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Atls Notes Ko Aldy PDF
Atls Notes Ko Aldy PDF
Triage
The process of prioritizing patient treatment during mass -casualty events.
Do the most good for the most patients using available resources
Sorting of patients based on their needs for treatment ABC
1
A = Airway & cervical spine control
Airway management
1. Clearing the airway & Suctioning
2. Administering oxygen
3. Securing the airway
B = Breathing
2
Blood should be drawn for type and crossmatch and baseline hematologic studies,
including a pregnancy test for all females of childbearing age.
Blood gases and/or lactate level should be obtained to assess the presence and
degree of shock.
Cardiac tamponade and tension pneumothorax are suggested by the presence of
distended neck veins. Decreased breath sounds, hyperresonance to percussion, and
shock may be the only indications of tension pneumothorax
Excessive manipulation of the pelvis should be avoided, because it can precipitate
additional hemorrhage & AP pelvic x-ray, performed as an adjunct to the primary
survey and resuscitation, can Dx pelvic fractures
1. Level of consciousness
2. Pupillary size and reaction
3. Lateralizing signs
4. Spinal cord injury level
# 2ry survey
1. Head-to-toe clinical evaluation
2. Complete history
3. Reassessment of all vital signs
3
Which patients do I transfer to a higher level of care?
When should the transfer occur?
Transfer should be considered whenever the patient’s treatment needs exceed the
capability of the receiving institution; including equipment, resources, and
personnel.
These criteria take into account the patient’s physiologic status, obvious anatomic
injury, mechanisms of injury, concurrent diseases, and other factors that can alter
the patient’s prognosis.
On arrival of the patient, the team leader supervises the hand-over by EMS
personnel, making certain that no team member begins working on the patient
unless immediate life-threatening conditions are obvious (“hands-off hand-over”).
A useful format is the MIST acronym:
o Mechanism (and time) of injury
o Injuries found and suspected
o Symptoms and Signs
o Treatment initiated
4
Airway and Ventilatory Management
5
Definitive Airway
Select the proper-size tube {same size as the infant’s nostril or little finger}
Insert the endotracheal tube not more than 2 cm past the cords
There are three types of definitive airways:
1. Orotracheal tubes
2. Nasotracheal tubes
3. Surgical airways (Cricothyroidotomy or tracheostomy).
1. Airway problems
Inability to maintain a patent airway by other means
Potential compromise of the airway (e.g., following inhalation injury, facial
fractures, or retropharyngeal hematoma)
2. Breathing problem
Inability to maintain oxygenation by face-mask
Presence of apnea
3. Disability problems
Head injury + GCS score of 8 or less
Protect airway from aspiration of blood or vomitus
Sustained seizure activity
6
Rapid Sequence Intubation {RSI}
If RSE failed, the patient must be ventilated with a bag-mask device until the
paralysis resolves; long acting drugs are not routinely used for RSI for this reason
Particular attention must be paid in cases of preexisting chronic renal failure, chronic
paralysis, and chronic neuromuscular disease
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Surgical Airway {Cricothyroidotomy or Tracheostomy} Indications
Edema of the glottis
Fracture of the larynx
Severe oropharyngeal hemorrhage obstructs the airway
Endotracheal tube cannot be placed through the vocal cords
Needle Cricothyroidotomy
Insertion of a needle through the cricothyroid membrane or into the trachea
It provides oxygen on a short-term basis until a definitive airway can be placed
Cannula 12- to 14-gauge for adults, and 16- to 18-gauge in children
Connected to oxygen at 15 L/min
Used for 30 to 45 min Because of the inadequate exhalation,
CO2 slowly accumulates, especially in patients with head injuries
Surgical Cricothyroidotomy
a skin incision that extends through the cricothyroid membrane.
A curved hemostat may be inserted to dilate the opening
Small ETT or tracheostomy tube (preferably 5 to 7 mm OD) can be inserted.
Care must be taken, especially with children, to avoid damage to the cricoid
cartilage, which is the only circumferential support for the upper trachea.
