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A single conversation across the table with a wise man
is worth a month's study of books
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assessment 2-2
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INTRODUCTION Trauma defined as any fortuitous event causedby an external force that acts quickly and results
in physical or mental injury( WORLD HEALTH ORGANISATION)
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Death patternFollows tri-modal distribution
Early phase- 50%Intermediate phase- 30%
Late phase- 20%
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P HYSIO
P ATHOLOGY OF INJURY
T rauma- C ontuse
- Penetrating
C an orient the health provider to suspect injuries inorgans or systems. T his orientation could lead us tosuspect internal & hidden injuries when possiblyno external signs are evident
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ATLS
APPRO
ACH
D r. James Styner( A merican orthopaedic surgeon)
Philosophy : T RE AT LETHA L INJURY FIRS T ,TH EN
RE A SSESS A ND T RE AT AGA INBased on 3 well established principles of:A BCD Es of assessment.primum non nocere( first , do no harm)T reatment of life threatening injuries within golden
hour
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Steps1 Survey- identify what is killing the patient
Resuscitation- treat what is killing the patient
2 Survey- proceed to identify all other causes
D efinitive care- develop a definitive mang. plan
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Wh at are t h e first steps to take at t h e
scene of accident?????Evaluation of the scene: safety & situation
Universal precautions( self safety)
Safety at the scene
Safety of the patient
Entrapment : RelativeAbsolute
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Scene assessment:C onsider resources required.C onsider possibility of major incident.Early situation report.D eliver situation report ME THA NE
M-Major incident standby or declaredE-Exact location of the incident.
T -T ype of incidentH -H azardsA -A ccess and egress route
N- Number, severity and type of causalityE-Emergency services present at the scene or required
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Essential EquipmentPersonal protectiveequipmentBackboard, straps, andhead motion-restrictor C ervical collar Oxygen and airway
equipmentT rauma box
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TRAIGE French verb tier , meaning to sort, siftor select
2 types of triage: Simple triageA dvanced triage.
Multiple casualtiesMass casualties
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REVISED
T
R A
UMA
SC
ORECoded value GCS SBP(mm Hg) RR(breaths/min)
0 3 0 0
1 4-5 90 10-30
An RTS of less than 11 is used to indicate the need for transport to a designated trauma center.
RTSc = 0.9368 GCSc + 0.7326 SBPc + 0.2908 RRc
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T h e Acute Ph ysiology and C h ronic Healt h Evaluation
(A P
ACHE)Introduced in 1981has 2 components-1) the chronic health evaluation
(2) the A cute Physiology Score ( A PS).
In 1985, the A PACH E system was revised ( A PACH E II) byreducing the number of A PS variables from 34 to 12.
T he most recent version, A PACH E III, was published in 1991
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P EDIATRIC TRAUMA SCORE score +2 +1 -1Weight >44lbs/ >20
kgs22-44lbs/ 10-20 kgs
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Ot h
er severity assessment system.T RISS(trauma and injury severity score)A bbreviated Injury Score ( A IS)
Injury Severity Score (ISS) New Injury Severity Score (NISS)A natomic Profile ( A P)Penetrating A bdominal T rauma Index (P AT I)ICD -based Injury Severity Score (I C ISS)
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How sh
ould t h
e patient be evaluated????
Wh at injuries could place t h e lives of t h e
victims in danger???
How does one decide w h et h er a patient is
critical or not????
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O bjectives:detect and treat life threatening injuries.
Follows the A BCD E approach: helps toidentify whether patients are critical or notT reatment should not be delayed but treated
as they are found as you go.life prevails over function and function over
aest h etics
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Primary survey
Primary surveyA BC s - Identified and simultaneous
management of the life-threatening conditions
A A irway management with C -spine controlB BreathingC C irculation & hemorrhage control
D D isability: neurologic statusE Exposure: completely undress the patient
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AIRWAY AND CERVICAL SP
INE CONTROLPatent airway is foremost priority in themanagement of trauma victims.
