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Chapter 1 Initial Assessment and management. OBJECTIVES n Identify the correct sequence of priorities in assessing the multiply injured patient n Apply.

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Presentation on theme: "Chapter 1 Initial Assessment and management. OBJECTIVES n Identify the correct sequence of priorities in assessing the multiply injured patient n Apply."— Presentation transcript:

1 Chapter 1 Initial Assessment and management

2 OBJECTIVES n Identify the correct sequence of priorities in assessing the multiply injured patient n Apply the primary and secondary evaluation surveys to assessment of the multiply injured patient n Apply guidelines and techniques in the initial resuscitative and definitive--case phase n Anticipate the pitfalls associated with the initial assessment and management ( minimize their impact ) n Conduct an initial assessment survey on a simulated multiply injured patient

3 CONCEPTS OF INITIAL ASSESSMENT n Preparation n Triage n Primary survey ( ABCDEs ) n Resuscitation n Adjuncts to primary survey and resuscitation n Secondary survey ( head-to-toe evaluation and history ) n Adjuncts to the secondary survey n Continued postresuscitation monitoring and reevaluation n Definitive care

4 n Repeat primary and secondary survey when finding any deterioration in the patient’s status n Primary survey and resuscitation are done simultaneously

5 PREPARATION n Prehospital – Airway maintenance – Control of external bleeding & shock – Immobilization of the patient – Communication with receiving hospital & immediate transport to the closest, appropriate facility – History taking ( include events ) n Inhospital – Advanced planning ( especially massive casualty ) – Equipment & personnel – Communicable disease protection – Transfer agreements

6 TRIAGE n Sorting of patients according to ABCs and available resources n Triages is the responsibility of prehospital personnel

7 n Not exceed the ability of the facility ==> treat life -- threatening patient first n Exceed the capacity of the facility ( mass casualties ) ==> Treat the greatest chance of survival, with the less time, less equipment & less personnel

8 PRIMARY SURVEY n Adult / Pediatric priorities same n Identified the life-threatening conditions and simultaneously managed – A: Airway maintenance with cervical spine protection – B: Breathing and ventilation – C: Circulation with hemorrhage control – D: Disability ( Neurologic status ) – E: Exposure / Environmental control: Undress the patient & prevent hypothermia

9 PRIMARY SURVEY n Airway Maintenance with Cervical Spine Protection – Oral foreign bodies, facial, mandibular, or tracheal / laryngeal fractures may result in airway obstruction – Assume C-spine injury n Multisystem trauma n Altered level of consciousness n Blunt injury above clavicle – Pitfalls: n Difficult airway n Obesity: surgical airway cannot be performed smoothly n laryngeal fracture or incomplete upper airway transection

10 PRIMARY SURVEY n Breathing and Ventilation – Airway patency  adequate breathing & ventilation – injury that may acutely impair ventilation n 1. Tension pneumothorax n 2. Flail chest with pulmonary contusion n 3. Massive hemothorax n 4. Open pneumothorax above problems need to be identified in the primary survey and managed – Pitfall: Differentiation of ventilation problems from airway compromise may be difficult

11 PRIMARY SURVEY n Circulation with Hemorrhage Control – Assess blood volume and cardiac output n level of consciousness n skin color n pulse – Bleeding control: direct manual pressure on the wound – Pitfall: n The response of elderly, children, athletes and others with chronic medical conditions to hypovolemia is different from normal people

12 PRIMARY SURVEY n Disability ( Neurologic Evaluation ) – Level of consciousness n A. Alert n V. Response to voice n P. Response to pain n U. Unresponsive – Pupils – Pitfall: n Lucid interval ( talk and die ) : EDH, frequent neurologic reevaluation can minimize this problem

13 PRIMARY SURVEY n Exposure/Environmental Control – Undress patient completely – Protect from hypothermia – Pitfall: n early control of the hemorrhage is the best method to keep body temperature( early surgical intervention)

14 RESUSCITATION n Protect/Secure airway & protect C-spine n Breathing/Ventilation/Oxygenation n Vigorous shock therapy – At last two large - caliber IV line – Crystalloid solution ( Ringer’s lactate 2~3 litter) – Type-specific blood – surgical intervention n Protect from Hypothermia : 39 o C warm IV fluid n Urinary/gastric catheters unless contraindication

15 ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION n Monitor: – Ventilatory rate and ABGs/ end-tidal CO 2 Pitfalls: Combative patients often extubate or bite endotracheal tube – Pulse oximetry – ECG & BP monitor – Temperature – urine output