It’s not recommended below 12 year
Note: percutaneous tracheostomy is not a safe procedure in the acute trauma Pt.
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Management of Oxygenation { Pulse oximetry & ABG}
1- Pulse oximetry
Noninvasive method
Measure oxygen saturation and pulse rate of arterial blood
It does not measure the partial pressure of oxygen (PaO2)
But if 95% or greater = adequate peripheral arterial oxygenation
(PaO2 >70 mm Hg, or 9.3 kPa)
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Shock
Treatment of shock
1. Providing adequate oxygenation& Ventilation
2. Appropriate fluid resuscitation
3. Stopping the bleeding.
Recognition of Shock
Hematocrit unreliable and should not be used to exclude the presence of shock
The failure of fluid resuscitation to restore organ perfusion suggests either
continuing hemorrhage or neurogenic shock
Patient with injuries above diaphragm may have evidence of inadequate organ
perfusion due to poor cardiac performance {inadequate venous return (preload).
o Blunt myocardial injury, Cardiac tamponade,
o Tension pneumothorax
o Spinal cord injury {Neurogenic Shock}
o Septic shock
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Neurogenic Shock
Cervical or upper thoracic spinal cord injury can produce hypotension due to loss of
sympathetic tone but
1. No tachycardia
2. No cutaneous vasoconstriction.
3. No narrowed pulse pressure
Septic Shock
Early septic shock can have a normal circulating volume + modest tachycardia
Warm skin, systolic pressure near normal, and a wide pulse pressure.
Hemorrhagic Shock
Normal blood volume is:
o Adult, 7% of body weight {70-kg male has approximately 5 L}.
o Child, 8% to 9% of body weight (80–90 mL/kg)
The usual dose is 1 to 2 L for adults and 20 mL/kg for pediatric patients.
Absolute volumes of resuscitation fluids should be based on patient response.
initial fluid amount includes any fluid given in the Prehospital setting
Excessive fluid administration can exacerbate the lethal triad of coagulopathy,
acidosis, and hypothermia with activation of the inflammatory cascade.
o Balancing the goal of organ perfusion with the risks of rebleeding by
accepting a lower-than-normal blood pressure has been termed “controlled
resuscitation,” “balanced resuscitation,” “hypotensive resuscitation
o The goal is the balance, not the hypotension.
o Such a resuscitation strategy may be a bridge to, but is not a substitute for,
definitive surgical control of bleeding
11
Adequate resuscitation should produce a urinary output of approximately 0.5
mL/kg/hr. in adults, whereas 1 mL/kg/hr. in pediatric patients
Persistent acidosis is usually caused by inadequate resuscitation or ongoing blood
loss and, it should be treated with fluids, blood, and consideration of operative
intervention to control hemorrhage. Serial measurement of these parameters can be
used to monitor the response to therapy. Sodium bicarbonate should not be used to
treat metabolic acidosis secondary to hypovolemic shock.
o Ohm’s law (V = I x R)
(V) blood pressure
(I) cardiac output
(R) (afterload). systemic vascular resistance
o Increase in blood pressure should not be equated with a concomitant
increase in cardiac output or the recovery from shock.
o An increase in peripheral resistance—for example, with vasopressor
therapy—with no change in cardiac output results in increased blood
pressure, but no improvement in tissue perfusion or oxygenation.
12
Crossmatched, Type-Specific, And Type O Blood
Hypothermia
Most efficient way to prevent hypothermia in any patient receiving massive volumes
of crystalloid is to heat the fluid to 39°C before infusing it.
Blood products cannot be warmed in a microwave oven
Massive transfusion, defined as >10 units of pRBCs within the first 24 hours.
