Introduction
trauma can be divided into two basic types
according to severity:
• Serious and life-threatening injury;
• Significant trauma requiring treatment but not immediately
life threatening.
Types of injury
according to mechanism
■ Blunt, e.g. car bonnet
■ Penetrating, e.g. knife
■ Blast, e.g. bomb
■ Crush, e.g. building collapse
■ Thermal
Crush injury
■ Muscle cells die. If reperfused, they release myoglobin
■ Injured tissue sequesters fluid
■ Renal shutdown results
■ Treatment is fluid loading with monitoring of renal output
to maintain diuresis
The approach to the traumatised patient is very
different
from that of a patient with an undiagnosed
medical condition as, in the latter, an extensive history, past medical
history, physical examination, differential diagnosis and investigations
ordered to confirm or refute this diagnosis are undertaken.
In the trauma setting, it is often not possible
to obtain
such information immediately; hence, a
standardised protocol of management is required.
The Advanced Trauma Life Support (ATLS) system
was therefore created initially in the USA and rapidly taken up globally.
The steps in the ATLS philosophy
■
Primary survey with simultaneous resuscitation – identify
and treat what is killing the patient
AMPLE HISTORY
■
Secondary survey – proceed to identify all other injuries
■
Definitive care – develop a definitive management plan
WHO IS THE
MULTIPLE TRAUMA PATIENT
Triage
·
Sorting of patients based on the need for treatment
and the available resources to provide that treatment
·
Based on ABC
1- pre-hospital triage – in order to despatch ambulance and
prehospital care resources;
2- at the scene of trauma;
3-on arrival at the receiving hospital.
Triage
RED --- FIRST PRIORITY-MOST URGENT
YELLOW---SECOND PRIORITY- URGENT
GREEN --- THIRD PRIORITY – NOT URGENT
BLACK --- FOURTH PRIORITY (DEAD)
Primary survey
ABC’s - Identified and simultaneous
management of the life-threatening conditions
·
A – Airway management with C-spine control
·
B – Breathing
·
C – Circulation & hemorrhage control
·
D – Disability: neurologic status
·
E – Exposure: completely undress the patient
Airway assessment
■ Check
verbal response
■ Clear
mouth and airway with large-bore sucker
■ If
GCS 8, consider intubation ; otherwise
use jaw thrust or oropharyngeal airway.
Inspect the Airway
•
Vomit, blood, teeth, dirt?
• Finger sweep
Clear large amounts and large particles
B – Breathing
·
Adequate gases exchange: O2 transfer & CO2
elimination
·
Involves adequate function of the lungs, chest wall
and diaphragm
·
Expose the patient chest
·
Visual inspection
& palpation
·
Auscultation
·
Percussion
Assess for Breathing out of hospital
·
Is the patient breathing?
Look, listen, & feel for 10 seconds
Ventilation Impair
·
Tension pneumothorax
·
Open pneumothorax
·
Flail chest with pulmonary contusion -----
TREAT AS NEEDED+
·
START THE PROPER VENTOLATORY SUPPORT + high flow
100%O2
Circulation (assessment and warning signs)
■ Deteriorating conscious state
■ Pallor
■ Rapid thready pulse is a more reliable and earlier
warning sign than a fall in blood
pressure
TO STOP OR MINIMIZE FURTHER BLOOD LOSS
VOLUME REPLACEMENT
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Resuscitation - IV Fluid therapy
·
Balanced salt solution: Ringer’s Lactate
·
In hypovolemic patient
- 2 l rapidly
·
Blood
D--- DISABILITY
·
The GCS allows for
a very rapid assessment of the patient’s level of consciousness, pupillary size
and reaction, motor function and, therefore, injury level and is also a good
prognostic indicator
·
It should be noted,
however, that hypoglycaemia,
alcohol and drug abuse may
also alter the level of
consciousness and shouldalso
be excluded.
Neurologic
GCS Score
Eye opening
Spontaneous 4
To voice 3
To pain 2
None 1
GCS Score
Verbal response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible words 2
None 1
GCS Score
Motor response
Obeys command 6
Localizes pain 5
Withdraw (pain) 4
Flexion (pain) 3
Extension (pain) 2
None 1
Adjuncts to the primary survey
■ Blood TEST – CBC, urea and electrolytes, clotting screen,
glucose, toxicology, cross-match
■ ECG
■ Two wide-bore cannulae for intravenous fluids
■ Urinary and gastric catheters
■ Radiographs of the ,chest and pelvis + cervical spine
E – Exposure / Environmental control
·
Undressing
·
Protection from hypothermia
History
·
A Allergies
·
M Medications
·
P Past illness
·
L Last meal
·
E Events/ environment related
to the injury
·
Mechanism of injury
·
Types of injury
SECONDARY SERVEY
HEAD TO TOE EXAM
*DO NOT
FORGET HEDDEN AREA
* NEEDED
INVEVSTIGATIONS
MTP.
*PRIMARY
SERVEY
*AMPLE
*SECONDARY
SERVEY
*DEFINITIVE MANAGEMENT
*CONT.
RE-EVALUATION
*PATIENT
REFFERAL & DISPOSITION.
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