TEAMProgram for Medical Students and Multidisciplinary Team Members Based on the ATLS Course for DocotrsCommittee on Trauma PresentsTrauma Evaluation And Management: Early Care of the Injured Patient

Goal / Principles of Trauma CareRapid, accurate, and physiologic assessmentResuscitate, stabilize, and monitor by priorityPrepare for transfer to definitive careTeamwork for optimal, safe patient care

ObjectivesDescribe fundamental principles of initial assessment and managementIdentify correct sequence of management prioritiesDescribe appropriate techniques of resuscitation

ObjectivesRecognize value of patients historyUnderstand importance of injury mechanismIdentify concepts of teamwork in caring for injured patient

The Need for Early TEAMLeading cause of death in ages 1 through 44Disabilities exceed deaths by ratio of 3:1Trauma-related cost > $400 billion per yearLack of public awareness for injury prevention

Injury PreventionABCDEAnalyze injury dataBuild local coalitionsCommunicate the problemDevelop prevention activities Evaluate the interventions

Trimodal Death Distribution

TEAM PrinciplesTreat greatest threat to life firstDefinitive diagnosis less importantPhysiologic approachTime is of the essenceDo no further harmTeamwork required for TEAM to succeed

TEAM ApproachABCDEAirway with c-spine protectionBreathing / ventilation / oxygenationCirculation: Stop the bleeding!Disability (neuro status) Expose / Environment / body temp

TEAM SequenceRapid primary survey ABCD + AdjunctsDetailed secondarysurvey / reevaluation Head-to-toe + AdjunctsDefinitivecareSafe transfer

TEAM Sequence and Teamwork Simultaneous primary survey and resuscitation of vital functions

Simultaneous secondary survey and reevaluation of vital functions

TEAM Work and TeamworkTL Team Leader A Airway Manager

N Nurse

Assistant

2 AssistantTogether Everyone Achieves More

Prehospital PreparationClosest appropriate facilityTransport guidelines / protocolsOn-line medical directionMobilization of resourcesPeriodic review of care

Inhospital PreparationPreplanning essntialTeam approachTrained personnelProper equipmentLab / x-ray capabilities Standard precautions Transfer agreements QI program

Standard Precautions Cap Gown Gloves Mask Shoe covers Goggles / face shield

Other factors, eg, salvagebiliy

Primary SurveyPriorities are theSame for all!

Primary SurveyABCDEAirway with C-spine protectionBreathing / Life-threatening chest injuryCirculation: Stop the bleeding!Disability / Intracranial mass lesion Expose / Environment / Body temp

Special Considerations: ChildrenLeading cause of deathImmature, anatomic / mechanical featuresVigorous physiologic responseLimited physiologic reserveOutcome depends on early aggressive

Special Consoderations: ChildrenSize, dosage, equipment, surface area, and psychologyAirway: Larynx anterior and cephalad, short tracheal lengthBreathing: Chest wall pliability, mediastinal mobility

Special Considerations: ChildrenCirculation: Vascular access, fluid volume, vital signs, and urinary outputNeurologic: Vomiting, seizures, and diffuse brain injuryMusculoskeletal: Immature skeleton, fracture patterns

Special Consideration: Pregnancy

Anatomic / physiologic changes modify response to injuryNeed for fetal assessment1st Priority: Maternal resuscitationOutcome depends on early, aggressive care

Special Considerations: pregnancyGestation and position of uterusPhysiologic anemia Pco2 Gastric emptyingSupine hypotensionIsoimmunizationSensitivity of fetus

Special considerations: Elders5th leading cause of deathDiminished physiologic reserve and responseComorbidities: Disease / MedicationsOutcome depends on early, aggressive care

Special Conciderations: Elders 5th leading cause of death Diminished physiologic reserve and response Comorbidities: Diseases / Medications Outcome depands on early, aggressive care