Early administration of pRBCs, plasma, and platelets, and minimizing aggressive
crystalloid administration is termed balanced, hemostatic or damage control
resuscitation
Prothrombin time, partial thromboplastin time, and platelet count are valuable
baseline studies to obtain in the first hour
13
Thoracic Trauma
Tension Pneumothorax
Most common cause is mechanical ventilation with positive-pressure ventilation
Must be Clinical diagnosis
Rx should not be delayed to wait for radiologic confirmation
Open Pneumothorax
Promptly closing the defect with a sterile occlusive dressing {large enough to overlap
the wound’s edges and then taped securely on three sides in order to provide a
flutter-type valve effect}
Then chest tube remote from the wound should be placed as soon as possible
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Massive Hemothorax
Rapid accumulation of more than 1500 mL of blood or one-third of the patient’s
blood volume in the chest cavity
Is suggested when shock is associated with the absence of breath sounds or dullness
to percussion on one side of the chest
Initially managed by the simultaneous restoration of blood volume and
decompression of the chest cavity
Cardiac Tamponade
Most commonly results from penetrating injuries.
Human pericardial sac is a fixed fibrous structure; a relatively small amount of blood
can restrict cardiac activity and interfere with cardiac filling.
Classic diagnostic Beck’s triad:
1. Elevated Venous pressure
2. Decline in arterial pressure
3. Muffled heart tones
Additional diagnostic includes; Echocardiogram & FAST, or pericardial window.
Preparation to transfer such a patient for definitive care is always necessary
Thoracotomy is indicated only when a qualified surgeon is available.
If surgical intervention is not possible, Pericardiocentesis can be diagnostic as well as
therapeutic, but it is not definitive treatment for cardiac tamponade
2. Penetrating thoracic injuries + CPR in the Prehospital setting + no any signs of life
and no cardiac electrical activity no further resuscitative effort should be made.
3. Blunt thoracic injuries + pulseless + with myocardial electrical activity (PEA) are not
candidates for emergency department resuscitative thoracotomy.
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PERICARDIOCENTESIS
Using a 16 to 18 gauge
6 in. (15-cm) or longer over-the-needle catheter
Attach a 35-mL empty syringe with a three-way stopcock
Puncture the skin 1 to 2 cm inferior to the left of the xiphochondral junction, at a 45-
degree angle to the skin.
After aspiration is completed, remove the syringe and attach a three-way stopcock,
leaving the stopcock closed. Secure the catheter in place.
COMPLICATIONS OF PERICARDIOCENTESIS
Aspiration of ventricular blood instead of pericardial blood
Laceration of ventricular epicardium/ myocardium
Laceration of coronary artery or vein
New hemopericardium, secondary to lacerations of the coronary artery or vein, and/or
ventricular epicardium/ myocardium
Ventricular fibrillation
Pneumothorax, secondary to lung puncture
Puncture of great vessels with worsening of pericardial tamponade
Puncture of esophagus with subsequent mediastinitis
Puncture of peritoneum with subsequent peritonitis or false positive aspirate
Simple Pneumothorax
An upright, expiratory x-ray of the chest aids in the diagnosis.
Any pneumothorax is best treated with a chest tube placed in the fifth ICS
You must inset ICT before any GA or using PPV and air ambulance
Pulmonary Contusion
Patients with significant hypoxia (PaO2 <65 mm Hg or SaO2 <90%) on room air may
require intubation and ventilation within the first hour after injury.
Associated medical conditions, such as chronic obstructive pulmonary disease and
renal failure, increase the likelihood of needing early intubation and mechanical
ventilation
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Traumatic aortic rupture
Common cause of sudden death after automobile collision or fall from height
Chest x-ray, finding which may indicate major vascular injury include:
o Widened mediastinum
o Obliteration of the aortic knob
o Deviation of the trachea to the right
o Depression of the left mainstem bronchus
o Elevation of the right mainstem bronchus
o Obliteration of the space between the pulmonary artery and the aorta
o Deviation of the esophagus (nasogastric tube) to the right
o Widened paratracheal stripe
o Widened paraspinal interfaces
o Presence of a pleural or apical cap
o Left hemothorax
o Fractures of the first or second rib or scapula
A properly performed and interpreted helical CT that is normal may obviate the need
for transfer to a higher level of care to exclude thoracic aortic injury.
