Truama management advance trauma support.pptx

ATLAS is important entity in medical practice

1. MUSTAFA KAMAL MOHAMED KHEIR EMERGENCY MEDICINE SPECIALITY(SMSB&ARAB BOARD) TRAUMA COURSE INSTRUCTOR (STEP MARYLAND) EMERGENCY &CRITICAL CARE ULTRASOUD IN SUDAN (ECCUSS) INSTRUCTOR ALS&BLS INSTRUCTOR ABCDE The Safe Approach To Multiple Trauma Patient

2. Content Introduction. Objectives. Trauma team. Approach to unstable trauma patient. The primary survey. The secondary survey. Transfer of unstable patient. Summery of skills. Massage to take home

3. I ntroduction The first document to set criteria for categorizing hospitals as trauma centers was Initiated by the American College of Surgeons (ACS) Committee on Trauma in 1976. The benefit of regionalized trauma systems has been shown in multiple studies . A meta-analysis of 14 studies demonstrated an overall 15% decline in mortality due to the presence of a trauma system.

4. Continue The care of the injured patient remains one of the mainstay of emergency medicine practice. Emergency physician play a vital role in the stabilization and diagnostic phase of trauma care. Management of these patient involve complex, time dependent decision making. Leadership capability, and technical skill, proper resuscitation can lead to functional out com even in severely injured patient.

5. Continue Because time is of the essence, a systematic approach that can be easily reviewed and practiced is most effective. This process is termed ( initial assessment )

6. Epidemiology Trauma is a disease . Trauma is predictable, preventable , and treatable. Trauma is the 4 th leading cause of death in the US. Trauma is the leading cause of death in people below the age of 45 in the US. 3.8 M deaths/ year/ worldwide 312 M injured

7. Objectives Review approach to multiple injured patient the primary and secondary survey Understand the concept of trauma team. Review knowledge and technical skills and life saving interventions Discuss appropriate investigations Discuss transfer of care

8. Trauma team Increasingly, both the medical literature and resuscitation training materials emphasize code team organization. Even though some health care providers remain skeptical and question the value of teamwork . The building evidence strongly supports code team organization as a worthwhile endeavor . An effective trauma system needs the teamwork of EMS, emergency medicine, trauma surgery, and surgery subspecialists

9. Traditional medical approach

10. The ABCDE approach Airway & oxygenation Breathing & ventilation Circulation & shock management Disability due to neurological deterioration Exposure & examination

11. The Safe Approach Primary survey using ABCDE Then secondary survey with traditional medical clerking .

12. The primary survey ABCDE assessment looking for immediately life threatening conditions Rapid intervention usually includes max O 2 , IV access, fluid challenge +/- specific treatment Should take no longer than 5 min Can be repeated as many times as necessary Get experienced help as soon as you need it If you have a team delegate jobs

13. Important First survey will allow you to decide to continue for secondary survey or ask for immediate senior review.

14. The secondary survey Performed when patient more stable Get a relevant history - PC, HPC, PMH, DH, SH, FH, SR & examination More detailed examination of patient Order investigations to aid diagnosis Diagnosis/impression and plan IF PATIENT DETERIORATES RETURN TO PRIMARY SURVEY

15. ABCDEs of Trauma C are + Airway with C spine protection. Breathing and ventilation. + Circulation with hemorrhage control. Disability / neurological statues. Exposure. A B C D E

16. Airway and C spine protection Assume c-spine injury in patients with multisystem trauma. C-spine clearance is both clinical and radiographic C-collar should remain in place until patient can cooperate with clinical exam Manual midline stabilization C-collar

17. Airway assessment Airway should be assessed for patency Is the patient able to communicate verbally ? A lucid replay implies patency . If the patient fails to replay a more detailed assessment is made using the look , listen and feel approach. LOOK for chest and abdominal movement. LISTEN for any noise associated with breathing, that may indicate partial airway obstruction. FEEL for airflow at mouth and nose. Inspect for any foreign bodies Examine for stridor, hoarseness, gurgling, pooled secretions or blood