A ssume cervical spine # until ruled out.CA USES:
Foreign body.
Facial, mandibular, tracheal/laryngeal #.OedemaBleeding.
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Airway obstruction: In supine patient if you leave t h e patient facing towards h eaven, it
wont be long before t h ey get t h ere
First thing to do.SEEK VERB A L RESPONSE
+VE RESPONSE----A
irway patent-VE RESPONSE---- A ssess and secure
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Airway obstructionAirway obstructionR ecognition
L ook
L isten
Feel
Is the airway clear ?
IF NOT ,DO SOMETHING ABOUT IT
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Unlocking airwaymanagement skills .
24
the key to patient survival.
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Airway obstructionAirway obstructionM anagement
The purpose:Maintain an intact airwayProtect the airway in jeopardyProvide the airway when not available
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C lear airway, ensure airway remains clear &secure.
Airway obstruction
MANUAL CLEARING OF THE AIRWAY
MANUAL MANEUVERS TO OPEN THE AIRWAY
SUCTION
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AIRWAY OBSTRUCTION--- CLEAR AIRWAY
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Fo r i ody ova l H i lianeuve r
2 ) Res i a l i w) C sci s a sta i
H eimlic ma e er- A rti icial cBac war a war t r st
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SuctionWide bore rigid suckers are preferable tofine bore flexible soft suction catheters.
Vigorous and prolonged suctioning canworsen hypoxemia.
Should not be carried for more than 15secs.
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Airway maintenance tec h nique....
J aw thrustChin lift
MANUAL
OropharyngealNasopharyngealDEVICES
Endotracheal intubationSurgical airway
DE F INI T IVE
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Manual maneuvers:
In unconscious pt.(supine position), thetongue loses its muscle tone and may bedisplaced towards the posterior
pharyngeal wall causing airwayobstruction.
T o avoid this, 2 techniques can be
applied:1. Mandible displacement(head-chin lift)along with MILS of head and neck.2.Jaw thrust maneuver
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J AW TH RUS TH EAD T IL T C H IN LI FT
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ORO P HARYNGEAL AIRWAY ORO P HARYNGEAL AIRWAY
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NASO P HARYNGEAL AIRWAY
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Definitive airway tec h nique
O ro tracheal intubationNaso tracheal intubationET
C ricothyroidotomyJ et insufflation of the airwayTracheostomy
surgical
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G uidelines A ssociation of A naethetists of G reat Britain & Ireland
Bilateral mand. #.C opious bleeding from mouthLoss of protective laryngeal reflexes.A GC S 2 point fallSeizuresD eteriorating blood gases.When gross swelling anticipated.In significant facial injuries where long inter-hospitaltransfer is req.
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SELLI C KS M A NEUVERS
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Endotracheal intubation
Nasotracheal intubation
Contraindication :Apneic patient
Skull base #
both techniques are safe & effective when performed properly
Orotracheal intubation
P referred technique
In tubatio n easier i n some pan f acial i nj uries??????
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Surgical techniqueT ime is of the essenceOptions:
C ricothyroidotomy (needle/surgical)T racheotomy (needle/surgical)T racheostomy (surgical/percutaneous)
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C ricothyroidotomy
Needle tech . routine use controversialbuy time
Surgical tech . now advocatedC hoice of EMR airway control when E T no
possible Needle Vs SurgicalT racheostomy : inappropriate in EMR setting
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N eedle C ricothyroidotomy S urgical C ricothyroidotomy
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CC--spine protectionspine protectionCC--spine protectionspine protection
C ervical spine injury 5-10% following blunt polytrauma.
AT LS teaches trauma occurring above the clavicleshould raise a high index of suspicion for a potentialC -spine injuryA lmost always accompanied by pain in the neck.
Neurologic examination does not rule outC- spine injury
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P atient wit h h elmet
If a motorcycle helmet needs to be removed or intubation is required, these should be performed within-line manual immobilization.
