1. Dr Anil KumarAssist Professor, Gen Surgery(Renal Transplant, Bariatric Sx,Endocrine Sx,Trauma Surgery)AIIMS-Patna

2. Objective to Learn Definition of Basic term Burden of Trauma in India What should be ideal protocol to overcome it? Expectations from others especially MBBS Students. To achieve good outcome in Trauma patients. Concept of scene safety & Triage Core Management of Trauma i.e ABCDE.. 3. Trauma: Trauma-Physical damage to the body -RTA -VIOLENCE -FALL -Others 4. EMERGENCY Definition-An event that will kill/disable one/many-where outcomecan be altered by TIMELY ACTION. DISASTER- If INJURY kills/disable many . Mass Casuality:No of pts & the severity of their injuries exceed thecapability of the hospital Multiple Casuality:No of pts & the severity of their injuries donotexceed the capability of the hospital OUTBREAK-If ILLNESS kills/disable many . 5. Burden of Trauma A/C to Gururaj G. Report 2005: Hospitalization= 2.5 million Death = 1,10,000 Persons Economic loss = 3% of GDP 6. Burden of Trauma A/C to NCRB 2011 Hospitalization= 4.0 million Death = 1,40,000 Persons One death in every 5 minutes 10-30% of Hospital registration are due to RTI. Majority of Victims belongs to poorer section of society. 7. Burden of Trauma in 2020 India will witness the death of > 2,50,000 pers. Hospitalization of > 4.5 million people. One death in every 3 minutes instead of current datai.e one death every 4- 5 minute. 8. Reality Major problem of India is Trauma. 76% of male age group of 15-44 years died/year No immunity Outcome is very well if treat it earliest andsystematically. 9. Reality of such Burden Recommendation is start treatment at scene site In our country - no such concept of Pre-Hospital Care In our country even Hospital care is not establishedfor trauma patients a/c to a standard protocol 10. Responsibilty Homogenous, Ideal & Standard protocol to Treat Traumapatients. Upgrade the concept of pre-hospital care at communitylevel. Training to common people by Medical Students To make a Benchmark 11. Treatment Protocol SANKATMOCHAN. BLS ( Basic Life Support) ATLS( Advanced Trauma Life Support). ACLS(Advanced cardiovascular life support) 12. Best Protocol-ATLSAdvance Trauma LifeSupport ------Best inmanaging Trauma Patients. 13. Treatment Plan Preparation( Mainly Pre-Hospital) Triage Primary Survey Resuscitation Adjunct to 1* survey & Resuscitation Secondary Survey( Head to Toe exam and history) 14. Cont Adjunct to 2ndary survey. Continued Post-Resuscitation monitoring and re-evaluation. Definite care. 15. Preparation. Pre Hospital. In Hospital. Goggles Gloves Gowns/Apron Mask/Cap Shoe cover. 16. PRE-HOSPITAL PHASE Receiving hospital is notify first Start care at Scene site i.e Pre-Hospital Care Send to the closest and appropriate Trauma Centre. HOSPITAL-PHASE-Advance planning for pt arrival 17. AIIMS-Patna effort. 18. AIIMS-Patna effort 19. QMRT(Quick Medical ResponseTeam ) Course 20. BLS-AIIMS Patna 21. Video on Pre-Hospital care 4common people 22. PHTC for Dy.S.P of Bihar 23. TAAC-Trauma & Android Course forAutodriver. 24. Purpose of these course: Educate every one to give Pre-Hospital care Make the maximum patients to reach upto hospital To reduce the mortality and morbidity 25. ProtocolPre-Hospital Care Hospital1 Scene safety & Response checking Preparation2 Triage Triage3 Primary Survey-ABCDE Primary survey-ABCDEA Helmet Removal/ F.B Removal ResucitationB Jaw Thrust/ Chin lift Maneuver Adjunct to Primary SurveyC Hemorrhage control Consider need for pt transferD IV Fluid Secondary SurveyE Spinal/# Immobilisation Adjunct to secondary surveyF Transport to closest & appropriatehospitalContinuous monitoring4 Definitive Care Definitive Care. 26. Scene Safety-First Priority 27. Scene Safety-First Priority 28. Methods of scene Safety- ShiftingDrags CarriesClothes Drag Cradle-in arms CarryBlanket Drag Pack-strap CarryElevated arm-to-arm Drag Extremity CarryFire Fighter Drag Fire-Fighter CarrySeat CarrySupporting CarryChair Carry 29. Clothes Drag 30. Blanket Drag 31. Elevated arm-to-arm Drag 32. Fire Fighter Drag 33. Cradle-in-arm Carry 34. Pack Strap Carry 35. Fire-Fighter Carry 36. Extremity Carry 37. Seat Carry 38. Supporting Carry 39. Chair Carry 40. Stretchers Portable stretcher Basket Stretcher Stair Stretcher Backboards 41. Portable stretcher 42. Basket stretcher 43. Stair stretcher 44. Backboard 45. Response Check( Tape & Talk) 46. http://www.futurefd.com/images/mci_planecrash.jpghttp://www.buscrash.net/wp-content/uploads/2011/05/Bus-Crash1.jpghttp://aditty.files.wordpress.com/2010/03/women-drivers-car-pile-up.jpg http://cryptome.org/cn/cn-quake3/pict51.jpg 47. Triage Sorting/Prioritizing of patients in