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Slide 1-

Initial Assessment and Management of the Trauma Patient 1 Hfastedge, Wikimedia Commons
Slide 2-

Objectives Epidemiology of Trauma Care History of Development of Trauma Care Mechanisms of Injury Basics of Trauma Management Primary Survey Resuscitation Secondary Survey ABCDE Format Cervical Spinal Immobilization Specific Case Examples 2
Slide 3-

Epidemiology Road Traffic Accidents are major cause of long term morbidity and mortality in developing nations In the first quarter of 2009, 372 deaths in Ghana from Road Traffic Accidents 25% increase from previous year WHO predicts that by 2020, Road Traffic Accidents will be second leading cause of loss of life for world’s population High Morbidity = Loss of income to society Challenges in Developing Countries Technological Advances in Trauma Care Lack of Infrastructure for Trauma Management EMS Pre-hospital notification MD/RN Training in trauma care 3
Slide 4-

Injury: Scale of the Global Problem 5.8 million deaths/year 10% of worlds deaths 32% more deaths than HIV, TB and Malaria combined Source: Global Burden of Disease, WHO, 2004 4
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Injury: Scale of the Global Problem Source: World Report on Road Traffic Injury Prevention 2004 5 World Health Organization, who.int
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Epidemiology Golden Hour = 80% of trauma deaths in first hour after injury Rapid trauma care has greatest level of impact in these patients Immediately Hours Days/Weeks 50% 30% 20% Trimodal Distribution of Trauma Deaths 6
Slide 7-

History of Trauma System Development Standardized Trauma Assessment Nebraska Cornfield, 1976 Orthopedic Surgeon Lead to development of ATLS Trauma Systems Development First developed my military in wartime i.e. MASH Units Expanded in US to Level 1, 2, 3 Trauma Centers Urban Systems Statewide networks of systems Level 1 – Highest level of care, Leaders in research, clinical care and education Level 2 – Provides definitive care in wide range of complex traumatic patients Level 3 – Provides initial stabilization and treatment. May care for uncomplicated trauma patients Level 4 – Provides initial stabilization and transfers all trauma patients for definitive care Otisarchives1 (flickr) 7
Slide 8-

Mechanisms of Injury Blunt Trauma Compression Forces Cells in tissues are compressed and crushed E.g. Spleen Shear Forces Acceleration/Deceleration Injury E.g. Aorta Shearing force = Spectrum from Full thickness tear (Exsanguination) to Partial tear (Pseudoaneurysm) Overpressure Body cavity compressed at a rate faster than the tissue around it, resulting in rupture of the closed space E.g. Plastic bag E.g. in trauma = diaphragmatic rupture, bladder injury 8
Slide 9-

Mechanisms of Injury Frontal Impact Collisions Lateral Impact Collisions (T bone) Rear Impact Collisions Rollover Mechanism Open Vehicle or Motorcycle/Moped Pedestrian Vs. Car Penetrating Injury (Guns vs. Knives) Vincent J Brown (flickr) Knockhill (flickr) Nxtiak (flickr) Nico.se (flickr) Juicyrai (flickr) 9
Slide 10-

Basics of Trauma Assessment Preparation Team Assembly Equipment Check Triage Sort patients by level of acuity (SATS) Primary Survey Designed to identify injuries that are immediately life threatening and to treat them as they are identified Resuscitation Rapid procedures and treatment to treat injuries found in primary survey before completing the secondary survey Secondary Survey Full History and Physical Exam to evaluate for other traumatic injuries Monitoring and Evaluation, Secondary adjuncts Transfer to Definitive Care ICU, Ward, Operating Theatre, Another facility 10
Slide 11-

