Lab 7: Trauma P. and S Evaluation

8/14/2019 Lab 7: Trauma P. and S Evaluation

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Primary and

secondary assessmentin trauma


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Jim Holliman, M.D., F.A.C.E.P.

Profesor Asociat de Chirurgie i Medicin de

Urgen

Director al Centrului Internaional de Medicin deUrgen

M.S. Hershey Medical Center

Penn State University

Hershey, Pennsylvania, USA


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SEQUENCE OF BASIC TREATMENTSEQUENCE OF BASIC TREATMENT

IN TRAUMAIN TRAUMA

Early primary examinationStart resuscitation maneuversConsideration of full secondary

examination It will assess whether the patient

requires emergency surgery ortransfer to another medical unit

Definitive treatmentRehabilitation


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Specific maneuvers in traumaSpecific maneuvers in trauma

Primary and secondary evaluation Opening the airway and ventilation

Orotracheal intubation and nasotrachealintubation

Installing intravenous lines Techniques for immobilization of limbs and spine Installing intraosseous line

Identify radiological lesions Surgical Procedures: cricothyrotomy, vein

denudation , pericardiocentesis, toracocentesis,chest drainage, perithoneal lavage, localanesthesia, suture of wounds


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Deaths occur in three important momentsDeaths occur in three important moments

AFTER TRAUMA INJURIESAFTER TRAUMA INJURIES

The first moment - from several seconds to

minutes after injury:

- Produced by :

brain tissue laceration or the upper level of

the spinal cord

heart and large vessels laceration - Few traumatized with such lesions can be

saved

- The best treatment is prevention''''


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The second important moment - fromseveral minutes to several hours after

injury - Produced by: subdural or epidural haematoma

haemo-and pneumotorax rupture of the spleen or liver pelvic fracturemassive loss of blood due to multiple

fractures These patients can often save with

coordinated emergency response


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The third moment - from several

days to several weeks - Produced by: Craniocerebral severe trauma

SepsisMultiple System and Organ FailureAn appropriate emergency

treatment can prevent some deathsin this range


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HEALTH CARE THAT GIVES TO MAJOR TRAUMA is

different from those which give patients medically stable

For stable patients medical standard sequence is:

history, medical history

physical examination from head to toe differential diagnosis

Laboratory examinations (lab, radiological, etc.).

Final diagnosis

This process is fully amended in front of atraumatized patient to prevent any issue whichmay cause his death


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THREE PRINCIPLES OF THETHREE PRINCIPLES OF THE

EMERGENCY MEDICAL ASSISTANCEEMERGENCY MEDICAL ASSISTANCE

IN TRAUMAIN TRAUMA

If the patient has multiple problems or injuries

, will be treated in the first one that couldimmediately threatening life of the patient

Appropriate treatment should not be delayed

just because the diagnosis is uncertain

It is necessary to begin a detailed history of a

patient assessment and treatment of

traumatized


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IDENTIFICATION of life-threatening injuriesIDENTIFICATION of life-threatening injuries

IN TRAUMAIN TRAUMA

Life-threatening injuries in trauma are(arranged in descending order of severity):

Airway obstruction - kills the fastest

Position of the head, blood, vomiting, foreignbody, external compression

Absence of breath - almost immediately kill

Pneumotorax, haemotorax, lung damage

Absence of circulation

Bleeding (internal or external), heart damage,arrhythmias

Intracranial expansive processes


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''''ABCDEABCDE"" IN TRAUMAIN TRAUMA

Always follow the following sequence

A - airway release (pay attention on the

cervical region ) B - breathing

C - circulation (attention to the cervicalcolumn)

D - neurological status E - exposure to environmental factors

It will follow by completely undress the patientto be examined, but take all necessary stepsto not induce hypothermia


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INITIAL ASSESSMENTINITIAL ASSESSMENT

Objectives

Identification and immediate

treatment of injuries respectingpriorities

Establish the necessity of carrying

out maneuvers of resuscitation afterthat will be follow by secondaryassessment

Appropriate triage in cases with

multiple victims


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Corect steps in trauma :

Initial Assessment Early Primaryexamination

The start of resuscitation maneuvers

Consideration of detailed secondaryexamination

Laboratory tests for diagnosis

frequent reassessment of the patientDefinitive care measures


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Basic principles of initial assessmentBasic principles of initial assessment

