Professional Documents
Culture Documents
Catastrophic Blast
Group 3
LI 1
Triage Multiple casualties Primary Survey
• Triage involves the • In multiple-casualty • Patients are assessed, and their
sorting of patients based incidents, although there is treatment priorities are
on their needs for
treatment and the
more than one patient, the established, based on their
resources available to number of patients and the injuries, vital signs, and the
provide that treatment. severity of their injuries do injury mechanisms.
• Treatment is rendered not exceed the capability of
based on the ABC the facility to render care.
priorities (Airway with • In such situations, patients
cervical spine protection, with life-threatening
Breathing, and Circulation
with hemorrhage
problems and those
control). sustaining multiple-system
• Other factors that may injuries are treated first.
affect triage and Mass casualties
treatment priority include • In mass-casualty events, the
injury severity, number of patients and the Adjunct to primary survey dan
salvageability, and severity of their injuries resuscitation
available resources. • Adjuncts that are used during the
• Triage also includes the
exceed the capability of the
facility and staff. primary survey include
sorting of patients in the
field so that a decision • In such situations, the electrocardiographic monitoring;
can be made regarding patients having the greatest urinary and gastric catheters; other
the appropriate receiving chance of survival and monitoring, such as ventilator rate,
medical facility. requiring the least arterial blood gas (ABG) levels,
expenditure of time, pulse oximetry, blood pressure, and
equipment, supplies, and x-ray examinations (e.g., chest and
personnel, are treated first. pelvis)
Advanced Trauma Life Support ed. 9th
Burn injuries
LI 2
Pathophysiology
• Cell damage occurs at temperatures of >45°C
• Results in a spectrum of local and systemic
homeostatic disorders that contribute to burn
shock.
• Local effects of thermal injury include the
liberation of vasoactive substances, disruption of
cellular function, and formation of edema
Rule of 9
• Associated injuries,
Etiology
• Penetrating/ blunt chest trauma simple
pneumothorax tension pneumothorax
• misguided attempt at subclavian / internal
jugular venous catheter insertion
• Traumatic defect in chest wall
Clinical Features
■ Chest pain
■ Air hunger
■ Respiratory distress
■ Tachycardia
■ Tracheal deviation away from the side of injury
■ Unilateral absence of breath sounds
■ Elevated hemithorax without respiratory movement
■ Neck vein distention
■ Cyanosis (late manifestation)
Immediate decompression
:
• inserting a large-caliber
needle (initial treatment)
• insertion of a chest tube
into the fifth intercostal
space (Definitive
treatment)
• Needle depression converts the tension pneumothorax into
Tension pneumothorax - needle
an open pneumothorax; needle decompression is a
temporizing measure and should be followed promptly with
tube thoracostomy
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Open Pneumothorax
Effective ventilation impaired : hypoxia &
hypercarbia Equilibration between
intrathoracic pressure & atmospheric pressure is
immediate
Treatment
• closing the defect with a sterile occlusive
dressing (initial treatment)
• definitive surgical closure of the defect is
frequently required
Massive Hemothorax
Etiology :
• penetrating wound that disrupts the systemic or
hilar vessels
• Blunt trauma
Clinical Features :
• neck veins may be flat if severe hypovolemia
present
• distended neck veins if there’s an associated
tension pneumothorax
• absence of breath sounds / dullness to
percussion on one side of the chest
Treatment
Thoracotomy indications :
• 1500 mL of fluid is immediately evacuated
• less than 1500 mL of fluid, but continue to bleed (200 mL/hr
for 2 to 4 hours)
*decision is also based on the patient’s physiologic status
Cardiac
Tamponade
Rapid, unchecked increase in
pressure in the pericardial sac
compress the heart, impairs
diastolic filling & reduces
cardiac output
Etiology
Commonly penetrating injury
Blunt injury
Clinical Features
• Classic diagnostic Beck’s triad : venous pressure
elevation, decline in arterial pressure & muffled
heart tones
• Kussmaul’s sign
• PEA
• Elevated CVP
Surgery
Initial i.v fluid will raise the venous pressure
and improve cardiac output transiently while
preparations are made for surgery
Pericardiocentesis (if surgery is not possible)
not be diagnostic / therapeutic when the
blood in the pericardial sac has clotted
Abdominal trauma
• Injuries are often categorized by type of
structure that is damaged:
– Abdominal wall
– Solid organ (liver, spleen, pancreas, kidneys)
– Hollow viscus (stomach, small intestine, colon,
ureters, bladder)
– Vasculature
Abdominal injury
Signs and symptoms
• Abdominal pain
– Pain from splenic injury sometimes radiates to the left
shoulder.
– Pain from a small intestinal perforation typically is
minimal initially but steadily worsens over the first
few hours.
– Patients with renal injury may notice hematuria.
• hypovolemia (tachycardia) or shock (eg, dusky
color, diaphoresis, altered sensorium,
hypotension)
inspection
• Penetrating injuries break in the skin.