18. Airway Interventions Supplemental oxygen Suction Chin lift/jaw thrust Oral/nasal airways Definitive airways RSI for agitated patients with c-spine immobilization ETI for comatose patients (GCS<8)

19. Basic airway maneuvers Head tilt chin lift Jaw thrust

20. Basic airway Oropharengeal airway Nasopharengeal airway Laryngeal mask airway

21. Intubation Indications - Nasotracheal – in suspected cervical Fx , neck injuries as neck need not be extended, seizures Oropharyngeal - most rapid. Cricoid pressure. Stomach decompression should be done with NG tube Apnea / Hypoxia Inability to protect airway (GCS < 8) Facial or cervical trauma / burns Persistent shock

22. Surgical airway Surgical needle Cricothyroidotomy

23. Surgical airway Surgical cricothyroidotomy

24. Difficult Airway

25. Breathing Thoracic trauma is the cause of about 25% of all injury related deaths and is a contributory factor in a further 50%. The vast majority approximately 85% of these conditions can be treated successfully without surgical interventions. Airway patency alone does not ensure adequate ventilation Inspect, palpate, percuss, auscultate.

26. Breathing assessment Breathing personal: Ensure ECG and peripheral oxygen saturation (sop2) monitors are attached. Inspect, palpate, percuss, auscultate the chest. Perform needle thoracotomy and chest tube insertion as indicated. Inspect and palpate the neck. Support team members if no chest intervention are required.

27. Life threatening breathing problems The breathing personel need to eliminate six life threatening conditions which can follow thoracic trauma : airway obstruction/ disruption. Tension pneumothorax. Open/sucking chest wond . Massive haemothorax . Flail chest. Cardiac tamponade .

28. Breathing Interventions Ventilate with 100% oxygen Needle decompression if tension pneumothorax suspected Chest tubes for pneumothorax / hemothorax Occlusive dressing to sucking chest wound If intubated , evaluate ETT position

29. Needle decompression Indications for inserting needle thoracostomy : Decompensating tension pneumothorax in non intubated patient. Needle thoracostomy

30. Chest tube insertion Indications: Simple pneumothorax. Tension pneumothorax Massive pneumothorax

31. Pericardiocentesis Indication: Cardiac tamponed and no surgical expertise available. Complications: Myocardial trauma, coronary artery laceration, thoracic and abdominal visceral injury.

32. Sucking chest wound One way adhesive dressing

33. Flail Chest

34. Circulation Circulation personal: Stop any external hemorrhage. Establish vascular access, take appropriate blood samples. Start fluid resuscitation, and blood products. Examine the abdomen, pelvis, and long bones. Apply pelvic binder if indicated. Start monitoring of heart rate(HR), Blood pressure(BP), And capillary refill time(CRT). If competent and indicated, perform sonography . Insert a urinary catheter if not contraindicated.

35. Circulation Knowledge Definition of shock: Shock is defined as generalized, life threatening, inadequate oxygen delivery to organs and tissues . Differential diagnosis of shock in trauma: Hemorrhagic / hypovolemic Obstructive (tension pneumothorax , tamponade ) Neurogenic (usually not cardiogenic, septic, or anaphylactic )

36. Hemorrhagic shock should be assumed in any hypotensive trauma patient Rapid assessment of hemodynamic status Level of consciousness Skin color Pulses in four extremities Blood pressure and pulse pressure

37. Classification of Hemorrhage

38. Recognition of shock Clinical examination: Signs of external or internal hemorrhage. Estimate volume of blood loss: Heart rate Blood pressure Respiratory rate Capillary refill time Skin color and temperature Urine output Conscious level Metabolic disturbance (blood gases): PH. Lactate. Base deficit.

