Dr. AHMED. N. ZAKARIAHDr. AHMED. N. ZAKARIAH(MD, MPM, EMBA, MPhil)(MD, MPM, EMBA, MPhil)

Consultant in Intensive Care Consultant in Intensive Care MedicineMedicine

&&DIRECTOR. NASDIRECTOR. NAS

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Table of ContentsTable of Contents

• Objectives of EMS

• Biomechanics of road traffic collision injuries

• Mechanisms of injury

• Patterns of injuries in road traffic accidents

• Coordination of physical and medical rescue

• Principles of Triage

• Assessment and Management Priorities

Objectives of emergency medical services:Objectives of emergency medical services:• Reduce proportion of persons who delay or have

difficulty in getting emergency medical care.

• Increase proportion of persons who have access to rapidly responding pre-hospital emergency services.

• Increase number of Institutions with trauma care systems that maximize survival and functional outcomes of trauma patients and help prevent injuries from occurring.

Biomechanics of road traffic collision Biomechanics of road traffic collision injuriesinjuries

• Important for diagnosing and managing road traffic injured patients.

• Degree of injury depends on mass and speed of collided vehicles.

• Collisions can be front impact, back impact, side impact; vehicle may turn over or patient may be ejected from vehicle.

• Each mechanisms has specific pattern of injury.

Biomechanics of road traffic collision Biomechanics of road traffic collision injuries contd.injuries contd.

• Injury varies depending on whether passenger was restrained with a seat belt or not.

• Seat belts tend to reduce head injuries and increase abdominal injuries.

• Compression injuries of intestines and urinary bladder tend to be more severe, causing rupture of hollow organs if pressure within organs high.

Mechanisms of injuryMechanisms of injury• Injured either by rapid deceleration or by deformation with

intrusion of vehicle components into interior of vehicle

• Occupant’s body thrown against interior of vehicle, often referred to as ‘second collision’

• ‘Third collision’ between soft tissues and skeletal structures.

• Ejection of occupant, rapid deceleration of body when it strikes the ground or another vehicle.

• Ejection associated with increased likelihood of serious injury and death.

Patterns of injuries in road traffic Patterns of injuries in road traffic accidentsaccidents

• head, face and cervical spine injuries;

• • cervical whiplash and sternal injuries;

• • sternal fracture and dorsal spine injury;

• • lower rib fractures with injury to kidneys, liver or spleen;

• • intra-abdominal and diaphragmatic injuries;• • pelvic fracture with lower urinary tract injury;• • lower limb fracture with hip dislocation or spinal

fracture.

The trauma chain that forms a continuum of The trauma chain that forms a continuum of care for road traffic casualtiescare for road traffic casualties

Coordination of physical and medical rescueCoordination of physical and medical rescue

• Extrication of trapped casualties needs close integration of physical and medical rescue

• Initial assessment by medical team

• Extrication team makes space (removal of car roof and sides)

• Medical team reassess

• Definitive extrication performed

Teamwork between emergency services to Teamwork between emergency services to extricate casualties safely at a road crash sceneextricate casualties safely at a road crash scene

Initial patient assessmentInitial patient assessment

• Primary survey carried out, and any critical interventions performed.

• Emphasis on finding conditions that might cause deterioration or death during extrication, i.e., airway obstruction, hypoxia, or tension pneumothorax.

• More importance placed on mechanism of injury and clinical assessment of physiology.

• Oxygen given, cervical spine stabilised, and basic monitoring (pulse rate and oxygen saturation) applied.

Further patient assessmentFurther patient assessment

• After extrication, patient reassessed.

• Prehospital medical interventions address each patient's needs, giving right intervention at right time.

• Major emphasis on airway and breathing interventions

• Increasing importance attached to preventing haemorrhage

• Preservation of body's natural clotting mechanism (by minimising movement, splintage, and pressure

PackagingPackaging• Patients “packaged” for transport with hard cervical

collar, head blocks, limb splints if required, and body splint such as scoop (bivalve) stretcher or vacuum mattress.

• Spinal immobilization standard procedure worldwide,

Golden HourGolden Hour• First 60 minutes following serious injury

• Rapid removal of casualty to hospital improves chances of survival.