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Imaging studiesImaging studies
Plain radiographs-Standard AT LS views(lateral,A P, and open mouth odontoid peg)H elical CT of entire C -spine: sensitive and specificIf helical not available the AT LS series + highresolution CT
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Assessment of t h e Cervical Spine X-Ray
T hink of the A BC s A dequacy and A lignment
BonesC artilages andSoft tissues.
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C-spine immobilizationC-spine immobilization
Rigid cervical collars (Laerdal Stif Nek)pressure sores
Semi rigid collars (A
spen)Sand bagsIf patient anaesthetized: lateralrestraints and tape adequate
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B REATHING AND VENTILATION Is oxygen getting to t h e blood? Is air moving?
Is it moving adequately? Is it moving at an adequate rate?
Administration of 100% oxygen
absolutely primordial in t h e trauma patient.
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B REATHINGA ssessment & give O 2
Look rate, chest movement, accessory muscle use, paradoxicalmovement
Listenauscultate
FeelPercussion
Monitoring equipment-pulse oximetry
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P atient breat h ing or not?????
NO- initiate C PR
YES- evaluate the work of breathing, chest movements, use of accessory muscles etc.
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Inadequate ventilationC heck airwayA dminister 100% oxygen, flow rate 10 -12lts min
Find out why ?????? & treat cause
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Single handed ventilation Two handed mask ventilation
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Circulation
Objectives of C step:-T o evaluate the circulatory status
-T o detect and control hemorrhage-D etermine whether the patient is in shock(type
and severity)
-Initiate treatment as soon as possible
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SH OC K
D efined as profound h emodynamic and metabolic disturbances, c h aracterized by
failure of t h e circulatory system to maintainadequate perfusion of t h e vital organs
HY P OVOLAEMIC SHOCK..
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B eware of early signs
Pallor C ool peripheries
A nxietyA bnormal behavior H ypotension(SBP
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D oes patient have radial pulse?A
bsent radial = systolic BP < 80D oes patient have carotid pulse?
A bsent carotid = systolic BP < 60
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CLASS I CLASS II CLASS III CLASS IV
Vol. Of bloodloss(% total)
40%)
Heart rate(bpm) Normal >100 >120 >140
Resp.Rate(rpm) Normal 20 30 30 40 >35
SB P (mm hg)palpable pulse
NormalRadialpalpable
NormalRadialpalpable
ReducedRadial pulsenot palpable
ReducedCarotidpalpable+/-
P ulse pressure Normal/ Decreased Decreased Decreased
Neurologicalstatus
Alert Anxious Confused Lethargic
Urineoutput(ml/hr) Normal 20 - 30 5 15 Minimum
CLASSI F ICA T ION O F SH OCK AMERICAN COLLEGE O F SURGEONS AT LS ,1997
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Confounding factors
A geA thletes
PregnancyPrevious diseaseMedication
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Most frequent cause of shock ishemorrhage.(hemorrhagic shock).
Other types :- H ypovolemic shock.- C ardiogenic shock.
- Neurogenic shock
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Management:
A im: Provide oxygen supply to tissuesreversing metabolism from anaerobic toaerobic.First guarantee a secured airway and correctventilation.C ontrol bleeding-most effective way
1. external hemorrhage2. internal hemorrhage
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Wh ere is t h e patient bleeding???C linical examination:Imaging technique:C
hest x rayFA ST scan(focussed assessment with ultrasound intrauma)CT scanPelvic x ray
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Control bleeding
External bleedingD irect pressure
Elevation of limbsPressure at proximal site.T ourniquet
Internal bleedingPleura thoraxA
bdomenRetro peritoneum-pelvisLong bones
P atie n ts own circulati n g warm blood is considerably better tha n an y substitute
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Hypothermia:Prevention most important.A
ll wet and humid clothes removed, well covered.T emp. of the ambulance and room should beconditioned 29 C
Fluids and blood derived products warmed
It is patients body temp. that is most important ,not thecomfort of the health care providers
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Fluid resuscitation: most controversial!!!!!