Primary Survey: Airway Assess for airway patency Snoring Gurgling Stridor Rocking chest wall motions Maxillofacial trauma / laryngeal injuryC-spine injury

Resuscitation: Patent Airway Chin lift / Modified jaw thrust Look, listen, feel Remove particulate matter Definitive airway as necessary Reasses frequentlyC-spineinjury

Resuscitation: Assess Breathing Chest rise and symmetry Air entry Rate / Effort Color / SensoriumTension / openpneumothorax

Resuscitation: BreathingAdminister supplemental oxygenVentilate as neededTension pneumothorax: Needle decompressionOpen pneumothorax: Occlusive dreassingReassess frequently

Primary Survey: Circulation Children Elderly Athletes Pregnancy Medication

Primary Survey: CirculationNonhemorrhagic shock - Cardiac tamponade - Tension pneumothorax - Neurogenic - Septic (late)

Primary Survey: CirculationAssess organ perfusion - Level of consciousness - Skin color - Pulse rate and character

Primary Survey: CirculationAssess Organ PerfusionTachycardiaVasoconstriction2. Cardiac output2. Narrow pulse pressure3. MAP3. Blood flow

Primary Survey: Circulation Children Elderly Athletes Pregnancy Medications

Resuscitation: Circulation Bleeding?IT!Find it!Direct pressure Operation Avoid blind clamping

Resuscitation: CirculationObtain venous accessRestore circulating volume - Ringers lactate, 1-2 L - PRBCs if transient response or no responseReassess frequently

Resuscitation: Circulation

Resuscitation: CirculationConsiderTension pneumothorax: Needle decompression and tube thoracostomyMassive hemothorax: Volume resuscitation and tube thoracostomyCardiac tamponade: Pericardiocentesis and direct operative repair

Primary Survey: DisabilityBaseline neurologic evaluationObserve forNeurologicdeteriorationPupillary responseNeurosurgical consult as indicated

Primary Survey: GCS ScoreEye opening: Range 1 4BEST Motor response: Range 1 6Verbal response: Range 1 5Score = (E + M + V)Best score = 15Worst score = 3

Primary Survey: Disability

Primary Survey: Expore Completely undress the patient Remove helmet if present Look for visible / palpable injuries Log roll, protect spinePreventhypothermia

Resuscitation: OverviewIf doubt, establish definitive airwayOxygen for all patientsChest tube may be definitive for chest injuryStop the bleeding!2 larger-caliber IvsPrevent hypothermia

Adjunct: Urinary CatheterBlood?Decompress bladderMonitor urinary output Blood at meatus Perineal ecchymosis / hematoma- High-riding prostate

Adjuncts: Gastric Catheter Blood? Decompress urinary output Monitor urinary outout Blood at meatus Perineal ecchymosis / hematoma- High-riding prostate

Primary Survey: AdjunctsMonitoringVital signsABGsECGPulse oximetryEnd-tidal CO2

Consider need for transferDiagnostic Tools Chest / pelvis x-ray C-spine x-rays when appropriate FAST DPL

Secondary Survey: Start AfterPrimary survey completedResuscitation in processABCDEs reassessedVital functions returning to normal

Secondary Survey: Key PartsAMPLE historyComplete physical exam: Head-to-toeComplete neurologic examSpecial diagnostic testsReevaluation

Secondary Survey: History A Allergies M Medications P Past illnennes / Pregnancy L Last meal E Event / Environment

Secondary Survey Mechanisms of InjuryAnatomyPhysiologyPattern ofInjuryMechanism ofInjury

Burn InjuryInhalation injury: Intubate and administer 100% oxygenAdminister 2 4 mL / kg % BSA burn in 24 hours (+ maintenance in children)Monitor urinary outputExpose and prevent hypothermiaChemical burn: Brush and irrigate