39. Hemorrhagic Shock External bleeding Control with direct pressure / staples / sutures Fluid resuscitation usually successful Internal bleeding May be from thorax, abdomen, or pelvis Usually requires surgical intervention if fluid resuscitation unsuccessful

40. Circulation Interventions Cardiac monitor Apply pressure to sites of external hemorrhage. Apply pelvic binder if indicated . Establish IV access 2 large bore IVs Central lines if indicated If competent and indicated, perform sonography . Cardiac tamponade decompression if indicated Volume resuscitation Have blood ready if needed Level One infusers available Foley catheter to monitor resuscitation if not contraindicated

41. Applying pelvic binder PELVIC SHEET PELVIC BINDER

42. Focus assessment with solography in trauma (FAST)

43. D- Disability Abbreviated neurological exam Level of consciousness Pupil size and reactivity Motor function GCS Utilized to determine severity of injury Guide for urgency of head CT and ICP monitoring

44. GCS EYE VERBAL MOTOR Spontaneous 4 Oriented 5 Obeys 6 Verbal 3 Confused 4 Localizes 5 Pain 2 Words 3 Flexion 4 None 1 Sounds 2 Decorticate 3 None 1 Decerebrate 2 None 1

45. Disability Interventions Spinal cord injury High dose steroids if within 8 hours ICP monitor- Neurosurgical consultation Elevated ICP Head of bed elevated Mannitol Hyperventilation Emergent decompression

46. E- Exposure Complete disrobing of patient Logroll to inspect back Rectal temperature Warm blankets/external warming device to prevent hypothermia

47. Always Inspect the Back

48. Logrolling trauma patient

49. Case 28 years old Male involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, “my belly”, “ uggghhh ”. HR 134 BP 87/42 RR 32 SaO2 89% on 100% facemask Brief initial exam: pt is drowsy but arousable to voice, has large hematoma over L parietal scalp, airway is patent, decreased breath sounds over R chest, diffuse abdominal tenderness, obvious deformity to L ankle

50. ABCDE What are the management priorities at this time? What are this patient’s possible injuries? What are the interventions that need to happen now?

51. Secondary survey The aims of the secondary survey are to: Examine the patient from head to toe, front and back so that the full extent of injuries can be identified. Request any further investigations or interventions as needed. Review all patient documentation: Surgical operation notes. Anesthetic record. Nursing reports. Radiology reports. All laboratory result. Obtain full medical history Review current treatment plan

52. Secondary Survey AMPLE history Allergies . medications . PMH . last meal. events. Physical exam from head to toe Frequent reassessment of vitals Diagnostic studies at this time simultaneously X-rays, lab work, CT orders if indicated FAST exam

53. Investigations 1) Blood work (including cross match) 2) CXR 3) Pelvic X-ray 4)Lat. C. spine 5) CT , FAST scan In unstable patient, do not usually need further X-rays or CT prior to transfer In stable patient, further investigations as indicated

54. Transfer of unstable patient Call for help early. Prior to transfer, carefully consider need to intubate or insert chest tubes. Ensure adequate IV access. Send with blood. Send with trained personnel. Send with CXR / pelvic X-ray if possible. Unnecessary investigations will delay transfer.

55. Summary - Knowledge Indications for intubation Indications for chest tube insertion Approach to shock / fluid resuscitation Familiarity with GCS Managing raised ICP

56. Summary - Skills Intubation Surgical airway (needle cricothyrodotomy ) Needle thoracostomy or chest tube insertion Intravenous line Central line insertion Interosseus insertion Arterial stab Applying a C-spine collar Foley / NG Applying a pelvic brace (FAST or DPL to look for intra-abdominal bleeding – usually in trauma centre or by local surgeon)

57. Remember… Managing an unstable trauma patient can be stressful . Following the “primary / secondary survey” approach with successful team work and communication will help you organize your thoughts and prioritize management.

58. S B A R ITUATION ACKGROUND SSESSMENT ECCOMENDATION Handover

59. Any Question