Transcript Introduction 1 - Ibaden

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Primary Trauma Care
Partners in Global Health Education
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How to use this
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Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
1 of 43
Welcome to the Primary Trauma
Care module!
Worldwide, trauma is a leading cause of
death especially in young adults.
In developing nations, it is the second
leading cause of death among all ages
and leading cause in the third and fourth
decades.
Simple and timely initial management
can save lives and greatly improve
outcomes for trauma victims.
For more information about the
authors and reviewers of this
module, click here
Urbanisation and industrialisation have led to an
increase in trauma-related deaths globally
Source: Environment, Nigeria Oct 2007
Primary Trauma Care
How to use this module
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
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•
•
•
•
•
•
This self-directed learning (SDL) module has been designed for all staff who
deal with the acutely injured patient.
We suggest that you start with the learning objectives and try to keep these
in mind as you go through the module at your own pace.
Print-out the question & answer sheets. Write your answers to the questions
on the mark sheet as best you can at the end of each section before looking
at the answers.
Repeat the module until you have achieved a mark of > 80%.
You should research any issues that you are unsure about. Look in your
textbooks, access the on-line resources indicated at the end of the module
and discuss with your peers and teachers.
Finally, enjoy your learning! We hope that this module will be enjoyable to
study and complement your learning about trauma management from other
sources.
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Primary Trauma Care
Partners in Global Health Education
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
3 of 43
Learning Outcomes
By the end of the module, you would be expected to be able to:
• Discuss the burden of trauma
• Describe the concept of triage
• Identify common life-threatening injuries
• Adequately resuscitate and re-evaluate the trauma patient
• Manage common life-threatening injuries effectively
• Perform a secondary survey to plan the next stage of care
Primary Trauma Care
Introduction
Introduction 1
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
4 of 43
• There are notable disparities in the
outcome of trauma care around the
world.
• 60% of preventable trauma
associated deaths occur in the first 24
hours.
• Difficulties facing trauma care in
developing countries include
manpower development,
infrastructure, availability of
equipment and organization.
• Much of the improvement in trauma
care has resulted from better
organization of trauma care services.
• The main focus of this module is
appropriate life-saving management
in the first few hours following trauma.
Primary Trauma Care
The burden of trauma
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
5 of 43
This can be divided into:
• The “direct” health burden:
morbidity and mortality
• The “indirect” burden: impaired
human and economic
development
Click on the boxes to find out more
Direct
burden
Indirect
burden
Primary Trauma Care
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Distribution of trauma-related deaths
How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
Trauma-related death has a trimodal
distribution:
Causes of trauma-related deaths according to time after
injury; MOF- multiple organ failure
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A.
Immediate deaths due to fatal
injuries
B.
Early deaths occur within a few
hours of the accident and are
largely preventable
C.
Late deaths occurring days and
weeks after the injury are usually
due to sepsis and other
sequelae of trauma
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Primary Trauma Care
Pathophysiology
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
7 of 43
Various mechanisms act in concert in major trauma. Hypotension and hypoxia lead
to ischemia and tissue death.
ISCHEMIA
Tissue death
Appropriate, timely intervention leads to reperfusion and reoxygenation of ischaemic
cells and restores cell integrity.
Undue delay in reversing these pathophysiological changes associated with trauma
leads to the activation of systemic inflammatory responses. Together, these
changes may ultimately culminate in the death of the patient. Early intervention
saves lives.
Take home message!
Like many diseases, adverse outcomes after trauma can be prevented
Primary Trauma Care
Triage in the emergency room
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
8 of 43
TRIAGE - “to sort or sieve”
•
•
Triage is employed to ensure optimal medical assistance to save lives and
prevent morbidity
Triage involves using systematic scoring systems which identify those
patients who need urgent medical attention
Current systems involve
measuring key physiological
variables in the brief initial
assessment:
• Level of consciousness
• Airway
• Vital signs
Take home messages!
Triage must be simple and swift but reproducible and reliable.
Triage should be done by the most experienced staff available.
Primary Trauma Care
Triage scenarios
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
9 of 43
Four accident victims are brought in a police truck to the
emergency room. You are the only doctor who is readily
available.
Which TWO of these patients are most likely to die without early
intervention? Click on the boxes to find the answers.
•
The first is quiet and appears calm and still
A
•
The second is in excruciating pain from an obvious femoral fracture
with the foot twisted in the opposite direction
B
•
The third patient is screaming at the site of his clothes soaked with
blood from an extensive scalp laceration
C
•
The fourth patient walks-in complaining of right sided chest pain and
difficulty with breathing
D
End of Section 1
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
10 of 43
Well done!