Preparation for Patient Arrival Organize Trauma Response Team Top and bottom images: http://www.trauma.org/archive/resus/traumateam.html 11
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Primary Survey Airway and Protection of Spinal Cord Breathing and Ventilation Circulation Disability Exposure and Control of the Environment 12
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Primary Survey Key Principles When you find a problem during the primary survey, FIX IT. If the patient gets worse, restart from the beginning of the primary survey Some critical patients in the Emergency Department may not progress beyond the primary survey 13
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Airway and Protection of Spinal Cord Why first in the algorithm? Loss of airway can result in death in < 3 minutes Prolonged hypoxia = Inadequate perfusion, End-organ damage Airway Assessment Vital Signs = RR, O2 sat Mental Status = Agitation, Somnolent, Coma Airway Patency = Secretions, Stridor, Obstruction Traumatic Injury above the clavicles Ventilation Status = Accessory muscle use, Retractions, Wheezing Clinical Pearls Patients who are speaking normally generally do not have a need for immediate airway management Hoarse or weak voice may indicate a subtle tracheal or laryngeal injury Noisy respirations frequently indicates an obstructed respiratory pattern 14
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Airway Interventions Maintenance of Airway Patency Suction of Secretions Chin Lift/Jaw thrust Nasopharyngeal Airway Definitive Airway Airway Support Oxygen NRBM (100%) Bag Valve Mask Definitive Airway Definitive Airway Endotracheal Intubation In-line cervical stabilization Surgical Crichothyroidotomy 15 Dept. of the Army, Wikimedia Commons Ignis, Wikimedia Commons U.S. Navy photo by Photographer's Mate 2nd Class Timothy Smith, Wikimedia Commons
Slide 16-

Protection of Spinal Cord General Principle: Protect the entire spinal cord until injury has been excluded by radiography or clinical physical exam in patients with potential spinal cord injury. Spinal Protection Rigid Cervical Spinal Collar = Cervical Spine Long rigid spinal board or immobilization on flat surface such as stretcher = T/L Spine Etiology of Spinal Cord Injury (U.S.) Road Traffic Accidents (47%) High energy falls (23%) Clinical Pearls Treatment (Immobilization) before diagnosis Return head to neutral position Do not apply traction Diagnosis of spinal cord injury should not precede resuscitation Motor vehicle crashes and falls are most commonly associated with spinal cord injuries Main focus = Prevention of further injury 16
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C-spine Immobilization Return head to neutral position Maintain in-line stabilization Correct size collar application Blocks/tape Sandbags James Heilman, MD, Wikimedia Commons Paladinsf (flickr) 17
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Breathing and Ventilation General Principle: Adequate gas exchange is required to maximize patient oxygenation and carbon dioxide elimination Breathing/Ventilation Assessment: Exposure of chest General Inspection Tracheal Deviation Accessory Muscle Use Retractions Absence of spontaneous breathing Paradoxical chest wall movement Auscultation to assess for gas exchange Equal Bilaterally Diminished or Absent breath sounds Palpation Deviated Trachea Broken ribs Injuries to chest wall 18
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Identify Life Threatening Injuries Tension Pneumothorax Air trapping in the pleural space between the lung and chest wall Sufficient pressure builds up and pressure to compress the lungs and shift the mediastinum Physical exam Absent breath sounds Air hunger Distended neck veins Tracheal shift Treatment Needle Decompression 2nd Intercostal space, Midclavicular line Tube Thoracostomy 5th Intercostal space, Anterior axillary line Breathing and Ventilation Author unknown, www.meddean.luc.edu/lumenMedEd/medicine/pulmonar/cxr/pneumo1.htm Delldot (wikimedia) 19
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Breathing and Ventilation Hemothorax Blood collecting in the pleural space and is common after penetrating and blunt chest trauma Source of bleeding = Lung, Chest wall (intercostal arteries), heart, great vessels (Aorta), Diaphragm Physical Exam Absent or diminished breath sounds Dullness to percussion over chest Hemodynamic instability Treatment = Large Caliber Tube Thoracostomy 10-20% of cases will require Thoracostomy for control of bleeding Author unknown, http://www.trauma.org/index.php/main/images/C11/ 20
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Breathing and Ventilation Flail Chest Direct injury to the chest resulting in an unstable segment of the chest wall that moves separately from remainder of thoracic cage Typically results from two or more fractures on 2 or more ribs Typically accompanied by a pulmonary contusion Physical exam = paradoxical movement of chest segment Treatment = improve abnormalities in gas exchange Early intubation for patients with respiratory distress Avoidance of overaggressive fluid resuscitation http://images1.clinicaltools.com/images/trauma/flail_chest_wounded.gif Author unknown, http://www.surgical-tutor.org.uk/default-home.htm?specialities/cardiothoracic/chest_trauma.htm~right 21
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Breathing and Ventilation Open Pneumothorax Sucking Chest Wound Large defect of chest wall Leads to rapid equilibration of atmospheric and intrathoracic pressure Impairs oxygenation and ventilation Initial Treatment Three sided occlusive dressing Provides a flutter valve effect Chest tube placement remote to site of wound Avoid complete dressing, will create a tension pneumothorax Middle and bottom images: Author unknown, http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/TreataSuckingChestWound.htm Author unknown, http://www.trauma.org/index.php/main/image/902/ 22
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Needle Thoracostomy Needle Thoracostomy Midclavicular line 14 gauge angiocath Over the 2nd rib Rush of air is heard Author unknown, www.trauma.org/index.php/main/article/199/index.php?main/image/95/ 23
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Tube Thoracostomy Insertion site 5th intercostal space, Anterior axillary line Sterile prep, anesthesia with lidocaine 2-3 cm incision along rib margin with #10 blade Dissect through subcutaneous tissues to rib margin Puncture the pleura over the rib Advance chest tube with clamp and direct posteriorly and apically Observe for fogging of chest tube, blood output Suture the tube in place Complications of Chest Tube Placement Injury to intercostal nerve, artery, vein Injury to lung Injury to mediastinum Infection Allergic reaction to lidocaine Inappropriate placement of chest tube Author unknown, http://www.trauma.org/images/image_library/chest0051a.jpg 24
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Circulation Shock Impaired tissue perfusion Tissue oxygenation is inadequate to meet metabolic demand Prolonged shock state leads to multi-organ system failure and cell death Clinical Signs of Shock Altered mental status Tachycardia (HR > 100) = Most common sign Arterial Hypotension (SBP < 120) Femoral Pulse – SBP > 80 Radial Pulse – SBP > 90 Carotid Pulse – SBP > 60 Inadequate Tissue Perfusion Pale skin color Cool clammy skin Delayed cap refill (> 3 seconds) Altered LOC Decreased Urine Output (UOP < 0.5 mL/kg/hr) 25
Slide 26-

