Initial Assessment and Management

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


Heart rate > 100 / min

Decreased pulse pressure


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





Crystalloid, blood components, definitive control of bleeding

*look for the source of bleeding> 2000 mL Blood Volume Loss (> 40%)Confused, lethargic

Hypotension



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


Heart rate < 100 / min


Urinary output 30 mL / hour

Crystalloids

*Normal vital signs

Anxious






Crystalloids

* dito nagstart tumaas ang HR (patient is TACHYCARDIC)Confused, anxious

Decreased blood pressure





Crystalloid, blood components, definitive control of bleeding

*look for the source of bleedingConfused, lethargic

Hypotension



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!

1

Initial Assessment and Management

Documents

Transcript of Initial Assessment and Management