All patients with a mechanism of injury and simple chest x-ray findings suggestive of
aortic disruption should be transferred to a facility capable of rapid definitive
diagnosis and treatment of this injury.
Diaphragm injuries
may be missed during the initial trauma evaluation.
An undiagnosed diaphragm injury can result in pulmonary compromise or
entrapment and strangulation of peritoneal contents
Esophageal injury
Should be considered in
o Any patient who has a left pneumothorax or hemothorax without a rib
fracture;
o Received a severe blow to the lower sternum or epigastrium and is in pain or
shock out of proportion to the apparent injury
o Presence of mediastinal air
o Confirmed by contrast studies and/or Esophagoscopy.
Treatment consists of wide drainage of the pleural space and mediastinum with
direct repair of the injury via thoracotomy, if feasible.
Repairs performed within a few hours of injury lead to a much better prognosis.
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Chest X-Ray
18
Abdominal and Pelvic Trauma
Any patient who has sustained significant blunt torso injury from a direct blow,
deceleration, or a penetrating injury must be considered to have an abdominal
visceral, vascular, or pelvic injury until proven otherwise
Airbag deployment does not preclude abdominal injury
CT scan
Can miss some gastrointestinal, diaphragmatic, and pancreatic injuries.
In the absence of hepatic or splenic injuries, the presence of free fluid in the
abdominal cavity suggests an injury to the GI tract and/or its mesentery, and many
trauma surgeons find this to be an indication for early operative intervention.
If there is early or obvious evidence that the patient will be transferred to another
facility, time-consuming tests, including abdominal CT, should not be performed.
FAST
Is performed with a low frequency (3.5 MHz) transducer
Higher frequency transducers may be appropriate for children or extremely thin adults
19
Most gunshot wounds to the abdomen
Are managed by exploratory laparotomy
Incidence of significant intraperitoneal injury approaches 98%
Tangential gunshot wounds often are not truly tangential
Blast injuries can cause intraperitoneal injury without peritoneal penetration.
An early normal serum amylase level does not exclude major pancreatic trauma.
Conversely, the amylase level can be elevated from nonpancreatic sources.
20
Head Trauma
Obtaining a CT scan should not delay patient transfer to a trauma center that is
capable of immediate and definitive neurosurgical intervention.
Early endotracheal intubation should be performed in comatose patients
Normal ICP in the resting state is approximately 10 mmHg. If ICP greater than 20
mmHg, particularly if sustained, are associated with poor outcomes.
Monro-Kellie doctrine theory explained why ICP not initially rise {due to decrease in
CSF and venous volume} However, once the limit is reached, ICP rapidly increases.
Every effort should be made to enhance cerebral perfusion and blood flow by
o Reducing elevated ICP,
o Maintaining normal intravascular volume,
o Maintaining a normal mean arterial blood pressure (MAP),
o Restoring normal oxygenation and normocapnia.
Hematomas that increase intracranial volume should be evacuated early.
21
Classifications of Head Injuries
22
High risk for neurosurgical intervention
• GCS score less than 15 at 2 hours after injury
• Suspected open or depressed skull fracture
• Basilar skull fracture (e.g., hemotympanum, raccoon eyes, CSF otorrhoea or
rhinorrhea, Battle’s sign)
• Vomiting (more than two episodes)
• Age more than 65 years
3. Mannitol {20% solution = 20 g per 100 ml) is used to reduce elevated ICP in a
euvolemic patient with dose of bolus of (1 g/kg) over 5 minutes)
4. Hypertonic saline {3% to 23.4%} is also used to reduce elevated ICP; this may be
the preferable agent with hypotension, as it does not act as a diuretic
6. Anticonvulsants.
o Prolonged seizures (30 to 60 minutes) may cause secondary brain injury Vs.
Anticonvulsants inhibit brain recovery, so they should be used only when
absolutely necessary {IV 1 g of phenytoin no faster than 50 mg/min followed
by maintenance 100 mg/8 hours, with the dose titrated to achieve
therapeutic serum levels}
o Note: it is important to remember that seizures are not controlled with
muscle relaxants.