• Platinum Ten Minutes" proposed as time taken to move casualty to ambulance

• ‘‘Platinum Ten Minutes’’ proposed as ideal• for on scene time

Triage: DefinitionTriage: Definition• Process for sorting injured people into groups based

on need for immediate medical treatment

• Process which places right patient in right place at right time to receive right level of care

• Process of prioritizing which patients are to be treated first

• Cornerstone of good trauma or disaster management

Trauma TriageTrauma Triage• Use of trauma assessment for prioritising of patients for

treatment or transport according to severity of injury

• Primary triage carried out at scene of accident

• Secondary triage at casualty clearing station at site of major incident.

• Triage repeated prior to transport away from scene and again at receiving hospital.

Triage: GoalsTriage: Goals

• Right patient to right place at right time

• Do the best for the most

• Resources not diverted for treatment of irrecoverable

• Must be repeated at every phase of Rx

Triage: TypesTriage: Types

1. Sieve:

During pre-hospital phaseBy paramedics

2. Sort: In hospitalBy medical person

Triage sieve: MethodTriage sieve: Method

Used at scene of major trauma and involves rapid assessment

Mobility

Airway

Breathing

Circulation

Method for triage sieveMethod for triage sieve

Yes

No

Injured ?N

Priority 3

DelayedY

Survivor area

Walking?

Not able to walkNot able to walkCheck for breathingCheck for breathing

DeadNOpen

AirwayY

N

Y

Priority 1Immediate

Breathing presentBreathing presentSee Respiratory rateSee Respiratory rate

10 or less30 or more

Priority 1Immediate

11-29

Capillary refill time

> 2 sec

< 2 sec Priority 2 Urgent

CirculationCirculation• Pulse rate can be used instead of

CRT

• 2 seconds CRT= Pulse 120/min

Breathing presentBreathing presentSee Respiratory rateSee Respiratory rate

10 or less30 or more

Priority 1Immediate

11-29> 120 / min

Priority 2 Urgent

< 120 / minPulse rate

PriorityPriority

Priority 1 Immediate

Priority 2 Urgent

Priority 3 Delayed

Priority 1: ImmediatePriority 1: Immediate

Needs urgent treatment Breathing only after airway management

Respiratory rate <10 or >30

Capillary refill time > 2 seconds or Pulse rate > 120/ min.

Priority 2: UrgentPriority 2: Urgent

Needs treatment within 4-6 hours

1. Patient is not walking

1. Resp. rate between 11-29 and

1. Capillary refill time < 2 sec. or

Pulse rate < 120/min.

Priority 3: DelayedPriority 3: Delayed

Walking patient who is injured

TRIAGE SIEVETRIAGE SIEVE

WALKING P3 DELAYED

BREATHING DEAD

RESPIRATORY RATE P1 IMMEDIATE

Capillary RefillToo cold or too dark measure pulse rate

PRIORITY 2

YES

NO

2 SEC OR UNDER

YES

30 OR MORE9 OR LESS

10 – 29 OVER 2 SEC

Triage sieve should not take >20 sec for each non-ambulant patient

TRIAGE SORTTRIAGE SORTMeasured Value Score

• Respiratory rate 10 – 29 4 >29 3

6 – 9 21 – 5 10 4

• Systolic Blood pressure >90 476 – 89 350 – 75 21 – 49 10 1

• Glascow Coma Scale 13 – 15 49 – 12 36 – 8 24 – 5 13 0

TRIAGE REVISED TRAUMA SCORE AND TRIAGE REVISED TRAUMA SCORE AND PRIORITYPRIORITY

PRIORITY TRTS

P1 1 – 10P2 11P3 12DEAD 0

Simple Triage and Rapid Assessment – STARTSimple Triage and Rapid Assessment – START

• Each patient should take less than 30 secs

Categories:

• BLACK – MORGUE

• RED – IMMEDIATE

• YELLOW – DELAYED

• GREEN - MINOR

Green – Walking WoundedGreen – Walking Wounded

• Clear the walking wounded using verbal instruction

• Direct them to green treatment area

• Tag as minor• Begin your RPMs

RPMs – 1) RespirationsRPMs – 1) Respirations

• 1) None: open airway

• Still none ? deceased – TAG BLACK

• Restored – TAG RED

• 2) present:• > 30 TAG RED• < 30 – check perfusion

RPMs – 2) PerfusionRPMs – 2) Perfusion

• Radial pulse absent or capillary refill > 2 sec : control bleeding & tag RED

• Radial pulse present or capillary refill < 2 sec : check mental status

RPMs – 3) Mental StatusRPMs – 3) Mental Status

• Can not follow simple commands (unconscious or altered LOC)

