Poly trauma -initial evaluation
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The document provides guidance on assessing and managing a polytrauma patient. It outlines that the priorities in the primary survey are airway, breathing, circulation, disability, and exposure (ABCDE). The secondary survey involves a full history, head-to-toe examination, and diagnostic tests. Adjuncts to assessment include FAST ultrasound, and management priorities are resuscitation of vital functions, hemorrhage control, and prevention of hypothermia and infection.
Poly trauma -initial evaluation
- 1. Initial assessment and Management in poly trauma Venugopalan P.P. MB;BS, DA, DNB, MNAMS.MEM-GW Director, Emergency Medicine PG teacher and Senior Faculty -NBE Malabar Institute of Medical Sciences Ltd., Kozhikode , India Aster DM Healthcare NBE-E learning 31st July 2017
- 2. Case Scenario ●44-year-old male driver who crashed head- on into a wall ●Patient found unresponsive at the scene ●Arrives at hospital via basic life support with c-collar in place and strapped to a backboard; technicians assisting ventilations with bag-mask What is the sequence of priorities in assessing this patient?
- 3. Objectives ●Apply principles of primary and secondary surveys ●Identify management priorities ●Institute appropriate resuscitation and monitoring procedures ●Recognize the value of the patient history and biomechanics of injury ●Anticipate and manage pitfalls
- 5. Standard Precautions ●Cap ●Gown ●Gloves ●Mask ●Shoe covers ●Goggles / face shield
- 6. Initial Assessment Primary survey and resuscitation of vital functions are done simultaneously using a team approach.
- 7. Poly Trauma
- 9. InitialAssessment and Management Committee on Trauma Presents Initial Assessment and Management
- 11. Trauma surgeon, Anaesthetist,Emergency physician,Nurse,EMT, Radiologist , Radiology tech,Blood bank,Medical Social worker….
- 13. Definitive Care Reevaluation Adjuncts Adjuncts Primary Survey Resuscitation Reevaluation Detailed Secondary Survey Concepts of Initial Assessment
- 14. What is a quick, simple way to assess a patient in 10 seconds? Quick Assessment
- 15. Quick Assessment What is a quick, simple way to assess a patient in 10 seconds? ●Identify yourself ●Ask the patient his or her name ●Ask the patient what happened
- 16. A Patent airway B Sufficient air reserve to permit speech C Sufficient perfusion to permit cerebration D Clear sensorium Appropriate Response Confirms
- 17. Primary Survey
- 18. The priorities are the same for all patients. Primary Survey
- 19. Priorities Airway Breathing Circulation Disability Exposure Airway cause will kill before a breathing cause Breathing cause will kill before a circulatory cause Circulatory cause will kill before a neurological cause
- 20. Special Considerations Trauma in the elderly Pediatric trauma Trauma in pregnancy
- 21. Establish patent airway and protect c-spine Occult airway injury Progressive loss of airway Equipment failure Inability to intubate Pitfalls Airway
- 23. Jaw thrust
- 24. Cervical spine immobilisation C-Collar , Side blocksIn line stabilisation
- 25. Hard cervical collar Philadelphia collar
- 26. Respiratory rate Chest movement Air entry Oxygen saturation Breathing Primary Survey • Assess and ensure adequate • oxygenation and ventilation
- 27. Breathing Airway versus ventilation problem? latrogenic pneumothorax or tension pneumothorax? Pitfalls Primary Survey
- 28. ●Level of consciousness ●Skin colour and temperature ●Pulse rate and character Assess for organ perfusion Circulation Primary Survey
- 29. Elderly Children Athletes Medications Circulatory Management Pitfalls Primary Survey ●Control hemorrhage ●Restore volume ●Reassess patient
- 36. Disability ●Baseline neurologic evaluation oGlasgow Coma Scale score oPupillary response Observe for neurologic deterioration Caution
- 38. Revised Trauma Score RTS- Score Trauma Triage Tool
- 39. Prevent hypothermia Exposure / Environment Completely undress the patient Missed injuries Primary Survey Pitfalls Caution
- 40. Exposure • Spin and Back • Per rectal exam • Log roll
- 42. Environment - Hypothermia Avoid hypothermia in Trauma resuscitation Induce hypothermia in cardiac resuscitation
- 43. ●Protect and secure airway ●Ventilate and oxygenate ●Stop the bleeding! ●Vigorous shock therapy ●Protect from hypothermia Resuscitation
- 47. Adjuncts to Primary Survey
- 49. 2nd Eurasian International Congress on Emergency Medicine 28th – 31st Nov 2008 at Antalya Turkey Diagnostic Tools Adjuncts to Primary Survey
- 50. What about C-Spine X Ray?? No roll in primary trauma survey
- 51. Diagnostic Tools ●FAST ●DPL Adjuncts to Primary Survey
- 52. FAST and E FAST
- 53. Focused Assessment with Sonography in Trauma
- 56. IVCPneumothorax
- 58. 2nd Eurasian International Congress on Emergency Medicine 28th – 31st Nov 2008 at Antalya Turkey ●Use time before transfer for resuscitation ●Do not delay transfer for diagnostic tests Consider Early Transfer Adjuncts to Primary Survey
- 59. Assess and Reassess in every point If no response to your intervention, go back to original level and look and relook what is wrong ….
