INITIAL ASSESMENT MANAGEMENTFAISAL MUCHTAR

EMERGENCY AND TRAUMATOLOGY SYSTEM

INTRODUCTIONThe main role of the doctor is SAVING LIFE ALLEVIATE SUFFERINGAny doctors should have these competences.The main tool of saving life is BASIC LIFE SUPPORT

ACCIDENTS OR DISASTERSAccidents or disasters may occur to :ANY WHEREANY TIMEANY ONE

Well preparedness is very important ( soft-ware and hard-ware )

A medical condition that starts suddenly and requires immediate care

A life or Organ threatening medical condition resulting from an injury or sickness that requires immediate treatment and, if left untreated, could result in permanent harm to the person.

What is EMERGENCY in Medicine ?

Conditions such as: heart attack, uncontrollable bleeding, loss of consciousness, convulsions, severe allergic reactions, poisoning, severe shortness of breath or difficulty breathing, or severe or multiple injuries, including obvious fractures. Some Example of Emergency Conditions

The Cause of Death in USTraffic accidents are the third cause of mortality after CVS and CancerDisease of the young, leading cause death age 1 to 40 years> 100,000 death /year in US Loss of productive work yearsTrauma management is expensive

Epidemiology of Trauma DeathTrimodal patterns Donald Trunkey

50%30%20%sechrdays/week%DeathATLS

Trauma DeathFirst PeakDeath that occurs at impact or soon after the accident 50 % deathNot preventablesevere head laceration, massive bleeding, heart injury etc.Prevention of accidents enforcement, education & awareness

Trauma DeathSecond PeakDeath within minutes to hours after injury Golden Hours 30 % of deathLife threatening injuries involving airway, breathing , circulation

Trauma DeathAirwayobstruction: tongue, secretion & blood, vomitusdifficult airway managementBreathing & Ventilationpneumothorax,heamothorax, penetrating chest injuries, flail chestCirculationhemorrhage, cardiac tamponade

Second PeakPreventableReflect adequacy, efficiency of EMS in prehospital resuscitationhospital emergency department resuscitationdefinitive therapy

Third peakThird PeakDeath within days or week after injury20 % deathSepsis or multiorgan failureReflects again efficiency at resuscitation, definitive care, aggressive ICU care, prevention of infection and rehabilitation

Cardigenic pulmonary oedema in ICU

INITIAL ASSESMENTInitial assessment include :PreparationTriagePrimary Survey ( ABCDE )ResuscitationSecondary Survey ( Head to toe evaluation )Definitive Care

1. PREPARATIONPreparation of the trauma patient occursin two different clinical settings

1. PRE-HOSPITAL PHASE2. IN HOSPITAL PHASE

PRE HOSPITAL Transportation is very important

Prehospital Trauma ResuscitationDefinitive care ? GOALSA clear airway, effective ventilation, hemorrhage control & restoration of adequate blood volume

Pre hospital CareAmbulance Response Time: Standard50 % of all calls are responded within 8 min.95 % of calls within 14 min. (urban)95 % of calls within 19 min. (rural )Nolan JP, Pars. BJA 1997;79,226-240

Pre hospital CommunicationCommunicationVital between prehospital & in-hospital trauma patient resuscitationPrepare ED personnel well aheadActivation of TRAUMA TEAM / DISASTER PLAN into action

2. Triagetrier sorting outIs the sorting of patient based on the need for treatment Triage Resuscitation RoomActivation of trauma team

Efficient methodTrained doctors & nursesVariety of tasks taken simultaneouslyhorizontal organizationreduced time to life-saving procedure by 50 %

Trauma Team-work

Trauma Team at Work Pit stop in a formula 1 motor race Managing trauma in a smooth and efficient mannerDo no further harm

3. The Primary SurveyAirway & cervical spine controlBreathing & ventilationCirculation & haemorrhage controlDisabilityExposure/Environment

Airway & Cervical Spine ControlDifficult AirwayGoalKeep airway patentprotect compromised airwayprovide airway if none

Suspect:Unconscious patientsInjury above claviclesNeck painWeakness or neurological deficitHistory of fall > 6 m

Cervical spine Fracture

Breathing & VentilationPatient in increasing respiratory distress, BLUE, BLUE, BLUE, BP DOWN, Not Recordable...Think :Tension Pneumothorax, haemotothorax, Flail chest, lung contusion, cardiac tamponadeGoals: Avoid Hypoxia, Hypercarbia. Bad for the Brain

TENSION PNEUMOTHORAX

Flail ChestSegmental ribs fracture of multiple ribsPanel moves in with inspiration and out with expiration

Cardiac Tamponade

Treatment of Cardiac Tamponade

Chest tubeMassive : > 1500 ml bloodDrainage: . 200 ml/hrCLAMPED CTUrgent thoracotomyHematothorax

Circulation Haemorrhage Control with Fluid therapyFirst Priority : Restore volume with fluid (RL/NaCl 0.9% )Second Priority : Restore blood with WB and PRC transfusionto restore oxygen carrying capacityRemember : did not die of anemia but die of hypovolemic shockThird Priority : Normalize coagulation statusFFP, Platelet, blood products

Disability ( Neurologic Evaluation )Rapid Neurologic evaluation is perform at the end of primary surveySimple Neurologic evaluation is AVPU methodA AlertV Responds to Vocal stimuliP Responds only to Painful stimuliU Unresponsive to all stimuli

4. ResuscitationAggressive resuscitation and the management of life threatening injuriesEssential to maximize patient survialAirway should be protect and secure Jaw thrust or Chin lift maneuverDefinitive airway if needed Breathing/ventilation and oxygenationInjured patient should received supplemental O2Circulation Controlled bleeding by direct pressure or operative intervention

End- Points of ResuscitationTraditional: Achieved definitive careBlood Pressure/ cerebral perfusion pressure/ ICPHeart rateUrine output

5. Secondary SurveyNot begin until the Primary Survey is completedIs Head to Toe evaluationHeadMaxillofacialCervical spine and NeckChestAbdomen Perineum / rectum / vagina MusculoskeletalNeurologic

6. Definitive CareSurgical interventionTransfer to higher trauma center

ConclusionTrauma continues to be the most common cause of deathBLS playing a big role in saving life in pre-hospital phase or in hospitalDo No Further Harm is the basic principle of BLSABCDE is a good guide to take action.

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