Vinnitsa National Pirogov Memorial Medical University
Department of Disaster Medicine and Military Medicine
METHODIC ELABORATION
For the self-study to the seminar
by the students of the 5th year of study specialty: general medicine and dentistry) on
the discipline «Emergency and urgent medical care»
THEME 2. THE PROCEDURE FOR PROVIDING EMERGENCY
MEDICAL CARE TO VICTIMS AND PATIENTS AT THE PRE-HOSPITAL
STAGE. SECONDARY EXAMINATION..
Vinnytsa - 2020
Trimodal distribution of death
1. INTRODUCTION TO TRAUMA
Trimodal Pattern of mortality following severe trauma
CNS/cardiovascular
hypoxia/hypercarbiaMOF/sepsis
GOLDEN HOUR
⚫ The first hour following a trauma during which
aggressive resuscitation can improve the chances
of survival and restore the normal functions.
⚫ Early pre-hospital care, early transport,
aggressive resuscitation and interventions in ED,
continued care in ICU have a definite and
significant role in preventing deaths due to
trauma.
PLATINUM MINUTES
⚫ THE IMPORTANCE OF TIME IN TRAUMA IS
INCREASING AS EVIDENT FROM THE
EVOLUTION OF THE CONCEPT OF
“THE PLATINUM TEN MINUTES”
INITIAL APPROACH TO
TRAUMA CARE⚫ Process that consists of
-Initial primary assessment
-Rapid resuscitation
-A more thorough secondary
assessment
-Followed by diagnostic tests and
disposition.
TRAUMA TEAM
RADIOGRAPHER
AIRWAY DOCTOR
AIRWAY NURSE
CIRCULATION DOCTOR
CIRCULATION NURSE
ORTHO REGISTRAR
WARDSPERSON
SCRIBE NURSETEAM LEADERSOCIAL WORKER
TRAUMA TEAM
ACTIVATION CRITERIA
ANATOMICAL
⚫ INJURY TO 2/ MORE BODY REGIONS
⚫ FRACTURE 2/ MORE LONG BONES
⚫ SPINAL CORD INJURY
⚫ AMPUTATION OF LIMB
⚫ PENETRATING INJURY TO HEAD, NECK TORSO/
PROX. LIMB
⚫ BURNS> 15% IN ADULTS, >10% IN CHILDREN,
AIRWAY BURNS
⚫ AIRWAY OBSTRUCTION
TRAUMA TEAM
ACTIVATION CRITERIA
PHYSIOLOGICAL
⚫ SBP<90mm Hg/ PR- >130BPM
⚫ RR<10/ >30 PER MIN
⚫ DEPRESSED CONSCIOUSNESS
⚫ AGE>70YR WITH CHEST INJURY
⚫ PREGNANCY>24 WEEKS WITH TORSO
INJURY
MECHANISM
⚫ BIKER/ PEDESTRIAN HIT BY
VEHICLE>30KM/HR
⚫ FALL>5 METRE
⚫ FATALITY IN SAME VEHICLE
⚫ MOTOR VEHICLE CRASH WITH
EJECTION
TRAUMA TEAM
ACTIVATION CRITERIA
Overview of ATLSChart Title
Definitive Care
Data / Information /
Response to Therapy
Secondary Survey
Resuscitation
Primary Survey
(ABCDE's)
PRIMARY SURVEY ADJUNCTS:-
MONITOR
⚫ VITALS
⚫ ECG
⚫ FOLEY’S CATHETER
⚫ GASTRIC TUBE
⚫ ABG
⚫ PULSE OXIMETER
⚫ URINE OUTPUT
PRIMARY SURVEY ADJUNCTS:-
DIAGNOSIS
⚫ CXR
⚫ PELVIS AP
⚫ LATERAL C-SPINE
⚫ DPL
⚫ FAST
BEFORE SECONDARY SURVEY
⚫ Complete primary survey
⚫ Establish resuscitation
⚫ Normalization of vital functions
SECONDARY SURVEY
The complete
history and
physical
examination
ATLS→SECONDARY
SURVEY
⚫ Head and Skull
⚫ Faciomaxillary Injuries
⚫ Neck
⚫ Chest & Spine
⚫ Abdomen
ATLS→SECONDARY
SURVEY
⚫ Perineum/ Rectum/ Vagina
⚫ Extremities→ Fractures
⚫ Complete Neurological Exam→ GCS
⚫ Appropriate X-Rays, Lab Tests and Special
Studies
⚫ “Tubes & fingers” in every orifice
SECONDARY SURVEY
COMPONENTS
⚫History
⚫Physical exam: head to toe
⚫“Tubes OR fingers in every orifice”
⚫Complete neurological exam
⚫Special diagnosis tests
⚫Re-evaluation
Secondary survey
History
“AMPLE”
A:Allergies
M:Medication currently being taken by the patient
P:Past illness and operations,pregnancy
L:Last meal
E:Event/Environment related to the injury
Secondary survey
HEAD
⚫ Signs of skull base
fracture
⚫ Pupillary size
⚫ Hemorrhages of
conjunctiva/fundi
⚫ Visual acuity
⚫ Penetrating injury
⚫ Contact lens
⚫ Dislocation of lens
⚫ Hyphaema
⚫ Ocular movement
⚫ Posterior scalp
laceration
SECONDARY SURVEY
⚫ Examination Neurologic
⚫Determine GCS score
⚫Re-evaluate pupils
⚫Sensory / motor evaluation
⚫Maintain immobilization
⚫Prevent secondary CNS injury ( keep stable vital signs, avoid increased ICP and treat IICP )
⚫Early neurosurgical consultation
GLASGOW COMA SCALE
Variables Score
Eye opening Spontaneous
To speech
To pain
None
4
3
2
1
Verbal response Oriented
Confused conversation
Inappropriate words
Incomprehensible sounds
None
5
4
3
2
1
Best motor response Obeys commands
Localizes pain
Normal flexion
Abnormal flexion
Extension
