Initial assessment

Trauma life support

Abd El -Aal Elbahnasy , MD

Emergency medicine specialistMinistry of health

&populationEGYPT,2016

WHAT IS THIS?WHAT IS THE FIRST STEP YOU DO?

OBJECTIVE

Initial assessment of trauma patients

Life saving maneuvers

Practicing trauma skills

TRAUMA SCENARIO MALE PATIENT 34 YEARS OLD COMING

TO ER AFTER ROAD TRAFFIC ACCIDENT:

HOARSNESS OF VOICEBP 90/50RR 30PULSE 130ABRASION ON LT CHESYWHAT DO YOU DO?

Initial assessment of trauma patient

1- primary survey2- secondary survey

Cap

Gown

Mask

Shoe covers

Goggles / face shield

Check safety before start primary survey

assess the patient in 10 seconds?

Ask patient about his

name

Breathing / ventilation / oxygenationCirculation with hemorrhage controlDisabilityExpose / Environment / body temp.

Primary SurveyAirway with c-spine protection

Airway Patent and clear If not open air way :chin lift , jaw trust

Use adjunct to airway:Oropharyngeal , nasopharyngeal ,

LMA,ET GIVE HIGH FLOW O2 TO ALL TRAUMA

PATIENT IF EIGHT INTUBATE

A

Sequence of air way maneuvers

chin lift

Jaw thrust

finger sweep

suction Oropharyngeal/ orotrachial tube

Cricothyroidotomy

Tracheostomy

C- SPINE PROTECTION INLINE

IMMBOLIZATION

NECK COLAR HEAD LOCK HARD BOARD bellets

BREATHING CHECK: CHEST MOVEMENT EQUALITY IN BOTH SIDE AIR ENTERY PERCUSSION O2 SATURATION RESPIRATORY RATE

B

Our task is to identify

Five life threatening thoracic conditions:

Tension Pneumothorax Massive Pneumothorax Open pneumothorax Flail segment Cardiac tamponade

Abnormal Findings

Un equality of chest movement

Hyper resonance on percussion

Decrease air entry

Tachypenic

Pneumo thoraxNeedle decompression &

chest tube

Abnormal FindingsUn equality of chest movement

Hyper resonance on percussion

Decrease air entry ,tachypenic

Deviated trachea ,congested neck vein

Tension Pneumo thoraxNeedle decompression &

chest tube

Abnormal Findings

Un equality of chest movement

Dullness on percussion

Decrease air entry

Tachypenic

heamothoraxchest tube

heamothorax

heamothorax

Abnormal Findings

Un equality of chest movement

Dullness on percussion

Normal air entry ,muffled heart sounds

Tachypenic, congested neck veins

Cardiac tamponadepericardiocentesis

(almost always seen with a penetrating wound)

Beck’s triad: Hypotension distended neck veins Muffled heart sounds Pulsus paradoxus

Cardiac tamponade

cardiac tamponade

Skills in B

Needle de compressionChest tube (thoracostomy)pericardiocentesisEndo tracheal intubation

circulationCheck : Bp Pulse Capillary refill Search for External bleeding Search for Internal bleeding 2 wide bore cannula Blood sample for ABO compatibility,

creatinine,urea,ABG GIVE 2 liters warmed crystalloid

C

Tachycardia in a cold patient indicates shock

Causes of shock following injury:

Hypovolemic Cardiogenic Neurogenic Septic

Adults- 2 lit of Ringer lact soln as initial fluid challenge

Children- 20mg/kg of body wt

Response to initial fluid challenge:

Immediate & sustained return of vital signs.

Transient response with later deterioration

No improvement.

Urine output –

0.5ml/kg/hr in adults

1ml/kg/hr in children

2ml/kg/hr in infants

Skills in C Direct compression

in site of external bleeding

Splint of long bone fractures

FAST( E- FAST) X-ray chest , pelvis Consult surgeon

Disability Determine Glasgow

coma scale Check pupil for

(equality-reactivity) Signs of

lateralization Neurological

assessment

DA.-AlertV.-Responds to VoiceP.-Responds to PainU.-UnresponsivePupil.-Size and reaction