TAG RED

• CAN follow simple commands TAG YELLOW

COLOUR CODING FOR PREHOSPITAL TRIAGE COLOUR CODING FOR PREHOSPITAL TRIAGE SYSTEMSYSTEM

COLOUR DESCRIPTION

RED CRITICAL: unstable, with acute problems for whom immediate intervention is likely to save life or limb. TRANSPORT IMMEDIATELY

YELLOW URGENT: acute problem and stable, but may deteriorate. TRANSPORT AFTER RED CASES

GREEN DELAYED: injured or ill, but stable and not likely to deteriorate if treatment is delayed (Referred to as the walking wounded). TRANSPORT AFTER RED and YELLOW CASES

BLACK EXPECTANT: dead or non-salvageable given the available resources. Lowest transport priorities

DISASTER PRIORITY CATEGORIESDISASTER PRIORITY CATEGORIES

PRIORITY DISASTER

1 CLASS 1 (EMERGENT) RED: critical, life threatening-compromised airway, shock, haemorrhage

2 CLASS II (URGENT) YELLOW: major illness or injury, requires treatment within 20 minutes to 2 hours-open fracture, chest wound

3 CLASS III (NON URGENT) GREEN: care may be delayed 2 hours or more, minor injuries; walking wounded-closed fracture, sprain, strain

4 CLASS IV (EXPECTANT) BLACK: dead or expected to die-massive head injury, extensive full-thickness burns

4444

Note:Note:the faster the injured arrives at a the faster the injured arrives at a hospital, the better the survival. hospital, the better the survival.

Primary surveyPrimary survey

• Aims to identify and immediately treat life-threatening injuries

• Based on 'ABCDE' resuscitation system.

• Priority given to patients most likely to deteriorate clinically

• Dynamic process and patients should be reassessed frequently.

'ABCDE' resuscitation system'ABCDE' resuscitation system• Airway control with stabilization of cervical spine

• .Breathing.

• Circulation (including control of external haemorrhage)

• Disability or neurological status.

• Exposure or undressing of patient while also protecting patient from hypothermia

Initial Assessment and ManagementInitial Assessment and Management

• Preparation (pre-hospital and hospital)• Triage• Primary Survey (ABCDE’s)• Resuscitation• Secondary Survey

(Head-to-toe evaluation &History)• Tertiary Survey

• Definitive Care

Assessment and Management Assessment and Management PrioritiesPriorities

• RAPID Primary Survey

• Resuscitation of Vital Functions

• Secondary Survey

• Definitive Care

• Tertiary Survey

Primary SurveyPrimary Survey• Diagnose and manage life-threatening injuries

in a proper sequence as they are identified!

Primary SurveyPrimary Survey

• A Airway with control of the spine

• B Breathing

• C Circulation

• D Disability

• E Events and environment

Primary Survey: AirwayPrimary Survey: Airway• Assess airway

• Is the airway patent?

- Establish airway- endotracheal intubation

• Protect cervical spine - Cervical stabilization

Primary Survey: BreathingPrimary Survey: Breathing

• Assess and ensure adequate oxygenation and breathing

Pitfalls:• Airway vs. ventilation problems?

• Pneumothorax or Tension Pneumothroax

Primary Survey- BreathingPrimary Survey- Breathing

• Spontaneous or Assisted

• Oxygen to all

• O2 Saturation > 90

• Inadequate Ventilation?

- Support ventilation

Primary Survey- CirculationPrimary Survey- Circulation

• Assess pulses

- radial, femoral, carotid

• Skin, pulse rate and character

• Level of consciousness

STOP THE BLEEDING!!!

Large-bore IV insertion

Start infusion of fluids

Primary Survey- CirculatoryPrimary Survey- Circulatory

• Control hemorrhage

• Restore Volume

• Reassess

Primary Survey- DisabilityPrimary Survey- Disability

•Assess mental status

•Is there head trauma?

