4 Types of assessment Primary Survey and resuscitation Identification of Life threatening conditionsAcBCDE ApproachSecondary SurveyDetailed head to toe examinationMedical historyAll lab and radiology investigation orderedManagement Plan
5 PURPOSE OF THE INITIAL ASSESSMENT Identification of LIFE-THREATENING emergenciesAssess – Change - ReassessInitiation of LIFE-SAVING measures (CPR)Illinois EMSC
6 5 second Round Pt is conscious or not Airway Ventilation Signs of massive external hemorrhageThere is any deformitySkin color and temp with feeling pulseIllinois EMSC
23 Flail 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
24 Massive 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
25 CIRCULATORY ASSESSMENT Carotid pulse (absent or present)Capillary refillSkin colorSkin temperatureSites of bleedingIllinois EMSC
26 CIRCULATORY 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?
27 Hemorrhagic Shock Most common cause of shock in trauma External vs Internal hemorrhagBlood volume = 7% of BWRx : Volume replacementShock classification
28 Classification Type 1 - 15% blood loss - p<100 - BP Normal - PP Normal- RR 14-20- Urine output > 30cc/h- Mental status : Slightly anxious
29 Classification Type 2 - 15-30% blood loss - p>100 - BP Normal - PP Decreased- RR 20-30- Urine output cc/h- Mental status : Mildly anxious
30 Classification Type 3 - 30-40% blood loss - p>120 - BP Decreased - PP Decreased- RR 30-40- Urine output > 5-15cc/h- Mental status : Confused
31 Classification Type 4 - >40% blood loss - p>140 - BP Decreased - PP Decreased- RR >35- Urine output Nil- Mental status : Confused/ Lerthargic
32 Fluid 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
33 Response 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
34 Neurogenic Shock Isolated intracranial injuries do not cause shock. Loss of sympathetic tone: Spinal cord injuryHypotension without tachycardiaInitially treated as HypovolemiaDDx for non responder
35 Dysfunction 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
36 Factors affecting level of consciousness OxygenationVentilationPerfusionHypoglycemiaAlcoholTrauma
37 Head injury severityGCSMild 13-15Moderate 9-12Severe <8
44 Management 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
45 Severe 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.
46 Exposure 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
48 Pause & 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
49 The well practiced trauma team should aim to complete the primary survey in less than 10 minutes Illinois EMSC
50 AdjunctsOnce 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.
51 Don’t forget medical aspects of trauma Judicious fluid managementAdequate and appropriate antibiotic coverage.Proper pain management.Continued vitals monitoring.
52 Secondary 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)
53 Abdominal 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
55 RecommendationsAll 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.