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7/6/12
TRAUMA , RESUSCITATION,
MCI, TRIAGEDr. Rajan KojuResident, Surgery
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Trauma is the study of medicalproblems associated with physicalinjury. The injury is the adverse effect
of a physical force upon a person.There are a variety of forces that canlead to injury,
including thermal, ionising radiationand chemical;
most injuries is mechanical,
leadin cause of death and disabilit
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Mechanism of injury
Blunt: acceleration/ decelerationfall/RTA
penetrating: weapons thermal
and blast
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Initial assessment
Standarized and predetermined planof identification and treatment ofimmediately life threatening
conditions.
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Objectives
Identify priorities in assessing andmanaging trauma patient.
Apply principles of ABCDE in primaryand secondary survey.
Guidelines and techniques of
treatment . Correlation with medical history and
mechanism of injury.
Anticipation of pitfalls.
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Primary survey
Rapid ABCDE
Resuscitation
Adjuncts Identical priorities for all patients
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Basic plan
A: airway with C-spine protection.
B: breathing
C: circulation and hemorrhagecontrol
D: disability, neurological status
E: exposure
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Airway and C-spine
Always assume c-spine injury(c-spineprotection)
Check for foreign bodies, maxillo-facial injury or fracture
Jaw thrust/chin lift
Oxygen 10 L/min via reservoir mask Definitive airway
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Breathing
Exposure of chest
Auscultation and percussion
Oxygenate ventilate
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Life threateningpotentially
Tension pneumothorax simplepneumothorax
Flail chest simple
hemothoraxMassive hemothorax pulmonarycontusion
Open pneumothorax cardiac injury
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circulation
Hypotension= hypovolemia
Assessment of organ perfusion:
1. Level of consciousness2. Pulse rate and character
3. Urine output
4. Skin colour and temperature
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Circulatory management
Stop bledding
Restore volume
Reassess
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Disability
Rapid neurological evaluation of levelof consciousness as well as pupillarysize and reaction.
A: alert
V: response to voice
P: response to pain U: unresponsive
GCS: eye: 1-4, motor: 1-6; verbal: 1-5
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Exposure
Completely undress
Examine front and back
Prevent hypothermia Warm room
Warm IV fluids
Cover patient
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Resuscitation
Aggressive resuscitation
Management of life threateninginjuries as they are identified
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Adjuncts to primary survey
Obtained as part of primary survey:
1. Vital signs
2. ABG3. Pulse oxymeter
4. Urinary/gastric catheters
5. ECG
. During or after primary survey
1. CXR and pelvic X-ray
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Secondary survey(head totoe)
Patient history
Head to toe examination
Complete neurological examination Diagnostic tests
Re-evaluation
Fingers and tubes in everyorifice
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Definitive care
Transfer of patient to best suitedcloset medical facility after primary,secondary survey and resuscitation
as well as necessary adjuncts havebeen completed
Done in agreement with receiving
doctor.
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Triage
It is the process by which themanagement of multiple patientcasualties is prioritized.
Patient with life threatening problemsare treated first.
Patient with the greatest chance ofsurvival are managed first.
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Y
N
N
Y 30
10-29 >2 sec
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Life saving procedures onscene
Intubation
Needle application
Hemorrhage control (direct pressure/tourniquet)
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Life saving first aidtreatment
A: removal of debris, chin lift, jawthrust, manual cervical stabilisation
B: mouth to mouth, mouth to nose,chest decompression
C: control of external hemorrhage,application of pressure dressing,fracture alignment and splintage
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Plan ahead for masscasualties
Any hospital treating war wounded orserving as major surgical referralcentre must be prepared to receive
large numbers of casualties. A heavy influx of wounded arriving
within short space of time can
quickly overwhelm the availableresources.
An influx of wounded can occur at
any time without warning. It may be
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Triage area
The ED may not be large enough todeal with an influx of patients.
Road access protection.
Crowd control (police).
Close hospital.
One way flow.
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Triage leader
The one person in charge of thetriage process
Experienced, has understanding oftrauma
Understand how hospital functions
Able to make clear decisions understress.
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Triage leader decisionsmust be respected
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Triage categories
Category I : serious/ immediateresuscitate and immediate surgery.
Those patients for whom urgent
surgery is required and for those thathave a good chance of recovery.
Category II: secondary/ delayed can
wait for surgery. Those patients thatrequire surgery but not on an urgentbasis. Fractures and head injuries.
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Category III : superficial/minimalwalking wounded. Those patient thatdo not require hospitalization
because their wounds are minor.Laceration, simple fracture.
Category IV : supportive/expectant.
Those patients that are so severelyinjured that they are likely to die.Penetrating head wounds, high spinal
cord injuries, severe burn>60% BSA
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COLOUR CODING
Category I RED
Category II YELLOW
Category III GREEN Category IV BLACK
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Triage process
Suspend routine operations andactivities
In arrival in the triage area eachpatient is assigned a triage numberand a file
The patient is quickly assessed and atriage category is assigned by thetriage leader
The patient is directed to a predetermined area for treatment
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Doctors and nurses assigned to thedifferent categories carry out thetreatment
Operations are started in order ofpriority
Patients are re-assessed and a newcategory may be assigned
Ward and ICU spaces are created byshifting or discharging patients.
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Documentation duringtriage
Basic information: name, time ofinjury, cause of injury, first aid given.
Vital signs: BP, Pulse, RR ,Neurological evaluation.
Diagnosis: concise and complete
Category of triage Complete pre operative orders
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Evaluation
Following each mock practice
Following each actual mass casualtyevents
Allow flaws to be detected andmodifications or improvementsmade.
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Planning for MCI
1. Surge capacity of hospital in MCI:
. Defined on the basis of : availablesurgical teams.
. Existence of specific surgicaldepartments
.
Number of operation room. Number of ICU bed
. National directive(UK) : 20 % of total
bed capacity, 2/3 ambulatory
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Expansion of ER capacity:
1. Immediate re-enforcement ofpersonnel in ER
2. Internal call-up via annoucement
3. External call-up via mobile, group
beepers.
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Evacuation of ER:
1. Rapid discharge of patients
2. Transfer of patients to hospitalwards
. Cessation of surgical operations
. Internal relocation of patients toevacuate surgical beds
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Goal: saving maximum salvageablecasualties while minimizingdisabilities.
Expectance : 10 % of casualties willneed immediate surgery( within 2hours of admittance).
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Continuous triage
Initial triage on scene
Primary triage at entrance to hospital
Ongoing triage within ER todetermine needs:
1. Imaging
2. OT
3. ICU
4.
Hospitalization
E di biliti f
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Expanding capabilities ofmedical teams
Pre designation of roles in variousMCI
Preparation of checklists
Training of personnel (strengtheningspecific professions: burns,orthopedics, trauma)
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Logistic sources
Allocation of stretcher carriers
Storage of medical equipment inimmediate vicinity of admitting sites
Organizing equipment on mobilecarts
Early preparation of medicaltreatment charts
Assignment of blood trustee to ER
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Thank you