith!
*oss of airwa( can res$lt in eath in ) !in$tes Prolonge h(&o7ia N @nae$ate &erf$sion, >n-organ
a!age /irwa( /ssess!ent
Gital Signs N RR, O2 sat
=ental Stat$s N /gitation, So!nolent, Co!a /irwa( Patenc( N Secretions, Strior, O#str$ction +ra$!atic @n5$r( a#o"e the cla"icles Gentilation Stat$s N /ccessor( !$scle $se, Retractions,
Wheeing Clinical Pearls
Patients who are s&eaking nor!all( generall( o notha"e a nee for i!!eiate airwa( !anage!ent
Aoarse or weak "oice !a( inicate a s$#tle tracheal orlar(ngeal in5$r(
ois( Res&irations fre$entl( inicates an o#str$cte
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Air%ay Interventions
=aintenance of /irwa( Patenc( S$ction of Secretions Chin *ift'Qaw thr$st aso&har(ngeal /irwa( Deniti"e /irwa(
/irwa( S$&&ort O7(gen RB= 100L3 Bag Gal"e =ask Deniti"e /irwa(
Deniti"e /irwa( >notracheal @nt$#ation
@n-line cer"ical sta#iliation
S$rgical Crichoth(roioto!(
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Protection of Sinal Cord 1eneral 5rinci!le: Protect the entire s&inal cor $ntil
in5$r( has #een e7cl$e #( raiogra&h( or clinical
&h(sical e7a! in &atients with &otential s&inal cor in5$r(. S&inal Protection
Rigi Cer"ical S&inal Collar N Cer"ical S&ine *ong rigi s&inal #oar or i!!o#iliation on at s$rface s$ch
as stretcher N +'* S&ine
>tiolog( of S&inal Cor @n5$r( U.S.3 Roa +raKc /ccients TL3 Aigh energ( falls 2)L3
Clinical Pearls +reat!ent @!!o#iliation3 #efore iagnosis
Ret$rn hea to ne$tral &osition Do not a&&l( traction Diagnosis of s&inal cor in5$r( sho$l not &recee
res$scitation =otor "ehicle crashes an falls are !ost co!!onl(
associate with s&inal cor in5$ries
=ain foc$s N Pre"ention of f$rther in5$r(1hana 7mer"ency +edicineCollaborative
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C&sine Immobili'ation
Ret$rn hea to ne$tral &osition =aintain in-line sta#iliation Correct sie collar a&&lication Blocks'ta&e San#ags
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*ource:www.ossur.com>bracesandsu!!orts>nec, ands!ine>!rehos!it...oncollars>!hillybloc,headAccessed ?>0>0?
-ahoo 6ma"es
Palainsf ickr3
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Breathing and (entilation
8eneral Princi&le% /e$ate gas e7change is re$ire to!a7i!ie &atient o7(genation an car#on io7ieeli!ination
Breathing'Gentilation /ssess!ent% >7&os$re of chest 8eneral @ns&ection
+racheal De"iation /ccessor( =$scle Use Retractions /#sence of s&ontaneo$s #reathing Parao7ical chest wall !o"e!ent
/$sc$ltation to assess for gas e7change
>$al Bilaterall( Di!inishe or /#sent #reath so$ns
Pal&ation De"iate +rachea Broken ri#s @n5$ries to chest wall
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@entif( *ife +hreatening @n5$ries
+ension Pne$!othora7 /ir tra&&ing in the &le$ral s&ace #etween
the l$ng an chest wall S$Kcient &ress$re #$ils $& an
&ress$re to co!&ress the l$ngs an shift
the !eiastin$! Ph(sical e7a! /#sent #reath so$ns
/ir h$nger
Distene neck "eins
+racheal shift
+reat!ent eele Deco!&ression
2n @ntercostal s&ace, =icla"ic$lar line
+$#e +horacosto!( th @ntercostal s&ace, /nterior a7illar(
line
Breathing and Ventilation
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*ource: www.meddean.luc.edulumen+ed7d>medicine>!ulmona
r>cxr>!neumo9.htmAccessed ?>0>0? / -ahoo6ma"es
elldot (wi,imedia)
http://rds.yahoo.com/_ylt=A0WTefTNU7ZKfNkATBujzbkF/SIG=135cptqle/EXP=1253549389/**http:/www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/atlas/images/81l.JPGhttp://rds.yahoo.com/_ylt=A0WTefTNU7ZKfNkATBujzbkF/SIG=135cptqle/EXP=1253549389/**http:/www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/atlas/images/81l.JPGhttp://rds.yahoo.com/_ylt=A0WTefTNU7ZKfNkATBujzbkF/SIG=135cptqle/EXP=1253549389/**http:/www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/atlas/images/81l.JPGhttp://commons.wikimedia.org/wiki/File:Sucking_chest_wound_mechanics.jpg
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Ae!othora7
Bloo collecting in the &le$ral s&acean is co!!on after &enetrating an#l$nt chest tra$!a
So$rce of #leeing N *$ng, Chest wall
intercostal arteries3, heart, great"essels /orta3, Dia&hrag!