Burn Injury

Burn Injury

Cold InjuryFrostbite: Rewarm with moist heat (40 C); wait for demarcation

Hypothermia: Passive or active rewarming

Monitor: Not dead until warm and dead

Secondary Survey: Head Complete neurologic exam GCS Score determination Comprehensive eye / ear - Unconscious patient- Periorbital edema- Occluded auditory canal

Secondary Survey: Maxillofacial Bony crepitus / instability Palpable deformity Comprehensive oral / dental examsPotential airway obstruction - Cribriform plate fracture- Frequently missed injury

Secondary Survey: C-spine Palpate for tenderness Complete motor / sensory exams Reflexes C-spine imaging- Injury above clavicles- Altered LOC- Other severe, painful injury

Secondary Survey: Neck Blunt vs penetrating

Airway obstruction, hoarseness

Crepitus, hematom, stridor, bruitDelayed symptom / signs

-Progressive airway obstruction

-Occult injuries

Secondary Survey: Chest Inspect, auscultate, palpate, percuss Reevaluate frequently Chest x-rays-- Missed injury- Chest tube drainage

Secondary Survey: Abdomen Inspect, auscultate, palpate, and percuss Reevaluate frequently Special studies: FAST, DPL, CT Hollow viscus and retroperitoneal injury Excessive pelvic manipulation

Secondary Survey Perineum Contusions, hematomas, lacerations, urethral blood

Rectum Sphincter tone, high-riding prostate, pelvic fracture, rectal wall integrity, blood

Vagina Blood, lacerations

Pregnancy

Secondary Survey: MusculoskeletalPotential blood lossLimb or life threat (primary survey)Missed fracturesSoft-tissue or ligamentous injury

Secondary Survey: MusculoskeletalOccult compartment syndrome (especially with altered LOC / hypotension)Examine patients back

Secondary Survey: PelvisPain on palpationSymphysis width Leg length unequalInstabilityPelvic x-rays

Pelvic Fracture Major source of hemorrhage Volum resuscitation Reduce pelvic volume External fixator Angiography / embolization

Secondary Survey: CNSFrequent reevaluationPrevent secondary brain injuryImaging as indicatedEarly neurosurgical consultation

Secondary Survey: SpineComplete motor and sensory examsImaging as indicatedMaintain inline immobilizationEarly neurosurgical consultation

Secondary Survey: NeurologicIncomplete immobilizationSubtle in ICP with manipulationRapid deterioration

Secondary Survey: AdjunctsBlood testsUrinalysisX-raysCTUrographyAngiographyUltrasonographyEchocardiographyBronchoscopyEsophagoscopyDo not delay transfer!

Reevaluation: Missed InjuriesHigh index of suspicionFrequent reevaluationContinuous monitoringRapidly recognize patient deterioration

Pain ManagementRelieve pain and anxiety as appropriateAdminister intravenouslyCareful patient monitoring is essential

Safe TransferWhen patients needs exceed institutional resources. Use time before transfer for resuscitationDo not delay transfer for diagnostic testsPhysician-to-physician communication

Transfer to Definitive

Emergency Preparedness Simple plan Command structure Disaster triage scheme Traffic control system

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Summary Primary Survey AdjunctsSecondary Survey AdjunctsDefinitive careSafe transferResuscitationContinuousReevaluation

SummaryDHeadTotoeBCA E One, safe way Do no further harm Treat greatest threat to life first Teamwork

The End

Supplement : The End

STARTTRIAGE

START TRIAGE

START TriageRESPIRATIONSYESUnder 30/minNOPosition AirwayNOYESImmediate Non-salvageableOver 30/min ImmediatePERFUSIONCap refill> 2 secCap refill< 2 sec Control BleedingImmediateSTATUS MENTALFailure to followsimple commandsCan followSimple commandsImmediateDelayedRadial Pulse PresentRadial Pulse Absent*All Walking WoundedMINOR

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TEAMWORK in ER

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ER Layout

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TIME IS ESSENTIAL

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