Corrections of situations posing an

immediate danger to life

(reanimation) should be done

simultaneously with primary

examination Start treatment before establish

definitive diagnosis


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COMMUNICATION BETWEEN THECOMMUNICATION BETWEEN THE

DEPARTMENT OF EMERGENCY ANDDEPARTMENT OF EMERGENCY AND

MEDICAL TEAM IN PREHOSPITALMEDICAL TEAM IN PREHOSPITAL

Support of patient is much improved

when there is proper communication

between hospital and prehospital

Telephone or radio report regarding

traumatized patient should be short

(under 45 seconds) and should begiven as early as possible before

arrival at hospital


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What information must containWhat information must contain

PREHOSPITAL REPORT ?PREHOSPITAL REPORT ? The number of victims, their age and sex

The mechanism of injury

Lesions suspected Vital signs

Treatment maneuvers performed so far

Approximate time to arrival at hospital

Special precautions needed to takeaccount of hospital staff:

contamination with hazardous materials

patient or belong to violent


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PREPARATIONS TO BE MADE INPREPARATIONS TO BE MADE IN

EMERGENCY DEPARTMENT BEFOREEMERGENCY DEPARTMENT BEFORE

ARRIVAL OF VICTIMS WITH MAJOR TRAUMAARRIVAL OF VICTIMS WITH MAJOR TRAUMA Alerting trained staff

Issue of a hospital bed for the victim

Arrange: equipment to support airway, IV lines and

infusion solutions, bandages, catheters of

pleurostoma and collection containers,type 0

negative blood

Alerting staff to:

radiology, laboratory, clinic ATI , special nursing

units and guard


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PRIMARY EXAMINATIONPRIMARY EXAMINATION

A - airway release (emphasis on thecervical column)

B - breathingC - circulation (control bleeding)D - neurological status ( neurological

"mini-exam" ) E - exposure to environmental

factors (D and E are greater in secondary

examination)


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HOW IS MADE THE PRIMARYHOW IS MADE THE PRIMARY

EXAMINATION?EXAMINATION?

The patient will be examined visuallyimmediately

breath? speaks?what is color skin? bleeding? is properly restrained? It will get a brief history:

mechanism of injury

when the incident occurred


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Issue airway if necessary (attention to thecervical column)

introduce an oropharyngeal route if thepatient is unconscious assist breathing:

listen with stethoscope the chest

pulsoximetry assisted ventilation if necessary

increased flow oxygen on masks to allpatients

Early protection of cervical spine: immobilize all suspected neck injury with

rigid cervical collar


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Patients that necessitate EARLYPatients that necessitate EARLY

IMMOBILISATION OF CERVICAL SPINEIMMOBILISATION OF CERVICAL SPINE

Setting lesion mechanism :

by drop

car crash

blow with a hard object in the head or neck

Unconscious

Neck pain

Crepitation or deformed in the rear part of the

neck

Altered state of consciousness (alcohol, drugs ,

etc..)


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CIRCULATION :

check pulse, blood pressure,breath frequency

temperature, if possible as

quickly check if the patient has externalbleeding and hemostasis by local

compression monitor the patient anddetermining the heart rate


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Airways:

maneuver to open airway

if unconscious - oropharyngeal way

Breathing: ventilation on mask and balloon

if necessary, Heimlich maneuver

OTI if the mask and ballon ventilationis ineffective


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OTI performed with the patient's head

supported by a nurse and neck in theshaft is the most appropriate

May be Nasopharyngeal-tracheal

intubation if:excluding nasal and facial fractures

excluded coagulopathy

Cricothyroidotomy if you can notmake OTI


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The circulatory disorders or suspected massive blood loss:

will mount at least one line i.v. Using a cannula plate(at least 18G, prefers 16-14G)

preference is to given Ringer Lactate or normal saline

solutions will be administered slowly if the patientpresents TCC(cranio-cerebral trauma) isolated,closed

solutions will be administered very quickly if thepatient is hypotensive

rapid blood transfusion with Type O negative (two ormore units if there is an obvious massive blood loss

or severe hypotension)

RESUSCITATION MEASURES TO BERESUSCITATION MEASURES TO BE

CARRIED OUT DURING THE PRIMARYCARRIED OUT DURING THE PRIMARY

EXAMINATIONEXAMINATION


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If there is a massive external bleeding:

direct pressure on the wound with abandage

rarely need direct clipping of the visible

injured arteries sterile dressings that cover any open

fracture or exposed visceral

tourniquet is almost never indicated





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After examining the thorax: look for rapidly fatal Injury

whether suspected masive hemotorax or suffocating

pneumotorax - toracostomy immediate followed bychest drainage

in case of coastal shutter - stabilization using a wide

adhesive valve penumotorax - the valve will close with

dressing and drainage will be spinning

suspicion of cardiac tamponade with imminent

cardiac arrest - pericardiocentesis





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COMPLETING PRIMARYCOMPLETING PRIMARY