- 61. The complete history and physical examination What is the secondary survey?
- 62. After ●Primary survey is completed ●ABCDEs are reassessed ●Vital functions are returning to normal Secondary Survey When do I start the secondary survey?
- 63. ●History ●Physical exam: Head to toe ●Complete neurologic exam ●Special diagnostic tests ●Reevaluation What are the components of the secondary survey? Secondary Survey
- 64. Mechanisms of Injury Secondary Survey
- 65. Secondary Survey SAMPLE or SAMPLES First S @ Symptoms Last S @ Social history
- 68. Unconsciousness Periorbital edema Occluded auditory canal Head Pitfalls ●External exam ●Scalp palpation ●Comprehensive eye and ear exam oIncluding visual acuity Secondary Survey
- 69. ●Bony crepitus ●Deformity ●Malocclusion Maxillofacial Potential airway obstruction Cribriform plate fracture Frequently missed Pitfalls Secondary Survey
- 70. Mechanism: Blunt vs penetrating Symptoms: Airway obstruction, hoarseness Findings: Crepitus, hematoma, stridor, bruit Neck (Soft Tissues) Delayed symptoms and signs Progressive airway obstruction Occult injuries Pitfalls Secondary Survey
- 71. Secondary Survey- H to F DCAP -BTLS - H to F TIC-Chest&Pelvis PMSR- Extremities CCTV - Neck D-Deformity C-Contusion A-Abrasion P-Penetration B-Burns T-Tenderness L-Laceration S-Swelling Tenderness Instability Crepitus Pulse Motor Sensory Reflex Head to Foot Chest & Pelvis Extremities Crepitus- Carotid- Trachea Venous Distension
- 73. Add - 4 As • Analgesia • Anti tetanus • Antibiotics • Adequate documentation
- 74. Analgesia in Poly trauma
- 75. Antibiotics in Poly trauma
- 77. Adequate Medical record Use separate case sheet for trauma evaluation
- 79. Trauma centres
- 80. PHC, CHC, Small hospitals Taluk Hospital,Medium Hospitals District hospitals Large hospitals Apex trauma centres Medical colleges Higherend Multispeciality set up
- 81. Airway + C Spine Breathing + Ventilation Circulation + Bleeding Control Disability Exposure + Environment Frequent Re- assessment Fahrenheit Fluids Get vitals GRBS Gastric+Bladder decompression Investigations Interventions Interactions Head to Toe assessment Judicious referrals A- B- C- D- E- F- G- H- I -J SUMMARY
- 84. 02 Thanks a lot for patient listening drvenugopalpp@gmail.com www.drvenu.blogspot.in 91 9847054747
Editor's Notes
- #3: 1-2 Case Scenario N/A
- #4: 1-3 Objectives Review the objectives with the students as provided on the slide. Emphasize that ATLS has a unique language, including such terms as primary and secondary survey, ABCDEs, and definitive care. Those individuals who complete the course will speak the same language, and thereby communicate more effectively.
- #6: 1-4 Standard Precautions Standard precautions are one component of preparing for the patient in the hospital. You may query what items are needed to protect the patient and the trauma team members. Emphasize the need to protect the patient and trauma team members from communicable diseases.
- #7: 1-5 Initial Assessment We recognize that, when a team is present, many individuals accomplish disparate tasks simultaneously. The ABCDE format is somewhat artificial, but it serves the purpose of establishing priorities and helping the student to return to “A” (home base) whenever the patient’s condition worsens or the patient does not respond as anticipated during the initial assessment process.
- #10: 1-1 Title Slide Introduce the topic and explain to students that, based on their preparation for the course, a series of questions will be asked throughout the lecture. Their active participation and responses are expected. Emphasize that this lecture summarizes the information provided throughout the course, and that all major components will be covered in depth during individual lectures, skill stations, and demonstrations. Because you will use the slide show to emphasize key points, it is important to be familiar with every slide. Proper sequencing of questions and responses facilitates an interactive presentation. Be sure to carefully manage the time allotted for this lecture.
- #14: 1-6 Concepts of Initial Assessment Initial assessment and management refers to the entire process of evaluating, treating, conducting a detailed head-to-toe evaluation, reevaluating the patient, and transferring that patient, as necessary, to a facility with the resources to provide optimal care.
- #15: 1-7 Quick Assessment What is a quick, simple method to assess the patient in 10 seconds? After asking this question, allow the students adequate time to consider the most efficient way of assessing for a patent airway, sufficient respiratory reserve to speak, and the level of cognition to process the question and respond appropriately. Answers appear on next slide.
- #16: 1-8 Quick Assessment
- #17: 1-9 Appropriate Response Confirms… Emphasize the need for adequate cardiac output to ensure clear sensorium. The patient who fails this simple test needs immediate attention.
- #18: 1-10 Primary Survey This is the student’s first encounter with the “ABCDEs,” so be sure to allow adequate time to discuss why the priorities are ordered in this manner.
