Date post: | 13-Apr-2018 |
Category: |
Documents |
Upload: | baihaqi-saharun |
View: | 214 times |
Download: | 0 times |
of 44
7/27/2019 W1L1 - Initial Assessment for Trauma_2
1/44
Initial assessment andmanagement of the severely
injured patient
By
Dr. Ahmed Negm
Ass. Professor of general surgery
Mansoura university
7/27/2019 W1L1 - Initial Assessment for Trauma_2
2/44
outline Introduction Preparation: pre-hospital & hospital phases
Triage:
Primary survey (ABCDEs)& resuscitation*adjuncts to primary survey
Secondary survey ( head to toe evaluation and
patient history)*adjuncts to secondary survey
Definitive care
7/27/2019 W1L1 - Initial Assessment for Trauma_2
3/44
Introduction Trauma is the leading
cause of death forindividuals of age 1-44years
3rdcause in all ages
For every trauma death,
2 people sufferpermanent disabilities
7/27/2019 W1L1 - Initial Assessment for Trauma_2
4/44
Mechanism of injuryPenetrating injuriesLow velocity
High velocityBlunt injuriesDirect
IndirectAcceleration injury
7/27/2019 W1L1 - Initial Assessment for Trauma_2
5/44
Preparation (prehospital phase) The prehospital system should notifythe receiving hospital
This allows for preparation of
trauma team & resources inemergency department
Emphasis should be placed on:
airway maintenance
control of external bleeding
immobilization
immediate transport
7/27/2019 W1L1 - Initial Assessment for Trauma_2
6/44
Preparation (hospital phase)
Protect myself
Prepare equipments
Pre-hospital information Nature & time of incident
Number, age & gender
Injuries identified
Treatment given
Initial & current vital signs
7/27/2019 W1L1 - Initial Assessment for Trauma_2
7/44
7/27/2019 W1L1 - Initial Assessment for Trauma_2
8/44
Triage
Multiple casusaltiesThe number of patients & severity of there injuries do not
exceedthe capability & facility of the hospitalPatients with life threatening problems are treated first.
Mass casualtiesThe number of patients & severity of there injuries exceeds
the capability & facility
Patients having the greatest chance of survival andrequiring the least facilities are treated first
7/27/2019 W1L1 - Initial Assessment for Trauma_2
9/44
Advanced Trauma Life Support (ATLS)
PROTOCOL :1. Primary survey/resuscitation
2. Secondary survey
3. Definitive treatment of individualinjuries
7/27/2019 W1L1 - Initial Assessment for Trauma_2
10/44
I. primary survey & resuscitation
objective
To IDENTIFYout and TREATallIMMEDIATELYlife threatening
conditions
To follow a systematic approach,reflecting the order which if untreatedwould lead to the patients death
7/27/2019 W1L1 - Initial Assessment for Trauma_2
11/44
Primary survey & resuscitation Steps
Airway maintenance with cervical spine protection
Breathingand ventilation
Circulation& control of haemorrhage
Disability: neurogenic status
Exposure& environmental control: completely
undress the patient, but prevent hypothermia
7/27/2019 W1L1 - Initial Assessment for Trauma_2
12/44
What is a quick, simple way
to assess a patient in 10seconds?
7/27/2019 W1L1 - Initial Assessment for Trauma_2
13/44
Primary survey & resuscitation
Same priorities for all patients
Specific considerations for: Elderly
Children
Pregnancy
7/27/2019 W1L1 - Initial Assessment for Trauma_2
14/44
Airway with cervical spine control
Aims
Assess
Clear and secure Provide oxygen
Prevent secondary
neurological damage
to the spine
7/27/2019 W1L1 - Initial Assessment for Trauma_2
15/44
Airway assessment (Look, Listen & Feel)
If the patient is capable of unstrained speech, hisairway is patent
All patients receive supplemental oxygen by mask
upon arrivalClinical clues
Noisy breathing
Respiratory effort
Silence
Trauma to the face or head
Burns: inhalational injury
7/27/2019 W1L1 - Initial Assessment for Trauma_2
16/44
Airway interventions Clear airway Vomitus, blood or foreign material
Support Manual: chin-lift or jaw-thrust
Oro-pharyngeal airway
Oxygen Reservoir mask High flow
Monitor SpO2 End tidal CO2
with C spine control
7/27/2019 W1L1 - Initial Assessment for Trauma_2
17/44
Tracheal intubation Apnea
Inhalation injuries
Closed head injuries(GCS OF 8or less)
Risk of aspiration
*Inline immobilization technique
Crico-thyroidotomy Percutaneous insertion of wide bore
needle
7/27/2019 W1L1 - Initial Assessment for Trauma_2
18/44
Cervical spine control
Clinical clues Cervical tenderness
Maxillofacial trauma
Neurological signs Unconsciousness
Cervical spine immobilization
Rigid neck collar
Radiological evaluation Done after stabilization of vital
systems
Lateral x-ray film
7/27/2019 W1L1 - Initial Assessment for Trauma_2
19/44
5 Chest clues in the neck
Wounds
Distended neck veins
Tracheal position
Surgical emphysema
Laryngeal crepitus
7/27/2019 W1L1 - Initial Assessment for Trauma_2
20/44
Breathing and ventilationAims
Support if
inadequate Eliminate any
immediately lifethreateningthoracic condition..
