Vinnitsa National Pirogov Memorial Medical University Department of Disaster 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

CNS/cardiovascular

hypoxia/hypercarbia MOF/sepsis

Trimodal Pattern of mortality following severe trauma 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

AIRWAY DOCTOR

AIRWAY NURSE CIRCULATION NURSE

CIRCULATION DOCTOR

ORTHO REGISTRAR RADIOGRAPHER

WARDSPERSON

SOCIAL WORKER TEAM LEADER SCRIBE NURSE TRAUMA TEAM ACTIVATION CRITERIA ANATOMICAL ⚫ TO 2/ MORE BODY REGIONS ⚫ FRACTURE 2/ MORE LONG BONES ⚫ SPINAL CORD INJURY ⚫ OF LIMB ⚫ PENETRATING INJURY TO HEAD, NECK TORSO/ PROX. LIMB ⚫ > 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 ⚫ PREGNANCY>24 WEEKS WITH TORSO INJURY TRAUMA TEAM ACTIVATION CRITERIA

MECHANISM

⚫ BIKER/ PEDESTRIAN HIT BY VEHICLE>30KM/HR ⚫ FALL>5 METRE ⚫ FATALITY IN SAME VEHICLE ⚫ MOTOR VEHICLE CRASH WITH EJECTION Overview ofChart ATLS Title

Primary Survey (ABCDE's)

Resuscitation

Secondary Survey

Data / Information / Response to Therapy

Definitive Care 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 ⚫ 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 ⚫ Contact lens fracture ⚫ Dislocation of lens ⚫ Pupillary size ⚫ Hyphaema ⚫ Hemorrhages of ⚫ Ocular movement conjunctiva/fundi ⚫ Posterior scalp ⚫ Visual acuity laceration ⚫ Penetrating injury 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 4 To speech 3 To pain 2 None 1 Verbal response Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Best motor response Obeys commands 6 Localizes pain 5 Normal flexion 4 Abnormal flexion 3 Extension 2 None 1 Physical Exam

◼ Battle Sign

◼ Raccoon's Eyes

◼ Cullen’s Sign

◼ Grey-Turner’s Sign

23 Classic Radiographic Findings ◼ Epidural ◼ Subdural Hematoma – Middle Meningeal Artery – Bridging Veins

24 Secondary survey

MAXILLOFACIAL ⚫ Associated with airway obstruction or major ⚫ 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

28 Secondary survey

ABDOMEN

➢ Inspect

➢ Auscultate

➢ Palpate

➢ Percuss

➢ Reevaluate

➢ Special studies ⚫ Look for distension, tenderness, seatbelt marks, , 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 ⚫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

Musculoskeletal: Pitfalls

➢ Potential blood loss

➢ Missed fractures

➢ Soft-tissue or ligamentous injury

➢ Compartment syndrome (especially with altered sensorium / hypotension) 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

38 Minimize missed injuries?

➢ High index of suspicion

➢ Frequent reevaluation and monitoring 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 Team Airway

Nurse

Team Member Team Member

Boss Attending 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 ) References 1. Bailey and Love’s Short Practice of . 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.