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Diagnosis of brain death
{no possibility for recovery of brain function}
1. Glasgow Coma Scale score = 3
2. Nonreactive pupils
3. Absent brainstem reflexes (oculocephalic, corneal, and Doll’s eyes, and no gag reflex)
4. No spontaneous ventilatory effort on formal apnea testing
Note: Local organ-procurement agencies should be notified about all patients with the
diagnosis or impending diagnosis of brain death prior to discontinuing artificial life support
measures.
24
Spinal Nerve Segments and Areas of Innervation
25
Neurogenic shock
Impairment of the descending sympathetic pathways in the cervical or upper
thoracic spinal cord.
Results in the loss of vasomotor tone and in sympathetic innervation to the heart.
Is rare in spinal cord injury below the level of T6; if shock is present in these patients,
an alternative source should be strongly suspected.
Atropine may be used to counteract hemodynamically significant bradycardia.
Spinal shock
Refers to the flaccidity and loss of reflexes seen after spinal cord injury.
“shock” to the injured cord may make it appear completely nonfunctional, although
the cord may not necessarily be destroyed.
The duration of this state is variable.
26
Musculoskeletal Trauma
There are three goals for the assessment of trauma patients’ extremities:
1. Identification of life-threatening injuries (primary survey)
2. Identification of limb-threatening injuries (secondary survey)
3. Systematic review to avoid missing any other musculoskeletal injury
(continuous reevaluation)
Doppler ankle/brachial index of less than 0.9 is indicative of an abnormal arterial
flow secondary to injury or peripheral vascular disease. The ankle/brachial index is
determined by taking the systolic blood pressure value as measured by Doppler at
the ankle of the injured leg and dividing it by the Doppler-determined systolic blood
pressure of the uninjured arm.
Limb-Threatening Injuries
1. Open fractures & Joint injuries,
2. Vascular injuries,
3. Compartment syndrome,
4. Neurologic injury secondary to fracture dislocation.
Muscle does not tolerate a lack of arterial blood flow for longer than 6 hours before
necrosis begins
A patient with multiple injuries who requires intensive resuscitation and emergency
surgery is not a candidate for replantation.
27
Traction splint of a femur fracture should be avoided if there is a concomitant
ipsilateral lower leg fracture.
Despite a thorough examination, occult associated injuries may not be identified
during the initial evaluation. it is imperative to repeatedly reevaluate the patient to
assess for these injuries.
Normal capillary refill (<2 seconds) of the pulp space or nail bed
28
Thermal Injuries
29
The initial fluid rate for burn patients
2 to 4 x kg x BSA per 1st 24h
o ½ in the 1st 8h
o then ½ to the remaining 16 h
example 100 kg with 80% burn {2 to 4 x 100 x 80} = 16000 or 32000 ml/24h
o Give 8000 ml in 1st 8 h {to 16000}
o Ten 8000 in the following 16 h {to 16000}
Amount of fluids provided should be adjusted based on the urine output target of
0.5 mL/ kg/ hr for adults and 1 mL/kg/hr for children <30 kg.
In very small children (i.e., <10 kg), it may be necessary to add glucose to their IV
fluids to avoid hypoglycemia
Pressure >30 mm Hg within the compartment may lead to muscle necrosis need
{Escharotomy} but usually are not needed within the first 6 hours after a burn injury
Do not apply cold water to a patient with extensive burns (>10% total BSA).
NO indication for prophylactic antibiotics in the early post-burn period. Antibiotics
should be reserved for the treatment of infection.
Alkali burns are generally more serious than acid burns, because the alkalies
penetrate more deeply. Alkali burns to the eye require continuous irrigation during
the first 8 hours after the burn
Patients with electrical injuries frequently need fasciotomy and should be
transferred to burn centers early in their course of treatment.
