Triage

The PPT on the Topic - Triage is based on the two topics of Bailey & Love - 26th edition.

1. TRAUMA ATLS TRIAGE Dr. Murali . U. M.S; M.B.A

2. Learning Outcomes Trauma is the commonest cause of death in the Trauma Describe the principles & concepts of triage in management of injured patient based on the mechanisms of injury List the types & phases of triage Discuss the principles of primary & secondary surveys in the assessment & management of trauma

3. I ntroduction In all regions of the world, adults over the age of 70 years,particularly females, have significantly higher fall-related mortality rates than younger people. However , children account for the largest morbidity – almost 50% of the total number of disability adjusted life-years (DALYs) lost globally to falls occur in children under 15 years of age. .

4. Introduction With ever increasing population growth and increased life expectancy , the injury mortality and morbidity statistics are likely to be skewed towards the two ends of the age spectrum, making the pediatric and the elderly very important with respect to global health care and economics.

5. Trauma - Types In essence, trauma can be divided into two basic types: • Serious and life-threatening injury • Significant trauma requiring treatment but not immediately life threatening. While it is acknowledged that the two can and often do overlap.

6. In Trauma - Types * Multiple casualties - Here , the number and severity of injuries do not exceed the ability of the facility to render care. Priority is given to the life-threatening injuries followed by those with polytrauma . * Mass casualties - The number and severity of the injuries exceed the capability and facilities available to the staff. In this situation , those with the greatest chance of survival and the least expenditure of time, equipment and supplies are prioritised .

7. Protocol The Advanced Trauma Life Support ( ATLS) system was therefore created initially in the USA and rapidly taken up globally. At present, over 40 countries worldwide are actively providing the ATLS course to their physicians.

8. Mechanism of Trauma Blunt Trauma – Direct or indirect blunt injury can occur. Seat belt reduces the blunt injury in vehicles. Penetrating injury – severity depends on the extent of deeper injury. Blast injury. Crush injury – earthquake, industrial accidents, and train accidents – causes crush syndrome, compartment syndrome. Burn injury. Injury in alcohol patients.

9. Concepts - Trauma Management Concept of “ golden hour “ to treat the trauma patient is important. Multidisciplinary approach Planning, setting up, organizing, team work. Assess respiratory system; circulation; breathing areas – as priority. Assess also whether patient is haemodynamically stable or unstable. Arrange fluids, blood, catheters, ventilator etc. Further definitive therapy depending on severity and site of injury.

10. TRIAGE

11. WHAT IS TRIAGE? WHY DO WE DO IT?

12. PRINCIPLE GOAL OF TRIAGE IS: TO DETERMINE , WHO SHOULD BE SEEN FIRST!!!!

13. A second major goal Not just sort but also stream To get the right patients to the right resources in the right place , and at the right time….

14. Definition a P rocess of prioritizing patients based on the severity of their condition. OR A medical classification process of priority of emergency care of simultaneous multiple patients in function of rear available care resources. ORIGIN T erm comes from the French verb ‘ trier ’ , Means to separate /sort / shift or select.

15. In Triage - Phases Triage is an important concept in modern health-care systems & three essential phases have developed: * pre-hospital triage – in order to despatch ambulance and prehospital care resources * at the scene of trauma * on arrival at the receiving hospital

16. ADVANCE TRAUMA LIFE SUPPORT ADVANCE TRAUMA LIFE SUPPORT Objective Identify the correct sequence of priorities for assessment of a multiple injured pt. Apply the principles outlined in primary and secondary evaluation surveys of ATLS. Apply guidelines and techniques in the initial resuscitative and definitive care phases of treatment.

17. ADVANCE TRAUMA LIFE SUPPORT ADVANCE TRAUMA LIFE SUPPORT Initial assessment Primary survey Secondary survey

18. ADVANCE TRAUMA LIFE SUPPORT A T L S Initial assessment Primary survey Secondary survey Initial assessment of the casualty Time interval Then proceed to the basic ATLS procedure i.e. (in short) ABCDE

19. ADVANCE TRAUMA LIFE SUPPORT A T L S Initial assessment Primary survey Secondary survey Breathing AIRWAY Circulation f Disability Exposure Confirmation If patient talks normally, airway not compromised Hoarse voice or audible breathing, suspicious Assess the patient for airway obstruction (coma) Agitation--------------- hypoxia Cyanosis---------------- hypoxemia, secondary to inadequate oxygenation Hoarseness,----------- suspected laryngeal fracture s/c emphysema & palpable fracture

20. ADVANCE TRAUMA LIFE SUPPORT A T L S Initial assessment Primary survey Secondary survey Breathing AIRWAY Circulation f Disability Exposure Established maintenance of airway through either of the two ---Head tilt-chin lift ---Jaw thrust JAW THRUST Rescuer fingers are placed behind the posterior border of the ramus of the mandible Displace the mandible forward, dislocating it while tilting the head backward Retract the lower lip with the thump JAW THRUST