You have come to the end of the first section.
Click here for
Question 1
We suggest that you answer Question 1 to assess your learning so
far. Please remember to write your answers on the mark sheet
before looking at the correct answers!
Primary Trauma Care
Managing the severely injured patient
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
11 of 43
Initial management (resuscitation) must be prioritised according to the
physiological needs for survival. In the ‘A,B,C,D,E’ of resuscitation, the ‘A’
comes before the ‘B’, the ‘B’ before ‘C’ and so on. A problem identified at
any step must be corrected immediately before moving to the next step.
Please note that there is an exception to this rule (see next slide)
A
A patent
Airway
B
Effective
Breathing / Ventilation
C
Adequate
Circulation and haemorrhage control
D
Neurological Disability
E
Adequate
Exposure to search for other injuries
Take home message!
Making a definitive diagnosis is the least important issue at this stage
Primary Trauma Care
Catastrophic heamorrhage: the exception to “A,B,C,D,E”
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
12 of 43
•
This is life threatening haemorrhage, often due to
traumatic amputation or crush injury to the limbs.
Bleeding is usually massive and the patient may be on
the point of exsanguination.
•
It is necessary to rapidly control the haemorrhage
before assessing the airway.
•
The bleeding vessel may be ligated if it can be
identified. If not, this may be one of the exceptional
cases when a tourniquet may be used. However, the
duration of application must be noted.
•
Remember that in patients with sickle cell disease a
tourniquet may precipitate a sequestration crisis.
Remember! Once the bleeding is temporarily controlled,
complete the ‘ABCDE’.
Primary Trauma Care
Partners in Global Health Education
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
Airway management: The conscious patient
• Speak to the patient.
• Does he respond? If he responds in a normal voice giving a logical
answer then he most probably can control his airway.
• However, cervical spine injury (CSI) may be present. First, inspect
the neck meticulously for wounds and other abnormalities. Click
here for a list of important clinical signs.
• Cover any penetrating wounds with clean gauze and plaster.
• Then, immobilise the cervical spine using one of these methods:
 MILS (Manual in-line stabilisation)
 Cervical collar
 Spinal board, head blocks, sandbags
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See next slide
Primary Trauma Care
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
14 of 43
Cervical spine stabilisation
Rigid cervical collar
Improvised cervical collar using
flip-flop slippers (Alonge et al.)
Primary Trauma Care
Airway management : The unconscious patient
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
15 of 43
Assess the airway and breathing
•
Check the mouth for foreign matter; if present remove by
suction or Magill's forceps.
•
If obstruction persists, perform a jaw thrust without tilting the
head (this may exacerbate cervical spine injury).
•
Should obstruction persists, insert an oropharyngeal or
nasopharyngeal airway.
Click picture
for larger
view
If obstruction persists despite these manoeuvres, consider more
advanced airway management such as orotracheal or nasotracheal
intubation.
Take home message!
Always give supplementary oxygen
Primary Trauma Care
Managing the severely injured patient
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How to use this
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Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
16 of 43
Case Scenario
A 30
30 year
year old
old man
man is
is brought
brought unconscious
unconscious to
to the
the emergency
emergency room
room
after a motor vehicle accident. His clothes are soaked in blood
from a scalp laceration. There is an obvious fracture of the left
forearm. What is the first step of your management?
(Click on the boxes for the answers)
•
Immediately suture the bleeding scalp laceration
A
•
Splint the forearm fracture to reduce pain
B
•
Ensure there is no foreign body obstructing the airway and the
tongue is not falling back
C
•
Give oxygen immediately
D
End of Section 2
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
17 of 43
Well done!
You have come to the end of the second section.
Click here for
Question 2
We suggest that you answer Question 2 to assess your learning so
far. Please remember to write your answers on the mark sheet
before looking at the correct answers!
Primary Trauma Care
Partners in Global Health Education
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
18 of 43
Breathing (Ventilation 1)
• Observe the respiratory rate and effort of the patient. Assess the use
of accessory respiratory muscles.
• Palpate the neck carefully for tracheal deviation.
• Identify emphysema (air in the subcutaneous tissue) by palpating the
chest wall for crepitation (a crackling feeling)
• Place your hands in the patient’s axillae and gently compress the
chest. Tenderness and emphysema suggest chest trauma.