None
6
5
4
3
2
1
Physical Exam
◼ Battle Sign
◼ Raccoon's Eyes
◼ Cullen’s Sign
◼ Grey-Turner’s Sign
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Classic Radiographic Findings◼ Epidural Hematoma
– Middle Meningeal Artery
◼ Subdural Hematoma
– Bridging Veins
24
Secondary survey
MAXILLOFACIAL
⚫ Associated with airway obstruction or major
bleeding
⚫ Fracture cribriform plate
⚫ No NG tube [performed oral route]
Secondary survey
NECK
⚫ Cervical tenderness, subcutaneous
emphysema
⚫ Oesophageal injury
⚫ Tracheal/laryngeal injury
⚫ Carotid injury (penetrating/blunt)
Secondary survey
CHEST
➢ Inspect
➢ Palpate
➢ Percuss
➢ Auscultate
➢ Obtain x-rays
Classic Radiographic Findings◼ Diaphragmatic rupture w/ spleen herniation
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Secondary survey
ABDOMEN
➢ Inspect
➢ Auscultate
➢ Palpate
➢ Percuss
➢ Reevaluate
➢ Special studies
Abdominal Trauma⚫ Look for distension, tenderness, seatbelt
marks, penetrating trauma, retroperitoneal
ecchymosis
⚫ Be suspicious of free fluid without evidence of
solid organ injury
FAST Exam
⚫ Focused Abdominal Scanning in Trauma
⚫ To find free fluid (blood) around heart (pericardiac eff.) or abdominal organ (hemoperitoneum) after trauma
⚫ 4 views:
– Cardiac
– RUQ (Morison’s Pouch)
– LUQ (Perispleenic Space)
– Pelvic (Pouch of Doughlas)
Splenic Injury
⚫Most commonly injured organ in
blunt trauma
⚫Often associated with other injuries
⚫Left lower rib pain may be indicative
⚫Often can be managed non-
operatively
Liver injury
⚫ Second most common solid organ injury
⚫ Can be difficult to manage surgically
⚫ Often associated with other abdominal injuries
Hollow Viscous Injury
⚫ Injury can involve stomach, bowel, or mesentery
⚫ Symptoms are a result from a combination of blood loss and peritoneal contamination
⚫ Small bowel and colon injuries result most often from penetrating trauma
⚫ Deceleration injuries can result in bucket-handle tears of mesentery
⚫ Free fluid without solid organ injury is a hollow viscus injury until proven otherwise
Secondary survey
⚫ Perineum:contusion,hematoma, laceration,urethral
blood
⚫ Rectum:sphincter tone,high riding prostate,pelvic
fracture,rectal wall integrity,blood
⚫ Vagina:blood,laceration
Secondary survey
Musculoskeletal
⚫ Contusion, deformity
⚫ Pain
⚫ Perfusion
⚫ Peripheral
neurovascular status
⚫ X-ray
Secondary Survey
➢ Potential blood loss
➢ Missed fractures
➢ Soft-tissue or ligamentous injury
➢ Compartment syndrome (especially with altered sensorium / hypotension)
Musculoskeletal: Pitfalls
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
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➢ High index of suspicion
➢ Frequent reevaluation and monitoring
Minimize missed injuries?
REEVALUATION
⚫ New findings / deterioration / improvement
⚫ High index of suspicion ==> early diagnosis & management
⚫ Continuous monitoring
⚫ Pain relief
Records, Legal Considerations
➢ Concise, chronologic documentation
➢ Consent for treatment
➢ Forensic evidence
Roles of the Trauma
TeamAirway
Nurse
Boss
Attending
Team Member
Team Member
Nurse
SUMMARY
⚫ Initial assessment & management of multiply injured patient
⚫ Primary survey ( ABCDEs )
⚫ Resuscitation & monitor ( life-threatening problems )
⚫ Secondary survey ( head-to-toe, history )
⚫ Definitive care ( early consultation, surgical intervention or transport )
References1. Bailey and Love’s Short Practice of Surgery. 25th Edition.
2. Kumar MV (2014) Clinical Companion in Surgery. 2nd
Edition
3. Davidson’s Principles and Practice of Medicine 21st
Edition
4. Carmont MR (2005). "The Advanced Trauma Life Support
course: a history of its development and review of related
literature". Postgraduate Medical Journal 81(952): 87–91.
5. Styner, Randy (2012). The Light of the Moon - Life, Death
and the Birth of Advanced Trauma Life Support. Kindle
Books: Kindle Books. p. 267.
6. Committee on Trauma, American College of
Surgeons (2008). ATLS: Advanced Trauma Life Support
Program for Doctors (8th ed.). Chicago: American
College of Surgeons.