Initial assessment & Management by DR.MUMTAZ ALI NAREJO.pptx

Initial assessment & management in trauma patients according to ATLS protocol

1. INITIAL ASSESSMENT & MANAGEMENT DR.MUMTAZ ALI NAREJO ASSISSTANT PROFESSOR & INCHARGE NEUROSURGERY DEPARTMENT LIMHS CIVIL HOSPITAL THATTA

2. OUTLINES Objectives Introduction Preparation Triage Primary survey with simultaneous resuscitation Adjuncts to primary survey simultaneous resuscitation Consider need for patient transfer Special population

3. OUTLINES Secondary survey Adjuncts to secondary survey Reevaluation Definitive care Records & legal consideration Team work Summary Refrences

4. OBJECTIVES Explain importance of preparation Identify correct sequence of priorties Explain principle of primary survey Explain contribution of history & mechanism of injury Explain need of immediate resuscitation during primary survey Describe the initial assessment Identify the pitfalls during initial assessment & management Identify way to avoid those pitfalls

5. OBJECTIVES Explain management techniques used in primary survey Identify adjuncts of primary survey Recognize need of transfer Identify components of secondary survey Discuss the importance of reevaluation Explain the importance of teamwork

6. INTRODUCTION OF INITIAL ASSESSMENT Systemic approach rapidly assessing injuries Instituting life preserving therapy Elements Preparation Triage Primary survey & resuscitation Adjuncts of primary survey & resuscitation Consideration need of patient transfer

7. INTRODUCTION OF INITIAL ASSESSMENT Secondary survey Adjuncts of secondary survey Post-resuscitation monitoring & reevaluation Definite care Assessment sequence : linear / longitudinal / progression of events The primary and secondary surveys are repeated frequently to identify any change in the patient’s status : additional intervention Judgment is required to determine which procedures are necessary

8. PREPARATION ; PRE-HOSPITAL PHASE Pre-hospital team/agency Airway maintenance Control of external bleeding Management of shock Immobilization of patient Immediate transfer Minimize time at scene Obtaining & reporting information Field triage decision scheme

9. PREPARATION;HOSPITAL PHASE Advance planning : arrival of pt Handover of patient : smooth Critical aspects: Resuscitation area Properly functioning airway equipments Warmed intravenous crystalloids Additional medical assistance Transfer agreements

10. TRIAGE; MULTIPLE & MASS CASUALITIES Sorting out injured patients: Required resources Available resources Severity of injury Ability to survive ABC Priority Multiple causalities: NO of patients & severity of injury < Hospital capabilities & Facilities Life threatening & Multiple system injuries are treated 1st

11. PRIMARY SURVEY WITH SIMULTANEOUS RESUSCITATION ABCDE 10s assessment : ABCD Ask name & what happened Appropriate response Ability to speak clearly : A Ability to generate air movements to permit speech : B Alert enough describe what happened : CD Inappropriate response : Urgent assessment & management Life threatening conditions are identified & treated Restoration of physiology 1 st rather than anatomy

12. AIRWAY MAINTENANCE WITH RESTRICTION OF CERVICAL SPINE MOTION Airway patency Signs of airway obstruction: Inspection of foreign body Identifying facial, mandibular # Identifying tracheal, laryngeal # Suctioning of blood & secretions Initial maneuvers:Chin lift & Jaw thrust Unconscious,no gag reflex:oropharyngeal Severe head injury GCS<8 = ETT NON-purposeful motor responses : ETT Tracheostomy/ cricothyroidotomy Restrict cervical movements

13. BREATHING & VENTILATION Gaseous Exchange Lungs, chest wall & diaphragm Jugular venous distension, Position of trachea & chest wall excursion Inspection & palpation : chest wall Auscultation : gas flow in lungs Percussion Tension & open pneumothorax, Massive hemothorax , tracheobronchial injuries Oxygenation : mask reservoir device Pulse oximeter : saturation Simple pneumohemothrax , rib #, contusions : lesser ventilator compromise Simple pneumothorax + ETT + PPV = tension pneumothorax

14. CIRCULATION WITH HEMORRHAGE CONTROLL;BLOOD VOLUME,CO & BLEEDING Major circulatory issues : Blood volume, Cardiac output & Bleeding Preventable death : Hemorrhage Hypotension : 1.Tension pneumothorax 2.Blood loss Elements of circulation Level of consciousness: <cerebral volume < CPP < consciousness Skin perfusion : ashen, gray facial skin and pale extremities Pulse : rapid, thready pulse Bleeding : External Vs Internal E xternal blood loss : Direct manual pressure VS Tourniquets VS Clamp

