initial evaluation of the trauma patientsfgh.surgery.ucsf.edu/media/2741381/lecture 2 initial...
TRANSCRIPT
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Initial Evaluation of the Trauma
Patient
William Schecter, MD
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Priorities
• Airway
• Breathing
• Circulation
• Disability (Mini-neurologic examination)
• Exposure (preservation of heat)
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Airway
• Open Airway
• Give O2
• Stabilize Cervical
Spine
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Open the Airway
• Chin Lift
• Jaw Thrust
• Suction
• Oral/Nasal Airway
• Intubation
• Cricothyroidotomy
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Airway
• Open Airway
• Give O2
• Stabilize Cervical
Spine
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Breathing
• The examination begins in the neck
• Look for tracheal deviation
• Look for distended neck veins
• Look for symmetric motion of the chest
wall
• Palpate the chest wall
• Listen for bilateral breath sounds
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Tension Pneumothorax
• Tracheal shift to
contralateral side
• Distended neck veins
• Decreased breath
sounds on ipsilateral
side of chest
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Pericardial Tamponade
• Hypotension
• Distended Neck Veins
• Muffled Heart Sounds
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Circulation
• Check pulse – Measure blood pressure
• Stop external hemorrhage
• Vascular Access
• Send blood to the blood bank
• Begin warm saline infusion
– 2 liters in adults
– 20 cc/kg in children
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Clinical Definition of Shock
• Rapid weak pulse
• Hypotension
SEND FOR A SURGEON
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Disability – Mini-Neurologic
Exam
• Mental Status
– Glascow Coma Scale
• Pupils
• Moves all four
extremities?
Unconscious: Send for a Neurosurgeon
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Exposure/Environment
• Disrobe the patient completely
• Log roll the patient maintaining axial
traction—INSPECT THE BACK
• Cover the patient to keep him warm!
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Priorities
• Airway
• Breathing
• Circulation
• Disability (Mini-neurologic examination)
• Exposure (preservation of heat)
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Stage of Resuscitation
• Re-evaluate ABC
• Monitors
• X-rays
– Chest
– Pelvis
– Cervical spine
– FAST Ultrasound
• Insert Foley and Gastric Tube
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Re-evaluate ABC
• If the patient remains hypotensive after 2
units of saline—GIVE BLOOD
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Monitors
• EKG
• Pulse Oximeter
• End tidal C02
• Continuous blood pressure measurement
• Consider arterial blood gases
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Chest x-ray
• Pneumothorax?
• Hemothorax?
• Rupture of Diaphragm?
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Pelvic Film
• Pelvic Fracture – Possible Source of
Hemorrhage
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Focused Abdominal Sonography for Trauma
(FAST)
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RUQ LUQ Pelvis
http://www.eastbaytrauma.org/Protocols/ER%20protocol%20pages/FAST-files/FAST-pelvis-1.htm
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Prior to Foley Insertion
• Blood at the Urethral Meatus?
• Rectal Exam - High riding Prostate?
• Hematoma of the Perineum?
Obtain retrograde Urethrogram prior
to inserting the Foley
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Massive Facial Trauma
• Do not insert NG tube
• Insert gastric tube by
mouth
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Stage of Resuscitation
• Re-evaluate ABC
• Monitors
• X-rays
– Chest
– Pelvis
– Cervical spine
– FAST Ultrasound
• Insert Foley and Gastric Tube
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Secondary Survey
• Complete Head to Toe Examination
• Continuous Reassessment
• Exam more detailed with each review
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―AMPLE‖ History
• A = Allergies
• M = Medications
• P = Previous Operations and Hospitalizations
• L = Last Meal
• E = Events leading to Injury
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Head
• Palpate skull
• Look for Battle’s Sign (hematoma over
mastoid process)
• Look for blood or fluid draining from the
ears
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Face
• Palpate
– Forehead
– Periorbital ridge
– Nose
– Maxilla
– Mandible
• Check extraocular motion and pupils
• Inspect mouth
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Neck
• Trachea
• Neck Veins
• Palpate for Subcutaneous Emphysema
• Remove anterior portion of neck collar –
palpate posteriorly searching for pain,
swelling or a bone abnormality
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Chest
• Symmetric Chest Expansion?
• Localized Pain to Palpation
• Subcutaneous Emphysema?
• Bilateral Breath Sounds?
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Abdomen
• Inspection
– Distension?
– Signs of penetrating injury?
– ―Seat belt‖ sign?
• Percussion/Palpation
– ―peritoneal signs‖
• Auscultation
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Additional Tests to Evaluate the
Abdomen
• FAST Exam
• Diagnostic Peritoneal Lavage
• CT Scan of the Abdomen
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Pelvis
• Do NOT check pelvic stability by rocking
the pelvis. This can increase retroperitoneal
hemorrhage. The diagnosis of pelvic
fracture is a radiologic diagnosis!!
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Extremities
• Palpate all extremities
• Palpate and record all pulses
• Do a careful motor and sensory examination
of all extremities
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Neurologic Examination
• Continuous re-assessment of patient’s
mental status by maintaining verbal contact
with the patient.
• Time and record mental status, sensory and
motor examinations
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Additional Test to Evaluate the
Brain
HEAD CT
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Consultants?
• Shock — Surgeon
• Unconscious or deteriorating mental status
— Neurosurgeon
• Fractures -- Orthopedist
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Summary
• Primary Survery
• Stage of Resuscitation
• Secondary Survey
• Transfer
• Definitive Treatment
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Suggested Reading
http://www.nda.ox.ac.uk/wfsa/html/u06
/u06_011.htm