7/27/2019 W1L1 - Initial Assessment for Trauma_2
21/44
Breathing and ventilation assessmentInspection
Respiratory rate, effort
Symmetry
Wounds & marks
Palpation Mid axilla
Anterior
Percussion
Mid axilla
Above & below nipple lineAuscultation
Mid axilla
Above & below nipple line
Check the back
7/27/2019 W1L1 - Initial Assessment for Trauma_2
22/44
life threatening thoracic conditions Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest with pulmonary contusion
Cardiac tamponade
7/27/2019 W1L1 - Initial Assessment for Trauma_2
23/44
7/27/2019 W1L1 - Initial Assessment for Trauma_2
24/44
Breathing and ventilationIntubated & ventilated:
Position/length of trachealtube
Tidal volume, rate
FiO2, eTCO2, SpO2 Peak inflation pressure
Feel
Symmetry of movement
Percussion
Listen
7/27/2019 W1L1 - Initial Assessment for Trauma_2
25/44
Circulation & control of haemorrhage
shock
1. Hemorrhagic
2. Cardiogenic
3. neurogenic
7/27/2019 W1L1 - Initial Assessment for Trauma_2
26/44
Action Control bleeding
Insert 2 large bore cannulas (central line may be
needed) Blood sample: for typing, cross matching, HB,
HTC
Ringer lactate infusion (a bolus of 1-2 L )
Monitor urine output (0.5-1 ml/kg/hour)
7/27/2019 W1L1 - Initial Assessment for Trauma_2
27/44
Bleeding
External bleeding is managed by
Major areas of internal hemorrhage
To identify the source
Management of internal hemorrhage
7/27/2019 W1L1 - Initial Assessment for Trauma_2
28/44
Disability (neurologic evaluation)Aims
Rapid neurologicalassessment Alert; Voice; Pain;
Unresponsive
Pupils
Mini-neurologicalassessment GCS score
Pupils
Lateralising signs
7/27/2019 W1L1 - Initial Assessment for Trauma_2
29/44
Exposure and environmentAims
Remove clothing to allow examination of entirepatient
Care when removing tight trousers
Prevent hypothermia
Remove spine board (unless patient transfer is considered)
7/27/2019 W1L1 - Initial Assessment for Trauma_2
30/44
Adjuncts to primary survey & resuscitation ECG
Urinary catheter (unless uretheral injury is suspected)
ABG Pulse oximetry
X-ray chest & pelvis
FAST & DPL
7/27/2019 W1L1 - Initial Assessment for Trauma_2
31/44
Pause & check
Are all immediately life-
threatening injuries
identified?
Is all monitoring in place? Investigations ordered?
Analgesia?
Relatives informed?
Non-essential team membersdisbanded?
7/27/2019 W1L1 - Initial Assessment for Trauma_2
32/44
II. Secondary survey
Only proceed if the life threatening conditions have
been corrected
7/27/2019 W1L1 - Initial Assessment for Trauma_2
33/44
Secondary surveyAims
AMPLE history
Examine head to toe, frontand back
Analyze all clinical, images &lab data
Identify all injuries
Develop a definitive care plan
Monitor continuously for immediately life threatening
conditions
7/27/2019 W1L1 - Initial Assessment for Trauma_2
34/44
Secondary survey (history)
Allergies
Medications
Pre existing medical conditions
Last meal
Events & Environment
*Mechanism of injury: (pre-hospital personnel)
t
7/27/2019 W1L1 - Initial Assessment for Trauma_2
35/44
Secondary survey ( examination)
The back 4 person technique
Examination
Remove debris Remove spine board
Dermatomes
Myotomes
7/27/2019 W1L1 - Initial Assessment for Trauma_2
36/44
Secondary survey
Analgesia Psychological
Fear, sadness, worry
Physical
Splinting, cooling, cover Pharmacological
Opioids
NSAIDs
Local anaesthesia
Entonox
7/27/2019 W1L1 - Initial Assessment for Trauma_2
37/44
Preparation for safe transfer
A Assessment
C Command & control C Communication
E Evaluate
P Prepare & Package
T Transfer
ACCEPT
7/27/2019 W1L1 - Initial Assessment for Trauma_2
38/44
Wash & brush up!
7/27/2019 W1L1 - Initial Assessment for Trauma_2
39/44
Reevaluation
7/27/2019 W1L1 - Initial Assessment for Trauma_2
40/44
Definitive care
7/27/2019 W1L1 - Initial Assessment for Trauma_2
41/44
Team function & organisationFunction: Identify and treat life
threatening injuries
Identify any other problems
Arrange appropriatetreatment and investigations
Arrange and transfer to
definitive care
Organisation:
Task allocation
Simultaneous activity
7/27/2019 W1L1 - Initial Assessment for Trauma_2
42/44
Team structure and function
Team leaders
Circulation Circulation
Airway
Relatives
Recorder
Radiographer
Breathing
7/27/2019 W1L1 - Initial Assessment for Trauma_2
43/44
Any questions?
7/27/2019 W1L1 - Initial Assessment for Trauma_2
44/44
Summary Primary survey & resuscitation: recognize and
treat immediately life threatening conditions
Secondary survey: identify & prioritize other
injuries The basic principles of safe transfer of a patient to
definitive care