Management of multiple injured patient 1 survey

1. Management of multiple injured patient (1� survey) MANAF ALOM

2. Trauma Care Prehospital Care Field professionals are responsible for performing the three major functions of prehospital care: (1) assessment of the injury scene, (2) stabilization and monitoring of injured patients, and (3) safe and rapid transportation of critically ill patients to the appropriate trauma center. The observations and interventions performed are important in guiding the resuscitation of an injured patient

3. Primary survey (ABCDE).Identify the injury Resuscitation; treat(ventilation, I.V. fluids & blood) Secondary survey ( a thorough head to toe exam) Definitive treatment or transfer to trauma center (imaging, lab studies & surgeries) This is the essence of Advanced Trauma Life Support (ATLS). Early identification & effective treatment for injury mainly in early deaths it also decreases the No of late deaths (Preventable deaths) The protocol of Initial evaluation.(ATLS)

4. The initial assessment is: Protection �during transport & treatment� from secondary injury to the spines or the cord,hypoxia hypotension and hypercarbia (second accident). Early airway control in patients with a GCS of less than 8 is essential. Pre hospital management

5. Management can be carried out as A �Scoop & run� policy for rapid & smooth transfer of pt. from the scene of accident to a well equipped and staffed hospital. It is best where transfer time to hospital is short, in the way apply life saving ABC measures. A �Stay & play� policy if transfer time will be prolonged, entrapment or delayed extrication. Apply ATLS if trained personnel and facilities are available. Pre hospital management

6. GLASGOW COMA SCALE 1. Eye Opening Spontaneous 4 To voice 3 To pain 2 None 1

7. GCS 2. Best Verbal Response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sound 2 None 1

8. GCS 3. Best Motor Response Obeys commands 6 Localizes pain 5 withdraws (pain) 4 Flexion (pain) 3 indicate decortication Extension (pain) 2 decerebration,damage brain stem None 1 Totals GCS 15

9. The primary survey aims to identify and treat immediately life-threatening injuries. �ABCDE� Airway control, stabilize the cervical spine. Breathing (work and efficacy). Circulation with control of external bleeding. Disability or neurologic status. Exposure (undressing of the patient). Primary survey

10. Assess the airway. (foreing body) Maintain the cervical spine in the neutral position(by A hard collar or sandbags ) maneuvers to alleviate obstruction . I- Airway with C-spine control

11. Simple suctioning: This removes obstructions caused by vomitus, phlegm, or other debris in the oropharynx. Jaw-thrust maneuver: The tongue itself can occlude the airway. A jaw thrust can successfully displace the tongue anteriorly from the pharyngeal inlet, relieving the obstruction. Nasopharyngeal airway: In the semiconscious patient, this can provide a conduit for ventilation, but it may result in emesis if it is used in fully conscious patients. Oropharyngeal airway:Mechanically displace the tongue anteriorly, securing airway patency. Because of their strong induction of the gag reflex and emesis, these devices should be used only in unconscious patients. Basic maneuvers to alleviate obstruction

12. Tracheal intubation :is indicated in any patient in whom concern for airway integrity exists (unconscious or semiconscious patients, patients with mechanical obstruction secondary to facial trauma or debris, combative and hypoxic patients). The emergent tracheal intubation of an uncooperative trauma patient is a high-risk undertaking. The most skilled operator available should secure the airway by the most expeditious means possible.

13. Assess the work of breathing and its efficacy by conducting the following: Inspection Distressed, tachypneic, symmetry of chest wall or wheezing . using of accessory muscles or paradoxical movement (flail chest)? II- Breathing

14. Is crepitus noted? Is the trachea located in the midline? Percussion and auscultation of the chest, looking for signs consistent with pneumothorax or hemothorax. Palpation for the trachea

15. Crepitus in surgical emphysema

16. CXR subcutaneous air

17. -Treatment may need to precede diagnostic maneuvers. -Tension pneumothorax is a clinical diagnosis (asymmetrical breathing sound , tracheal deviation, hyperresonance ) Breathing

