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Objectives
 Apply principles of primary and secondary surveys  Identify Management priorities  Institute appropriate resuscitation and monitoring procedures  Recognize value of patient’s history and biomechanics of injury  Anticipate pitfalls

Key Questions
 How do I prepare for a smooth transition from the prehospital to the hospital environments?  What is a quick, simple way to assess the patient in 10 seconds?  What is the secondary survey and when does it start?

More Key Questions
 How can I minimized missed injuries?  Which patients do I transfer to a higher level of care?  When should the transfer occur?

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Prepare for a smooth transition from the prehospital environ?  Transport guidelines / protocols  Online medical direction  Mobilization of resources  Periodic review of care  Closest. appropriate facility .

personnel.Prepare for a smooth transition to the inhospital environ?  Preplanning is essential  Equipment. services  Standard precautions  Prearranged transfer agreements .

Standard Precautions  Cap  Gown  Gloves  Mask  Shoe Covers  Goggles / face shield .

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simple way to asses the patient in 10 seconds? Identify yourself Ask the patient his / her name Ask the patient what happened .Quick.

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Primary Survey The priorities are the same for all patients. .

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Special Considerations Trauma in the elderly Pediatric trauma Trauma in pregnant women .

Primary Survey Establish patent airway  Protect c-spine  Pitfalls? • Equipment failure • Inability to intubate • Occult airway injury • Progressive loss of airway .

Primary Survey Assess and ensure adequate oxygenation and ventilation  Pitfalls? • Airway vs ventilation problem? • Iatrogenic pneumothorax or tension pneumothorax .

Assess for organ perfusion?  Level of consciousness  Skin color and temperature  Pulse rate and character .

Primary Survey Circulatory Management  Control hemorrhage  Restore volume  Reassess parameters  Pitfalls? • Elderly • Children • Athletes • Medications .

Primary Survey Disability  Baseline neurologic evaluation • GCS scoring • Pupillary response Observe for neurologic deterioration .

Primary Survey Exposure / Environment  Completely undress the patient Prevent hypothermia .

Resuscitation  Protect and secure airway  Ventilate and oxygenate  Stop the bleeding  Vigorous shock therapy  Protect from hypothermia .

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Adjuncts to Primary Survey Diagnostic Tools  DPL  FAST .

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When do I start it? After  Primary survey is completed  ABCDEs are reassessed  Vital functions are returning to normal .

What are the components?  History  Physical exam: Head-to-toe  “Tubes and fingers in every orifice”  Complete neurologic exam  Special diagnostic tests  Reevaluation .

Secondary Survey History Allergies Medications Past illnesses Last meal Events / Environment .

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Secondary Survey Head  GCS Score  Neurologic exam  Comprehensive eye and ear exam Pitfalls?  Unconsciousness  Periorbital edema  Occluded auditory canal .

Secondary Survey Maxillofacial  Bony crepitus  Deformity  Malocclusion Pitfalls?  Potential airway obstruction  Cribriform plate fracture  Frequently missed .

Secondary Survey Cervical Spine  Tenderness  Complete motor/ sensory exams  Reflexes  Imaging studies Pitfalls?  Altered sensorium  Inability to cooperate with clinical exam .

hoarseness  Findings: Crepitus. stridor. hematoma.Secondary Survey Neck (soft tissues)  Mechanism: Blunt vs penetrating  Symptoms: Airway obstruction. bruit .

Secondary Survey Neck (soft tissues): Pitfalls  Delayed symptoms and signs  Progressive airway obstruction  Occult injuries .

Secondary Survey Chest  Inspect  Palpate  Percuss  Auscultate  Obtain x-rays .

Secondary Survey Abdomen  Inspect  Auscultate  Palpate  Percuss  Reevaluate  Special studies .

Secondary Survey Abdomen: Pitfalls?  Hollow viscus injury  Retroperitoneal injury  Excessive pelvic manipulation .

rectal wall integrity. lacerations Urethral injury in women. hematomas. urethral blood Sphincter tone .Secondary Survey Perineum Rectum Contusions. blood Vagina Pitfalls Blood. pelvic fracture. pregnancy . lacerations. high–riding prostate.

deformity  Pain  Perfusion  Peripheral neurovascular status  X-rays as needed .Secondary Survey Musculoskeletal: Extremities  Contusion.

Secondary Survey Musculoskeletal: Pelvis  Pain on palpation  Symphysis width ↑  Leg length unequal  Instability  X-rays as needed .

Secondary Survey Musculoskeletal: Pitfalls Potential blood loss Missed fractures Soft-tissue or ligamentous injury Compartment syndrome (especially with altered sensorium / hypotension) .

Secondary Survey Neurologic: Brain Early neurosurgical consult  GCS Score  Lateralizing signs  Frequent reevaluation  Prevent secondary brain injury .

Secondary Survey Neurologic: Spine and Cord  Complete motor and sensory exams  Imaging as indicated  Reflexes Early neurosurgical / orthopaedic consult .

Secondary Survey Neurologic: Pitfalls Incomplete immobilization Subtle ↑ in ICP with manipulation Rapid deterioration .

Adjuncts to Secondary Survey  Special diagnostic test as indicated  Pitfalls? • Patient deterioration • Delay of transfer .

Minimize missed injuries?  High index of suspicion  Frequent reeveluation and monitoring .

Pain Management  Relief of pain /anxiety as appropriate  Administer intravenously  Careful monitoring is essential .

Which patients do I transfer?  Those whose injuries exceed institutional capabilities  Examples • Multisystem or complex injuries • Patient with comorbidity or age extremes .

When do I transfer the patient?  As soon as possible after stabilizing measures are completed  Airway and ventilatory control  Hemorrhage control (operation) Avoid needless delay .

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Records. choronologic documentation  Consent for treatment  Forensic evidence . Legal Considerations  Concise.

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Primary Survey Resuscitation Adjuncts Secondary Survey Definitive Care Adjuncts .