Vinnitsa National Pirogov Memorial Medical University

Department of Disaster Medicine and Military Medicine

METHODIC ELABORATION

For the self-study to the seminar

by the students of the 5th year of study specialty: general medicine and dentistry) on

the discipline «Emergency and urgent medical care»

THEME 2. THE PROCEDURE FOR PROVIDING EMERGENCY

MEDICAL CARE TO VICTIMS AND PATIENTS AT THE PRE-HOSPITAL

STAGE. SECONDARY EXAMINATION..

Vinnytsa - 2020

Trimodal distribution of death

1. INTRODUCTION TO TRAUMA

Trimodal Pattern of mortality following severe trauma

CNS/cardiovascular

hypoxia/hypercarbiaMOF/sepsis

GOLDEN HOUR

⚫ The first hour following a trauma during which

aggressive resuscitation can improve the chances

of survival and restore the normal functions.

⚫ Early pre-hospital care, early transport,

aggressive resuscitation and interventions in ED,

continued care in ICU have a definite and

significant role in preventing deaths due to

trauma.

PLATINUM MINUTES

⚫ THE IMPORTANCE OF TIME IN TRAUMA IS

INCREASING AS EVIDENT FROM THE

EVOLUTION OF THE CONCEPT OF

“THE PLATINUM TEN MINUTES”

INITIAL APPROACH TO

TRAUMA CARE⚫ Process that consists of

-Initial primary assessment

-Rapid resuscitation

-A more thorough secondary

assessment

-Followed by diagnostic tests and

disposition.

TRAUMA TEAM

RADIOGRAPHER

AIRWAY DOCTOR

AIRWAY NURSE

CIRCULATION DOCTOR

CIRCULATION NURSE

ORTHO REGISTRAR

WARDSPERSON

SCRIBE NURSETEAM LEADERSOCIAL WORKER

TRAUMA TEAM

ACTIVATION CRITERIA

ANATOMICAL

⚫ INJURY TO 2/ MORE BODY REGIONS

⚫ FRACTURE 2/ MORE LONG BONES

⚫ SPINAL CORD INJURY

⚫ AMPUTATION OF LIMB

⚫ PENETRATING INJURY TO HEAD, NECK TORSO/

PROX. LIMB

⚫ BURNS> 15% IN ADULTS, >10% IN CHILDREN,

AIRWAY BURNS

⚫ AIRWAY OBSTRUCTION

TRAUMA TEAM

ACTIVATION CRITERIA

PHYSIOLOGICAL

⚫ SBP<90mm Hg/ PR- >130BPM

⚫ RR<10/ >30 PER MIN

⚫ DEPRESSED CONSCIOUSNESS

⚫ AGE>70YR WITH CHEST INJURY

⚫ PREGNANCY>24 WEEKS WITH TORSO

INJURY

MECHANISM

⚫ BIKER/ PEDESTRIAN HIT BY

VEHICLE>30KM/HR

⚫ FALL>5 METRE

⚫ FATALITY IN SAME VEHICLE

⚫ MOTOR VEHICLE CRASH WITH

EJECTION

TRAUMA TEAM

ACTIVATION CRITERIA

Overview of ATLSChart Title

Definitive Care

Data / Information /

Response to Therapy

Secondary Survey

Resuscitation

Primary Survey

(ABCDE's)

PRIMARY SURVEY ADJUNCTS:-

MONITOR

⚫ VITALS

⚫ ECG

⚫ FOLEY’S CATHETER

⚫ GASTRIC TUBE

⚫ ABG

⚫ PULSE OXIMETER

⚫ URINE OUTPUT

PRIMARY SURVEY ADJUNCTS:-

DIAGNOSIS

⚫ CXR

⚫ PELVIS AP

⚫ LATERAL C-SPINE

⚫ DPL

⚫ FAST

BEFORE SECONDARY SURVEY

⚫ Complete primary survey

⚫ Establish resuscitation

⚫ Normalization of vital functions

SECONDARY SURVEY

The complete

history and

physical

examination

ATLS→SECONDARY

SURVEY

⚫ Head and Skull

⚫ Faciomaxillary Injuries

⚫ Neck

⚫ Chest & Spine

⚫ Abdomen

ATLS→SECONDARY

SURVEY

⚫ Perineum/ Rectum/ Vagina

⚫ Extremities→ Fractures

⚫ Complete Neurological Exam→ GCS

⚫ Appropriate X-Rays, Lab Tests and Special

Studies

⚫ “Tubes & fingers” in every orifice

SECONDARY SURVEY

COMPONENTS

⚫History

⚫Physical exam: head to toe

⚫“Tubes OR fingers in every orifice”

⚫Complete neurological exam

⚫Special diagnosis tests

⚫Re-evaluation

Secondary survey

History

“AMPLE”

A:Allergies

M:Medication currently being taken by the patient

P:Past illness and operations,pregnancy

L:Last meal

E:Event/Environment related to the injury

Secondary survey

HEAD

⚫ Signs of skull base

fracture

⚫ Pupillary size

⚫ Hemorrhages of

conjunctiva/fundi

⚫ Visual acuity

⚫ Penetrating injury

⚫ Contact lens

⚫ Dislocation of lens

⚫ Hyphaema

⚫ Ocular movement

⚫ Posterior scalp

laceration

SECONDARY SURVEY

⚫ Examination Neurologic

⚫Determine GCS score

⚫Re-evaluate pupils

⚫Sensory / motor evaluation

⚫Maintain immobilization

⚫Prevent secondary CNS injury ( keep stable vital signs, avoid increased ICP and treat IICP )

