TEAM for Medical Students

8/11/2019 TEAM for Medical Students

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Goal / Principles of Trauma Care

Rapid, accurate, and physiologic

assessment

Resuscitate, stabilize, and monitor bypriority

Prepare for transfer to definitive care

Teamwork for optimal, safe patient care


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Objectives

Describe fundamental principles of initial

assessment and management

Identify correct sequence of management

priorities

Describe appropriate techniques of

resuscitation


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Objectives

Recognize value of patients history

Understand importance of injury

mechanism

Identify concepts of teamwork in caring for

injured patient


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The Need for Early TEAM

Leading cause of death in ages 1 through 44

Disabilities exceed deaths by ratio of 3:1

Trauma-related cost > $400 billion per year Lack of public awareness for injury

prevention


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Injury Prevention

A

B

C

D

E

Analyze injury data

Build local coalitions

Communicate the problem

Develop prevention activities

Evaluate the interventions


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Trimodal Death Distribution


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TEAM Principles

Treat greatest threat to life first

Definitive diagnosis less important

Physiologic approach Time is of the essence

Do no further harm

Teamwork required for TEAM to succeed


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TEAM Approach

A

B

C

D

E

Airway with c-spine protection

Breathing / ventilation / oxygenation

Circulation: Stop the bleeding!

Disability (neuro status)

Expose / Environment / body temp


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TEAM Sequence

Rapid primary surveyABCD + Adjuncts

Detailed secondarysurvey / reevaluation

Head-to-toe + Adjuncts

Definitive

care

Safe transfer


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TEAM Sequence and Teamwork

Simultaneous

primary survey

and resuscitation of

vital functions

Simultaneous

secondary surveyand reevaluation of

vital functions


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TEAM Work and Teamwork

TL Team

Leader

A AirwayManager

N Nurse

1 Assistant

2 AssistantTogether Everyone Achieves More


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Prehospital Preparation

Closest appropriate facility

Transport guidelines / protocols

On-line medical direction Mobilization of resources

Periodic review of care


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Inhospital Preparation

Preplanning

essntial

Team approach Trained personnel

Proper equipment

Lab / x-raycapabilities

Standard

precautions

Transferagreements

QI program


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Standard Precautions

Cap

Gown

Gloves Mask

Shoe covers

Goggles / faceshield


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Other factors, eg, salvagebiliy


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Primary Survey

Priorities are the

Same for all!


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Primary Survey

A

B

C

D

E

Airway with C-spine protection

Breathing / Life-threatening chest injury

Circulation: Stop the bleeding!

Disability / Intracranial mass lesion

Expose / Environment / Body temp


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Special Considerations: Children

Leading cause of death

Immature, anatomic / mechanical features

Vigorous physiologic response Limited physiologic reserve

Outcome depends on early aggressive


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Special Consoderations: Children

Size, dosage, equipment, surface area, and

psychology

Airway: Larynx anterior and cephalad,short tracheal length

Breathing: Chest wall pliability, mediastinal

mobility


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Special Considerations: Children

Circulation: Vascular access, fluid volume,

vital signs, and urinary output

Neurologic: Vomiting, seizures, and diffusebrain injury

Musculoskeletal: Immature skeleton,

fracture patterns


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SpecialConsideration: Pregnancy

Anatomic / physiologic changes modify

response to injury

Need for fetal assessment 1stPriority: Maternal resuscitation

Outcome depends on early, aggressive care


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Special Considerations: pregnancy

Gestation and position of uterus

Physiologic anemia

Pco2 Gastric emptying

Supine hypotension

Isoimmunization Sensitivity of fetus


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Special considerations: Elders

5th leading cause of death

Diminished physiologic reserve and

response

Comorbidities: Disease /

Medications

Outcome depends on early,aggressive care


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Special Conciderations: Elders