2-Wide bore intravenous access(ideally 12 14 G )Initial fluid bolus:
-A dults: 1-2lts
-Pediatric: 20ml/kg3:1 RuleC entral pulse A BSEN T , radial pulse A BSEN T : strong indicationC entral pulse PRESEN T , radial pulse A BSEN T : relativeindicationC entral pulse PRESEN T , radial pulse PRESEN T : D O NO T commence FR until signs of poor central perfusion
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Wh ich one to give????
T ypes of fluids:-crystalloids/RL sol.
-colloids:H
ES 6% (50 ml/kg)-hypertonic saline 7.5%-oxygen carriers-solutions with anti-inflammatory
properties & ringer ethyl pyruvatesolution.(experimental)
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YET ANOTHER DILEMMA!!!!!!
CRYSTALLOIDS OR COLLOIDS ???
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Recent trends- Permissive hypotension
- SBP 80 mm H g guide to FR.(if drops below 80, instead of 1-2lts bolus, smaller aliquots(250 ml) recommended
Pitfalls : Aggressive and excessive approac h to fluid replacement??????
- Risks of dilutional coagulopathy
- concealing the state of shock - pop the clot phenomenon- hypothermia- A ctivation of an inflammatory systemic response .
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Evaluation of fluid resuscitation:
G eneral assessmentUrinary output.
Sensitive indicator.A dults:0.5ml/kg/hr Pediatric:1.0ml/kg/hr
>1 year:2ml/kg/hr A cid-Base balance:
Persistent acidosis-----inadequate resuscitation
Adequate fluidreplacement
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Res pon se:RAPID T RANSIEN T NO RESPONSE
Vital signs R eturn to normal Transientimprovement
R emain abnormal
E stimated blood
loss
M inimal 10 -20% M oderate and
ongoing 20-40%
Severe > 40%
Need for morecrystalloid
L ow High High
Need for blood L ow M oderate - high Immediate
Blood prep. Type and cross
matched
Type specific EMR blood
release
O perativeintervention
possibly L ikely
E arly presence of surgeon
Yes Yes Yes
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DISA BILI TY( NEUROLOGIC EVALUA T ION)
Rapidly performed at the end of primary survey.Establishes level of cons. as well as pupillary sizeand reactionA VPU method
A - A lertV- Responds to Verbal stimuli
P- Responds to Painful stimuliU- Unresponsive to all stimuli
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4-Spontaneoulsy3-To Verbal command2- To Pain1- No Response
EYE OPENING
6-Obeys5-Localizes to pain4-Flexion-withdrawl3-Flexion-abnormal (decorticate rigidity)2-Decerbate rigidity1- No response
BEST MOTOR RESPONSE
5- Oriented and Converses4- Disoriented and Converses3-Inappropriate words2-Incomprehensible sounds1-No Response
BEST VERBALRESPONSE
TEASDALE AND JENNETT,1974
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74
Modified GC S for C hildrenE YE OPENING
> 1 Year> 1 YearSpontaneousSpontaneousT o SpeechT o SpeechT o PainT o Pain
No Response No Response
< 1 Year< 1 YearSpontaneousSpontaneousT o ShoutT o ShoutT o PainT o Pain
No Response No Response
ScoreScore44
33
22
11
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MO T OR RESPONSE
>1 YearObeys C ommand
Localizes PainFlexion
Withdrawal
D ecorticateD ecerebrate
No Response
< 1 YearSpontaneous
Localizes PainFlexion
Withdrawal
D ecorticateD ecerebrate
No Response
Score6
54
3
21
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VER BAL RESPONSE> 5 years> 5 years
OrientedOrientedD isorientedD isoriented
InappropriateInappropriatewordswordsIncomprehensibleIncomprehensiblesoundssounds
No response No response
22--5 years5 yearsA ppropriateA ppropriatewordswords
InappropriateInappropriatewordswordsPersistent criesPersistent criesG runtsG runts
No response No response
00--23 months23 monthsSmiles,Smiles,C ries, consolableC ries, consolable
Persistent inapp.Persistent inapp.criescriesG runts, agitated,G runts, agitated,restlessrestless
No response No response
ScoreScore5544
332211
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IN T ERPRE TAT ION O F SCORES :15 -- mi nor head i nj ury.13 -14 --mild head i nj ury.