Rx:
o Place the injured part in circulating water at a constant 40°C until pink color
and perfusion return (usually within 20 to 30 minutes).
o Rewarming can be extremely painful, and adequate analgesics (intravenous
narcotics) are essential.
o Cardiac monitoring during rewarming is advised.
Hypothermia
Core temperature below 36°C
Severe hypothermia is any core temperature below 32°C
30
Pediatric Trauma
Pediatric Trauma Score
31
LMA sizes
1 (appropriate for infants <6.5 kg)
1.5 (for 5 to 10 kg)
2 (for 10 to 20 kg)
2.5 (for 20 to 30 kg)
3 (for between 30 and 70 kg)
over 70 kg, adult sizing is appropriate
32
Cardiopulmonary resuscitation (CPR)
CPR done in the field + return of spontaneous circulation = 50% chance of
neurologically intact survival.
CPR done in the field + still arrest = dismal prognosis.
CPR >15 minutes + Fixed pupils = predict nonsurvival.
Operative management is indicated not by the amount of intraperitoneal blood, but
by hemodynamic abnormality and its response to treatment.
Blood found on a DPL would not mandate operative exploration in a child who is
otherwise stable
An infant who is not in a coma but who has bulging fontanelles or suture diastases
should be treated as having a more severe injury. Early neurosurgical consultation is
essential.
GCS is useful when applied to the pediatric age group. However, the verbal score
component must be modified for children younger than 4 years
Phenobarbital 10 to 20 mg/kg/dose
Diazepam 0.1 to 0.2 mg/kg/dose; slow IV bolus
Phenytoin 15 to 20 mg/kg
Loading dose; 0.5 to 1.5 mL/kg/min
Then maintenance 4 to 7 mg/kg/day
Hypertonic saline 3% 3 to 5 mL/kg
Mannitol 0.5 to 1.0 g/kg (rarely required)
33
Geriatric Trauma
Mortality rate was three times greater in older patients with preexisting disease
(9.2% vs 3.2%).
However, more than 80% of injured older adults can return to their preexisting level
of independent living after aggressive resuscitation and follow-up care
Consequently, whereas broken dentures should be removed, intact well-fitted
dentures are often best left in place until after airway control is achieved
Undue manipulation of the osteoarthritic cervical spine, leading to spinal cord injury.
With aging, total blood volume decreases and circulation time increases
A common pitfall in the evaluation of geriatric trauma patients is the mistaken
impression that “normal” blood pressure and heart rate indicate normovolemia
Hypothermia not attributable to shock or exposure should alert the physician to the
possibility of occult disease—in particular, sepsis, endocrine disease, or
pharmacologic causes.
The most common locations of fractures in elderly patients are the ribs, proximal
femur, hip, humerus, and wrist
2. Elder maltreatment
Is any willful infliction of injury, unreasonable confinement, intimidation, or cruel
punishment that results in physical harm, pain, mental anguish, or other willful
deprivation by a caretaker of goods or services that are necessary to avoid physical
harm, mental anguish, or mental illness.
3. End-of-life decisions
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Trauma in Pregnancy and Intimate Partner Violence
There are few data to support perimortem cesarean section in pregnant trauma
patients who experience hypovolemic cardiac arrest.
For other causes of maternal cardiac arrest, perimortem cesarean section
occasionally may be successful if performed within 4 to 5 minutes of the arrest.
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App A- Ocular Trauma
Hypothermia
Core body temperature below 35°C {Mild till 32, moderate till 30 and sever < 30}
Depressed level of consciousness is the most common feature
Determination of death can be very difficult; Patients should not be pronounced
dead until full efforts have been made to rewarm them except
o Anoxic, still normothermic
o Serum potassium level greater than 10 mmol/L
Rx of Severe hypothermia with active core rewarming methods
o Bladder irrigation
o Adding warmed humidification to ventilation
o Surgical rewarming such as peritoneal lavage, pleural lavage, arteriovenous
rewarming, and cardiopulmonary bypass
Cardiac drugs and defibrillation are not usually effective in the presence of acidosis,
hypoxia, and hypothermia {postponed until the patient is warmed to at least 28°C}
inadvisable to insert a subclavian or internal jugular line in hypothermic patients due
to the risk of triggering an uncontrollable cardiac arrhythmia.
