02 atls initial assessment and management
TRANSCRIPT
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ATLS: Initial Assessmentand
ManagementSAUSHEC Medical Student
Lecture Series
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Objectives
• Identify sequence of priorities in assessing the multiply injured patient
• Apply principles outlined in primary and secondary evaluation surveys
• Apply guidelines and techniques in the initial resuscitative and definitive-care phases of treatment
• Identify how patient’s medical history and mechanism of injury contribute to identification of injuries
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Objectives
• Identify pitfalls associated with initial assessment and management and apply steps to minimize their impact
• Be able to conduct an initial assessment survey, using the correct sequence of priorities and management techniques for primary treatment and stabilization
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Concepts of Initial Assessment
• Rapid primary survey
• Resuscitation
• Adjuncts to primary survey/resuscitation
• Detailed secondary survey
• Adjuncts to secondary survey
• Reevaluation
• Definitive care
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Initial Assessment
• Primary survey and resuscitation of vital functions are done simultaneously-a team approach.
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PreparationPre-Hospital System
• Transport guidelines/protocols
• On-line medical direction
• Mobilization of resources
• Periodic review of care
• Closest appropriate facility
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PreparationIn-Hospital
• Preplanning
• Equipment, personnel, services
• Standard precautions
• Transfer agreement
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Standard Precautions
• Cap
• Gown
• Gloves
• Mask
• Shoe covers
• Goggles/face shields
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Triage
• Sorting of patients according to:– ABCDE’s– available resources
• Multiple casualties
• Mass casualties
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Primary Survey
• adult/pediatric/pregnant women=priorities are the same
• A airway with C-spine protection
• B breathing
• C circulation with hemorrhage control
• D disability
• E exposure/environment
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Special Considerationstrauma in the elderly
• 5th leading cause of death
• decreased physiologic reserve
• comorbidities: diseases/medications
• Outcome depends on early, aggressive care
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Primary SurveyA
• Establish patent airway– assume C-spine trauma
• Pitfalls– equipment failure– inability to intubate– occult airway injury– progressive loss of airway
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Primary Survey
• Suspect C-spine injury– spinal protection– C-spine X-ray when appropriate
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Primary SurveyB
• Assess
• Oxygenate
• Ventilate
• Pitfalls:– Airway vs ventilation problem– iatrogenic pneumothorax/tension
pneumothorax
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Primary SurveyC
• Assessment of organ perfusion– Level of Consciousness– Skin color and temperature– Pulse rate and character
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Primary SureveyC
• Circulatory Management– Control Hemorrhage– Restore Volume– Reassess
• Pitfalls:– elderly, athletes, children– medications
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Primary SurveyD
• Disability– Baseline neurologic evaluation– GCS Scoring– Pupillary response
• Continuously reassess for deterioration/changes
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Primary SurveyE
• Exposure– Completely undress the patient
• Environment– core temperature– prevent hypothermia
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Resuscitation
• Protect and secure the airway
• Ventilate and oxygenate
• Stop the bleeding
• Protect from hypothermia
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Adjuncts to Primary Survey
• Vital Signs/ECG monitoring
• ABGs• POX/CO2
• Urinary/gastric catheters
• Urinary output
• ECG
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Adjuncts to Primary Survey
• Diagnostic tools– CXR, C-spine, Pelvis– DPL– Ultrasound
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Adjuncts to Primary Survey
• Consider Early Transfer– do not delay transfer for diagnostic tests– time to transfer=resuscitation
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Reevaluate
• Proceed to secondary survey after:– Primary survey completed– ABCDE’s reassessed– initial resuscitation of vital functions
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Secondary SurveyKey Components
• History
• Complete head-to-toe examination
• “Tubes and Fingers in every orifice”
• Complete Neuro exam
• Special diagnostic tests
• Reevaluation
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Secondary SurveyHistory
• A Allergies
• M Medications
• P Past Medical/Surgical History/Pregnancy
• L Last meal
• E Events/Environment related to injury
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Secondary SurveyHead
• Complete Neuro exam
• GCS Score
• Comprehensive eye/ear exams
• Pitfalls:– unconscious patient– periorbital edema– occluded auditory canal
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Secondary SurveyMaxillofacial
• Bony crepitus/stability
• Palpable deformity
• Pitfalls:– potential airway obstruction– cribriform plate fracture– frequently missed injuries
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Secondary SurveyCervical Spine
• Palpate for tenderness/stepoffs/crepitus
• Complete motor/sensory exams
• Reflexes
• C-spine imaging
• Pitfalls:– altered LOC for any reason– distracting injury
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Secondary SurveyNeck (soft tissues)
• Mechanism: blunt vs penetrating
• Symptoms: airway obstruction, hoarseness
• Findings: crepitus, hematoma, stridor, bruit
• Pitfalls:– may have delayed symptoms/signs– progressive airway obstruction– occult injuries
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Secondary SurveyChest
• Inspect
• Palpate
• Percuss
• Auscultate
• X-rays
• Pitfalls:– elderly, children
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Secondary SurveyAbdomen
• Inspect, auscultate, palpate, percuss
• Reevaluate frequently
• Special studies
• Pitfalls:– hollow viscus and retroperitoneal injuries– excessive pelvic manipulation
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Secondary Survey
• Perineum-contusions, hematomas, lacerations, urethral blood
• Rectum-sphincter tone, prostate, pelvic fracture, rectal wall integrity, blood
• Vagina-blood, lacerations
• Pitfalls:– urethral injury, pregnancy
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Secondary SurveyMusculoskeletal:Extremities
• contusion, deformity
• pain
• perfusion
• peripheral NV status
• X-rays as indicated
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Secondary SurveyMusculoskeletal:Pelvis
• Pain on palpation
• increased symphysis width
• uneven leg length
• instability
• special X-rays as indicated
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Secondary SurveyMusculoskeletal
• Pitfalls:– potential blood loss– missed fractures– soft-tissue or ligamentous injuries– compartment syndrome
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Secondary SurveyNeurologic
• Spine/Cord:– complete motor and sensory exams– reflexes– imaging as indicated
• CNS:– frequent reevaluation– prevent secondary brain injury
• Early neurosurgical consultation
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Secondary SurveyNeurologic
• Pitfalls:– incomplete immobilization– subtle increases in ICP with manipulation– rapid deterioration
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Adjuncts to Secondary Survey
• Special diagnostic tests as indicated
• Pitfalls:– patient deterioration– delay of transfer
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Reevaluation
• Minimizing missed injuries– high index of suspicion– frequent reevaluation and continuous
monitoring
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Reevaluation
• Pain Management– relief of pain/anxiety– IV titration– monitor carefully
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Definitive Care? Transfer
• Patient– injuries– physiologic status– concurrent diseases– factors that may alter prognisis
• Hospital– overall capabilities– specialized care
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Records, Legal Considerations
• concise, complete, chronologic documentation
• consent for treatment
• forensic evidence
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Summary
• Primary Survey
• Resuscitation– Adjuncts
• Secondary Survey– Adjuncts
• Definitive Care
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?