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QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN

ELIZABETH

LECTURE 1

INITIAL
ASSESSMENT
&
MANAGEMENT
POLYTRAUMA
July 4, 2015

MANAGEMENT OF POLYTRAUMA

QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

CASE SCENARIO

What is the sequence of priorities in assessing


this patient?
44-year-old male driver who
crashed head-on into a wall
Patient found unresponsive at the
scene
Arrives at hospital via basic life
support with c-collar in place and
strapped to a backboard; Lions
ambulance assisting ventilations
with bag-mask

July 4, 2015

MANAGEMENT OF POLYTRAUMA

QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

OBJECTIVES

Apply principles of primary and


secondary surveys
Identify management priorities
Institute appropriate resuscitation
and monitoring procedures
Recognize the value of the patient
history and biomechanics of injury
Anticipate and manage pitfalls

July 4, 2015

MANAGEMENT OF POLYTRAUMA

QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

STANDARD
PRECAUTIONS

Cap
Gown
Gloves
Mask
Shoe covers
Goggles / face
shield

July 4, 2015

MANAGEMENT OF POLYTRAUMA

QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

CONCEPT OF INITIAL
ASSESSMENT

Primary Survey

Definitive Care

Adjuncts
Resuscitation

Reevaluation

Reevaluation
Detailed
Secondary
Survey

Adjuncts

Primary survey and resuscitation of vital functions are done


simultaneously using a team approach.
July 4, 2015

MANAGEMENT OF POLYTRAUMA

QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

QUICK ASSESSMENT

What is a quick, simple way


to assess a patient in 10
seconds?

July 4, 2015

MANAGEMENT OF POLYTRAUMA

QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

QUICK ASSESSMENT

Identify yourself
Ask the patient his or her name
Ask the patient what happened

July 4, 2015

MANAGEMENT OF POLYTRAUMA

QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

QUICK ASSESSMENT

APPROPRIATE RESPONSE CONFIRMS


:

Patent airway

Sufficient air reserve to permit


speech

Sufficient perfusion to permit


cerebration

D
July 4, 2015

Clear sensorium
MANAGEMENT OF POLYTRAUMA

QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

PRIMARY SURVEY

Airway with c-spine protection


Breathing with adequate oxygenation
Circulation with hemorrhage control
Disability
Exposure / Environment

July 4, 2015

MANAGEMENT OF POLYTRAUMA

PRIMARY SURVEY :
AIRWAY

QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

Establish patent airway


and
protect c-spine
Pitfalls

Occult airway injury


Progressive loss of
airway
Equipment failure
Inability to intubate
July 4, 2015

MANAGEMENT OF POLYTRAUMA

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ELIZABETH

PRIMARY SURVEY

: BREATHING

Assess and ensure adequate oxygenation


and ventilation

Respiratory rate

Chest movement

Air entry

Oxygen saturation

July 4, 2015

Pitfalls

Airway versus ventilation


problem?
latrogenic pneumothorax
or
tension pneumothorax?

MANAGEMENT OF POLYTRAUMA

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QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

PRIMARY SURVEY
Assess for organ perfusion by :
Level of
consciousness
Skin color and
temperature
Pulse rate and
Management for organ perfusion by :
character
Control
hemorrhage

CIRCULATION
Pitfalls

Elderly
Children
Athletes
Medications

Restore volume
Reassess patient
MANAGEMENT OF POLYTRAUMA

July 4, 2015

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ELIZABETH

PRIMARY SURVEY

: DISABILITY

Baseline neurologic
evaluation
Glasgow Coma Scale
score

Pupillary response

Caution

Observe for
neurologic
deterioration
July 4, 2015

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ELIZABETH

PRIMARY SURVEY
EXPOSURE / ENVIRONMENT

Completely undress the patient


Caution

Prevent
hypothermia

Pitfalls

Missed
injuries
July 4, 2015

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ELIZABETH

RESUSCITATION

Protect and secure airway


Ventilate and oxygenate
Stop the bleeding!
Vigorous shock therapy
Protect from hypothermia

July 4, 2015

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ELIZABETH

ADJUNCTS TO PRIMARY
SURVEY
Vital signs
ABGs

ECG

PRIMARY SURVEY
Urinary
output
Urinary / gastric catheters
unless contraindicated
July 4, 2015

MANAGEMENT OF POLYTRAUMA

Pulse
oximeter
and CO2

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ADJUNCTS TO PRIMARY
SURVEY

DIAGNOSTIC TOOLS

July 4, 2015

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ELIZABETH

ADJUNCTS TO PRIMARY
SURVEY

DIAGNOSTIC TOOLS
1.Fast
2.DPL

July 4, 2015

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ELIZABETH

SECONDARY SURVEY

The complete history and physical


Components of
examination

When to start the secondary survey?