- #19: 1-11 Primary Survey Emphasize that, for the purposes of this course, the ABCDE priority is the standard. ATLS is intended to guide the assessment and resuscitation of injured patients. Judgment is required to determine what procedures are necessary, because not all patients require all procedures. This also is an appropriate time to stress that ATLS is intended to guide the assessment and resuscitation of injured patients. Judgment is required to determine what procedures are necessary, because not all patients require all procedures.
- #21: 1-12 Special Considerations Remind the students that there are special issues to consider with each of these types of trauma patients, but that the priorities remain the same.
- #22: 1-13 Primary Survey: Establish patent airway and protect c-spine Concerns regarding the c-spine may be new to those students who are familiar with cardiac life support procedures, but have not taken the ATLS Course. Emphasize the need to protect the c-spine during airway management, especially avoiding the ACLS head-tilt maneuver. You may then query the students about what pitfalls they may encounter with managing the airway or, depending on available time, caution the students to avoid these pitfalls.
- #27: 1-14 Primary Survey: Assess and ensure adequate oxygenation and ventilation Emphasize the need to attend to adequate oxygenation and ventilation in the injured patient, recognizing that altered chest wall mechanics may be new to those doctors who have taken only the cardiac life support course. Emphasize that, if the patient is receiving high-flow oxygen, adequate oxygenation is no guarantee of adequate ventilation.
- #28: 1-15 Primary Survey: Assess and ensure adequate oxygenation and ventilation Emphasize the need to attend to adequate oxygenation and ventilation in the injured patient, recognizing that altered chest wall mechanics may be new to those doctors who have taken only the cardiac life support course.
- #29: 1-16 Primary Survey: Assess for organ perfusion Emphasize the reasons for assessing for signs of inadequate tissue perfusion instead of focusing on the patient’s blood pressure.
- #30: 1-17 Primary Survey: Circulatory Management Emphasize the need to control hemorrhage or stop the bleeding. Also emphasize that the patient may require an operation to stop the bleeding. Stress the importance of reassessing the patient’s response to treatment.
- #37: 1-18 Primary Survey: Disability Emphasize that it is essential to identify neurologic injury using the tools of GCS score and pupil response early in order to avoid secondary brain injury, identify surgically correctible lesions rapidly, and provide a baseline GCS score to identify trends and changes.
- #40: 1-19 Primary Survey: Exposure and Environment The ‘E’ of the ABCDEs. Emphasize the need to completely undress the patient to adequately assess the entire patient, while at the same time preventing hypothermia.
- #44: 1-20 Resuscitation Emphasize that treatment is administered at the time the life-threatening problem is identified and that assessment and treatment during the primary survey and resuscitation phases of the initial assessment process often are done simultaneously.
- #50: 1-22 Adjuncts to Primary Survey The primary purpose of these adjuncts during the primary survey is to determine where occult bleeding may be occurring that is not obvious on clinical exam. Emphasize the need to determine the source of shock. Portable chest and pelvic x-rays in the emergency department are the ONLY x-rays obtained during the primary survey. Previous editions of the course included lateral cervical spine x-rays, but this film is now obtained selectively and at the appropriate time, based on the doctor’s judgment. (X-rays courtesy of Dr. Ray McGlone, A&E Consultant, Royal Lancaster Infirmary; UK.)
- #52: 1-23 Adjuncts to Primary Survey DPL and FAST may also be used during the primary survey to detect intraabdominal blood.
- #59: 1-24 Adjuncts to the Primary Survey: Consider Early Transfer Emphasize that the time to initiate the transfer process is when the need is recognized. Therefore, the need to transfer must be considered early. The sooner the need is recognized and communicated, the more efficiently it occurs. In addition, transfer should not be delayed to perform the secondary survey or to perform diagnostic tests such as CT scans. The time spent waiting for transportation to arrive should be spent stabilizing the patient.
- #62: 1-25 What is the secondary survey? Expand upon the definition of the secondary survey after eliciting students’ responses.
- #63: 1-26 Secondary Survey: When do I start it? These slides transition the student to the secondary survey. Emphasize that issues identified during the primary survey have been addressed and reevaluated before proceeding to the secondary survey.
- #64: 1-27 Secondary Survey: What are the components of the secondary survey? You may use these items as a summary of the discussion on the components of the secondary survey. This slide also serves as an introduction to each component of the secondary survey.
- #65: 1-29 Secondary Survey: Mechanisms of Injury Ask the students how the mechanism of injury can influence the type and pattern of injury sustained.
- #66: 1-28 Secondary Survey: History Introduce this simple mnemonic for obtaining an “AMPLE” or complete patient history.
- #69: 1-30 Secondary Survey: Head You may query the student about what to examine and/or evaluate during the examination of the injured patient’s head.
- #70: 1-31 Secondary Survey: Maxillofacial Students should be instructed to check mid-face stability, dental occlusion, and contraindications for nasogastric tubes.
- #71: 1-32 Secondary Survey: Neck (soft-tissues) You may query the student about they should look for during the examination of the injured patient’s maxillofacial area.