Ph(sical >7a! /#sent or i!inishe #reath so$ns D$llness to &erc$ssion o"er chest
Ae!o(na!ic insta#ilit(
+reat!ent N *arge Cali#er +$#e +horacosto!(
10-20L of cases will re$ire +horacoto!( for control of#leeing
Breathing and (entilation
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htt&%''www.tra$!a.org'ine7.&h&'!ain'i!ages'C11'/ccesse 9'20'09 I Jahoo @!ages
http://www.trauma.org/index.php/main/images/C11/http://www.trauma.org/index.php/main/images/C11/http://www.trauma.org/index.php/main/image/119/C11http://www.trauma.org/index.php/main/images/C11/http://www.trauma.org/index.php/main/images/C11/
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Breathing and (entilation
lail Chest Direct in5$r( to the chest res$lting in an$nsta#le seg!ent of the chest wall that!o"es se&aratel( fro! re!ainer ofthoracic cage
+(&icall( res$lts fro! two or !ore
fract$res on 2 or !ore ri#s +(&icall( /cco!&anie #( a &$l!onar(cont$sion
Ph(sical >7a! N Parao7ical !o"e!entof chest seg!ent
+reat!ent N @!&ro"e /#nor!alities in
gas e7change >arl( @nt$#ation for &atients with
res&irator( istress /"oiance of o"eraggressi"e $i
res$scitation
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htt&%''i!ages1.clinicaltools.co!'i!ages'tra$!a'ailchestwo$ne.gif
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Breathing and (entilation
O&en Pne$!othora7 S$cking Chest Wo$n *arge efect of chest wall
*eas to ra&i e$ili#ration ofat!os&heric an intrathoracic
&ress$re @!&airs o7(genation an
"entilation
@nitial +reat!ent +hree Sie occl$si"e ressing
Pro"ies a $tter "al"e e6ect Chest t$#e &lace!ent re!ote to
site of wo$n /"oi co!&lete ressing, will
create a tension &ne$!othora7
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=ile an #otto! i!age%
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htt&%''www.tra$!a.org'ine7.&h&'!ain'i!age'902'/ccesse 9'20'09, Jahoo @!ages
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)eedle Thoracostomy
eele +horacosto!(
=icla"ic$lar line 1T g$age angiocath
O"er the 2n ri#
R$sh of air is hear
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Tube Thoracostomy @nsertion site
th intercostal s&ace,
/nterior a7illar( line Sterile &re&, anesthesia with liocaine 2-) c! incision along ri# !argin with 10
#lae Dissect thro$gh s$#c$taneo$s tiss$es to
ri# !argin P$nct$re the &le$ra o"er the ri# /"ance chest t$#e with cla!& an irect
&osteriorl( an a&icall( O#ser"e for fogging of chest t$#e, #loo
o$t&$t S$t$re the t$#e in &lace Co!&lications of Chest +$#e Place!ent
@n5$r( to intercostal ner"e, arter(, "ein @n5$r( to l$ng @n5$r( to !eiastin$! @nfection /llergic reaction to liocaine
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Circulation Shock
@!&aire tiss$e &erf$sion +iss$e o7(genation is inae$ate to !eet !eta#olic e!an Prolonge shock state leas to !$ltiorgan s(ste! fail$re an
cell eath Clinical Signs of Shock
/ltere !ental stat$s
+ach(caria AR X 1003 N =ost co!!on sign /rterial A(&otension SBP 1203 e!oral P$lse I SBP X H0 Raial P$lse I SBP X 90 Caroti P$lse I SBP X F0
@nae$ate +iss$e Perf$sion
Pale skin color Cool cla!!( skin Dela(e ca& rell X ) secons3 /ltere *OC Decrease Urine O$t&$t UOP 0. !*'kg'hr3
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Circulation
+(&es of Shock in +ra$!a Ae!orrhagic
/ss$!e he!orrhagic shock in all tra$!a &atients$ntil &ro"en otherwise
Res$lts fro! @nternal or >7ternal Bleeing
O#str$cti"e Cariac +a!&onae +ension Pne$!othora7
e$rogenic S&inal Cor in5$r(
So$rces of Bleeing
Chest /#o!en Pel"is Bilateral e!$r ract$res
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Circulation >!ergenc( $rsing +reat!ent
+wo *arge @G *ines Cariac =onitor Bloo Press$re =onitoring
8eneral +reat!ent Princi&les Sto& the #leeing
/&&l( irect &ress$re
+e!&oraril( close scal& lacerations Close o&en-#ook &el"ic fract$res
/#o!inal &el"ic #iner'#esheet
Restore circ$lating "ol$!e Cr(stalloi Res$scitation 2*3 /!inister Bloo Pro$cts
@!!o#ilie fract$res Res&oners "s. onres&oners
+ransient Res&onse to "ol$!e res$scitation N sign of ongoing#loo loss
onres&oners N Consier other so$rce for shock state oro&erating roo! for control of !assi"e he!orrhage
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Circulation
Pericarial +a!&onae Pericari$! or sac aro$n heart llswith #loo $e to &enetrating or#l$nt in5$r( to chest
BeckMs +ria Distene 5$g$lar "eins A(&otension =$Ye Aeart So$ns
+reat!ent
Ra&i e"ac$ation of &ericarial s&ace Perfor!e thro$gh a Pericariocentesis
te!&oriing !eas$re3 O&en +horacoto!(
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Pericari$!
