INITIAL ASSESSMENT & MANAGEMENT Trauma Physical injury #5 killer in the Philippines Prevention, treatment, rehabilitation **Before 197

97 , no stan!ar! in the treatment of trauma "oncept Treat the #reatest threat to life first $ack of a !efinitive !ia#nosis shoul! never impe!e treatment % !etaile! history &as not an essential prere'uisite to be#in the evaluation of an acutely injure! patient (esult %) %ir&ay &ith cervical spine control B) Breathin# ") "irculation *) *isability or neurolo#ic status +) +,posure -.n!ress/ &ith temperature control 0r!er of prioriti1ation) 2reatest to lo&est Tri3mo!al !istribution of !eath *eath that can be prevente! by e!ucation *eath by injury *eath because of complications 4nitial %ssessment -% systemic approach that can be revie&e! 5 practice!/ Preparation 6ospital to be brou#ht to, transport, personnel, e'uipment Public hospital 5 Trainin# hospital has more trauma patients than private hospitals Tria#e 4n the fiel! 7ortin# out 5 prioriti1ation of victims 8ee! imme!iate action *oesn9t nee! imme!iate action Physiolo#ic status intact 4njury not too severe %natomical injury not too #reat :ust prevent hospital overloa!, since this tips off the balance of hospital tria#e, facilities &ill all be use! up 6ospital tria#e 2reatest chance of survival &ith minimal cost ;hen there is hospital overloa!, #reatest injury is consi!ere! !ea! Primary survey (esuscitation 7econ!ary survey -6ea! to toe/ "ontinue! post3resuscitation monitorin# 5 re3evaluation *efinitive care Primary 7urvey %) %ir&ay maintenance &ith cervical spine control %scertain patency <orei#n bo!ies <acial, man!ibular, tracheal or laryn#eal fractures "hin3lift or ja& thrust maneuver "ervical spine immobili1ation "7 to T1 cross3table lateral cervical spine =3ray :ulti3system trauma, altere! level of consciousness, or a blunt injury above the clavicle 4mmobili1ation) 7trap in the shoul!er, &aist, thi#h, ankle Breathin# 5 ventilation

%ssure a!e'uate ventilation) <unction of the lun#s, chest &all 5 !iaphra#m 4njuries that acutely impair ventilation Tension pneumothora, 7evere enou#h to cause me!iastinum to be pushe! to the opposite si!e 8o flo& of bloo! to the car!iac chambers 7hock, !yspnea, !isten!e! neck veins <lail chest &ith pulmonary contusion 0pen pneumothora, 4njuries that compromise ventilation to a lesser !e#ree 6emothora, 7imple pneumothora, <racture! ribs Pulmonary contusion "irculation &ith hemorrha#e control Bloo! volume 5 car!iac output $evel of consciousness) before attributin# the altere! level of consciousness to the cerebrum, must assess 1st air&ay 5 breathin# 7kin color Pulse) "aroti!, femoral Blee!in# +,ternal, severe hemorrha#e is i!entifie! 5 controlle! in the primary survey +,ternal bloo! loss is mana#e! by !irect manual pressure 6emorrha#e into the thoracic or ab!ominal cavities, into muscles surroun!in# a fracture, or as a result of penetratin# injury can account for major bloo! loss *isability) 8eurolo#ic status -8eurolo#ic evaluation/ $evel of consciousness 5 papillary si1e 5 reaction %) %lert >) (espon!s to vocal stimuli P) (espon!s to painful stimuli .) .nresponsive *ecrease! level of consciousness *ecrease! cerebral o,y#enation 5?or perfusion %lcohol 5 !ru#s +,posure? +nvironmental control@ completely un!ress the patient, but prevent hypothermia Patient shoul! be completely un!resse! -:anipulation must be minimal/ "over 5 protect from hypothermia ;arm blankets 4ntravenous flui!s shoul! be &arme! :aintain &arm environment 6ypothermia) 7hift hemo#lobin !issociation curve to the left $ife threatenin# con!itions are i!entifie! 5 mana#ement is be#un simultaneously Priorities for the care of the pe!iatric patient are basically the same as for a!ults "6(%B4 %ir&ay Aa&3thrust or chin3lift maneuver 8asopharyn#eal air&ay 0ropharyn#eal air&ay Breathin#? >entilation? 0,y#enation +n!otracheal intubation 7ur#ical air&ay3 "ricothyroi!otomy -use small !iameter tubes, temporary/ "hest !ecompression 7upplemental o,y#en therapy