Circulation Types of Shock in Trauma Hemorrhagic Assume hemorrhagic shock in all trauma patients until proven otherwise Results from Internal or External Bleeding Obstructive Cardiac Tamponade Tension Pneumothorax Neurogenic Spinal Cord injury Sources of Bleeding Chest Abdomen Pelvis Bilateral Femur Fractures 26
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Circulation Emergency Nursing Treatment Two Large IV Lines Cardiac Monitor Blood Pressure Monitoring General Treatment Principles Stop the bleeding Apply direct pressure Temporarily close scalp lacerations Close open-book pelvic fractures Abdominal pelvic binder/bed sheet Restore circulating volume Crystalloid Resuscitation (2L) Administer Blood Products Immobilize fractures Responders vs. Nonresponders Transient response to volume resuscitation = sign of ongoing blood loss Non-responders = consider other source for shock state or operating room for control of massive hemorrhage 27
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Circulation Pericardial Tamponade Pericardium or sac around heart fills with blood due to penetrating or blunt injury to chest Beck’s Triad Distended jugular veins Hypotension Muffled heart sounds Treatment Rapid evacuation of pericardial space Performed through a pericardiocentesis (temporizing measure) Open thoracotomy Heart Blood Pericardium Epicardium Aceofhearts1968(Wikimedia) 28
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Pericardiocentesis Puncture the skin 1-2 cm inferior to xiphoid process 45/45/45 degree angle Advance needle to tip of left scapula Withdraw on needle during advance of needle Preferable under ultrasound guidance or EKG lead V attachment Complications Aspiration of ventricular blood Laceration of coronary arteries, veins, epicardium/myocardium Cardiac arrhythmia Pneumothorax Puncture of esophagus Puncture of peritoneum Author unknown, http://www.trauma.org/images/image_library/chest0054_thumb.jpg Author unknown, www.brooksidepress.org/ProductsTrauma_Surgery?M=A 29
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Circulation A word about cardiac arrest . . . Care of the trauma patient in cardiac arrest CPR Bilateral Tube Thoracostomy Pericardiocentesis Volume Resuscitation Traumatic cardiac arrest due to blunt injury has very low survival rate (< 1%) No point for emergency thoracotomy Selected cases of cardiac arrest due to penetrating traumatic injury may benefit from emergent thoracotomy Pericardial tamponade Cross clamp aorta Author unknown, http://www.trauma.org/images/image_library/chest0046.jpg 30
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Disability Baseline Neurologic Exam Pupillary Exam Dilated pupil – suggests transtentorial herniation on ipsilateral side AVPU Scale Alert Responds to verbal stimulation Responds to pain Unresponsive Gross Neurological Exam – Extremity Movement Equal and symmetric Normal gross sensation Glasgow Coma Scale: 3-15 Rectal Exam Normal Rectal Tone Note: If intubation prior to neuro assessment, consider quick neuro assessment to determine degree of injury 31
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Disability Glasgow Coma Scale Eye Spontaneously opens 4 To verbal command 3 To pain 2 No response 1 Best Motor Response Obeys verbal commands 6 Localizes to pain 5 Withdraws from pain 4 Flexion to pain (Decorticate Posturing) 3 Extension to pain (Decerebrate Posturing) 2 No response 1 Verbal Response Oriented/Conversant 5 Disoriented/Confused 4 Inappropriate words 3 Incomprehensible words 2 No response 1 GCS ≤ 8 Intubate 32
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Disability Key Principles Precise diagnosis is not necessary at this point in evaluation Prevention of further injury and identification of neurologic injury is the goal Decreased level of consciousness = Head injury until proven otherwise Maintenance of adequate cerebral perfusion is key to prevention of further brain injury Adequate oxygenation Avoid hypotension Involve neurosurgeon early for clear intracranial lesions 33
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Disability Cervical Spinal Clearance Patients must be alert and oriented to person, place and time No neurological deficits Not clinically intoxicated with alcohol or drugs Non-tender at all spinous processes No distracting injuries Painless range of motion of neck 34
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Exposure Remove all clothing Examine for other signs of injury Injuries cannot be diagnosed until seen by provider Logroll the patient to examine patient’s back Maintain cervical spinal immobilization Palpate along thoracic and lumbar spine Minimum of 3 people, often more providers required Avoid hypothermia Apply warm blankets after removing clothes Hypothermia = Coagulopathy Increases risk of hemorrhage 35
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Exposure Author unknown, http://www.trauma.org/index.php/main/image/98/C11 36
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Exposure Author unknown, http://www.trauma.org/images/image_library/chest0044b.jpg 37
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Trauma Logroll One person = Cervical spine Two people = Roll main body One person = Inspect back and palpate spine 38 Cdang, Wikimedia Commons
Slide 39-