After the primary examination (ABC andresuscitation measures) was completed we

will begin secondary examination


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PRIORITIES OF SECONDARYPRIORITIES OF SECONDARY

EXAMINATIONEXAMINATION Undress patient fully to allow detailedexamination - this may involve cutting clothes

if movements are painful or life threatening

for the patient

It will use heat sources (heaters, blankets) to

protect the patient from hypothermia

It is reassessing vital signs - temperature

should be measured


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Full review "from head to toe"

Nasogastric tube and / or bladder (if

there are contraindications) X-rays - the common are X-rays of

thorax, lateral cervical column , pelvis

It will assess the need for otherlaboratory tests

PRIORITIES OF SECONDARYPRIORITIES OF SECONDARY



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SECONDARY EXAMINATIONSECONDARY EXAMINATION

First is established trauma history

Comprehensive medical history:

allergies

medication pathological history

last meal (at what time)

events preceding the trauma Injury mechanism is established

Assessing the presence of other harmful factors

hypoglycemia, exposure to toxins , CO


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Full review "from head to toe"Full review "from head to toe"

It assesses the state of consciousness - GCS

The scalp

Examine the eardrum

Examine the nose and mouth

The face and mandible

Check pupillary response and eye movements


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It immobilizes the head and neck:

cervical collar is removed, examine the frontof the neck and check the position of trachea

look and papation the back of the neck

further application of cervical collarExamine the chest wall and clavicula by

percussion and palpation

Hear lung and heartPalpation of the upper portion of the back


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Potentially fatal chest injuriesPotentially fatal chest injuries

break tracheae

pulmonary contusion

myocardial contusion

aneurysm of aorta

rupture of diaphragm

rupture of the esophagus


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Currently non-lethal injuriesCurrently non-lethal injuries

rib fractures, the clavicle, the sternum

strain sternoclaviculara

scapula fracture

traumathic asphyxia

simple chest contusion


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Listening, palpating and percussion

The abdomen

The back

The pelvis

The patient lie flat back side maintaining the shaft spine

The genitals

It is necessary a vaginal and rectal examination:

will assess any damage to the prostate Analysis stool with tincture of guaiac


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Palpating the limbs

Assessing articulations

Palpating peripheral pulse and measure

capillary refill

Tendon function is evaluated


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Assessing neurological status - GCS

Mental status / orientation (recognition ofindividuals, orientation in space and time)

Examination of cranial nerves II-XII

Examination of motor, sensory and reflexes of

all four limbs Coordination of movements


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Secondary ExaminationSecondary Examination

Immobilization and dressing wounds

Pruning wounds for a better appreciation of

the depth Deep penetrating bodies are not extracted ,

do this only in the operating room(premature removal can giveexsanguination, if penetrating bodytamponing one major blood vessel)


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Should be considered an ECG carried out on 12 derivation (in case

of hypotension, major chest trauma, chest pain)

Radiographs minimum required (for a major injury of the torso)

are lateral cervical column, skull, pelvis (is required to make

secondary examination)

Radiographs of all parties suspected of fracture

Additional tests if needed: peritoneal lavage, CT, angiography,

ECO

Nasogastric tube and bladder, if not contraindication is present

Secondary Examination - FinalSecondary Examination - Final


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CONTRAINDICATIONSCONTRAINDICATIONS

nasogastric and urinary tubenasogastric and urinary tubeNasogastric probe :

nasal fractures, mediofaciale, severe

coagulopathies in such cases the probe is inserted

orogastric

Urinary probe urethral lesions suspected - blood in urine

meat , impalpable prostate, perinealhaematoma


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SUMMARY OF INITIALSUMMARY OF INITIAL

EXAMINATIONEXAMINATIONI. Primary assessment / resuscitation

A, B, C, D, E

II. Secondary assessmentX-ray, laboratory, nasogastric tube and urinary

III.Reevaluations

Final diagnosisoptions: letting the patient home, admission to a ward,

admission to ATI, the entry in the operating room,

another clinical trasnfer

Lab 7: Trauma P. and S Evaluation

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