After
Primary survey is
completed
ABCDEs are
reassessed
Vital functions are
returning to normal
July 4, 2015

the secondary
survey

History
Physical exam: Head
to toe
Complete neurologic
exam
Special diagnostic
tests

MANAGEMENT OF POLYTRAUMA

Reevaluation

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ELIZABETH

SECONDARY SURVEY

History
Allergies
Medications
Past

illnesses

Last

meal

Events

/ Environment /
Mechanism

July 4, 2015

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ELIZABETH

SECONDARY SURVEY

Mechanisms of Injury

July 4, 2015

MANAGEMENT OF POLYTRAUMA

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ELIZABETH

SECONDARY SURVEY

Head
External exam
Scalp palpation
Comprehensive
eye and ear
exam
Including
visual acuity

July 4, 2015

Pitfalls

Unconsciousness
Periorbital edema
Occluded auditory
canal

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ELIZABETH

SECONDARY SURVEY

Maxillofacial
Bony crepitus
Deformity
Malocclusion

Pitfalls

Potential
airway
obstruction
Cribriform plate fracture
Frequently missed

July 4, 2015

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SECONDARY SURVEY

Neck (Soft
Tissues)

Mechanism:

Symptoms:
hoarseness
Findings:

Blunt vs penetrating
Airway obstruction,
Crepitus, hematoma, stridor, bruit
Pitfalls

Delayed symptoms and


signs
Progressive airway
obstruction
July 4, 2015

Occult injuries

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ELIZABETH

SECONDARY SURVEY

Chest
Inspect
Palpate
Percuss
Auscultate
X-rays

July 4, 2015

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QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

SECONDARY SURVEY

Abdomen
Inspect /
Auscultate
Palpate / Percuss
Reevaluate
Special studies
Pitfalls

Hollow viscous injury


Retroperitoneal injury

July 4, 2015

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ELIZABETH

SECONDARY SURVEY

Perineum
Contusions, hematomas, lacerations,
urethral blood

Rectum
Sphincter tone, high-riding prostate, pelvic
fracture,
rectal wall integrity, blood
Pitfalls

Urethral injury

Vagina

Pregnancy

Blood, lacerations
July 4, 2015

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ELIZABETH

SECONDARY SURVEY

Pelvis
Pain on palpation
Leg length unequal
Instability
X-rays as needed
Pitfalls

Excessive pelvic
manipulation
July 4, 2015

Underestimating pelvic
blood loss
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ELIZABETH

SECONDARY SURVEY

Extremities
Contusion,
deformity
Pain
Perfusion
Peripheral
neurovascular
status
X-rays as needed
July 4, 2015

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ELIZABETH

SECONDARY SURVEY

Pitfalls

Potential blood loss


Missed fractures
Soft tissue or ligamentous injury
Compartment syndrome (especially
with altered sensorium /
hypotension)

July 4, 2015

MANAGEMENT OF POLYTRAUMA

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QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

SECONDARY SURVEY

Neurologic:
Brain

GCS
Pupil size and
reaction
Lateralizing signs
Frequent
reevaluation
Prevent secondary
brain injury
July 4, 2015

MANAGEMENT OF POLYTRAUMA

Early
neurosurgical
consult
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QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

SECONDARY SURVEY

Neurologic: Spinal
Assessment

Whole spine
Tenderness and swelling
Complete motor and sensory exams
Reflexes
Imaging studies
Pitfalls

