Download - TEAM for Medical Students
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Goal / Principles of Trauma Care
Rapid, accurate, and physiologic
assessment
Resuscitate, stabilize, and monitor bypriority
Prepare for transfer to definitive care
Teamwork for optimal, safe patient care
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Objectives
Describe fundamental principles of initial
assessment and management
Identify correct sequence of management
priorities
Describe appropriate techniques of
resuscitation
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Objectives
Recognize value of patients history
Understand importance of injury
mechanism
Identify concepts of teamwork in caring for
injured patient
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The Need for Early TEAM
Leading cause of death in ages 1 through 44
Disabilities exceed deaths by ratio of 3:1
Trauma-related cost > $400 billion per year Lack of public awareness for injury
prevention
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Injury Prevention
A
B
C
D
E
Analyze injury data
Build local coalitions
Communicate the problem
Develop prevention activities
Evaluate the interventions
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Trimodal Death Distribution
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TEAM Principles
Treat greatest threat to life first
Definitive diagnosis less important
Physiologic approach Time is of the essence
Do no further harm
Teamwork required for TEAM to succeed
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TEAM Approach
A
B
C
D
E
Airway with c-spine protection
Breathing / ventilation / oxygenation
Circulation: Stop the bleeding!
Disability (neuro status)
Expose / Environment / body temp
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TEAM Sequence
Rapid primary surveyABCD + Adjuncts
Detailed secondarysurvey / reevaluation
Head-to-toe + Adjuncts
Definitive
care
Safe transfer
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TEAM Sequence and Teamwork
Simultaneous
primary survey
and resuscitation of
vital functions
Simultaneous
secondary surveyand reevaluation of
vital functions
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TEAM Work and Teamwork
TL Team
Leader
A AirwayManager
N Nurse
1 Assistant
2 AssistantTogether Everyone Achieves More
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Prehospital Preparation
Closest appropriate facility
Transport guidelines / protocols
On-line medical direction Mobilization of resources
Periodic review of care
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Inhospital Preparation
Preplanning
essntial
Team approach Trained personnel
Proper equipment
Lab / x-raycapabilities
Standard
precautions
Transferagreements
QI program
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Standard Precautions
Cap
Gown
Gloves Mask
Shoe covers
Goggles / faceshield
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Other factors, eg, salvagebiliy
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Primary Survey
Priorities are the
Same for all!
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Primary Survey
A
B
C
D
E
Airway with C-spine protection
Breathing / Life-threatening chest injury
Circulation: Stop the bleeding!
Disability / Intracranial mass lesion
Expose / Environment / Body temp
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Special Considerations: Children
Leading cause of death
Immature, anatomic / mechanical features
Vigorous physiologic response Limited physiologic reserve
Outcome depends on early aggressive
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Special Consoderations: Children
Size, dosage, equipment, surface area, and
psychology
Airway: Larynx anterior and cephalad,short tracheal length
Breathing: Chest wall pliability, mediastinal
mobility
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Special Considerations: Children
Circulation: Vascular access, fluid volume,
vital signs, and urinary output
Neurologic: Vomiting, seizures, and diffusebrain injury
Musculoskeletal: Immature skeleton,
fracture patterns
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SpecialConsideration: Pregnancy
Anatomic / physiologic changes modify
response to injury
Need for fetal assessment 1stPriority: Maternal resuscitation
