assessment of the multiply injured patient o'connor

Assessment of the Assessment of the MultiplyMultiply Injured Injured

PatientPatientDr. Michael O’ConnorDr. Michael O’ConnorProfessor, Dept. of Emergency Professor, Dept. of Emergency Medicine, Queen’s University, Medicine, Queen’s University, CANADACANADA

The ATLS ProgramThe ATLS Program““Advanced Trauma Life Support”Advanced Trauma Life Support”

Originated in the USA- ~1980-Originated in the USA- ~1980-Trauma- “The Neglected Disease of Trauma- “The Neglected Disease of Modern Society”Modern Society”

Intended for the Primary Care Intended for the Primary Care PhysicianPhysician

Addressing early Assessment and Addressing early Assessment and RecognitionRecognition

Standardized in 32 countries Standardized in 32 countries

Regrettably, War and Conflict Regrettably, War and Conflict have consistently lead to have consistently lead to improved care of the Injured.improved care of the Injured.

Death Following TraumaDeath Following Trauma

0%

5%

10%

15%

20%

25%

30%

35%

40%

< 30 min. Hours Days-Weeks

The Stages…..The Stages….. Preparation- Prior to HospitalPreparation- Prior to Hospital Primary SurveyPrimary Survey ResuscitationResuscitation

Preparation - Prior to HospitalPreparation - Prior to Hospital

Vital SignsVital SignsPulse and Blood PressurePulse and Blood Pressure

Level of ConsciousnessLevel of Consciousness

Glasgow Coma ScaleGlasgow Coma Scale MotorMotor VerbalVerbal Eyes OpeningEyes Opening

MechanismMechanismHigh VelocityHigh Velocity

Outside conditions Outside conditions (cold)(cold)

Patient FactorsPatient Factors AgeAge Medical conditionMedical condition PregnancyPregnancy

Primary SurveyPrimary Survey

A- A- AAirway maintenance (C-spine)irway maintenance (C-spine)

B-B- BBreathing and Ventilationreathing and Ventilation

C-C- CCirculation and Hemorrhage Controlirculation and Hemorrhage Control

D- D- DDisability- Neurological Statusisability- Neurological Status

E-E- EExposure, Environmental Control xposure, Environmental Control

AIRWAYAIRWAY Relieve Airway Relieve Airway

ObstructionObstruction Head Injury, Blood, Teeth, Head Injury, Blood, Teeth,

Vomitus Vomitus

OxygenationOxygenation

Simple Airway Simple Airway maneuversmaneuvers

BREATHINGBREATHING Look ForLook For……

Equal Rise and Fall of the ChestEqual Rise and Fall of the Chest

ListenListen For...For... Air entry on both sides of chestAir entry on both sides of chest

Feel For…Feel For… Rib Fractures (Elderly Patient)Rib Fractures (Elderly Patient) Subcutaneous emphysemaSubcutaneous emphysema

Continuous Pulse Oximeter to monitor oxygenContinuous Pulse Oximeter to monitor oxygen

CIRCULATIONCIRCULATIONSHOCKSHOCK

Hemorrhage most common, Hemorrhage most common, notnot isolated isolated Brain Injury- expect Brain Injury- expect Tachycardia and Tachycardia and Cutaneous VasoconstrictionCutaneous Vasoconstriction

Other Causes-Other Causes- Cardiac- Direct InjuryCardiac- Direct Injury Tension PneumothoraxTension Pneumothorax Neurogenic- Spinal Cord InjuryNeurogenic- Spinal Cord Injury

DISABILITYDISABILITY

Neurological Neurological ExaminationExamination

EXPOSUREEXPOSURE

Undress the PatientUndress the Patient

Prevent Prevent HypothermiaHypothermia

Elderly PatientElderly Patient

Conditions that correlate with Conditions that correlate with High Mortality:High Mortality:

Head TraumaHead Trauma ShockShock HypoxiaHypoxia Sepsis-Multisystem Organ FailureSepsis-Multisystem Organ Failure Prolonged ventilationProlonged ventilation

Specific Organ Specific Organ SystemsSystems

Head InjuryHead Injury High primary Mortality, Poor functional High primary Mortality, Poor functional

outcome post discharge.outcome post discharge. High predisposition to subdural with High predisposition to subdural with

subtle presentation-- (subtle presentation-- (CT Scans)CT Scans) Airway, Cautious hyperventilation, Airway, Cautious hyperventilation,

Definitive care and decisions Definitive care and decisions

Specific Organ SystemsSpecific Organ Systems

Chest InjuriesChest Injuries

Rib and Sternal InjuriesRib and Sternal InjuriesFlail segment, Flail segment, splinting, hypoventilation and pneumoniasplinting, hypoventilation and pneumonia

Chest compliance & pulmonary reserveChest compliance & pulmonary reserve Cardiac Arrhythmia- Premorbid vs ? Direct Cardiac Arrhythmia- Premorbid vs ? Direct

injuryinjury

SUMMARYSUMMARY

Anticipate the ProblemAnticipate the Problem Primary SurveyPrimary Survey Resuscitation PhaseResuscitation Phase Know when to ask for AssistanceKnow when to ask for Assistance Elderly patients pose special Elderly patients pose special

problemsproblems