4Types of assessment Primary Survey and resuscitation Identification of Life threatening conditionsAcBCDE ApproachSecondary SurveyDetailed head to toe examinationMedical historyAll lab and radiology investigation orderedManagement Plan
5PURPOSE OF THE INITIAL ASSESSMENT Identification of LIFE-THREATENING emergenciesAssess – Change - ReassessInitiation of LIFE-SAVING measures (CPR)Illinois EMSC
65 second Round Pt is conscious or not Airway Ventilation Signs of massive external hemorrhageThere is any deformitySkin color and temp with feeling pulseIllinois EMSC
23Flail Chest> 2 ribs fractured in 2 or more places usually on the same or opposite side of the chest.Paradoxical chest wall movement.Adequate ventilation/ inadequate ventilationChest tube insertion
24Massive heamothorax>1500 cc or 1/3 of the blood volume in the lung cavityI/V resuscitationChest tube insertionThoracotomy> 1500 cc immediately200 cc/h for 2-4 hours
25CIRCULATORY ASSESSMENT Carotid pulse (absent or present)Capillary refillSkin colorSkin temperatureSites of bleedingIllinois EMSC
26CIRCULATORY INTERVENTIONS If central pulse is absent, begin CPRApply direct pressure to open wounds.IV access (2 wide bore cannulae14/16G).Fluids (colloids Vs crystalloids) 20ml/KgPeripheral Vs central line?
27Hemorrhagic Shock Most common cause of shock in trauma External vs Internal hemorrhagBlood volume = 7% of BWRx : Volume replacementShock classification
28Classification Type 1 - 15% blood loss - p<100 - BP Normal - PP Normal- RR 14-20- Urine output > 30cc/h- Mental status : Slightly anxious
29Classification Type 2 - 15-30% blood loss - p>100 - BP Normal - PP Decreased- RR 20-30- Urine output cc/h- Mental status : Mildly anxious
30Classification Type 3 - 30-40% blood loss - p>120 - BP Decreased - PP Decreased- RR 30-40- Urine output > 5-15cc/h- Mental status : Confused
31Classification Type 4 - >40% blood loss - p>140 - BP Decreased - PP Decreased- RR >35- Urine output Nil- Mental status : Confused/ Lerthargic
32Fluid Replacement Class 1-2 : Crystalloid Class 3-4 : Crystalloid , BloodInitial Fluid Therapy- 1 to 2 L for adult- 20cc/kg for children“3-for-1 Rule”- 1cc blood loss = 3 cc crystalloid replacement
33Response to Fluid resuscitation Rapid response- < 20% blood loss- Cross match and surgical consultTransient response% blood loss- Ongoing blood loss- Blood transfusion, Surgical InterventionNo response- Immediate operative intervention
34Neurogenic Shock Isolated intracranial injuries do not cause shock. Loss of sympathetic tone: Spinal cord injuryHypotension without tachycardiaInitially treated as HypovolemiaDDx for non responder
35Dysfunction of the CNS Aims Rapid neurological assessment Alert; Voice; Pain; UnresponsivePupilsMini-neurological assessmentGCS score / AVPULateralising signsBlood sugarIf GCS 8 or less intubate if not already done so
36Factors affecting level of consciousness OxygenationVentilationPerfusionHypoglycemiaAlcoholTrauma
44Management Mild Hi(GCS 13-15) - Neuro-observation - CT scan if LOC >5 minsAmnesiaSevere headacheFocal neurological deficitModerate (GCS 9-13)- CT brain- Admit and observe neurosigns/ FU CT in hrs
45Severe head injury Prompt diagnosis & treatment Do not delay patient’s transfer to obtain CT scan!!!Inform the Neurosurgery team and Neurology team on call as required.Intubate if indicted by the ABG’s and clinical signs.Transfer patient to OR or ICU ASAP.
46Exposure and environment AimsRemove clothing to allow examination of entire patientCare when removing tight trousersPrevent hypothermiaPatient dignityRemove spine boardPrevent hypothermiaCover overWarming devicesRoom temperatureWorse if spinal injury
48Pause & checkAre all immediately life-threatening injuries identified?Is all monitoring in place?Investigations ordered?Analgesia?Relatives informed?Non-essential team members disbanded?Ensure all monitoring in placeECG, BP, SpO2, etCO2, urine outputTests:Chest and pelvic x-raysUltrasoundCTFBC, U&Es, BS, cross-match, pregnancy test, arterial blood gases
49The well practiced trauma team should aim to complete the primary survey in less than 10 minutes Illinois EMSC
50AdjunctsOnce the patient is stabilized the patient is sent to radiology for the survey:Cervical spine X-ray (AP and lateral view)Chest X- ray (Rib cage)Pelvis X-rayAbdomen and Pelvis U/SCT brain is ordered if there is suspicion of head traumaX-ray of extremities if fracture is suspected.
51Don’t forget medical aspects of trauma Judicious fluid managementAdequate and appropriate antibiotic coverage.Proper pain management.Continued vitals monitoring.
52Secondary Survey Not to begin until primary survey is complete History (AMPLE)- Allergies- Medications- Past illnesses/ Pregnanacy- Last meal- EventsHead-to-toe examinationGCSX-raysSpecialized diagnostic tests (CT,MRI,Endoscopy)
53Abdominal trauma Mechanism of injury - Blunt - Penetrating History and Physical examination- inspection, palpation, percussion and auscultation- Evaluation of penetrating wound- Pelvic stability- Penile, perineal and gluetal examination- vaginal and rectal examination
55RecommendationsAll Trauma patients should be assessed using the universal AcBCDE approach.Management of Poly-trauma should include primary and secondary survey.Team work is standard in management of trauma patient.High index of suspicion should be kept for aortic trauma in any posttraumatic chest pain.