9-12 -- moderate head i nj ury.3-8-- severe head i nj ury.
* A GCS score o f
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Interpretation of pupillary finding
Pupil size Light response Interpretation
Unilaterally dilated Sluggish/fixed 3 rd nerve compression
Bilaterally dilated Sluggish/fixed Inadequate brainperfusion
Unilaterally dilated Cross reactive Optic nerve injury
Bilaterally constricted Difficult to determine Drugs(opiates)
Unilaterally constricted preserved Injured sympatheticpathway
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EX P OSURE/ENVIRONMENTAL CONTROL
You cant treat what you dont find!If you dont look, you wont see!
Should be carried out respecting dignity of the patient.Prevent hypothermia.
It is patients body temp. that is most important ,not thecomfort of the health care providersC over patient with blanket when finished
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Adjuncts to 1 surveyMonitoring
a. Arterial blood gas analysis and ventilatory rateb. End tidal CO2
c. ECGd. P ulse oximetrye. Blood pressure
Urinary and gastric catheters
X-rays and diagnostic studies( chest, pelvis, C-spine)
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Primary Resuscitation Primary Resuscitation
Minimum Time On Scene
Maximum Treatment InRoute
Have a PLAN!
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P atient is not critical t h en h ow to proceed????????
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Secondary survey
H istory and Physical ExamYou WILL get here with MOS T trauma patientsPerform ONLY after primary survey is completedand life threats correctedD o NO T hold critical patients in field for secondary survey
T ube and f i n gers i n every ori f ice H ead to toe evaluatio n
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H IS T OR Y SAMPLE History
S- SymptomsA- A llergiesM- M edications currently usedP - P ast illness/ P regnancy
L - L ast mealE - E vents/ E nvironment related to the injury
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P hysical Ex ami natio n
Stepwise, organizedE very patient, same way, every timeSuperior to inferior; proximal to distalL ook --L istenFeel
M ost frequently missed areas
Back M outhNeuro exam
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P HYSICAL EXAMINATION H ead & skullMaxillofacial
Neck C hestA bdomenPerineum/rectum/vaginaMusculoskeletalC omplete neurological examination
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Head & maxillofacial A ssessment:
Inspect & palpate entirehead and face.
Reevaluate pupils, LO C , &GC S score.A ssess eye.Evaluate cranial nerve
functionInspect nose and ear for C SF leak Inspect mouth.
Management:Maintain airwaycontinue ventilation and
oxygenation.C ontrol hemorrhage.Prevent 2 brain injury.
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Cervical spine & neck
A ssessment:InspectPalpateA uscultateRadiographs
Remember TWEL V e
Management:Maintain MILSneutral positionProtection of cervicalspine
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C h est
Assessment:
Inspect chest wallsPalpatePercuss.A uscultate
Management: Needledecompression/tube
thoracostomyA ttach chest tube to under water seal drainage device.C orrect dressing.Pericardiocentesis.T ransfer to O T if indicated
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Abdomen
Assessment:
InspectPalpateA uscultateRadiographs/ CT /US G
Seat belt injuries
Management:T ransfer to O T if indicated.A pply P A SG for control of
hemorrhage
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Musculoskeletal:
Assessment:
InspectPalpateObtain X-Rays
Management:
A pply splinting devices.
Maintain immobilizationA pply P A SG if indicatedC onsider possibility of
compartment syndrome
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Neurologic
Assessment:Reevaluate pupils andlevel of consciousness.
Determine GCS.Motor and sensoryfunction.
Management:Continue ventilationand oxygenation.
Maintain adequateimmobilization.