Outcome depends on early, aggressive care
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Special Considerations: pregnancy
Gestation and position of uterus
Physiologic anemia
Pco2 Gastric emptying
Supine hypotension
Isoimmunization Sensitivity of fetus
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Special considerations: Elders
5th leading cause of death
Diminished physiologic reserve and
response
Comorbidities: Disease /
Medications
Outcome depends on early,aggressive care
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Special Conciderations: Elders
5thleading cause of death
Diminished physiologic reserve
and response
Comorbidities: Diseases /
MedicationsOutcome depands on early,
aggressive care
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Primary Survey: Airway
Assess for airway patency
Snoring
Gurgling Stridor
Rocking chest wall motions
Maxillofacial trauma / laryngeal injury
C-spineinjury
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Resuscitation: Patent Airway
Chin lift / Modified jaw thrust
Look, listen, feel
Remove particulate matter
Definitive airway as necessary
Reasses frequentlyC-spine
injury
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Resuscitation: Assess Breathing
Chest rise and symmetry
Air entry
Rate / Effort Color / Sensorium
Tension / open
pneumothorax
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Resuscitation: Breathing
Administer supplemental oxygen
Ventilate as needed
Tension pneumothorax: Needledecompression
Open pneumothorax: Occlusive dreassing
Reassess frequently
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Primary Survey: Circulation
Children
Elderly
Athletes
Pregnancy
Medication
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Primary Survey: Circulation
Nonhemorrhagic shock
- Cardiac tamponade
- Tension pneumothorax- Neurogenic
- Septic (late)
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Primary Survey: Circulation
Assess organ perfusion
- Level of consciousness
- Skin color- Pulse rate and character
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Primary Survey: Circulation
Assess Organ Perfusion
1. Tachycardia
2. Vasoconstriction2. Cardiac output
2. Narrow pulse pressure
3. MAP
3. Blood flow
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Primary Survey: Circulation
Children
Elderly Athletes
Pregnancy
Medications
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Resuscitation: Circulation
Bleeding?
IT!
Find it!
-Direct pressure
-Operation
-Avoid blind
clamping
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Resuscitation: Circulation
Obtain venous access
Restore circulating volume
- Ringers lactate, 1-2 L- PRBCs if transient response or no
response
Reassess frequently
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Resuscitation: Circulation
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Resuscitation: Circulation
Consider
Tension pneumothorax: Needle
decompression and tube thoracostomy Massive hemothorax: Volume
resuscitation and tube thoracostomy
Cardiac tamponade: Pericardiocentesisand direct operative repair
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Primary Survey: Disability
Baseline neurologic evaluation
Observe for
Neurologic
deterioration
-Pupillary response-Neurosurgical consult
as indicated
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Primary Survey: GCS Score
Eye opening: Range 14
BEST Motor response: Range 16
Verbal response: Range 15
Score = (E + M + V)
Best score = 15
Worst score = 3
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Primary Survey: Disability
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Primary Survey: Expore
Completely undress the patient
Remove helmet if present
Look for visible / palpable injuries
Log roll, protect spine
Prevent
hypothermia
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Resuscitation: Overview
If doubt, establish definitive airway
Oxygen for all patients
Chest tube may be definitive for chestinjury
Stop the bleeding!
2 larger-caliber Ivs Prevent hypothermia
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Adjunct: Urinary Catheter
Blood?
Decompress bladder
Monitor urinary output
- Blood at meatus
- Perineal ecchymosis /
hematoma
- High-riding prostate
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Adjuncts: Gastric Catheter
Blood?