(esuscitation "irculation T&o lar#e3caliber 4> catheters -7hort for faster infusion/ Bloo! type, crossmatch, pre#nancy test Balance! salt solution 13B $ Bo cc?C# in chil!ren Bloo! transfusion) Type3specific bloo!, 03ne#ative bloo!, unmatche!3type specific bloo! 6ypovolemic shock shoul! not be treate! by) >asopressors, steroi!s or so!ium bicarbonate -must treat !eficit 1st/ 6ypothermia +"2 breathin# .rinary 5 2astric "atheters (outine urine analysis .rethral injury is suspecte! if there is Bloo! at the penile meatus Bloo! in the scrotum Prostate is hi#h3ri!in# or cannot be palpate! Bloo! in the #astric aspirate may represent 7&allo&e! bloo! Traumatic insertion %ctual injury to the stomach 4f the cribriform plate is fracture! or fracture is suspecte!, naso#astric tube shoul! be inserte! orally -or else, it may #o to the cranial vault/ :onitorin# >entilatory rate 5 arterial bloo! #ases) +n!3ti!al carbon !io,i!e monitorin# Pulse o,imetry) %ppropriate o,y#enation is a reflection of proper air&ay, breathin# 5 circulatory status Bloo! pressure +"2 monitorin# "onsi!er the nee! for patient transfer (emember) $ife3savin# measures are initiate! &hen the problem is i!entifie!, rather than after the primary survey *urin# the primary survey 5 the resuscitation phase, the evaluatin# physician fre'uently has enou#h information to in!icate the nee! for transfer of the patient to another facility (eferrin# physician to receivin# physician communication is essential (oent#eno#rams 7houl! be use! ju!iciously 5 not !elay patient resuscitation 4n blunt trauma, =3rays to be obtaine! "ervical spine "ross3table lateral "1 to "7 "hest -%P/ pneumothora, Pelvis -%P/ %fter all life3threatenin# injuries are i!entifie!) "omplete cervical, thoracic 5 lumbar spine 4n penetratin# injuries, =3rays are "hest -%P/ <ilms pertinent to the site of &oun!in# 7econ!ary 7urvey DTubes 5 fin#ers in every orificeE The secon!ary survey !oes not be#in until the primary survey -%B"s/ is complete!, resuscitation is initiate!, 5 the patient9s %B"s are reassesse! 6ea!3to3toe evaluation "omplete neurolo#ic e,amination -2las#o& coma scale/ 7pecial proce!ures Peritoneal lava#e, ra!iolo#ic evaluation 5 laboratory stu!ies

6istory %) %ller#ies :) :e!ication currently taken P) Past illnesses $) $ast meal +) +vents? environment relate! to injury Blunt trauma Penetratin# trauma Burns 6a1ar!ous environment Physical +,amination 6ea! 7calp 5 skull e,amination +ye 5 +ar e,amination :a,illofacial) "ribriform plate fracture) oro#astric intubation "ervical spine 5 neck Presume injury in patients &ith ma,illofacial or hea! trauma +,treme care must be taken &hen removin# helmet "hest >isual e,amination) 0pen pneumothora,, flail chest Palpation) <racture %uscultation "ar!iac tampona!e) !istant heart soun!s 5 narro& pulse pressure, !isten!e! neck veins Tension pneumothora,) *ecrease! breath soun!s, shock, !isten!e! neck veins "hest =3ray) ;i!ene! me!iastinum, pneumohemothora,, fractures %b!omen % normal initial e,amination of the ab!omen !oes not e,clu!e intraab!ominal injury "an!i!ates for peritoneal lava#e .ne,plaine! hypotension 8eurolo#ic injury 4mpaire! sensorium secon!ary to alcohol or !ru#s <ractures of the pelvis or lo&er rib ca#e may hin!er a!e'uate ab!ominal e,amination Perineum? (ectum? >a#ina (ectal e,amination Presence of bloo! &ithin the bo&el lumen 6i#h3ri!in# prostate Pelvic fractures 4nte#rity of the rectal &all Fuality of the sphincter tone >a#inal e,amination Bloo! in the va#inal vault >a#inal lacerations Pre#nancy test :usculoskeletal +,tremities) *eformity, abnormal movement, ten!erness, crepitation Pelvis Pressure over anterior iliac spine 5 symphysic pubis %ssessment of peripheral pulses $i#ament rupture, muscle3ten!on injury, nerve injury or ischemia 8eurolo#ic :otor, sensory, level of consciousness, papillary reaction 4mmobili1ation of the entire patient "ervical collar 4f there is neurolo#ic !eterioration, %B"s must be reassesse! (e3evaluation 8e& fin!in#s are not overlooke!

*iscover !eterioration .n!erlyin# me!ical problems +ffective anal#esia :onitorin# >ital si#ns .rinary output %rterial bloo! #as "ar!iac monitorin# !evices

*efinitive care) DThe closest appropriate hospital shoul! be chosen base! on its overall capabilities to care for the injure! patientE "6(%B4