Secondary Survey Secondary Survey is completed after primary survey is completed and patient has been adequately resuscitated. No patient with abnormal vital signs should proceed through a secondary survey Secondary Survey includes a brief history and complete physical exam 39
Slide 40-

History AMPLE History Allergies Medications Past Medical History, Pregnancy Last Meal Events surrounding injury, Environment History may need to be gathered from family members or ambulance service 40
Slide 41-

Physical Exam Head/HEENT Neck Chest Abdomen Pelvis Genitourinary Extremities Neurologic 41
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Physical Exam Difficult airway Source unknown 42
Slide 43-

Physical Exam Seatbelt sign http://www.itim.nsw.gov.au/images/seat_belt_mark_2.jpg Accessed 9/20/09 – Google Image Search 43
Slide 44-

Physical Exam Battle Sign Raccoon's Eyes Cullen’s Sign Grey-Turner’s Sign http://sfghed.ucsf.edu/Education/ClinicImages/Battle's%20sign.jpg Accessed 9/20/09 – Yahoo Images http://health-pictures.com/eye/Periorbital-Ecchymosis.htm Accessed 9/20/09 – Yahoo Images H. L. Fred and H.A. van Dijk (Wikimedia) H. L. Fred and H.A. van Dijk (Wikimedia) 44
Slide 45-

Adjuncts to Secondary Survey Radiology Standard emergent films C-spine, CXR, Pelvis Focused Abdominal Sonography in Trauma (FAST) Additional films Cat scan imaging Angiography Foley Catheter Blood at urethral meatus = No Foley catheter Pain Control Tetanus Status Antibiotics for open fractures 45
Slide 46-

FAST Exam Focused Abdominal Sonography in Trauma 4 views of the abdomen to look for fluid. RUQ/Morrison’s pouch Sub-xiphoid – view of heart LUQ – view of spleno-renal junction Bladder – view of pelvis 46
Slide 47-

FAST Has largely replaced deep peritoneal lavage (DPL) Bedside ultrasound looking for blood collection in an unstable patient. If the patient is unstable and a blood collection is found, proceed emergently to the operating theater. 47
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FAST Sensitivity of 94.6% Specificity of 95.1% Overall accuracy of 94.9% in identifying the presence of intra-abdominal injuries. Yoshil: J Trauma 1998; 45 48
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FAST Right Upper Quadrant - Morrison’s Pouch Between the liver and kidney in RUQ. First place that fluid collects in supine patient. 49
Slide 50-

FAST Exam - RUQ University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm 50
Slide 51-