>&icari$!
/ceofhearts19FH Wiki!eia3
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Pericardiocentesis
P$nct$re the skin 1-2 c! inferior to7i&hoi &rocess
T'T'T egree angle /"ance neele to ti& of left sca&$la Withraw on neele $ring a"ance of
neele Prefera#le $ner $ltraso$n g$iance or
>E8 lea G attach!ent Co!&lications
/s&iration of "entric$lar #loo *aceration of coronar( arteries, "eins,
e&icari$!'!(ocari$! Cariac arrh(th!ia Pne$!othora7 P$nct$re of eso&hag$s P$nct$re of &eritone$!
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Circulation
/ wor a#o$t cariac arrest . . . Care of the tra$!a &atient in cariac
arrest CPR Bilateral +$#e +horacosto!( Pericariocentesis Gol$!e Res$scitation
+ra$!atic Cariac /rrest $e to#l$nt in5$r( has "er( low s$r"i"alrate 1L3 o &oint for e!ergenc( thoracoto!(
Selecte cases of cariac arrest $eto &enetrating tra$!atic in5$r( !a(#enet fro! e!ergent thoracoto!( Pericarial ta!&onae Cross cla!& /orta
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Disability
Baseline e$rologic >7a! P$&illar( >7a! Dilate &$&il I s$ggests transtentorial herniation on i&silateral
sie
/GPU Scale /lert
Res&ons to "er#al sti!$lation Res&ons to &ain Unres&onsi"e
8ross e$rological >7a! I >7tre!it( =o"e!ent >$al an s(!!etric or!al gross sensation
8lasgow Co!a Scale% )-1 Rectal >7a!
or!al Rectal +one ote% @f int$#ation &rior to ne$ro assess!ent, consier
$ick ne$ro assess!ent to eter!ine egree of in5$r(
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Disability 8lasgow Co!a Scale
>(e S&ontaneo$sl( o&ens T
+o "er#al co!!an )
+o &ain 2 o res&onse 1
Best =otor Res&onse
O#e(s "er#al co!!ans F *ocalies to &ain
Withraws fro! &ain T le7ion to &ain Decorticate Post$ring3 ) >7tension to &ain Decere#rate Post$ring3 2
o res&onse 1
Ger#al Res&onse Oriente'Con"ersant Disoriente'Conf$se T
@na&&ro&riate wors ) @nco!&rehensi#le wors 2
o res&onse 1
GCS ≤ 8
Intubate
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Disability
Ee( Princi&les Precise iagnosis is not necessar( at this&oint in e"al$ation
Pre"ention of f$rther in5$r( anientication of ne$rologic in5$r( is the goal
Decrease le"el of conscio$sness N Aeain5$r( $ntil &ro"en otherwise
=aintenance of ae$ate cere#ral &erf$sionis ke( to &re"ention of f$rther #rain in5$r(
/e$ate o7(genation /"oi h(&otension
@n"ol"e ne$ros$rgeon earl( for clearintracranial lesions
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Disability
Cer"ical S&inal Clearance Patients !$st #e alert an oriente to
&erson, &lace an ti!e
ot clinicall( into7icate with alcohol orr$gs
on-tener at all s&ino$s &rocesses
o focal ne$rological ecits o istracting in5$ries
Painless range of !otion of neck
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E*osure Re!o"e all clothing
>7a!ine for other signs of in5$r(
@n5$ries cannot #e iagnose $ntil seen #( &ro"ier
*ogroll the &atient to e7a!ine &atientMs #ack
=aintain cer"ical s&inal i!!o#iliation Pal&ate along thoracic an l$!#ar s&ine
=ini!$! of ) &eo&le, often !ore &ro"iers re$ire
/"oi h(&other!ia
/&&l( war! #lankets after re!o"ing clothes A(&other!ia N Coag$lo&ath(
@ncreases risk of he!orrhage
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E*osure
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E*osure
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Trauma +ogroll One &erson N Cer"ical S&ine +wo &eo&le N Roll !ain #o( One &erson N @ns&ect #ack an
&al&ate s&ine
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Secondary Survey
Seconar( S$r"e( is co!&lete after&ri!ar( s$r"e( is co!&lete an&atient has #een ae$atel(
res$scitate. o &atient with a#nor!al "ital signs
sho$l &rocee thro$gh a seconar(
s$r"e( Seconar( S$r"e( incl$es a #rief
histor( an co!&lete &h(sical e7a!