Exposure Remove clothes Log roll Prevent

hypothermia

E

Resuscitation

ADJUNCTS

Vital signs

ABGs

Pulse oximeter and CO2

Urinary / gastric catheters unless contraindicated

Urinary output

ECG

CONSIDER EARLY PATIENT TRANSFER

Do not delay transfer for diagnostic tests

Use time before transfer for resuscitation

Secondary Survey

AMPLE HistoryAllergies

Medications

Past illnesses

Last meal

Events / Environment

HEAD Inspection Palpation Signs of fracture

base Eye (PUPIL) Nose (RHINORRHEA) Maxilla (FRACTURE) Mouth Ear(HAEMOTYPMAN

UM

Fracture base skull Haemotympny

m Otorrhea Rhinorrhea Rakon eyes Battle s signs

NECK Inspection(abrasion-cut wounds) Palpation(mass , surgical

emphysema ,trachea , carotid pulse -Cervical spine fractures)

Auscultation carotid bruit

CHEST InspectionPalpationPercussionauscultation

Search for potentially life threatening injuries

Pulmonary complication Myocardial contusion Aortic tear Diaphragmatic tear Oesophageal tear Tracheobronchial tear Early thoracotomy if initial haemorrhage > 1500 ml

ABDOMEN Inspection Auscultation

Palpation percussion

PELVIS Clinical assessment of stability X-ray stabilize pelvis with

fixator/clamps –pelvic binder If urethral injury is suspected high up prostate in PR blood in meatus perineal haematoma

Inspection

•Wounds• Swelling• Source of bleeding

Palpation• Peripheral

pulsation• Click of fracture• Compartmental

syndrome

EXTERMITIES

Radiography: The "trauma triple" is a portable cervical spine, anteroposterior chest, and anteroposterior pelvis radiographs.

Laboratory studies: Obtain a complete blood cell count and chemistry, including a sodium level, potassium level, renal function assessment, urinalysis, urinary toxicology screen, and a beta-human chorionic gonadotropin value in all females of childbearing age.

ADJUCANTS

Blood preparations: Order a type and screen, and consider cross-matching 2-4 units of RBCs, depending on the severity of the trauma and shock.

Urinary and gastric catheterization

Temperature, ECG and oxygen saturation monitoring

TRAUMA SCENARIO MALE PATIENT 34 YEARS OLD COMING

TO ER AFTER ROAD TRAFFIC ACCIDENT:

HOARSNESS OF VOICEBP 90/50RR 30PULSE 130ABRASION ON LT CHESYWHAT YOU DO?

THE ANSWERABCDE

Current conceptsPermissive hypotension

Maintain systolic B.P. at 85 - 95 mm of Hg

Turn off the tap and do not infuse too much of fluid and blood products

Complications Tetanus A.R.D.S. Fat embolism D.I.C. Crush syndrome Multisystem

organ failure (M.S.O.F.)

A.R.D.S. Tachypnoea Dyspnoea Bilateral infiltrates in C XRTreated with mechanical

ventilation CPAP with or without PEEP

GlucocorticoidsInhaled nitric oxide

Fat embolism Around 72 hours Tachycardia Tachypnoea Dyspnoea Chest pain Petechial haemorrhageTreated with ----- mechanical ventilation ------anticoagulants ------fixation of fractures

Disseminated intravascular coagulation Follows severe blood loss and sepsis Restlessness , confusion,neurological

dysfunction,skin infercation,oligurea Excessive bleeding Prolonged PT,PTT,TT,hypofibrinogenemia

Treatment– prevention and early correction and shock

Crush syndrome When a limb remains compressed for many hours Compartment syndrome and further ischaemia Cardiac arrest due to metabolic changes in blood Renal failure

Treatment Prevention-ensure high urine flow during

extrication IV Crystalloids,Forced mannitol alkaline diuresis Fasciotomy and excision of devitalised muscles Amputation

M.S.O.F.Progressive and sequential dysfunction of

physiological systemsHypermetabolic stateIt is invariably preceded by a condition known as

Systemic Inflammatory Response Syndrome (SIRS)

Characterised by two or more of the following Temperature >38º C or < 36ºC Tachycardia >90 /min Respiratory rate >20/min WBC count >12,000/cmm or <4,000/cmm

M.S.O.F.Treatment : Key word is PREVENTION Prompt stabilisation of fracture Treatment of shock Prevention of hypoxia Excision of all dirty and dead tissue Early diagnosis and treatment of infection Nutritional support

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