Transcript 1ry. Survey and Resuscitation

‫سبحان الذى هدانا و ما كنا لنهتدى لوال أن هدانا هللا‬
Initial Assessment and Management
( ACS – COT )
Presented by Dr. M. Essam El Gammal
(MSEM – MACEP )
In 1977
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Male, 29 years old, involved in Bus turn over
conscious, oriented, complaining of chest pain.
Innocent chest wound, mild surgical
emphysema.
Dx # Rib
Sudden death in Emergency Surgical Ward
In 1984
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Male 48 years old, MVA with multiple facial
laceration conscious, oriented,
complaining of chest pain.
Respiratory distress, multiple # ribs
Died in X-ray Department.
In 1991
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Child 4 years old with laceration above
his right eyebrow.
ALS, ACLS, ATLS, APLS
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Simple
Safe
Systematic
RESUSCITATION
How You Can Do It
Clinical Skills: How to Diagnose (Dx)
A - airway obstruction
B - tension pneumothorax, sucking chest wound, flail chest
C - cardiac tamponade, cardiac contusion, shock
D – diagnostic: x-ray, U/S, ABG, ECG
TECHNICAL SKILLS:
How to Treat (Rx)
A -
B-
CDE-
Airway + C Spine stabilization
ET intubation
Crico thyrodotomy
B.V.M. ventilation or IMV
Needle thoracocentesis
Intercostal tube insertion
Canulation peripheral venous, central venous
catheters urinary, NG
DpL U/S bedside- FAST
Extremities fixation (#)
Initial Assessment and Management
To have a systematic approach for the
management of multiple trauma patients .
To know how to identify and manage
life threatening conditions .
To know when and what diagnostic
procedures you need .
To know how to transfer the patients to
definitive care
Initial Assessment and Management
Pre Hospital Phase :1. Airway – C spine
2. Immobilization
3. Control of bleeding
4. IV line
5. Immediate appropriate transfer
Initial Assessment and Management
Inter Hospital Phase :1. Policy and Procedures
2. Equipments
3. Recourses Lab., X-ray, BB., OR,
Initial Assessment and Management
Triage
Sorting patients out according to priorities and
capabilities .
1. Multiple casualties: Patient no. = capabilities
2. Mass casualties: patient no. > capabilities
In this situation you treat those with best
survival chances with the need of least time
and supplies
(1) 1ry. Survey and Resuscitation
(3) Reevaluation
ABCDE
• Adjuncts to 1ry. Survey
(2) 2ry. Survey
(4) Definitive care
Head to toe examination
Tubes and fingers in every orifice
• Adjuncts to 2ry. survey
(5) Transfer
Initial Assessment and Management
1ry. Survey and Resuscitation
Identify and treat life threatening conditions
A
Air way + C spine protection
B
Breathing + Ventilation
C
Circulation + Control of Hemorrhage
D
Disabilities ( Neurologic evaluation )
E
Exposure + Environmental control
Initial Assessment and Management
1ry. Survey and Resuscitation
Rule 1: Once A B C problem is identified it should be corrected
Rule 2: Many of these activities
can occur in parallel or simultaneously
Rule 3: Priorities are the same for pediatric patient, pregnant and elderly
are the same with special consideration
Initial Assessment and Management
1ry. Survey and Resuscitation
A
Air way + C spine protection
• Signs and causes of air way obstruction
• Methods to open the air way
• air way protection is needed when GCS<8
• In line stabilization of C spine :
•Multi system trauma with altered LOC
•Blunt trauma above the clavicle
Rule 1: Frequently evaluate the air way
Rule 2: Definitive air way is indicated if there is doubt
Initial Assessment and Management
1ry. Survey and Resuscitation
A
Air way + C spine protection
Pitfalls
• Obese short neck patient
• ET tube in patient with incomplete upper air way transection
or laryngeal fracture
• Inability to intubate after paralysis
• Equipment failure
Initial Assessment and Management
1ry. Survey and Resuscitation
B
Breathing and Ventilation
1.
Expose the chest and Asses RR, R depth and Type
2.
Give oxygen
3.
Check chest wall, lungs and diaphragm by inspection , palpation,
percussion and auscultation
4.
Pulse oximeter
5.
Identify and treat:
Tension Pneumothorax
Open Pneumothorax
Flail chest
Massive Hemothorax
6.