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ADJUNCTS TO 2 SURVEY
Specialized diagnostic procedure.C omputerized tomography.C
ontrast X-rays studiesExtremity X-raysEndoscopy and ultrasonography
Bronchoscopy. Etc..
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REEV A LU AT ION
Re-evaluate constantlyD iscover deterioration
C ontinuous monitoring of vital sigs and UOA BG & cardiac monitoring devices should
be used.
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How s h ould t h e patient be immobilized???Wh ere s h ould t h e patient be transferred to????
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D efinitive Field C are
P erformed ONLY on stable patients
PackagingBandagingSplinting
If patient critical, all fractures stabilizedsimultaneously by securing patient to board
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T ransfer:Early transfer foremost priority.Should be made to appropriate centreD uring transfer continuous monitoring and primary survey
repeated if any change in condition of patient.Pain management and psychological support
S C OOP A ND RUN policyS TA Y A ND PL A Y policy
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Communications wit h Medical Direction
communicate with thereceiving centre.H andling of patient should
be accompanied by bothverbal and writteninformation.
If it isnt documented, it wasnt done
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MANAGEMENT IN HOS P ITAL
P LANNING & P RE P ARATION Must have purpose-built and well equipped resuscitation room.Medical staff should ideally be trained in trauma system- AT LS.
Nursing and other professional staff should also be trainedwithin the system.TRAUMA TEAM
M ust be e ff icie n t and is quicker.
4- Doctors5- N urses
Radiogra pher
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Anatomic C h aracteristics of t h e P ediatric P atient
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Anatomic C aracteristics of t e ediatric atient and Significance to Trauma Care
V ariable V ariable SignificanceSignificanceLarge volume of blood in headLarge volume of blood in head Cerebral edema develops rapidlyCerebral edema develops rapidly
Poor muscular support in neckPoor muscular support in neck Flexion/extension injuries occurFlexion/extension injuries occur
Decreased alveolar surface areaDecreased alveolar surface area
Increased metabolic rateIncreased metabolic rate
Injury leads to rapid compromiseInjury leads to rapid compromise
Decreased airway caliberDecreased airway caliber Increased airway resistanceIncreased airway resistance
Heart higher in chest,Heart higher in chest,Small pericardial sackSmall pericardial sack
Prone to injury and cardiacProne to injury and cardiactamponadetamponade
Thin walled, small abdomenThin walled, small abdomen Organs not well protectedOrgans not well protectedBones soft and pliableBones soft and pliable Fractures less commonFractures less common
Renal function not well developedRenal function not well developed Prone to develop acute renalProne to develop acute renalfailurefailure
Large body surface areaLarge body surface area Prone to hypothermiaProne to hypothermia
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Vital functions:Agegroup
Weight(kg)
HR(bpm) BP(mm Hg) RR(bpm) UO(ml/kg/hr
Birth 6mnths
3-6 180-160 60-80 60 2
Infant 12 160 80 40 1.5
Preschool 16 120 90 30 1
Adolescent
35 100 100 20 0.5
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M anageme nt o f the geriatric trauma patie n t.
Organ system changes in the heart,vasculature, lungs, kidneys and liver lead todecreased physiologic reserveT horacic cage is far more fragile, increasingthe risk of both rib fractures and pulmonarycontusions.Edentulous patients may be difficult to mask ventilate.
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D irect laryngoscopy may be more difficult due todecreased cervical spine mobility.Fluids should be administered with care, particularly in the
presence of cardiovascular and/or renal disease.Invasive monitoring should be considered early and with a
lower thresholdT hese patients are also vulnerable to hypothermia due to
pre-existing hypothermia, decreased (heat generating)muscle mass and (insulating) subcutaneous fat
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Conclusion.T he sum of actions carried out during the critical
period is a determining factor in short and long termsurvival of patient and posterior morbidity.
lost time consumes lifelife prevails over function and function over aest h etics
primum non nocere ......
OBSERVE TRAFFIC RULES
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OBSERVE TRAFFIC RULES