PRIMARY MANAGEMENT OF TRAUMA.pptx

TRAUMA

1. WELCOME

2. PRIMARY MANAGEMENT OF TRAUMA Presented by : Dr.Md.Mominur Rahman Phase-A Resident,MS ( Paediatric Surgery) Mymensingh Medical College Hospital.

3. CONTENTS: Introduction Mechanisms of Trauma Initial Assessment Primary survey Secondary survey Definitive care References Conclusion

4. What is Trauma ? Trauma is the study of medical problems associated with physical injury. There are a variety of forces that can lead to injury,including thermal,ionizing radiation and chemical.However in most injuries is mechanical.

5. Epidemiology Trauma is the most common cause of death in children and young adult between the age of 1 to 44 years worldwide. In addition to mortality,injuries have the potential to cause many other long-term health problems with serious consequences for individuals,families,communities and health-care systems. Worldwide,childhood injuries are a growing problem.Childhood injuries are most common between 5-10 years of age group. Every Year 8,75,000 child die globally.

6. Mechanisms of Trauma : Trauma can be classified in type by causation and by effect- * Blunt trauma e.g. RTA * penetrating trauma e.g. knife * Blast injuries e.g. bomb * Crush injuries e.g. building collapse * Tharmal injuries. * Chemical injuries.

7. Cause of childhood trauma: * Fall from heights (62%) * At play ground * Assault * road traffic accidents.

8. Paediatric Trauma Score: Score weight Airway Systolic BP(mm/Hg) CNS Skeleton Skin +2 >20 Normal >90 Awake None None +1 10-20 Controlled 50-90 Obtunded / LOC Closed fracture Minor wound -1 <10 Unmainta-inable <50 Coma Open/ Multiple fracture Major/ penetrating

9. Trauma team: Composition: * Doctors from the emergency department. * Anaesthetics and/ critical care doctor. * Orthopaedics surgeon. * General/ Paediatric surgeon. * Radiology & haematology doctor.

10. PRIORITY: Highest priority: * Cervical spine injury. * Respiratory impairment. * Cardiovascular insufficiency. * Severe external hemorrhage. * Intraperitoneal injuries. * Brains and spinal cord injuries. * Severe burns or extensive soft tissue injuries.

11. Priority: Low priority: * peripheral vascular,nerve and tendon injuries. * Fractures and dislocation. * Minor trauma etc.

12. Initial Assessment & management : Objectives : * Identify the correct sequence of priorites in assessing the polytrauma patient. * Apply principles of advanced trauma life support (ATLS) philosophy. * Apply guidelines & technique of resuscitative & definitive care

13. Initial Assessment & management : Trauma management phase: Preparation Triage Primary survey(ABCDEs) Resuscitation Secondery survey Continued monitoring & reevaluation Definitive care

14. Preparation : Pre hospital phase In hospital phase

15. Pre hospital phase: Airway maintenance Control of external bleeding & shock Immobilization Notify receiving hospital Send to the closest,appropriate facilities. In general, children fare worse than adults in the out of hospital phase of resuscitation.The injury adjusted death rate for children is twice that of adults.

16. In hospital phase Team assembly Proper trauma care facilities should be available e.g. * proper airway equipment * I/V fluids * monitoring facilities * lab & imaging facilities * facilities for taking universal precautions etc.

17. Triage : Triage means to short and allocation of the injured patients into certain categories on basis of priority & urgent need of treatment for saving maximum live.

18. Type of triage: Two types: * Triage sieve : Triage sieve mean to separate the dead and walking from injured patients. * Triage short :Triage short mean to categorize the injured patients in different categories.

19. Triage categories: Priority Colour Medical need Clinical status Example First(I) Red Immediate Critical,but likely to survive if treatment given early Severe facial trauma,tension pneumothorax,flial chest,haemothorax,profuse ext. bleeding,intra abdominal heg . Etc. Second(II) Yellow Urgent Critical,but likely to survive if treatment given within hours. Compound fracture, degloving injuries,ruptures abdominal viscus,spinal injuries etc. Third(III) Green Non-urgent Stable,likely to survive if treatment is delayed for hours to days Simple fractures,sprains,minor lacerations. Last(0) Black Unsalvageable Not breathing,pulseless,so severely injured that no medical care is likely to help. Severe brain damage,very extensive burns,major disruption/loss of chest or abdominal wall structures.