FAST – Sub-xiphoid Evaluate for pericardial fluid View through liver Transhepatic or Parasternal Searches for fluid between heart and pericardium 51
Slide 52-

FAST – Sub-xiphoid University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm University of Louisville ED. www.louisville.edu/medschool/emergmed/ultrasoundfast.htm 52
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FAST – Left Upper Quadrant View between the spleen and kidney Another dependent place that fluid collects Also see diaphragm in this view 53
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FAST - LUQ University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm 54
Slide 55-

FAST – Bladder View Evaluates for fluid in the pouch of Douglas Posterior to bladder Dependent potential space 55
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FAST – Bladder View University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm 56
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Interpret this FAST Image: University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm 57
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Trauma in Special Populations Pregnancy Supine Hypotensive Syndrome After 20 weeks, enlarged uterus with fetus and amniotic fluid compresses inferior vena cava Decreases venous return and decrease cardiac output Keep pregnant patients in left lateral decubitus position to avoid excessive hypotension Optimal maternal and fetal outcome is determined by adequate resuscitation of mother Fetal Monitoring 58
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Trauma in Special Populations Pediatric Trauma Resuscitation Differences in head to body ratio and relative size and location of anatomic features make children more susceptible to head injury, abdominal injury Underdeveloped anatomy leads to chest pliability and less protection of thoracic cage Cardiac Arrest Typically result from respiratory arrest degrading into cardiac arrest Resuscitation Broselow Tape ABCDE Author unknown, http://dukehealth1.org/images/deps_tape4_sm.gif 59
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Classic Radiographical Findings Pelvic Fracture Author unknown, http://www.itim.nsw.gov.au/images/Open_book_pelvic_fracture_xray.jpg 60
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Classic Radiographic Findings Femur Fracture Author unknown, www.flickr.com/photos/40939239@N08/3771820024/ 61
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Classic Radiographic Findings Epidural Hematoma Middle Meningeal Artery Subdural Hematoma Bridging Veins Author unknown, http://rad.usuhs.mil/medpix/tachy_pics/thumb/synpic4098.jpg Author unknown, http://rad.usuhs.edu/medpix/tachy_pics/thumb/synpic519.jpg 62
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Classic Radiographic Findings Diaphragmatic rupture w/ spleen herniation Author unknown, http://commons.wikimedia.org/wiki/File:Diaphragmatic_rupture_spleen_herniation.jpg 63
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Classic Radiographic Findings Widened Mediastinum – Aortic Injury Author unknown, www.trauma.org/index.php/main/image/45/print 64
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Definitive Care Secondary Survey followed by radiographic evaluation CatScan Consultation Neurosurgery Orthopedic Surgery Vascular Surgery Transfer to Definitive Care Operating Room ICU Higher level facility 65
Slide 66-

Case Example Mr. Jones – 45 y/o male involved in a rollover road traffic accident and was ejected from the vehicle. Patient was unrestrained. Patient was not ambulatory on scene of accident and is brought into trauma bay for evaluation. What concerns you about story? First steps of evaluation and management Pete Prodoehl (flickr) 66
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Case Example Exam Awake, diaphoretic Pulse = 120 BP = 90/60 RR = 18 O2 sat = 94% What do you want to do next? 67
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Case Example Preparation Primary Survey Awake, alert, talking to provider Breathing Absent breath sounds on left What do you want to do next? Circulation Vital Signs? Access? Resuscitation? IV/O2/Monitor Disability GCS = 14 Exposure 68
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Case Example Chest tube placed Rush of air heard consistent with pneumothorax Repeat Vital Signs Pulse 120 BP 80/40 RR = 15 O2 sat = 99% NRBM What do you want to do next? Patient complaining of abdominal pain Ecchymosis noted over left flank Resuscitation? 69
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Case Example Blood Product Administration Transfer to definitive care = Operating Theatre Bonemesh (flickr) 70
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Conclusion Assessment of the trauma patient is a standard algorithm designed to ensure life threatening injuries do not get missed Primary Survey + Resuscitation Airway Breathing Circulation Disability Exposure Secondary Survey Definitive Care 71
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Questions? Dkscully (flickr) 72
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References American College of Surgeons. Advanced Trauma Life Support. 6th Edition. 1997. Feliciano, David et al. Trauma. 6th Edition. McGraw Hill. New York. 2008. Hockberger, Robert et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 6th Edition. Mosby. 2006. Tintinalli et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 6th Edition. McGraw Hill. 2003. 73