29. emergency room trauma
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TRAU M A IN TH EEM ERGEN CY RO O M
UNHAS SEKOLAH KEDOKTERANPRESENTED BY DR PHILIP STOKOE16 FEBRUARY 2011
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THE CALGARY CAM BRIGE SCHEM E
Initiating the session
Gathering information
Physical examination Explanation and planning
Closing the session
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POM R - Problem oriented M edical Record
A% History• &all• Head in'(ry•
Headache• )i*c(lty in +al,ing• Semi-conscio(s
.% Past history Hypertension Treatment )ia/etes mellit(s )r(g addict Alcohol (se
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POM R - Problem oriented M edical Record -Cont’d
C% Exam)% )i1erential diagnosisE% Initial pro/lem related plans
• Imaging• .lood Exam• !onitoring Tests• Treatment
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HISTORY TAKING SE!ENCE
Presenting Symptoms 3PS4
History of Presenting Illness 3HPI4
Past History 3PH4 Social History 3SH4
&amily History 3&H4
System e5ie+ 3S4
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PROGRESS NOTES
S7 S(/'ecti5e #7 #/'ecti5e A7 Assessment P7 Plan
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FLOW CHART
Dx : Diagno!i" T#! •B$oo% #xa&•I&aging
'x: 'oni!o(ing T#! •Con!in)o) B$oo% T#!•S#"on% I&aging•*$ago+ "a$#
Rx: T(#a!&#n! •I, -)i%•O2
E%: E%)"a!ion •Con)$!a!ion•Pa!i#n! A%.i"#•Fa&i$/ A%.i"#
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"I##ERENTIAL "IAGNOSIS #ROM
SYM PTOM S$SIGNS
A% Ne(rological systems and mentalstate9% )o yo( get headache:
$% Is yo(r headache 5ery se5ere and did it/egin 5ery s(ddenly: S(/-arachnoidhaemorrhage
0% Ha5e yo( had memory pro/lems or tro(/leconcentrating
2% Ha5e yo( had fainting episodes; <ts or/lac,o(ts:
6% )o yo( ha5e tro(/le seeing or hearing:
8% Are yo( di==y:UNHAS – TAU!A IN E!EGENC" ##! >
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"I##ERENTIAL "IAGNOSIS #ROM
SYM PTOM S$SIGNS % Cont’d
>% Ha5e yo( had +ea,ness; n(m/ness orcl(msiness in yo(r arms or legs:
?% Ha5e yo( e5er had a stro,e or head
in'(ry:@% Ha5e yo( had di*c(lty sleeping:
9%)o yo( feel sad or depressed; or ha5epro/lems +ith yo(r Bner5es:
99%Ha5e yo( e5er /een sex(ally or physicallya/(sed:
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"I##ERENTIAL "IAGNOSIS #ROM
SYM PTOM S$SIGNS % Cont’d
.% Epilepsy• Genetic• Head tra(ma• Intra cranial t(mo(rs• Stro,es• A/cess• Alcohol• )r(gs• Uraemia
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"I##ERENTIAL "IAGNOSIS #ROM
SYM PTOM S$SIGNS % Cont’d
C% Unconscio(sness• .oggy scalp s+elling• )epression crani(m• Alcohol /reath• Needle mar,s• Hepatomegaly• HypertensionDhypotension• )ia/etic coma – s+eet /reath
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GRA"ING O# COM A
9% Alert
$% )ro+sy /(t responds to 5er/al stim(lation
0% Unconscio(s – no response to 5er/al
stim(lation; /(t +ithdra+al response to pain
2% Unconscio(s – decorticate responses to pain3exion of (pper lim/ and extension of lo+erlim/4
6% Unconscio(s – decere/rate responses to pain3hyperextension of /oth (pper and lo+erlim/s4
8% Unconscio(s p no response to pain
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GLASGO& COM A SCALEPa!i#n!
(#on#
S"o(# 0300 1030
0
1230
0
E/# o#ning Son!an#o) 4
To ##"5
To ain 2
Non# 1
B#! .#(7a$(#on#
O(i#n!#% 8
Con9)#% 4
Ina(o(ia!#
In"o&(#5#ni7$# 2
Non# 1
B#! &o!o((#on#
O7#/ing 6
Lo"a$iing 8UNHAS – TAU!A IN E!EGENC" ##! 9$
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SYM PTOM S$SIGNS O# COM A
Ta,e history if possi/le
Assess le5el of conscio(sness – (se Glasgo+coma scale /(t remem/er its limitations
Foo, for sings of meningeal irritation Assess p(pils
Assess oc(lar mo5ements; if necessary (singdolls head manoe(5re
Assess motor responses Assess respiration
Perform a general physical examination;incl(ding the heart; a/domen and s,(ll
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CRITERIA #OR BRAIN "EATH
)ilated p(pils
No corneal response
esti/(lar oc(lar reex !otor response to painf(l stim(l(s to
gla/ella
No gag response to trachealresponse
Steroterio(s /reathing
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THE !NCONSCIO!S PATIENT
C –C#$ narcosis 3respiratory fail(re7(ncommon4
O – #5erdose7 for example; trang(illisers;
alcohol; salicylates; car/on monoxide;antidepressants
'- !eta/olic7 for example; hypoglycaemia;dia/etic ,etoacidosis; (raemia;
hypothyroidism; hepatic coma;hypercalcaemia; adrenal fail(re
A- Apoplexy7 for example; head in'(ry;cere/ro5asc(lar accident 3infarction or
haemorrhage4; s(/d(ral or extrad(ralUNHAS – TAU!A IN E!EGENC" ##! 96
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GENERAL INSPECTION O# TRA!M A PATIENT
emem/er A-.-C7
Air+ay;
.reathing and
Circ(lation
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GENERAL INSPECTION O# TRA!M A PATIENT-
Cont’d
Air+ay and .reathing7
Foo, to see if the patient is /reathing; as indicated/y chest +all mo5ement% If not; (rgent attention is
re(ired; incl(ding clearing the air+ay andpro5iding 5entilation% Note partic(larly the patternof /reathing% Cheyne Sto,es respiration 3+hichmay indicate diencephalic in'(ry; /(t is notspeci<c4; irreg(lar ataxic /reathing 3.iots
/reathing; from an ad5anced /rainstem lesion4;and deep rapid respiration 3e%g% (ssma(l/reathing; secondary to a meta/olic acidosis; as india/etes mellit(s4 are important signs to loo, for%
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GENERAL INSPECTION O# TRA!M A PATIENT-
Cont’d
Circ(lation 7
Foo, for signs of shoc,; dehydration
and cyanosis% A typical cherry-redcolo(r occ(rs rarely in cases of car/onmonoxide poisoning% Ta,e the p(lserate and /lood press(re%
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