Primary Care in Trauma Patient

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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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    75

    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