Initial Assessment and Management - emteaching.co.ukemteaching.co.uk/ATLS.pdf · ATLS: Initial...
Transcript of Initial Assessment and Management - emteaching.co.ukemteaching.co.uk/ATLS.pdf · ATLS: Initial...
Objectives• Identify sequence of priorities in assessing the multiply
injured patient• Apply principles outlined in primary and secondary
evaluation surveys• Apply guidelines and techniques in the initial
resuscitative and definitive-care phases of treatment• Identify how patient’s medical history and mechanism of
injury contribute to identification of injuries
Objectives• Identify pitfalls associated with initial assessment and
management and apply steps to minimize their impact• Be able to conduct an initial assessment survey, using
the correct sequence of priorities and management techniques for primary treatment and stabilization
Concepts of Initial Assessment
• Rapid primary survey• Resuscitation• Adjuncts to primary survey/resuscitation• Detailed secondary survey• Adjuncts to secondary survey• Reevaluation• Definitive care
Initial Assessment
• Primary survey and resuscitation of vital functions are done simultaneously-a team approach.
PreparationPre-Hospital System
• Transport guidelines/protocols• On-line medical direction• Mobilization of resources• Periodic review of care• Closest appropriate facility
PreparationIn-Hospital
• Preplanning• Equipment, personnel, services• Standard precautions• Transfer agreement
Triage
• Sorting of patients according to:– ABCDE’s– available resources
• Multiple casualties• Mass casualties
Primary Survey
• adult/pediatric/pregnant women=priorities are the same
• A airway with C-spine protection• B breathing• C circulation with hemorrhage control• D disability• E exposure/environment
Special Considerationstrauma in the elderly
• 5th leading cause of death• decreased physiologic reserve• comorbidities: diseases/medications• Outcome depends on early, aggressive
care
Primary SurveyA
• Establish patent airway– assume C-spine trauma
• Pitfalls– equipment failure– inability to intubate– occult airway injury– progressive loss of airway
Primary SurveyB
• Assess• Oxygenate• Ventilate• Pitfalls:
– Airway vs ventilation problem– iatrogenic pneumothorax/tension
pneumothorax
Primary SurveyC
• Assessment of organ perfusion– Level of Consciousness– Skin color and temperature– Pulse rate and character
Primary SureveyC
• Circulatory Management– Control Hemorrhage– Restore Volume– Reassess
• Pitfalls:– elderly, athletes, children– medications
Primary SurveyD
• Disability– Baseline neurologic evaluation– GCS Scoring– Pupillary response
• Continuously reassess for deterioration/changes
Primary SurveyE
• Exposure– Completely undress the patient
• Environment– core temperature– prevent hypothermia
Resuscitation
• Protect and secure the airway• Ventilate and oxygenate• Stop the bleeding• Protect from hypothermia
Adjuncts to Primary Survey
• Vital Signs/ECG monitoring• ABGs• POX/CO2• Urinary/gastric catheters• Urinary output• ECG
Adjuncts to Primary Survey
• Consider Early Transfer– do not delay transfer for diagnostic tests– time to transfer=resuscitation
Reevaluate
• Proceed to secondary survey after:– Primary survey completed– ABCDE’s reassessed– initial resuscitation of vital functions
Secondary SurveyKey Components
• History• Complete head-to-toe examination• “Tubes and Fingers in every orifice”• Complete Neuro exam• Special diagnostic tests• Reevaluation
Secondary SurveyHistory
• A Allergies• M Medications• P Past Medical/Surgical
History/Pregnancy• L Last meal• E Events/Environment related to injury
Secondary SurveyHead
• Complete Neuro exam• GCS Score• Comprehensive eye/ear exams• Pitfalls:
– unconscious patient– periorbital edema– occluded auditory canal
Secondary SurveyMaxillofacial
• Bony crepitus/stability• Palpable deformity• Pitfalls:
– potential airway obstruction– cribriform plate fracture– frequently missed injuries
Secondary SurveyCervical Spine
• Palpate for tenderness/stepoffs/crepitus• Complete motor/sensory exams• Reflexes• C-spine imaging• Pitfalls:
– altered LOC for any reason– distracting injury
Secondary SurveyNeck (soft tissues)
• Mechanism: blunt vs penetrating• Symptoms: airway obstruction,
hoarseness• Findings: crepitus, hematoma, stridor,
bruit• Pitfalls:
– may have delayed symptoms/signs– progressive airway obstruction– occult injuries
Secondary SurveyChest
• Inspect• Palpate• Percuss• Auscultate• X-rays• Pitfalls:
– elderly, children
Secondary SurveyAbdomen
• Inspect, auscultate, palpate, percuss• Reevaluate frequently• Special studies• Pitfalls:
– hollow viscus and retroperitoneal injuries– excessive pelvic manipulation
Secondary Survey
• Perineum-contusions, hematomas, lacerations, urethral blood
• Rectum-sphincter tone, prostate, pelvic fracture, rectal wall integrity, blood
• Vagina-blood, lacerations• Pitfalls:
– urethral injury, pregnancy
Secondary SurveyMusculoskeletal:Extremities
• contusion, deformity• pain• perfusion• peripheral NV status• X-rays as indicated
Secondary SurveyMusculoskeletal:Pelvis
• Pain on palpation• increased symphysis width• uneven leg length• instability• special X-rays as indicated
Secondary SurveyMusculoskeletal
• Pitfalls:– potential blood loss– missed fractures– soft-tissue or ligamentous injuries– compartment syndrome
Secondary SurveyNeurologic
• Spine/Cord:– complete motor and sensory exams– reflexes– imaging as indicated
• CNS:– frequent reevaluation– prevent secondary brain injury
• Early neurosurgical consultation
Secondary SurveyNeurologic
• Pitfalls:– incomplete immobilization– subtle increases in ICP with manipulation– rapid deterioration
Adjuncts to Secondary Survey
• Special diagnostic tests as indicated
• Pitfalls:– patient deterioration– delay of transfer
Reevaluation
• Minimizing missed injuries– high index of suspicion– frequent reevaluation and continuous
monitoring
Definitive Care? Transfer
• Patient– injuries– physiologic status– concurrent diseases– factors that may alter prognisis
• Hospital– overall capabilities– specialized care
Records, Legal Considerations
• concise, complete, chronologic documentation
• consent for treatment• forensic evidence