16 X-RAY AND DIAGNOSTIC STUDIES n Can’t delay or interrupt the primary survey and resuscitation n Trauma series ( portable X-ray ): CXR, C-spine/ lateral view, pelvic AP view n A negative or inadequate c-spine x-ray can’t exclude cervical spinal injury n Sonography / DPL Pitfalls: obesity ( Sonography and DPL are difficult )

17 CONSIDER NEED FOR PATIENT TRANSFER Referring doctor -to -receiving doctor communication Closest appropriate hospital

18 BEFORE SECONDARY SURVEY n Complete primary survey n Establish resuscitation n Normalization of vital functions

19 SECONDARY SURVEY n History taking n Complete neurologic exam. n Head-to-toe evaluation n Roentgenograms n Special procedure n Tubes and fingers in every orifice n Re-evaluation

20 SECONDARY SURVEY n History – A. Allergies – M. Medications currently used – P. Past illness / pregnancy – L. Last meal – E. Events / Environment related to injury

21 HISTORY Mechanisms of injury n Blunt – Automobile collisions n Seat belt usage n Steering wheel deformation n Direction of impact n Ejection of passenger form the vehicle n Burns and Cold injury – Inhalation injury and CO. intoxication in fire field n Hazardous environment n Penetrate – Anatomy factors – Energy transfer factor n Velocity and caliber of bullet n Trajectory n Distance

22 SECONDARY SURVEY n Physical Examination – Head – entire scalp and head – eye: n pupil n visual acuity n EOM n foreign body ( soft contact lens….) – Pitfalls: Severe facial swelling or unconsciousness p’t still need eye exam.

23 SECONDARY SURVEY n Physical Examination – Maxillofacial n No airway obstruction or massive bleeding ==> treat later n Midfacial fracture ==> R/O cribriform plate fracture Pitfalls: Some facial bone fracture is difficulty identified early ==> reassessment is crucial

24 SECONDARY SURVEY n Physical Examination – C-spine and Neck n Maintain immobilization n Complete evaluation n Complete radiology study n Cautions helmet removed n Penetrating injury: Not be explored in the emergency department; explored & treat in the operative room Pitfalls: Blunt injury to Neck: Carotid artery intima injury or dissection ( delay onset ) Immobilization ==> decubitus ulcer Immobilization ==> decubitus ulcer

25 SECONDARY SURVEY n Physical Examination – Chest n Pitfalls: – Poor tolerance to minor pulmonary trauma in elderly patients – A normal CXR can’t role out chest injury in children

26 SECONDARY SURVEY n Physical Examination – Abdomen n Identify a surgical abdomen is more important than doing a specific diagnosis ==> early consult surgeon n Close observation & frequent reevaluation of the abdomen n DPL, sonography, abdomen CT Pitfalls: – Excessive manipulation of the pelvis should be avoid ==> just do pelvic x-ray – Retroperitoneal organs ( pancreatic & hollow organ ) are very difficult to identify

27 SECONDARY SURVEY n Physical Examination – Perineum / rectum / vagina n Perineum: Contusions, hematomas, urethral bleeding……. n Rectum: Sphincter tone, high riding prostate, blood….. n Vagina: Blood, laceration Pitfalls: Female urethral injury is difficult to detect

28 SECONDARY SURVEY n Physical Examination – Musculoskeletal n Extremities / pelvis: Contusion, deformity, pain crepitation, abnormal movement n Vascular: Assess all peripheral pulses n Spine: Physical findings, mechanism of injury

29 SECONDARY SURVEY n Physical Examination – Neurologic n Determine GCS score n Re-evaluate pupils n Sensory / motor evaluation n Maintain immobilization n Prevent secondary CNS injury ( keep stable vital signs, avoid increased ICP and treat IICP ) n Early neurosurgical consultation Pitfalls: Intubation should be done expeditiously and as smoothly as possible ( Intubation will increase ICP )

30 REEVALUATION n New findings / deterioration / improvement n High index of suspicion ==> early diagnosis & management n Continuous monitoring n Pain relief

31 DEFINITIVE CARE n Trauma center n Closest appropriate hospital

32 RECORDS AND LEGAL CONSIDERATIONAS n Records: Concise, chronologic documentation n Consent for treatment Forensic Evidence: preserve the evidence Forensic Evidence: preserve the evidence

33 SUMMARY n Initial assessment & management of multiply injured patient n Primary survey ( ABCDEs ) n Resuscitation & monitor ( life-threatening problems ) n Secondary survey ( head-to-toe, history ) n Definitive care ( early consultation, surgical intervention or transport )

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