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!istory
/=P*> Aistor(Allergies+eications
5ast =eical Aistor(, Pregnanc(Last =eal7"ents s$rro$ning in5$r(, >n"iron!ent
Aistor( !a( nee to #e gathere fro!fa!il( !e!#ers or a!#$lance ser"ice
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Physical E*am
Aea'A>>+ eck Chest
/#o!en Pel"is 8enito$rinar( >7tre!ities e$rologic
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Physical E*am
DiKc$lt /irwa(
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So$rce Uneter!ine
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Physical E*am
Seat#elt sign
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Physical E*am
Battle Sign
RaccoonZs >(es
C$llenMs Sign
8re(-+$rner Sign
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Adjuncts to Secondary Survey
Raiolog( Stanar e!ergent l!s
C-s&ine, C[R, Pel"is
2oc$se A#o!inal *onogra&h( in 8ra$!a /S+3 /itional l!s
Cat scan i!aging /ngiogra&h(
ole( Catheter Bloo at $rethral !eat$s N o ole( catheter
Pain Control +etan$s Stat$s /nti#iotics for o&en fract$res
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Classic .adiograhical 5indings
Pel"ic ract$re
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Classic .adiograhic 5indings
e!$r ract$re
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Classic .adiograhic 5indings
>&i$ralAe!ato!a =ile =eningeal /rter(
S$#$ralAe!ato!a Briging Geins
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Classic .adiograhic 5indings
Dia&hrag!atic R$&t$re w' s&leenherniation
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Classic .adiograhic 5indings
Wiene =eiastin$! I /ortic @n5$r(
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"efinitive Care Seconar( S$r"e( followe #(
raiogra&hic e"al$ation CatScan
Cons$ltation e$ros$rger( Ortho&eic S$rger( Gasc$lar S$rger(
+ransfer to Deniti"e Care
O&erating Roo! @CU
Aigher le"el facilit(
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Case E*amle =r. Qones I T ('o !ale
in"ol"e in a rollo"er roatraKc accient an wase5ecte fro! the "ehicle.Patient was $nrestraine.Patient was not a!#$lator( onscene of accient an is#ro$ght into tra$!a #a( fore"al$ation. What concerns (o$ a#o$t stor(
irst Ste&s of >"al$ation an=anage!ent
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Case E*amle
>7a!
/wake, ia&horetic
P$lse N 120
BP N 90'F0
RR N 1H
O2 sat N 9TL
What o (o$ want to o ne7t
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Case E*amle
Pre&aration Pri!ar( S$r"e(
/wake, alert, talking to &ro"ier Breathing
/#sent #reath so$ns on left What o (o$ want to o ne7t
Circ$lation Gital Signs /ccess Res$scitation
@G'O2'=onitor Disa#ilit(
8CS N 1T
>7&os$re1hana 7mer"ency +edicine
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Case E*amle Chest t$#e &lace
R$sh of air hear consistent with &ne$!othora7
Re&eat Gital Signs P$lse 120
BP H0'T0
RR N 1
O2 sat N 99L RB=
What o (o$ want to o ne7t Patient co!&laining of a#o!inal &ain
>cch(!osis note o"er left ank
Res$scitation
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Case E*amle Bloo Pro$ct /!inistration +ransfer to eniti"e care N O&erating
+heatre
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Conclusion
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Conclusion /ssess!ent of the tra$!a &atient is a
stanar algorith! esigne to ens$re lifethreatening in5$ries o not get !isse
Pri!ar( S$r"e( ] Res$scitation
/irwa( Breathing
Circ$lation
Disa#ilit(
>7&os$re Seconar( S$r"e( Deniti"e Care
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.eferences /!erican College of S$rgeons. /"ance
+ra$!a *ife S$&&ort. Fth >ition. 199. eliciano, Da"i et al. +ra$!a. Fth >ition.
=c8raw Aill. ew Jork. 200H.
Aock#erger, Ro#ert et al. RosenMs >!ergenc(=eicine% Conce&ts an Clinical Practice. Fth >ition. =os#(. 200F.
+intinalli et al. +intinalliMs >!ergenc(
=eicine% / Co!&rehensi"e St$( 8$ie. Fth >ition. =c8raw Aill. 200).