18. Diagnosis: absence of breath sounds, hyperresonance, tracheal deviation away from the side of the abnormality, and associated hypotension due to decreased venous return. Treatment: immediate decompressive therapy (a chest x-ray should not delay treatment) via placement of a 14-gauge intravenous catheter in the second intercostal space in the midclavicular line, immediately followed by tube thoracostomy. Tension pneumothorax

19. Diagnosis: Absent or decreased breath sounds without tracheal deviation usually indicate a simple pneumothorax or hemothorax on the affected side. A chest x-ray can usually confirm these conditions. Treatment: tube thoracostomy (32 Fr. or larger for hemothorax), connected to an underwater seal-suction device adjusted to �20 cm water suction Pneumothorax or hemothorax

20. Diagnosis: paradoxical chest wall motion with spontaneous respirations (three or more contiguous ribs with two or more fractures per rib). Pulmonary contusion often accompanies such an injury. Chest x-ray often reveals the extent of fractures and underlying lung injury. Treatment: adequate pain control (often with epidural analgesia), aggressive pulmonary toilet, and respiratory support. Many patients require early mechanical ventilatory support. Flail chest

21. Diagnosis: A chest wound communicating with the pleural space that is greater than two thirds the diameter of the trachea will preferentially draw air into the thorax (�sucking chest wound�). Treatment: Cover with a partially occlusive bandage secured on three sides (securing all four sides can result in a tension pneumothorax and should be avoided), preventing air from entering the thorax but allowing it to exit via the wound if necessary. Prompt tube thoracostomy should follow placement of the partially occlusive dressing. Open pneumothorax

22. Diagnosis: Severe subcutaneous emphysema with respiratory comprise is suggestive; bronchoscopy is diagnostic. Treatment: Tube thoracostomy placed on the affected side will reveal a large air leak, and the collapsed lung may fail to re-expand. The patient is stabilized by intubation of the unaffected bronchus until operative repair can be performed Tracheobronchial disruption

23. Flail chest

24. Multiple fracture ribs

25. Chest tube & tension pneumothorax

26. CT tension pneumothorax

27. The goal of this portion of the primary survey is to identify and treat the presence of shock. -all active external hemorrhage is controlled with direct pressure, and -obvious fractures are stabilized. -The pulse and blood pressure are obtained. -The skin perfusion is determined by noting skin temperature and evaluating capillary refill. Over time, end-organ perfusion during a trauma resuscitation is estimated using mental status and urine flow as markers III- Circulation

28. Shock is defined as the inadequate delivery of oxygen and nutrients to tissue. The etiologies of shock can be divided into three broad categories: hypovolemic, cardiogenic, and distributive

29. Hypovolemic shock is the most common type of shock seen in trauma patients and occurs as a result of decreased intravascular volume, most commonly secondary to acute blood loss In its severe form, it can manifest as a rapid pulse, decreased pulse pressure, diminished capillary refill, and cool, clammy skin Therapy is restoration of the intravascular volume the patient should have two large-bore intravenous lines placed (14 or 16 gauge). The antecubital veins are the preferred sites.

30. If a peripheral intravenous catheter cannot be placed secondary to venous collapse, an 8.5-French cannula (Cordis catheter) should be placed via the Seldinger technique into the femoral vein Resuscitation should consist of an initial bolus of 2 L of crystalloid solution (children should receive an initial bolus of 20 mL/kg) If hypotension is unresponsive to this fluid ,it implies massive hemorrhage. It is a trigger for blood, packed RBCs and immediate surgical intervention

31. Sources of ongoing hemorrhage: External, i.e, from the scalp, skin, or nose Pleural & pericardial spaces. Peritoneum Pelvis and/or retroperitoneum Long bone fracture Circulation & hemorrhage

32. Cardiogenic shock occurs when the heart is unable to provide adequate cardiac output to perfuse the peripheral tissues. In the trauma setting, such shock can occur in one of two ways:

33. 1) extrinsic compression of the heart leading to decreased venous return and cardiac output. Patients in cardiogenic shock secondary to extrinsic compression of the heart usually present with cool, pale skin, decreased BP, and distended jugular veins. They often respond transiently to an initial fluid bolus, but more definite therapy is always needed. Tension pneumothorax is the most common etiology. Cardiac tamponade is a less common cause

34. (2) myocardial injury causing inadequate myocardial contraction and decreased cardiac output. Patients in cardiogenic shock secondary to myocardial injury can also present with cool skin, decreased BP, and distended jugular veins. -Acute myocardial infarction can manifest in this way. Often, it is responsible for the traumatic event, but it can also occur as a result of the stress following an injury. Diagnosis of a myocardial infarction is via electrocardiogram (ECG) and troponin levels

35. -Severe blunt cardiac injury is another manifestation of myocardial injury. It usually occurs in the setting of high-speed motor vehicle crashes. An ECG and possibly an echocardiogram are essential. Therapy ranges from close monitoring with pharmacologic support in an intensive care unit (ICU) to operative repair

36. Distributive shock occurs as a result of an increase in venous capacitance leading to decreased venous return. Neurogenic shock secondary to acute quadriplegia or paraplegia is one type. Loss of peripheral sympathetic tone is responsible for the increased venous capacitance and decreased venous return. These patients present with warm skin, absent rectal tone, and inappropriate bradycardia. They often respond to an initial fluid bolus but often require pharmacologic support. Phenylephrine or norepinephrine can be used to restore peripheral vascular resistance. Chronotropic agents such as dopamine are sometimes used for bradycardic patients. Of note, the leading cause of shock in a trauma patient is hypovolemia, and thus neurogenic shock is usually a diagnosis of exclusion.

37. Estimated Blood Loss by Initial Hemodynamic Variables

38. The goal of this phase of the primary survey is to identify and treat life-threatening neurologic injuries, and priority is given to evaluating level of consciousness and looking for lateralizing neurologic signs. The level of consciousness is quickly assessed using the AVPU system (ascertaining whether the patient is awake, opens eyes to voice, opens eyes to painful stimulus, or is unarousable). The pupils are examined, and their size, symmetry, and responsiveness to light are noted. Focal neurologic deficits are noted. Signs of significant neurologic impairment include inability to follow simple commands, asymmetry of pupils or their response to light, and gross asymmetry of limb movement to painful stimuli. Both intracranial and spinal injuries require urgent evaluation. IV- Disability

39. The last component of the primary survey is exposure with environmental control. Its purpose is to allow for complete visual inspection of the injured patient while preventing excessive heat loss. The patient is first completely disrobed, with clothing cut away so as not to disturb occult injuries. The patient then undergoes visual inspection, including logrolling to examine the back, splaying of the legs to examine the perineum, and elevation of the arms to inspect the axillae. The nude patient loses heat rapidly to the environment unless specific countermeasures are undertaken. V- Exposure

40. Monitor; pulse rate, blood pressure, respiratory rate, and urine output. Urinary catheters are mandatory, however, precautions are taken for pelvic trauma and for those with blood at the urethral meatus. Normal output 0,5ml /kg/h Gastric tubes . monitors

41. C-spine CXR to assess: � the position of tubes and lines, � the presence of treatable life-threatening conditions, & causes of shock e.g, pneumo & hemothorax, widened mediastinum, lung parenchymal injuries, and injuries to the thoracic cage. pelvis Radiographs

42. It includes; history, physical exam, angio-gram,CT scans, and other lab. tests. The FAST(Focused assessment with sonography for trauma) examination can be a part of the primary survey. Prompt definitive treatment for identified injuries should start without delay. Secondary survey

43. The AMPLE history should include: A - History of patient�s allergies M - Patient�s medication history P - Past medical and surgical history L - Time of last meal E - Full description of events leading to injury HISTORY

44. Severe closed-head injury occurs in major trauma and contributes largely to disability & carries a 30% mortality rate. Inspect the whole head: Scalp bleeding are rapidly sutured. Palpate for facial fractures. Secondary survey Examination of the Head and face and neurology

45. Thanx