21. ADVANCE TRAUMA LIFE SUPPORT A T L S Initial assessment Primary survey Secondary survey Breathing AIRWAY Circulation f Disability Exposure If debris ( broken tooth, dentures) is present, remove it by—Finger sweep technique or --Yankauer suction or -- Magill’s forceps (for large object) If ---no foreign body is visible, endotracheal tube should be used to secure the established airway --- If the foreign body cannot be removed quickly or the vocal cords cannot be adequately visualized or endotracheal intubation is not possible, then cricothyroidotomy is indicated

22. ADVANCE TRAUMA LIFE SUPPORT Yankauer suction Magill’s forceps CRICOTHYROIDOTOMY A T L S

23. ADVANCE TRAUMA LIFE SUPPORT A T L S Initial assessment Primary survey Secondary survey Breathing AIRWAY Circulation f Disability Exposure In patient sustaining significant blunt injury, should be assume to have cervical spine injury, until prove other-wise --- such pt. should have cervical spine immobilized with semi rigid cervical collar and bilateral sand bags or block joined with tapes or straps across the forehead

24. ADVANCE TRAUMA LIFE SUPPORT A T L S semi rigid cervical collar block joined with tapes or straps across the forehead

25. BREATHING Airway Circulation f Disability Exposure ADVANCE TRAUMA LIFE SUPPORT A T L S Initial assessment Primary survey Secondary survey Conditions that acutely compromised breathing are-- Tension pneumothorax Massive hemothorax Flail thorax accompanied by pulmonary contusion open pneumothorax compromise breathing Such condition can be diagnosed with physical examination & should be treated immediately It can be treated with endotracheal intubation, mechanical ventilation, needle thoracocentesis, or tube thoracostomy.

26. ADVANCE TRAUMA LIFE SUPPORT NEEDLE THORACOCENTESIS TUBE THORACOSTOMY A T L S

27. Breathing Airway CIRCULATION Disability Environment & exposure ADVANCE TRAUMA LIFE SUPPORT A T L S Initial assessment Primary survey Secondary survey Circulatory problems in trauma patients are usually caused by hemorrhage First action is to stop bleeding For --- Intra oral bleeding-----------------bite a cotton swap Tongue laceration------------------deep suture across the laceration Bleeding from fracture-----------manually reducing and brittle wiring of the fracture fragments mandible end Mobile maxilla---------------------rubber mouth gags Soft tissues of head & neck----direct pressure on the bleeding site Torrential bleeding from--------epistat tube with anterior and posterior balloons the nasopharynx region

28. Breathing Airway Circulation f DISABILITY Environment & exposure ADVANCE TRAUMA LIFE SUPPORT A T L S Initial assessment Primary survey Secondary survey Assessment of the neurological status. The Glasgow coma score (GCS) worst score is 3 points GCS can be caused by a focal brain injury Optimal oxygenation and circulation are important to prevent secondary injury to the brain Impaired consciousness can be caused by hypoxia or hypotension for which ABC stabilization is essential Patients who open their eyes spontaneously, obey commands, and are normally oriented score a total of 15 points

29. Breathing Airway CIRCULATION f Disability EXPOSURE ADVANCE TRAUMA LIFE SUPPORT A T L S Initial assessment Primary survey Secondary survey Represent Hypothermia Burns, and Possible exposure to chemical and radioactive substance Should be evaluated and treated

30. ADVANCE TRAUMA LIFE SUPPORT A T L S Initial assessment Primary survey Secondary survey Under this the pt. is examined from head to toe Appropriate additional radiographs of the thoracic and lumbar spine and the extremities are performed when indicated. CT scans, when indicate Secondary survey mnemonics Head/skull Has Maxillofacial My Cervical Spine Critical Chest Care Abdomen Assessed Pelvis Patient's Perineum Priorities Orifices Or Neurological Next Musculoskeletal Management Diagnostic tests/ Decision? Definitive care

31. ADVANCE TRAUMA LIFE SUPPORT RE-EVALUATION IF, DURING THE SECONDARY SURVEY, THE PATIENT'S CONDITION DETERIORATES, THE PRIMARY SURVEY SHOULD BE REPEATED BEGINNING WITH “A”.

32. ADVANCE TRAUMA LIFE SUPPORT ADVANCE TRAUMA LIFE SUPPORT Analgesia Documentation & Legal Definitive care

33. Triage at an accident scene is performed by a paramedic or an emergency physician, using the four-level scale of Cannot wait Has to wait Can wait Lost No chance of survival

34. category meaning c onsequences examples T1 (I) acute danger for life immediate treatment, transport as soon as possible arterial lesions, internal haemorrhage, major amputations T2 (II) severe injury constant observation and rapid treatment, transport as soon as practical minor amputations, flesh wounds, fractures and dislocations T3 (III) minor injury or no injury treatment when practical, transport and/or discharge when possible minor lacerations, sprains, abrasions T4 (IV) no or small chance of survival observation and if possible administration of analgesics severe injuries, uncompensated blood loss, negative neurological assessment T5 (V) deceased collection and guarding of bodies, identification when possible dead on arrival, downgraded from T1-4, no spontaneous breathing after clearing of airway

35. References Bailey & Love’s - Short Practice of Surgery 26 th edition. Internet websites .