20. Implementation of triage: Triage should be implemented in the * Field of accident. * Emergency department. * Radiology department.

21. Advanced trauma life support : Dr. james Kenneth Styner,programmed ATLS in 1976. ATLS is the most comprehensive method of assessment and management of an injured child.

22. Components of ATLS: Primary survey with simultaneous resuscitstion : identify and treat what is killing the patients. Secondary survey: proceed to identify all other injuries. Definitive care: develop a definitive management plan.

23. Primary survey and resuscitstion : The initial management of the traumatized pt must first consists of a rapid primary evaluation and resuscitation of vital functions. In primary survey clinical evaluation of the child is done. The primary survey comprise the fundamental principles of the ATLS system,the “ABCDE” of trauma care.

24. ABCD of trauma care: A- Airway with cervical spine protection. B- Breathing and ventilation. C- Circulation with haemorrhage control. D- Disability: neurological status. E- Exposure: completely undress the patient and assess for other injury.

25. Airway & cervical spine: Assessment of – * Patency of airway * Any airway obstruction. * Check for trachea,larynx and faciomaxillary injury. * check for vocal response. Management: * Jaw thrust and chin lift, if required. * Ensure cervical spine immobilization by neck brace,sand bag . * Clear mouth and air way if FB,blood,vomitus & secretion. * If Glasgow coma score <8 ,consider definitive air way.

26. Breathing & ventilation : Assessment of the patient – * Inspect/percuss & auscultate chest * Cyanosis * Rate and depth of respiration. * Any abnormality in the chest wall movement * Check for pneumothorax,haemothorax ,# rib etc. Management- * Give 100% oxygen or high flow. * Insert chest drain for pneumothorax/ haemothorax . * Major vessels with in the chest needs to controlled.

27. Circulation & control of bleeding: Assessment- * Identify the site of bleeding * Check pulse and blood pressure,temperature Management- * Secure two large bore cannula,take blood and fluid resuscitation. * Examine for evidence of blood loss and treat accordingly .

28. Disability : Rapid assessment of the patient`s level of consciousness by GCS. Or by Assessment of pupillary size and reaction. Fracture of the limbs is the most common cause of either temporary or permanent disability.So limb immobilization by plaster cast,pain management and blood transfusion is necessary.

29. Disability: Assess mental state using the AVPU or Paediatric Glasgow coma scale. AVPU : * A- Alert child * V- Response to voice * P- Response to pain * U- unconscious.

30. Disability: Paediatric Glasgow coma Scale: Score Eye opening verbal Grimace response Motor response 1 None None None None 2 To pain Occational whimper/moan Mild to pain Extension to pain 3 To voice Inappropriate cry Vigorous to pain Flexes to pain 4 Spontaneous Decrease verbal/irritable cry Less than usual face movement withdraws 5 Allert babbles/words as normal Spontaneous face movement Localises to pain 6 Obeys commands

31. Exposure: Complete undress the patient,baby should be covered by warm blanket to prevent hypothermia. Examine the baby from front and back using a careful controlled log roll.

32. Adjucents to the primary survey: Blood tests- CBC ECG,ABG,Pulse oximetry. Two wide bore cannulae for I/V fluids. Urinary and gastric catheters. Radiographs of cervical spine,chest and pelvis .

33. Secondary survey : The secondary survey dose not begin until after the primary survey has been completed. The purpose of secondary survey is to identify all others injuries and perform head to toe examination Reassessment of vitals. Review of patient`s history- * A- Allergy. * M- Medication * P- Past medical history. * L- Last meal. * E- Event of incidence.

34. Continue…. Specific visceral injuries are common in children- * Duodenal haematoma * Pancreatic injury * Small bowel perforation * Mesenteric injuries * Bladder injury

35. Definitive care : * Definitive treatment plan according to cause * Live saving surgery may need .

36. References: Bailey & Love`s- 27 th edition Pediatric surgery –Arnold G. Coran-7 th edition. Jones` clinical Pediatric Surgery-7 th edition.

37. THANK YOU