W1L1 - Initial Assessment for Trauma_2

7/27/2019 W1L1 - Initial Assessment for Trauma_2

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Initial assessment andmanagement of the severely

injured patient

By

Dr. Ahmed Negm

Ass. Professor of general surgery

Mansoura university


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outline Introduction Preparation: pre-hospital & hospital phases

Triage:

Primary survey (ABCDEs)& resuscitation*adjuncts to primary survey

Secondary survey ( head to toe evaluation and

patient history)*adjuncts to secondary survey

Definitive care


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Introduction Trauma is the leading

cause of death forindividuals of age 1-44years

3rdcause in all ages

For every trauma death,

2 people sufferpermanent disabilities


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Mechanism of injuryPenetrating injuriesLow velocity

High velocityBlunt injuriesDirect

IndirectAcceleration injury


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Preparation (prehospital phase) The prehospital system should notifythe receiving hospital

This allows for preparation of

trauma team & resources inemergency department

Emphasis should be placed on:

airway maintenance

control of external bleeding

immobilization

immediate transport


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Preparation (hospital phase)

Protect myself

Prepare equipments

Pre-hospital information Nature & time of incident

Number, age & gender

Injuries identified

Treatment given

Initial & current vital signs


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Triage

Multiple casusaltiesThe number of patients & severity of there injuries do not

exceedthe capability & facility of the hospitalPatients with life threatening problems are treated first.

Mass casualtiesThe number of patients & severity of there injuries exceeds

the capability & facility

Patients having the greatest chance of survival andrequiring the least facilities are treated first


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Advanced Trauma Life Support (ATLS)

PROTOCOL :1. Primary survey/resuscitation

2. Secondary survey

3. Definitive treatment of individualinjuries


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I. primary survey & resuscitation

objective

To IDENTIFYout and TREATallIMMEDIATELYlife threatening

conditions

To follow a systematic approach,reflecting the order which if untreatedwould lead to the patients death


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Primary survey & resuscitation Steps

Airway maintenance with cervical spine protection

Breathingand ventilation

Circulation& control of haemorrhage

Disability: neurogenic status

Exposure& environmental control: completely

undress the patient, but prevent hypothermia


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What is a quick, simple way

to assess a patient in 10seconds?


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Primary survey & resuscitation

Same priorities for all patients

Specific considerations for: Elderly

Children

Pregnancy


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Airway with cervical spine control

Aims

Assess

Clear and secure Provide oxygen

Prevent secondary

neurological damage

to the spine


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Airway assessment (Look, Listen & Feel)

If the patient is capable of unstrained speech, hisairway is patent

All patients receive supplemental oxygen by mask

upon arrivalClinical clues

Noisy breathing

Respiratory effort

Silence

Trauma to the face or head

Burns: inhalational injury


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Airway interventions Clear airway Vomitus, blood or foreign material

Support Manual: chin-lift or jaw-thrust

Oro-pharyngeal airway

Oxygen Reservoir mask High flow

Monitor SpO2 End tidal CO2

with C spine control


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Tracheal intubation Apnea

Inhalation injuries

Closed head injuries(GCS OF 8or less)

Risk of aspiration

*Inline immobilization technique

Crico-thyroidotomy Percutaneous insertion of wide bore

needle


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Cervical spine control

Clinical clues Cervical tenderness

Maxillofacial trauma

Neurological signs Unconsciousness

Cervical spine immobilization

Rigid neck collar

Radiological evaluation Done after stabilization of vital

systems

Lateral x-ray film


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5 Chest clues in the neck

Wounds

Distended neck veins

Tracheal position

Surgical emphysema

Laryngeal crepitus


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Breathing and ventilationAims

Support if

inadequate Eliminate any

immediately lifethreateningthoracic condition..


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Breathing and ventilation assessmentInspection

Respiratory rate, effort

Symmetry

Wounds & marks

Palpation Mid axilla

Anterior

Percussion

Mid axilla

Above & below nipple lineAuscultation

Mid axilla

Above & below nipple line

Check the back


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life threatening thoracic conditions Tension pneumothorax

Open pneumothorax

Massive haemothorax

Flail chest with pulmonary contusion

Cardiac tamponade


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Breathing and ventilationIntubated & ventilated:

Position/length of trachealtube

Tidal volume, rate

FiO2, eTCO2, SpO2 Peak inflation pressure

Feel

Symmetry of movement

Percussion

Listen


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Circulation & control of haemorrhage

shock

1. Hemorrhagic

2. Cardiogenic

3. neurogenic


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Action Control bleeding

Insert 2 large bore cannulas (central line may be

needed) Blood sample: for typing, cross matching, HB,

HTC

Ringer lactate infusion (a bolus of 1-2 L )

Monitor urine output (0.5-1 ml/kg/hour)


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Bleeding

External bleeding is managed by

Major areas of internal hemorrhage

To identify the source

Management of internal hemorrhage


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Disability (neurologic evaluation)Aims

Rapid neurologicalassessment Alert; Voice; Pain;

Unresponsive

Pupils

Mini-neurologicalassessment GCS score

Pupils

Lateralising signs


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Exposure and environmentAims

Remove clothing to allow examination of entirepatient

Care when removing tight trousers

Prevent hypothermia

Remove spine board (unless patient transfer is considered)


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Adjuncts to primary survey & resuscitation ECG

Urinary catheter (unless uretheral injury is suspected)

ABG Pulse oximetry

X-ray chest & pelvis

FAST & DPL


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Pause & check

Are all immediately life-

threatening injuries

identified?

Is all monitoring in place? Investigations ordered?

Analgesia?

Relatives informed?

Non-essential team membersdisbanded?


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II. Secondary survey

Only proceed if the life threatening conditions have

been corrected


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Secondary surveyAims

AMPLE history

Examine head to toe, frontand back

Analyze all clinical, images &lab data

Identify all injuries

Develop a definitive care plan

Monitor continuously for immediately life threatening

conditions


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Secondary survey (history)

Allergies

Medications

Pre existing medical conditions

Last meal

Events & Environment

*Mechanism of injury: (pre-hospital personnel)

t


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Secondary survey ( examination)

The back 4 person technique

Examination

Remove debris Remove spine board

Dermatomes

Myotomes


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Secondary survey

Analgesia Psychological

Fear, sadness, worry

Physical

Splinting, cooling, cover Pharmacological

Opioids

NSAIDs

Local anaesthesia

Entonox


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Preparation for safe transfer

A Assessment

C Command & control C Communication

E Evaluate

P Prepare & Package

T Transfer

ACCEPT


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Wash & brush up!


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Reevaluation


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Definitive care


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Team function & organisationFunction: Identify and treat life

threatening injuries

Identify any other problems

Arrange appropriatetreatment and investigations

Arrange and transfer to

definitive care

Organisation:

Task allocation

Simultaneous activity


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Team structure and function

Team leaders

Circulation Circulation

Airway

Relatives

Recorder

Radiographer

Breathing


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Any questions?


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Summary Primary survey & resuscitation: recognize and

treat immediately life threatening conditions

Secondary survey: identify & prioritize other

injuries The basic principles of safe transfer of a patient to

definitive care

Documents

W1L1 - Initial Assessment for Trauma_2