• Cutaneous lesions are often small, with minimal
bleeding, although occasionally wounds are large,
sometimes accompanied by evisceration
• Blunt trauma ecchymosis (eg, the transverse,
linear ecchymosis termed seat belt sign)
• Abdominal distention indicates severe
hemorrhage (2 to 3 L)
palpation
• Abdominal tenderness
– Although not very sensitive, when detected,
peritoneal signs (eg, guarding, rebound) strongly
suggest the presence of intraperitoneal blood
and/or intestinal contents.
• Rectal examination gross blood due to a
penetrating colonic lesion
• there may be blood at the urethral meatus or
perineal hematoma due to GU tract injury
Blunt trauma
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – flexion rotation
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – flexion
Distraction
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – Vertical
compression
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – Extension
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – combination
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – combination
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – physical
examination
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – diagnosis
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – imaging
X-ray CT cervical
• Standard radiography for the • Multidetector CT is more sensitive
identification of bony cervical and specific than plain
injury includes three views of the radiography for evaluating the
cervical spine: lateral, anterior- cervical spine in trauma patients
posterior, and odontoid and can be performed quickly
• The main advantages of plain – useful at the craniocervical
radiography are that it can be and cervicothoracic regions,
done at the bedside, exposes the where the sensitivity of plain
patient to only small amounts of films is most limited
ionizing radiation, and has a • Furthermore, a cost analysis
relatively low cost showed CT to be cost-effective to
• One of the main disadvantages of screen for cervical spine injuries in
plain films is that they are poor for moderate- to high-risk patients
imaging C1 and C2 • In addition, if plain radiography is
– In addition, visualization of the chosen as the primary imaging
entire cervical spine by plain Tintinalli J.modality, a CT
Tintinalli's Comprehensive guide of should be8th ed.
emergency medicine. ordered
New York: McGraw-Hill; 2016
Spine trauma – imaging (spinal
cord & tissue)
• MRI is the diagnostic test of choice for describing the
anatomy of nerve injury. Entities such as herniated
disks or spinal cord contusions can also be delineated
on MRI
• MRI is indicated in patients with neurologic findings
with no clear explanation after plain films and/or CT
scanning
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – Prehospital care
• Prehospital care for spinal injuries traditionally involves
immobilization of the entire spine at the scene with a
rigid cervical collar (or similar devices) plus a long
backboard
– In contrast, cervical collars and long backboards can induce
complications such as pressure sores, patient discomfort, and
respiratory compromise
• In contrast, spinal immobilization is no longer
recommended for fully conscious, neurologically intact
patients with isolated penetrating neck injury because
collars can delay resuscitation and obscure neck
injuries
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma
Airway Hypotension
• Unstable spine lesions above C3 • Although hypotension
can cause immediate respiratory
arrest, and lesions affecting C3- and relative bradycardia
C5 can affect the phrenic nerve are classic signs of
and diaphragm function neurogenic shock,
– For this reason, some experts bradycardia can also be
recommend that any patient
with an injury at C5 or above associated with
should have the airway intraperitoneal bleeding
secured by endotracheal or prior medication with
intubation
• Maintain in-line spinal stabilization
calcium channel blockers
while intubating, because human or β-blockers
cadaver studies demonstrate less
cervical motion and glottis
• Hypotension is initially
visualization with in-line treated with IV crystalloid
Tintinalli J. Tintinalli's comprehensive guide of emergency medicine. 8th ed. New york: mcgraw-hill; 2016
Spine trauma – spine
immobilization
• Long spine boards are • Hard cervical collars
associated with pressure are associated with
sores, so remove them as patient discomfort and
soon as possible
pressure sores of the
• Some experts recommend neck
the “6+ lift and slide
maneuver” because it • Do not overtighten the
produces less spine cervical collar on head-
motion than log rolling injured patients,
– The 6+ maneuver consists because jugular venous
first of unstrapping the
patient from the board. Next,
compression can raise
one person maintains inline intracranial pressure,
stabilization at the head, although Stifneck® and
while six others positioned at
the chest, pelvis, and lower Miami J® collars may
extremities levels lift the be better than other
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – treatment
Cervical S&C
• Until transfer of care to a • In general, transverse
fractures through the body
surgeon, spine are most significant in that
precautions should be they cause injury to part or
maintained, associated all of the cauda equina
injuries stabilized, and • Longitudinal fractures may
the patient carefully cause radiculopathy
monitored for respiratory • Sacral fractures that involve
the central sacral canal can
or neurologic produce bowel or bladder
deterioration dysfunction
• Treatment is symptomatic
with analgesics and use of a
rubber doughnut pillow
Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016
Spine trauma – treatment
(corticosteroid)
• High-dose • Patients who received
methylprednisolone high-dose
remains a controversial methylprednisolone and
treatment in acute blunt
spinal cord injury and
longer duration
should not be given protocols were more
routinely likely to develop
– Believed to work is in its complications such as
inhibition of free radical– severe sepsis, severe
induced lipid peroxidation
pneumonia, wound
– Increase levels of spinal
cord blood flow, increase infection and delayed
extracellular calcium, and healing, pulmonary
prevent loss of potassium embolism and deep
from injured cord tissue
– Methylprednisolone is vein thrombosis, GI
advocated in preference to bleeding, and death
other steroids because it Tintinalli J. Tintinalli's Comprehensive guide of emergency medicine. 8th ed. New York: McGraw-Hill; 2016