• Auscultate the lung fields in the axillae and compare both sides. No
air entry to both sides occurs in:
– an inadequately patent upper airway
– massive tension pneumothorax
– tracheal laceration
Take home message!
The respiratory rate and effort are sensitive indicators of chest trauma.
They should be monitored and recorded at frequent intervals.
Primary Trauma Care
Breathing (Ventilation 2)
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
19 of 43
• When assessing the
trauma patient’s chest
in the primary survey,
expose the patient
adequately without
causing hypothermia
• Certain immediate lifethreatening conditions
must be considered
Life-threatening chest
conditions in trauma
patients
•
Tension pneumothorax
Click
•
Open pneumothorax
Click
•
Massive haemothorax
Click
•
Flail chest
Click
•
Cardiac tamponade
Click
End of Section 3
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How to use this
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Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
26 of 43
Well done!
You have come to the end of the third section.
Click here for
Question 3
We suggest that you answer Question 3 to assess your learning so
far. Please remember to write your answers on the mark sheet
before looking at the correct answers!
Primary Trauma Care
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
27 of 43
Circulation: assessment
Quickly re-check airway patency, breathing and oxygen supply before
assessing circulation.
Assess the 5 features of hypovolemia
• Cold, clammy extremities
• poor capillary refill
• tachycardia (>120 beats / minute)
• low blood pressure (systolic blood pressure <80mmHg)
• altered consciousness (hypovolemia alone can cause
decreased conscious level)
Take home message!
Hypoperfusion causes acidosis.
Primary Trauma Care
Circulation: management
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
28 of 43
Stop external haemorrhage.
• Direct pressure is the preferred method
• Fractured long bones must be splinted
• If possible, avoid tourniquets as they increase distal ischeamia. If they must be used,
the duration of application must be monitored.
Volume replacement
• Establish 2 large bore IV lines (14G or 16G cannulae)
• Obtain blood samples for CBC, urea & electrolytes and cross match
• Administer IV fluids (warm crystalloids: normal saline or Ringers lactate). In young
adults, 2 liters of IV fluid can safely be given in the first hour.
Click here for the exception
Take home message!
Consider a venous cut down or intraosseous needle if peripheral
lines are not accessible
Primary Trauma Care
Disability
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
• A
• This is a rapid neurological
assessment
• Assessing AVPU is quick
and easy to do
• It is a baseline for more
detailed neurological
examination carried out in
the secondary survey
Click to see GCS
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ALERT
GCS 14-15
RESPONSE
• V VERBAL STIMULATION
GCS 9 - 13
• P
RESPONDS TO PAIN ONLY
GCS 4 - 8
• U
UNRESPONSIVE
GCS 3
Primary Trauma Care
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How to use this
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Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
30 of 43
Exposure and environmental control
• Fully expose the patient whilst assuming that other injuries are
present
• Prevent hypothermia by controlling room temperature or covering
the patient with blankets immediately after examination.
Hypothermia may be a cause of coagulopathy; both hypothermia
and coagulopathy are components of the lethal triad (see later).
• To expose the patient, use scissors to cut along the seams of
clothes to avoid worsening any injury and ensure minimal movement
of the patient.
• Do not forget to do a rectal examination whilst log rolling the patient
Click to read rectal findings
Take home message!
You may miss injuries if you do not fully expose the patient
Primary Trauma Care
Three components of the lethal triad
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How to use this
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Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
31 of 43
COAGULOPATHY
LETHAL TRIAD
ACIDOSIS
HYPOTHERMIA
Primary Trauma Care
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How to use this
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Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
At the end of the primary survey what next?
• Is the airway patent and secure?
• Is the patient receiving high flow oxygen?
• Is the cervical collar in place?
• Are all the tubes in place? i.e. urinary catheter, nasogastric tube
and intravenous lines
• Have blood samples been sent to appropriate laboratories?
• Are the vitals signs being recorded every 5 minutes?
• Have the X-ray forms been filled?
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Only then can you consider a secondary survey
Primary Trauma Care
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
33 of 43
Some notes of caution
• If there is bleeding from the ears and nostrils
– pass the nasogastric tube carefully
– make sure it is not coiled in the cranial fossa
• Bleeding from the penile meatus may be
suggestive of urethral injury which is a relative
contraindication to urethral catheterisation
• If the patient vomits while lying flat, in the
absence of a suctioning machine, roll him/her to
one side keeping the nose and the umbilicus in
line all the time.