Attempts to actively rewarm should not delay transfer to a critical care setting
Heat Injuries
Heat exhaustion
Core temperature usually less than 39°C
Caused by excessive loss of body water, electrolyte depletion, or both
Intact mental function
Heat stroke
Core temperature ≥ 40°C
Life-threatening disease {mortality is up to 80%}
CNS dysfunction {delirium, convulsions, and coma} & may progress to DIC
Prompt correction of hyperthermia by immediate cooling and support of organ-
system function are the two main therapeutic objectives in patients with HS
36
App C- Austere and Armed Conflict Environments
Medical Response Team: A team of 1to 4 health care professionals, led by an acute
care specialist, that provides emergency medical care to an individualpatient.
37
Phases of Disaster Management
1. Preparation
2. Mitigation
3. Response
4. Recovery
Preparation
Identify risks, build capacity, and identify resources
These activities include a risk assessment of the area, the development of a simple,
yet flexible, disaster plan that is regularly reviewed and revised as necessary, and
provision of training that is necessary to allow these plans to be implemented when
indicated.
Mitigation
involves the activities a hospital undertakes in attempting to lessen the severity and
impact of a potential disaster.
These include adoption of an incident command system for managing internal and
external disasters, and the exercises and drills necessary to successfully implement,
test, and refine the hospital disaster plan.
There is no substitute for adequate training and drilling.
Response
involves activities a hospital undertakes in treating victims of an actual disaster
These include activation of the hospital disaster plan, including the ICS, and
management of the disaster as it unfolds, implementing schemes for patient
decontamination, triage, surge capacity and surge capability.
Recovery
involves activities designed to help facilities resume operations after an emergency.
The local public health system plays a major role in this phase of disaster
management, although health professionals will provide routine health care to the
affected community consistent with available resources, in terms of operable
facilities, usable equipment, and credentialed personnel.
38
Blunt Trauma
Vehicular impact when the patient is inside the vehicle
Pedestrian injury
Injury to cyclists
Assaults (intentional injury)
Falls
Blast injury
Passenger restraints
Reduce fatalities by up to 70%
10-fold reduction in serious injury.
Frontal air bags provide no protection in rollovers, second crashes, or lateral
When worn correctly, safety belts can reduce injuries. When worn incorrectly—for
example, above the anterior/superior iliac spines—the forward motion of the
posterior abdominal wall and vertebral column traps the pancreas, liver, spleen,
small bowel, duodenum, and kidney against the belt in front.
Blast injuries
Primary: result from the direct effects of the pressure wave and are most injurious
to gas-containing organs. The tympanic membrane is the most vulnerable to the
effects of primary blast
Secondary: result from flying objects striking an individual.
Tertiary: thrown against a solid object or the ground.
Quaternary: burn injury, crush injury, respiratory problems from inhaling dust,
smoke, or toxic fumes, and exacerbations or complications of existing conditions
such as angina, hypertension, and hyperglycemia.
Penetrating Trauma
1. Low energy—knife or hand-energized missiles {little cavitation}
2. Medium energy—handguns {5-time cavitation}
3. High energy—military or hunting rifles {up to 30-time cavitation}
39
Tetanus Immunization
Adequate tetanus prophylaxis is important in patients with multiple injuries,
particularly when open-extremity trauma is present.
The average incubation period for tetanus is 10 days; most often it is 4 to 21 days. In
severe trauma cases, tetanus can appear as early as 1 to 2 days after injury.
Recent studies conclude that it is not possible to determine clinically which wounds
are prone to tetanus; Thus, all traumatic wounds should be considered at risk for the
development of tetanus infection.
Passive immunization
250 units of human TIG intramuscularly must be considered for each patient.
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Revised Trauma Scores
41