Decompress urinary output
Monitor urinary outout
-Blood at meatus
-Perineal ecchymosis /
hematoma
- High-riding prostate
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Primary Survey: Adjuncts
Monitoring
Vital signs
ABGs
ECG
Pulse oximetry
End-tidal CO2
Consider need for transfer
Diagnostic Tools
Chest / pelvis x-ray
C-spine x-rays when
appropriate FAST
DPL
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Secondary Survey: Start After
Primary survey completed
Resuscitation in process
ABCDEs reassessed
Vital functions returning to normal
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Secondary Survey: Key Parts
AMPLE history
Complete physical exam: Head-to-toe
Complete neurologic exam
Special diagnostic tests
Reevaluation
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Secondary Survey: History
A Allergies
M Medications
P Past illnennes / Pregnancy
L Last meal
E Event / Environment
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Secondary Survey
Mechanisms of Injury
AnatomyPhysiology
Pattern of
Injury
Mechanism of
Injury
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Burn Injury
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Burn Injury
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Cold Injury
Frostbite: Rewarm with moist heat
(40 C); wait for demarcation
Hypothermia: Passive or active
rewarming
Monitor: Not dead until warm and dead
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Secondary Survey: Head
Complete neurologic exam
GCS Score determination
Comprehensive eye / ear
- Unconscious patient- Periorbital edema
- Occluded auditory canal
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Secondary Survey: Maxillofacial
Bony crepitus / instability
Palpable deformity
Comprehensive oral / dental exams
-Potential airway obstruction
- Cribriform plate fracture- Frequently missed injury
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Secondary Survey: C-spine
Palpate for tenderness
Complete motor /
sensory exams
Reflexes
C-spine imaging - Injury above
clavicles
- Altered LOC- Other severe,
painful injury
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Secondary Survey: Neck
Blunt vs
penetrating
Airway
obstruction,hoarseness
Crepitus,
hematom, stridor,
bruit
-Delayed
symptom / signs
-Progressiveairway obstruction
-Occult injuries
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Secondary Survey: Abdomen
Inspect, auscultate, palpate, and percuss
Reevaluate frequently
Special studies: FAST, DPL, CT
Hollow viscus andretroperitoneal injury
Excessive pelvic
manipulation
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Secondary Survey
Perineum Contusions, hematomas,
lacerations, urethral blood
Rectum Sphincter tone, high-riding
prostate, pelvic fracture,rectal wall integrity, blood
Vagina Blood, lacerations
Pregnancy
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Secondary Survey: Musculoskeletal
Potential blood loss
Limb or life threat (primary survey)
Missed fractures
Soft-tissue or ligamentous injury
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Secondary Survey: Musculoskeletal
Occult compartment syndrome
(especially with altered LOC /
hypotension)
Examine patients back
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Secondary Survey: Pelvis
Pain on palpation
Symphysis width
Leg length unequal
Instability
Pelvic x-rays
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Pelvic Fracture
Major source of
hemorrhage
Volum resuscitation
Reduce pelvic volume External fixator
Angiography /
embolization
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Secondary Survey: CNS
Frequent reevaluation
Prevent secondary brain injury
Imaging as indicated
Early neurosurgical consultation
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Secondary Survey: Spine
Complete motor and sensory exams
Imaging as indicated
Maintain inline immobilization
Early neurosurgical consultation
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Secondary Survey: Neurologic
Incomplete immobilization
Subtle in ICP with manipulation
Rapid deterioration
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Secondary Survey: Adjuncts
Blood tests
Urinalysis
X-rays
CT
Urography
Angiography
Ultrasonography
Echocardiography
Bronchoscopy
Esophagoscopy
Do not delay transfer!
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Reevaluation: Missed Injuries
High index of suspicion
Frequent reevaluation
Continuous monitoring
Rapidly recognize patient deterioration
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Pain Management
Relieve pain and anxiety as appropriate
Administer intravenously
Careful patient monitoring is essential
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Safe Transfer
When patients needs exceed institutional
resources.
Use time before transfer for resuscitation
Do not delay transfer for diagnostic tests
Physician-to-physician communication
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Transfer to Definitive
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Emergency Preparedness
Simple plan
Command
structure Disaster triage
scheme
Traffic controlsystem
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Summary
Primary SurveyAdjuncts
Secondary SurveyAdjuncts
Definitive care
Safe transfer Resuscitation
Continuous
Reevaluation
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Summary
DHead
To
toe
B C
A
E
One, safe way
Do no furtherharm
Treat greatest
threat to life first
Teamwork
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STARTTRIAGE
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START TRIAGE
START Triage*All Walking Wounded
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RESPIRATIONS
YES
Under 30/min
NO
Position Airway
NO YES
ImmediateNon-
salvageable
Over 30/min
Immediate
PERFUSION
Cap refill
> 2 sec
Cap refill
< 2 sec
Control
Bleeding
Immediate
STATUS
MENTAL
Failure to follow
simple commands
Can follow
Simple commands
Radial Pulse PresentRadial Pulse Absent
MINOR