End of Section 4
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
34 of 43
Well done!
You have come to the end of the fourth section.
Click here for
Question 4
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Primary Trauma Care
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
35 of 43
Radiological Investigations
• A multiply injured patient requires X-rays in the resuscitation room
– Cervical X-ray (recent modifications now tend to move this to the
secondary survey because of the associated time delay)
– Chest X-ray
– Pelvic X-ray
Further radiological investigation should be taken at the end of the
secondary survey.
Primary Trauma Care
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How to use this
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Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
36 of 43
Secondary survey
• Once the immediate life-threatening conditions
have been managed or excluded, the patient
should be completely re-examined
• If the patient deteriorates at any stage, the airway,
breathing and circulatory systems must be reexamined as discussed previously for the primary
survey
• The secondary survey is a head-to-toe, front-toback assessment along with a detailed medical
history and appropriate investigations
Primary Trauma Care
Secondary survey: History
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How to use this
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Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
37 of 43
Remember “AMPLE”
A
Allergies
M
Medications
P
Previous medical/ surgical history
L
Last meal (Time)
E
Events / Exact circumstances
Primary Trauma Care
Secondary survey: Examination
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How to use this
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Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
Has
Head/Skull
My
Maxillofacial
Critical
Cervical spine
Care
Chest
Assessed
Abdomen
Patients
Pelvis
Priorities
Perineum
Or
Orifices (PR/PV)
Next
Neurological
Management
Musculoskeletal
Decision?
Diagnostic tests/ definitive care
Source: Hughes S C A, ATLS secondary survey mnemonic: Has My Critical Care Assessed Patient’s Priorities Or
Next Management Decision? Emergency Medicine Journal 2006; 23:661-662.
38 of 43
Primary Trauma Care
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
39 of 43
Transition to definitive care
Once the patient has been adequately assessed and
resuscitated, definitive care can start. This may require
surgery and/or intensive care
Factors which determine priority of treatment:
• Are the injuries immediately life-threatening?
• Are the injuries potentially life-threatening?
• Are the injuries limb-threatening?
• What is the physiological state of the patient?
• What resources are available in the hospital?
• Will the patient require transfer for further specialist care?
End of Section 5
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How to use this
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Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
40 of 43
You have come a long way!
This is the end of the last section.
Click here for
Question 5
For the section just ended, you should be able to answer Question 5
to assess what you have learnt. It is still required that you put down
your answers on the mark sheet before looking at the right answer!
Primary Trauma Care
Partners in Global Health Education
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
41 of 43
References
1. Trauma care manual. Oxford University Press Inc., New York
2002
2. Basic Trauma Care. Temitope Alonge 3nity Concepts. Ibadan
Nigeria 2007
3. Guidelines for essential trauma care WHO / International
association for the surgery of trauma and surgical intensive
care( IATSIC) 2004
Primary Trauma Care
Authors and reviewers
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
42 of 43
Authors:
Dr. Oludolapo Afuwape
Consultant General
Surgeon/Lecturer, College of
Medicine, University of Ibadan/
University College Hospital
Ibadan, Nigeria.
Dr. Stephen Allen
Reader in Paediatrics and
Honorary Consultant
Paediatrician, The School of
Medicine, Swansea University,
Swansea, UK
Mrs. Abiodun Alao, Senior
System Analyst, University of
Ibadan/ College of Medicine,
Ibadan, Nigeria.
Expert reviewers:
Mr Ian Pallister
Reader in Trauma & Orthopaedics
The School of Medicine, Swansea University,
Swansea, UK
Mr Temitope Alonge FRCS MD Leicester
Senior Lecturer / Consultant Surgeon
Orhtorpeadics and Trauma,
College of Medicine, University of Ibadan /
University College Hospital Ibadan, Nigeria.
Permissions:
Please note that verbal permission was granted
from patient and relations to use the images
in this module for teaching purposes only.
The images should not be used for any
other purpose.
Back
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How to use this
module
Learning
outcomes
Introduction
Burden of trauma
Pathophysiology
Triage
Management
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Transition to
definitive care
Authors and
reviewers
43 of 43
Sources of information and
further reading
1. Initial evaluation of the trauma patient
http://www.emedicine.com/med/topic3221.htm
2.
Sabiston Textbook of Surgery, 17th ed.,
Copyright © 2004 Elsevier
3. Trauma Care Manual Second Edition
http://www.trauma.myzen.co.uk/trauma_care_manual.pdf