15. CIRCULATION WITH HEMORRHAGE CONTROLL;BLOOD VOLUME,CO & BLEEDING I nternal : chest, abdomen, retro peritoneum, pelvis, long bones Identification : O/E , CXR, Pelvic X-ray, FAST(U/S), DPL Immediate Rx : Chest decompression + Pelvic stabilizing devices + extremity splints Definitive Rx : Surgical + Radiological + Pelvic/long bone stabilization Aim : Definitive bleeding control + replacement of intravascular volume Vascular access : Two large I/V bore canula /blood sampling/ Intraosseous access/CVP/Venous cut down Presence & degree of shock : ABGS & Lactate level 1L crystalloid solution( 37°C-40°C or 98.6°F-104°F) then blood transfusion Severe trauma : >1.5L crystalloid : coagulopathy : >death

16. DISABILITY (NEUROLOGICAL EXAMINATION) Level of consciousness + pupil size & reaction + lateralizing sign + spinal cord injury GCS : E4V5M6 : cerebral oxygenation & cerebral perfusion Motor component : outcome ALOC : Oxygenation, Ventilation, Perfusion, Hypoglycemia & Drugs Primary VS secondary brain injury Refer to Neurosurgeon

17. EXPOSURE & ENVIROMENTAL CONTROL Undress : Cut off garments : thorough examination & assessment Cover with warm blankets & external warming devices = Hypothermia Fluid warmer Microwave oven : Crystalloid only Maintain room temperature

18. ADJUNCTS TO PRIMARY SURVEY & RESUSSCITATION ECG Pulse oximetry CO2 monitoring Ventilatory rate assessment ABGS Urinary catheter :urine output+hematuria Gastric catheter : Distension decompression + Blood assessment Blood lactate + CXR + pelvic x ray + FAST + DPL Adequate resuscitation : Pulse rate, BP, R/R, T, ABGS, Urine output

19. CONSIDER NEED FOR PATIENT TRANSFER Trauma surgeon Sufficient information Adminstrative person Trauma team leader Don’t delay transfer In-depth diagnostic evaluation Stabilization, resuscitation, safe transfer Communication Referring & receiving doctors

20. SPECIAL POPULATION Children : unique physiology & anatomy Quantity : blood, fluid, medication, injury pattern, degree of lost heat Abundant physiological reserve : few signs = severe hypovolemia Pregnancy : change response to injury Early recognition : palpation of abdomen for gravid uterus + hCG Old age : aging process diminishes physiologic reserve CA, HTN, DM, COPD, IHD, CLD, CVA, VHD, PVD, Metabolic diseases Obese : anatomy : difficult intubation, FAST, DPL, CT, procedures Athelete : don’t have early sign of shock : tachycardia & tachypnea Have normally low systolic & diastolic B.P

21. SECONDARY SURVEY : COMPLETE HISTORY When it is started? Evaluation : head to toe Hx : AMPLE Mechanism of injury Blunt trauma Penetrating trauma Thermal injury Hazardous environment

22. SECONDARY SURVEY : EXAMINATION Head Maxillofacial Cervical spine Chest Abdomen Pelvis Perineum Rectum Vagina MSK Neurological exam

23. ADJUNCTS TO SECONDARY SURVEY When performed Additional X-ray CT scans Contrast urography Angiography Trans esophageal U/S Esophagoscopy Bronchoscopy Endoscopy Laproscopy

24. REEVALUATION Constant reevaluation : Deterioration + Missed findings Initial life threating injuries managed New injuries apparent Facilitates : early diagnosis & management Continuous monitoring : vital signs, Urine output, O2 saturation Urine output : Adults = 0.5ml/kg & peds = 1ml/kg Periodic monitoring : ABGS & end tidal CO2 Effective Anelgesia

25. DEFINITIVE CARE When transfer is needed

26. RECORDS & LEGAL CONSIDERATION Document times of all events Assign one team member Assess changes in condition : chronological reporting with flow sheets Consent for treatment Forensic evidence Clothing Bullets Blood alcohol level

27. TEAM WORK Size composition : vary Teal leader, airway manager, trauma nurse, trauma technician, students , residents Team leader : supervises preparation , checks, directs assessment, Hands-over, Transfer, Who can be team leader? Team leader assigns roles : Assessing the patient, including airway assessment and management Undressing and exposing the patient Applying monitoring equipment

28. TEAM WORK Obtaining intravenous access and drawing blood Serving as scribe or recorder of resuscitation activity HANDS OFF HAND OVER : MIST Mechanism & time of injury Injuries found & suspected Symptoms & signs Treatment initiated

29. SUMMARY

30. REFRENCES Advance trauma life support student course manual book 10 th edition

31. THANKS