•Pupils (Is it reactive? Blown pupil?)

•Glasgow Coma Scale

•Gross localizing signs

DSTCDSTC

Primary Survey- ExposurePrimary Survey- Exposure

•Undress the patient COMPLETELY

•Rewarm all patients

Hypothermia + Trauma = DEATH!

Assessment and Management Assessment and Management PrioritiesPriorities

• RAPID Primary Survey

• Resuscitation of Vital Functions

• Secondary Survey

• Definitive Care

• Tertiary Survey

ResuscitationResuscitation• Protect and secure airway

• Ventilate and oxygenate

• Control hemorrhaging!

• 2 large-bore IV’s

• Vigorous shock therapy

• Protect from hypothermia

Secondary SurveySecondary Survey

When?

• After primary survey completed

• A-B-C-D-E’s are reassessed

• Vitals returning to normal

What are the componentsWhat are the components

• History

• Top to toe survey

• Front to back survey

HistoryHistory

• A Allergies

• M Medications

• P Past Medical History

• L Last Meal

• E Events

Secondary Survey: HeadSecondary Survey: Head

Head

•GCS score

•Neurologic exam

•Comprehensive eye and ear exam

Secondary Survey MaxillofacialSecondary Survey Maxillofacial

• Bony crepitus

• Deformity

• Malocclusion

DSTCDSTC

Secondary SurveySecondary Survey Cervical Spine Cervical Spine

• Palpate for tenderness

• Complete motor/sensory exam

• Reflexes

• Diagnostic tools-spine x-ray

Secondary SurveySecondary Survey

Neck (soft tissues Neck (soft tissues))• Mechanisms: Blunt vs. Penetrating

• Findings: Airway obstruction, crepitus, hoarseness hematoma, stridor

Pitfalls• Delayed symptoms and signs• Progressive obstruction• Occult injuries

Secondary Survey: ChestSecondary Survey: Chest

•Inspect•Palpate•Percuss•Auscultate•Diagnostic tools x-ray

Pitfalls-Expanding pneumothorax -Haemothorax (cont. hemorrhage)

Secondary Survey: AbdomenSecondary Survey: Abdomen

• Inspect, Auscultate, Palpate, Percuss• Reevaluate• Special studies (FAST, DPL)

Pitfalls

- Hollow viscous injury

- Retropertioneal bleeds

Secondary Survey: Musculoskeletal Secondary Survey: Musculoskeletal ExtremitiesExtremities

• Deformity, Contusion, Pain• Neurovascular exam• X-rays

Pitfalls• Blood loss• Missed fractures• Soft-tissue/ligamentous injury• Compartment syndrome

Musculoskeletal PelvisMusculoskeletal Pelvis

• Palpate

• Leg length unequal

- shortened, externally rotated

• Instability

• Pelvis X-rays

Secondary Survey: Spine and BrainSecondary Survey: Spine and Brain• GCS score

• Complete motor and sensory

• Log-roll and palpate entire spine

• Imaging as indicated

Assessment and Management Assessment and Management PrioritiesPriorities

• RAPID Primary Survey

• Resuscitation of Vital Functions

• Secondary Survey

• Definitive Care

• Tertiary Survey

Definitive CareDefinitive Care

• Survival depends on time to definitive care

• ICU, Operating Theatre or Transfer to other facility

Assessment and Management Assessment and Management PrioritiesPriorities

• RAPID Primary Survey

• Resuscitation of Vital Functions

• Secondary Survey

• Definitive Care

• Tertiary Survey

Tertiary SurveyTertiary Survey

• Repeat the complete secondary survey within first 24hrs.

• Evaluate for Unrecognised injuries

• Underlying medical problems

• Decrease missed injuries

Summary 1Summary 1

• Assessment and management of trauma:

- RAPID Primary Survey

- Resuscitation of Vital Functions

- Secondary Survey

- Definitive Care

- Tertiary Survey

• Complete primary survey and address life-threatening injuries

Summary 2Summary 2

DSTCDSTC

What is the primary survey?•A Airway with control of the spine•B Breathing•C Circulation•D Disability•E Events and environment

What is the secondary survey?

•Head to toe physical exam and history (AMPLE)