Needs for assisted ventilation
Initial Assessment and Management
1ry. Survey and Resuscitation
B
Breathing and Ventilation
Rule 1: CXR is needed after intubation and ventilation, but not
to diagnose Tension Pneumothorax
Pitfalls
• Differentiation of ventilation problems from air way obstruction
may be difficult
• Intubation of Pneumothorax patient with ventilation may result
in further deterioration of the patient
Initial Assessment and Management
1ry. Survey and Resuscitation
C
Circulation with Hemorrhage control
• Blood Volume and Cardiac output assessment depend on level
of consciousness, skin color and the pulse
• Start X2 I.V. lines, draw blood samples ( Central line ? )
• Identify the need of blood transfusion
• Control Bleeding:
Direct pressure on the wound
Pneumatic splinting devices
No Tourniquet except in amputation
•Identify occult blood loss
•Assess for the need of operative intervention
Initial Assessment and Management
1ry. Survey and Resuscitation
C
Circulation with Hemorrhage control
Pitfalls
• P.R., ABP has little correlation with cardiac output in older
patients
• Children show few signs of hypovolemia
• Use of medications affect the response to hypovolemia
Initial Assessment and Management
1ry. Survey and Resuscitation
D
Disabilities (Neurologic Evaluation)
Level of consciousness L.O.C.
A
alert
V
to verbal stimuli
P
to painful stimuli
U
unresponsive
Pupils size and reaction
Initial Assessment and Management
1ry. Survey and Resuscitation
D
Disabilities (Neurologic Evaluation)
Rule: Depressed L.O.C: may be due to decreased Cerebral
Oxygenation , Brian injury or Drugs
Pitfalls
• Lucid interval commonly occur with Acute Epidural Hematoma
( Talk and die ), this emphasizes the need for frequent Neurologic
Re-evaluation
Initial Assessment and Management
1ry. Survey and Resuscitation
E
Exposure / Environmental control
• Undress completely ( use trauma scissor )
• Prevent hypothermia ( warm blanket, room temp. )
• Warm I.V. fluids and blood
Pitfalls
• Early control of hemorrhage will minimize hypothermia
Initial Assessment and Management
1ry. Survey and Resuscitation: SUMMARY
A Air way obstruction + C-spine stabilization
B
C
Breathing problems: Tension Pneumothorax,
Open Pneumothorax
Circulation: Shock, Cardiac tamponade.
D Disabilities: AVPU, Pupils
E
Exposure / Environmental control
Initial Assessment and Management
ADJUNCTS to 1ry. Survey and Resuscitation
1
ECG monitoring
2
Urinary and Gastric Catheters
3
Monitoring: RR, ABG, Pulse Oximetry, ABP, PR,Urine O/P,
Temp.,CVP / JV
4
X-ray and diagnostic: CXR, Pelvis, Lat. C-spine and Diagnostic
peritonel Lavage and abdominal ultra sound
CONSIDER Need for patient transfer
Initial Assessment and Management
2ry. Survey
1
Complete History
2
Head to toe examination
3
Re-assessment of vital signs
4
Complete neurological examination GCS.
5
Special procedures, Specific X-rays and laboratory studied
Initial Assessment and Management
2ry. Survey
1
Complete History
A
allergies
M
medications
P
past illness / pregnancy
L last meal
E
events / environment / mechanism of injury:blunt,
penetrating, burn, hazardous
environment
Initial Assessment and Management
2ry. Survey
2
Head to toe examination
1. Head, Maxillofacial, Cspine and Neck
2. Chest
3. Abdomen
4. Perineum / Rectum / Vagina
5. Musclockeletal / Pelvis / Back
6. Neurologic evaluation
Initial Assessment and Management
2ry. Survey
3
Re-assessment of vital signs
Objectives:
1. Identify new Clinical findings
2. Discover deterioration
3. Assure that life threatening injuries are managed
4. Diagnose underlying medical problems
Initial Assessment and Management
2ry. Survey
3
Re-assessment of vital signs
Done by:
1. Clinical Reassessment
2. Monitoring of LOC, PR, Urine O/P, ABP, ABG,
CVP
3. Review of Diagnostic results
4. Use of Analgesia
Initial Assessment and Management
2ry. Survey
4
Complete neurological examination GCS.
•
LOC / GCS
•
Pupils Complete neurological examination GCS.
•
Laterilization
•
Deterioration of LOC / GCS
Initial Assessment and Management
2ry. Survey
5
Special procedures, Specific X-rays and laboratory studied
•
Additional X-rays Extremities, Spine
•
CT
•
Contrast X-rays, Urography, Angiography
•
Endoscopy
Not till the patient is stable
Initial Assessment and Management
2ry. Survey
1
Complete History
2
Head to toe examination
3
Re-assessment of vital signs
4
Complete neurological examination GCS.
5
Special procedures, Specific X-rays and laboratory studied
Initial Assessment and Management
Definitive care
According to the clinical and other
data the patient will be taken to
OR, ICU or others
Initial Assessment and Management
Transfer
To other facility according to the
patient need and the
institution’s capability
(1) 1ry. Survey and Resuscitation
(3) Reevaluation
ABCDE
• Adjuncts to 1ry. Survey
(2) 2ry. Survey
(4) Definitive care
Head to toe examination
Tubes and fingers in every orifice
• Adjuncts to 2ry. survey
(5) Transfer