Transcript Chapter1_Initial_Assessment_Management

Chapter 1
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Apply principles of primary and secondary
surveys
Identify management priorities
Institute appropriate resuscitation and
monitoring procedures
Recognize value of patient’s history and
biomechanics of injury
Anticipate pitfalls
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How do I prepare for a smooth transiiton
from the prehospital to the hospital
environments?
What is a quick, simple way to assess the
patient in 10 seconds?
What is the secondary survey and when does
it start?
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How can I minimize missed injuries?
Which patients do I transfer to a higher level
of care?
When should the transfer occur?
Primary survey
Adjuncts
Definitive care
Resuscitation
Reevaluation
Reevaluation
Detailed secondary survey
Adjuncts
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Primary survey and
resuscitation of vital
functions are done
simultaneously in a
team approach
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Transport guidelines/protocols
Online medical direction
Mobilization of resources
Periodic review of care
Closest, appropriate facility
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Preplanning is essential
Equipment, personnel, services
Standard precautions
Prearranged transfer agreements
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Cap
Gown
Gloves
Mask
Shoe covers
Goggles/face shield
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Triage is the process of determining the
priority of patients' treatments based on the
severity of their condition. This rations
patient treatment efficiently when resources
are insufficient for all to be treated
immediately.
Sorting of patients according to
◦ ABCDEs
◦ Available resources
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Identify yourself
Ask the patient his/her name
Ask the patient what happened
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A – patent airway
B – sufficient air reserve to permit speech
CD – clear sensorium
If no response, proceed with rapid primary
survey.
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A – Airway
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B – Breathing/ventilation/oxygenation
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C – Circulation: Stop the bleeding
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D – Disability (neuro status)
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E – Expose/environment/body temperature
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Trauma in the elderly
Pediatric trauma
Trauma in pregnant women
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Establish patent airway
◦ Protect c-spine
◦ Pitfalls?
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Equipment failure
Inability to intubate
Occult airway injury
Progressive loss of airway
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Assess and ensure adequate oxygenation and
ventilation
Pitfalls
◦ Airway vs ventilation problem?
◦ Iatrogenic pneumothorax or tension pneumothorax
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Level of consciousness
Skin color and temperature
Pulse rate and character
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Circulatory Management
◦ Control hemorrhage
◦ Restore volume
◦ Reassess parameters
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Pitfalls?
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Elderly
Children
Athletes
Medication
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Disability
◦ Baseline neurologic evaluation
◦ GCS scoring
◦ Pupillary response
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Observe for neurologic deterioration
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Exposure/Environment
◦ Completely expose the patient
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Prevent hypothermia
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Protect and secure airway
Ventilate and oxygenate
Stop the bleeding
Vigorous shock therapy
Protect from hypothermia
Vital
Signs
Catheters/
Output
ADJUNCTS
ECG
ABGs/Pulse
oximeter
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Diagnostic tools
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FAST (Focused Assessment Sonography in
Trauma)
DPL (Diagnostic Peritoneal Lavage)
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Consider Early Transfer
◦ Do not delay transfer for diagnostic tests
◦ Use time before transfer for resuscitation
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The complete
history and
physical
examination.
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After
◦ Primary survey is completed
◦ ABCDEs are reassessed
◦ Vital functions are returning to normal
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History
Physical exam: Head-to-toe
“Tubes and fingers in every orifice”
Complete neurologic exam
Special diagnostic tests
Reevaluation
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History
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Allergies
Medications
Past illnesses
Last meal
Events/environment
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Mechanisms of injury
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HEAD
◦ Glascow Coma Score (GCS)
◦ Neuro exam
◦ Comprehensive eye and ear exam
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Pitfalls?
◦ Unconsciousness
◦ Periorbital edema
◦ Occluded auditory canal
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Maxillofacial
◦ Bony crepitus
◦ Deformity
◦ Malocclusion
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Pitfalls
◦ Potential airway obstruction
◦ Cribriform plate fracture
◦ Frequently missed
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Cervical spine
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Tenderness
Complete motor/sensory exams
Reflexes
Imaging studies if warranted
Pitfalls
◦ Altered consciousness
◦ Inability to cooperate with clinical exam
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Neck (soft tissues)
◦ Mechanism: Blunt vs penetrating
◦ Symptoms: Airway obstruction, hoarseness
◦ Findings: Crepitus, hematoma, stridor, bruit
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Neck (soft tissue): Pitfalls
◦ Delayed symptoms and signs
◦ Progressive airway obstruction
◦ Occult injuries
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Chest
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Inspect
Palpate
Percuss
Auscultate
(aka IPPA)
Obtain X-rays if
indicated
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Abdomen
◦ IAPP – in this case, auscultation is done before
percussion
◦ Reevaluate
◦ Special studies (CT>FAST>DPL)
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Abdomen: Pitfalls?
◦ Hollow viscus injury
◦ Retroperitoneal injury
◦ Excessive pelvic manipulation
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Peritoneum
Contusions, hematomas,
lacerations, urethral
blood
Rectum
Sphincter tone, highriding prostate, pelvic
fracture, rectal wall
integrity, blood
Vagina
Blood, lacerations
Pitfalls? Urethral injury in women, pregnancy
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Musculoskeletal: Extremities
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Contusion, deformity
Pain
Perfusion
Peripheral neurovascular status
X-rays as indicated
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Musculoskeletal: Pelvis
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Pain on palpation
Symphysis width increasing
Leg length unequal
Instability
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Musculoskeletal: Pitfalls?
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Potential blood loss
Missed fractures
Soft-tissue or ligamentous injury
Compartment syndrome
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Neurologic: Brain
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GCS score
Lateralizing signs
Frequent evaluation
Imaging as indicated
Prevent secondary brain injury
Early neurological consult
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Neurologic: Spinal cord
◦ Complete motor and sensory exams
◦ Imaging as indicated
◦ Reflexes
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Early neurological/orthopedic consult
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Special diagnostic tests as indicated
Pitfalls:
◦ Patient deterioration
◦ Delay of transfer
◦ Missed injuries: High index of suspicion
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Relief of pain/anxiety as appropriate
Administer IV
Careful monitoring
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Those whose injuries exceed institutional
capabilities
When do I transfer?
◦ As soon as possible after stabilizing
◦ Avoid needless delay
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Primary survey
Adjuncts
Resuscitation
Secondary survey
Adjuncts
Definitive care