5thleading cause of death

Diminished physiologic reserve

and response

Comorbidities: Diseases /

MedicationsOutcome depands on early,

aggressive care


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Primary Survey: Airway

Assess for airway patency

Snoring

Gurgling Stridor

Rocking chest wall motions

Maxillofacial trauma / laryngeal injury

C-spineinjury


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Resuscitation: Patent Airway

Chin lift / Modified jaw thrust

Look, listen, feel

Remove particulate matter

Definitive airway as necessary

Reasses frequentlyC-spine

injury


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Resuscitation: Assess Breathing

Chest rise and symmetry

Air entry

Rate / Effort Color / Sensorium

Tension / open

pneumothorax


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Resuscitation: Breathing

Administer supplemental oxygen

Ventilate as needed

Tension pneumothorax: Needledecompression

Open pneumothorax: Occlusive dreassing

Reassess frequently


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Primary Survey: Circulation

Children

Elderly

Athletes

Pregnancy

Medication


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Nonhemorrhagic shock

- Cardiac tamponade

- Tension pneumothorax- Neurogenic

- Septic (late)


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Assess organ perfusion

- Level of consciousness

- Skin color- Pulse rate and character


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Assess Organ Perfusion

1. Tachycardia

2. Vasoconstriction2. Cardiac output

2. Narrow pulse pressure

3. MAP

3. Blood flow


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Children

Elderly Athletes

Pregnancy

Medications


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Resuscitation: Circulation

Bleeding?

IT!

Find it!

-Direct pressure

-Operation

-Avoid blind

clamping


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Obtain venous access

Restore circulating volume

- Ringers lactate, 1-2 L- PRBCs if transient response or no

response

Reassess frequently


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Consider

Tension pneumothorax: Needle

decompression and tube thoracostomy Massive hemothorax: Volume

resuscitation and tube thoracostomy

Cardiac tamponade: Pericardiocentesisand direct operative repair


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Primary Survey: Disability

Baseline neurologic evaluation

Observe for

Neurologic

deterioration

-Pupillary response-Neurosurgical consult

as indicated


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Primary Survey: GCS Score

Eye opening: Range 14

BEST Motor response: Range 16

Verbal response: Range 15

Score = (E + M + V)

Best score = 15

Worst score = 3


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Primary Survey: Disability


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Primary Survey: Expore

Completely undress the patient

Remove helmet if present

Look for visible / palpable injuries

Log roll, protect spine

Prevent

hypothermia


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Resuscitation: Overview

If doubt, establish definitive airway

Oxygen for all patients

Chest tube may be definitive for chestinjury

Stop the bleeding!

2 larger-caliber Ivs Prevent hypothermia


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Adjunct: Urinary Catheter

Blood?

Decompress bladder

Monitor urinary output

- Blood at meatus

- Perineal ecchymosis /

hematoma

- High-riding prostate


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Adjuncts: Gastric Catheter

Blood?

Decompress urinary output

Monitor urinary outout

-Blood at meatus

-Perineal ecchymosis /

hematoma

- High-riding prostate


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Primary Survey: Adjuncts

Monitoring

Vital signs

ABGs

ECG

Pulse oximetry

End-tidal CO2

Consider need for transfer

Diagnostic Tools

Chest / pelvis x-ray

C-spine x-rays when

appropriate FAST

DPL


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Secondary Survey: Start After

Primary survey completed

Resuscitation in process

ABCDEs reassessed

Vital functions returning to normal


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Secondary Survey: Key Parts

AMPLE history

Complete physical exam: Head-to-toe

Complete neurologic exam

Special diagnostic tests

Reevaluation


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Secondary Survey: History

A Allergies

M Medications

P Past illnennes / Pregnancy

L Last meal

E Event / Environment


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Secondary Survey

Mechanisms of Injury

AnatomyPhysiology

Pattern of

Injury

Mechanism of

Injury


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Burn Injury


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Burn Injury


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Cold Injury

Frostbite: Rewarm with moist heat

(40 C); wait for demarcation

Hypothermia: Passive or active

rewarming

Monitor: Not dead until warm and dead


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Secondary Survey: Head

Complete neurologic exam

GCS Score determination

Comprehensive eye / ear

- Unconscious patient- Periorbital edema

- Occluded auditory canal


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Secondary Survey: Maxillofacial