⚫Early neurosurgical consultation

GLASGOW COMA SCALE

Variables Score

Eye opening Spontaneous

To speech

To pain

None

4

3

2

1

Verbal response Oriented

Confused conversation

Inappropriate words

Incomprehensible sounds

None

5

4

3

2

1

Best motor response Obeys commands

Localizes pain

Normal flexion

Abnormal flexion

Extension

None

6

5

4

3

2

1

Physical Exam

◼ Battle Sign

◼ Raccoon's Eyes

◼ Cullen’s Sign

◼ Grey-Turner’s Sign

23

Classic Radiographic Findings◼ Epidural Hematoma

– Middle Meningeal Artery

◼ Subdural Hematoma

– Bridging Veins

24

Secondary survey

MAXILLOFACIAL

⚫ Associated with airway obstruction or major

bleeding

⚫ Fracture cribriform plate

⚫ No NG tube [performed oral route]

Secondary survey

NECK

⚫ Cervical tenderness, subcutaneous

emphysema

⚫ Oesophageal injury

⚫ Tracheal/laryngeal injury

⚫ Carotid injury (penetrating/blunt)

Secondary survey

CHEST

➢ Inspect

➢ Palpate

➢ Percuss

➢ Auscultate

➢ Obtain x-rays

Classic Radiographic Findings◼ Diaphragmatic rupture w/ spleen herniation

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Secondary survey

ABDOMEN

➢ Inspect

➢ Auscultate

➢ Palpate

➢ Percuss

➢ Reevaluate

➢ Special studies

Abdominal Trauma⚫ Look for distension, tenderness, seatbelt

marks, penetrating trauma, retroperitoneal

ecchymosis

⚫ Be suspicious of free fluid without evidence of

solid organ injury

FAST Exam

⚫ Focused Abdominal Scanning in Trauma

⚫ To find free fluid (blood) around heart (pericardiac eff.) or abdominal organ (hemoperitoneum) after trauma

⚫ 4 views:

– Cardiac

– RUQ (Morison’s Pouch)

– LUQ (Perispleenic Space)

– Pelvic (Pouch of Doughlas)

Splenic Injury

⚫Most commonly injured organ in

blunt trauma

⚫Often associated with other injuries

⚫Left lower rib pain may be indicative

⚫Often can be managed non-

operatively

Liver injury

⚫ Second most common solid organ injury

⚫ Can be difficult to manage surgically

⚫ Often associated with other abdominal injuries

Hollow Viscous Injury

⚫ Injury can involve stomach, bowel, or mesentery

⚫ Symptoms are a result from a combination of blood loss and peritoneal contamination

⚫ Small bowel and colon injuries result most often from penetrating trauma

⚫ Deceleration injuries can result in bucket-handle tears of mesentery

⚫ Free fluid without solid organ injury is a hollow viscus injury until proven otherwise

Secondary survey

⚫ Perineum:contusion,hematoma, laceration,urethral

blood

⚫ Rectum:sphincter tone,high riding prostate,pelvic

fracture,rectal wall integrity,blood

⚫ Vagina:blood,laceration

Secondary survey

Musculoskeletal

⚫ Contusion, deformity

⚫ Pain

⚫ Perfusion

⚫ Peripheral

neurovascular status

⚫ X-ray

Secondary Survey

➢ Potential blood loss

➢ Missed fractures

➢ Soft-tissue or ligamentous injury

➢ Compartment syndrome (especially with altered sensorium / hypotension)

Musculoskeletal: Pitfalls

Adjuncts to Secondary Survey

◼ Radiology– Standard emergent films

◼ C-spine, CXR, Pelvis– Focused Abdominal Sonography in Trauma (FAST)– Additional films

◼ Cat scan imaging◼ Angiography

◼ Foley Catheter– Blood at urethral meatus = No Foley catheter

◼ Pain Control◼ Tetanus Status◼ Antibiotics for open fractures

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➢ High index of suspicion

➢ Frequent reevaluation and monitoring

Minimize missed injuries?

REEVALUATION

⚫ New findings / deterioration / improvement

⚫ High index of suspicion ==> early diagnosis & management

⚫ Continuous monitoring

⚫ Pain relief

Records, Legal Considerations

➢ Concise, chronologic documentation

➢ Consent for treatment

➢ Forensic evidence

Roles of the Trauma

TeamAirway

Nurse

Boss

Attending

Team Member

Team Member

Nurse

SUMMARY

⚫ Initial assessment & management of multiply injured patient

⚫ Primary survey ( ABCDEs )

⚫ Resuscitation & monitor ( life-threatening problems )

⚫ Secondary survey ( head-to-toe, history )

⚫ Definitive care ( early consultation, surgical intervention or transport )

References1. Bailey and Love’s Short Practice of Surgery. 25th Edition.

2. Kumar MV (2014) Clinical Companion in Surgery. 2nd

Edition

3. Davidson’s Principles and Practice of Medicine 21st

Edition

4. Carmont MR (2005). "The Advanced Trauma Life Support

course: a history of its development and review of related

literature". Postgraduate Medical Journal 81(952): 87–91.

5. Styner, Randy (2012). The Light of the Moon - Life, Death

and the Birth of Advanced Trauma Life Support. Kindle

Books: Kindle Books. p. 267.

6. Committee on Trauma, American College of

Surgeons (2008). ATLS: Advanced Trauma Life Support

Program for Doctors (8th ed.). Chicago: American

College of Surgeons.