Altered sensorium

Inability to cooperate with


clinical exam
July 4, 2015

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ELIZABETH

SECONDARY SURVEY

Neurologic: Spine and


Cord
Conduct an in-depth evaluation
of the patients spine and spinal
cord

Early
neurosurgical /
orthopedic
consult
July 4, 2015

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ELIZABETH

SECONDARY SURVEY

Neurologic

Pitfalls

Incomplete immobilization
Neurologic deterioration

July 4, 2015

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ELIZABETH

ADJUNCTS TO
SECONDARY SURVEY

Special Diagnostic Tests as Indicated


Pitfalls

Patient
deterioration
Delay of
transfer

Deterioration
during transfer
Poor
communication
July 4, 2015

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ELIZABETH

PAIN MANAGEMENT

Relief of pain /
anxiety as
appropriate
Administer
intravenously
Careful monitoring is
essential

July 4, 2015

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QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

SUMMARY

Primary Survey
Adjuncts
Resuscitation

Definitive Care

Reevaluation

Reevaluation
Detailed
Secondary
Survey
July 4, 2015

MANAGEMENT OF POLYTRAUMA

Adjuncts
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ELIZABETH

ANY
QUESTIONS ?

July 4, 2015

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ELIZABETH

LECTURE 1

TRAUMA TEAM
CONCEPT &
PHILOSOPHY
July 4, 2015

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ELIZABETH

INTRODUCTION

TRAUMA TEAM
Many studies in developing countries
have shown that > 30% of total hospital
death is due to trauma.
A well integrated trauma system based
upon TEAMWORK and PARTNERING
can reduce the mortality rate to less than
10%.
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ELIZABETH

TEAM WORK

ORGANISATION OF TEAMWORK

Vertical Team Organization

Horizontal Team Organization


July 4, 2015

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ELIZABETH

VERTICAL TEAM
ORGANISATION

1. Command & instructions are


determined by the Team Leader.
2. Task carried out sequentially.
3. Focused on Team Leader.
4. Inefficient work culture.
July 4, 2015

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QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

VERTICAL TEAM
TEAM
LEADER

WORKER 1

WORKER 3
WORKER 2

July 4, 2015

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ELIZABETH

HORIZONTAL TEAM
ORGANISATION

All members carry out individual tasks


simultaneously.
Not focused on any particular team member
or team leader.
Enhance Team Performance and Improved
Outcome.
Most efficient organisation
July 4, 2015

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ELIZABETH

HORIZONTAL TEAM

TEAM LEADER

WORKER 1

July 4, 2015

WORKER 2

MANAGEMENT OF POLYTRAUMA

WORKER 3

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ELIZABETH

TEAM WORK

Features of an efficient teamwork


1. Task divided into manageable units.
2. Specifically allocated to individual
members.
3. Task evenly divided among Team
Members.
4. Task carried out SIMULTANEOUSLY.
July 4, 2015

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ELIZABETH

TRAUMA TEAM

Current System in Managing Multiple Trauma in


Malaysia.

1. Resuscitation carried out with a mixture of


vertical and horizontal task distribution.
2. Variable team size.
3. Members tend to arrive at different times.
4. Lack of overall coordination.
5. Junior doctors.
July 4, 2015

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ELIZABETH

TRAUMA TEAM

Trauma Team Structures and


Functions
1. Optimal size depends on the severity
of injuries and experience of the
individual team members.
2. Ideally an 8-member team.
3. The strength of the team is as strong
as its weakest link.
July 4, 2015

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ELIZABETH

July 4, 2015

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QUEEN TRAUMA LIFE SUPPORT COURSE HOSPITAL QUEEN


ELIZABETH

RESUSCITATION ZONE

Resuscitation Zone Layout


A dedicated and proper working area to
facilitate performance of the Trauma
Team.
Golf Swing movement.
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ELIZABETH

ROLE OF TEAM LEADER

Team Leader :
The most experienced personnel
Perform the most important aspects of
the management e.g primary survey
and resuscitation procedures.

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TRAUMA TEAM

Development of Trauma Team in Malaysia


Phase I
First 5 - 10 minutes :
ED

3 Member Team from

Phase II
From 3 - 6 hours :

6 Member Team
additional members
from the respective departments.

July 4, 2015

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SUMMARY

Trauma should be managed as


smoothly and as efficiently as a

PIT STOP
in a

FORMULA ONE RACE


July 4, 2015

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ELIZABETH

INITIAL ASSESSMENT

ANY
QUESTIONS ?

July 4, 2015

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