Bony crepitus / instability

Palpable deformity

Comprehensive oral / dental exams

-Potential airway obstruction

- Cribriform plate fracture- Frequently missed injury


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Secondary Survey: C-spine

Palpate for tenderness

Complete motor /

sensory exams

Reflexes

C-spine imaging - Injury above

clavicles

- Altered LOC- Other severe,

painful injury


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Secondary Survey: Neck

Blunt vs

penetrating

Airway

obstruction,hoarseness

Crepitus,

hematom, stridor,

bruit

-Delayed

symptom / signs

-Progressiveairway obstruction

-Occult injuries


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Secondary Survey: Abdomen

Inspect, auscultate, palpate, and percuss

Reevaluate frequently

Special studies: FAST, DPL, CT

Hollow viscus andretroperitoneal injury

Excessive pelvic

manipulation


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Secondary Survey

Perineum Contusions, hematomas,

lacerations, urethral blood

Rectum Sphincter tone, high-riding

prostate, pelvic fracture,rectal wall integrity, blood

Vagina Blood, lacerations

Pregnancy


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Secondary Survey: Musculoskeletal

Potential blood loss

Limb or life threat (primary survey)

Missed fractures

Soft-tissue or ligamentous injury


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Secondary Survey: Musculoskeletal

Occult compartment syndrome

(especially with altered LOC /

hypotension)

Examine patients back


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Secondary Survey: Pelvis

Pain on palpation

Symphysis width

Leg length unequal

Instability

Pelvic x-rays


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Pelvic Fracture

Major source of

hemorrhage

Volum resuscitation

Reduce pelvic volume External fixator

Angiography /

embolization


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Secondary Survey: CNS

Frequent reevaluation

Prevent secondary brain injury

Imaging as indicated

Early neurosurgical consultation


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Secondary Survey: Spine

Complete motor and sensory exams

Imaging as indicated

Maintain inline immobilization

Early neurosurgical consultation


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Secondary Survey: Neurologic

Incomplete immobilization

Subtle in ICP with manipulation

Rapid deterioration


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Secondary Survey: Adjuncts

Blood tests

Urinalysis

X-rays

CT

Urography

Angiography

Ultrasonography

Echocardiography

Bronchoscopy

Esophagoscopy

Do not delay transfer!


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Reevaluation: Missed Injuries

High index of suspicion

Frequent reevaluation

Continuous monitoring

Rapidly recognize patient deterioration


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Pain Management

Relieve pain and anxiety as appropriate

Administer intravenously

Careful patient monitoring is essential


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Safe Transfer

When patients needs exceed institutional

resources.

Use time before transfer for resuscitation

Do not delay transfer for diagnostic tests

Physician-to-physician communication


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Transfer to Definitive


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Emergency Preparedness

Simple plan

Command

structure Disaster triage

scheme

Traffic controlsystem


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Summary

Primary SurveyAdjuncts

Secondary SurveyAdjuncts

Definitive care

Safe transfer Resuscitation

Continuous

Reevaluation


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Summary

DHead

To

toe

B C

A

E

One, safe way

Do no furtherharm

Treat greatest

threat to life first

Teamwork


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STARTTRIAGE


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START TRIAGE

START Triage*All Walking Wounded


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RESPIRATIONS

YES

Under 30/min

NO

Position Airway

NO YES

ImmediateNon-

salvageable

Over 30/min

Immediate

PERFUSION

Cap refill

> 2 sec

Cap refill

< 2 sec

Control

Bleeding

Immediate

STATUS

MENTAL

Failure to follow

simple commands

Can follow

Simple commands

Radial Pulse PresentRadial Pulse Absent

MINOR

Documents

TEAM for Medical Students