an MCI basedon the severity of their injuries or no of the pts. Goal = the greatest benefit for the greatest number ofpatients Triage should be easy and fast. 48. START Triage One system of triage is called START START stands for Simple Triage And Rapid Treatment START categorizes patients into 4 groups based onbreathing, circulation, and mental status Red, Yellow, Green, and Black 60 seconds per patient 49. Triage Breathing yes or no? NO: Open airway with Jaw Thrust/Chin lift If patient begins to breathe = RED Keep airway open (recovery position) If patient does not begin to breathe = BLACK (Dead) YES = Fast or not fast? Breathing fast RED Breathing normally YELLOW 50. Triage Circulation only check if the patient isbreathing Look for severe bleeding and stop it Ask for help if necessary Severe bleeding = RED All others = YELLOW 51. Triage Mental Status only check if the patient isbreathing If patient is unconscious or cannot follow simplecommands= RED If patient can follow simple commands= YELLOW 52. Marking or Tagging Patients Official tags may not be available. Write the classified colour on the patients forehead orupper arm If enough assistance is available, designate areas as Red,Yellow, Green or Black and move the patients to thosearea. 53. Priority of Transport Red Transport FIRST Need immediate care! Yellow Transport AFTER Red Need urgent medical care Can delay up to 1 hour Green - The walking wounded Care can be delayed up to 3 hours Black - Dead, or expected to die soon no matter whatcare you provide 54. Benefit of Triage Prevent avoidable death( Red area pt) Avoid mis-using assets on hopeless cases.(Black) Avoid to miss any visible ongoing bleeding Proper medical t/t with a minimal time frame. 55. Remember: SRTT Scene Safety Response Checking Triage Transport. 56. Primary Survey Airway with cervical spine protection Breathing and ventilation Circulation with Hemorrhage control Disability: GCS Exposure(Undress)/Events with Hypothermia control 57. HISTORY: only AMPLE A - Allergy M- Medication currently used P Past Illness L Last meal taken E Events. 58. Air way with C-Spine Protection Helmet Removal Cervical Collar Foreign Body Removal Jaw Thrust/Chin Lift Maneuver In advanced setting/Hospital Airway & ET Intubation 59. Helmet Removal 60. Cervical collar Cartoon Paper Roll Brick Blanket Socks with paper inside it Anything that you are getting at scene site. Purpose : immobilize the spine 61. Cervical collar 62. Cervical collar 63. Proper Cervical collar- Hospital 64. In Patient with low GCS-JawThrust/Chin Lift Tongue can fall backward Can obstruct the hypopharynx Can be managed by- Jaw Thrust-Chin Lift Don't do Head tilt in Trauma patient . 65. Jaw Thrust 66. Chin Lift 67. In advanced setting 68. ET Intubation-G-MATHS GCS < 8 MF Injury Aspiration risk( Bleeding/vomiting) Tracheal Injury Hematoma over neck Stridor 69. ET Intubation If Facility available 70. Air way.. Best way=communicate verbally Mc cause of airway obstruction- Tongue fall Techniques to open the airway=1.Chin lift maneuver. 2.Jawthrust maneuver Intubation is the definitive Airway C-Spine Protection is mandatory. 71. B=Breathing & Ventilation Adequate gas exchange to maximize oxygenation andCO2 elimination. Ventilation- adequate function of the LUNGS, CHESTWALL & DIAPHRAGM. Exposed the chest-INSPECTION,PALAPTION,PERCUSSION &AUSCULTATION 72. Problem in B Tension Pneumothorex Flail chest with pulmonary contusion Massive hemothorex and Open Pneumothorex T/T= Almost same- Needle decompression/ CHESTTUBE, Ventilatory support. 73. Circulation & Hge Control: Hemorrhage predominant cause of death in RTI. Rapid & accurate assessment is essential. Remember Floor & 4 More Clap to look the bleeding. 4 More( CLAP) Chest- Long bones( Femur & Humerus)- Abdomen- Pelvis 74. MC Organs injured in BTA Solid Organs is the most commonly injured in BTA. MC organ Injured in BTA is Spleen 2nd MC Organ Injured in BTA Liver 3rd MC organ Injured in BTA - Kidney 75. MC Organs injured in PenetratingTrauma Abdomen(PTA) Mc organ i.e Small Intestine (Cos of Larger S.Area) 2nd MC organ is Liver 3rd MC organ is Colon. 76. Elements of Clinical Observation Level of Consciousness: Altered cos of Low BV. Skin Color : CRT( Capillary Refill Time) & Ashen,Gray Facial Skin with White extremity. Pulse : Usually Either Carotid or Femoral: Not less than 10 seconds: If Rapid & Thready- Hypovolemia 77. Control of Haemorrage First- Direct Pressure to stop bleeding Put 2 large bore (16 gauze) canulla. Take Blood sample for grouping & Cross matching Infused 2 lit Warm R.L . Very Fast. Find out the cause of Bleeding: USG 78. FAST : USG in Trauma Focused Assessment Sonography in Trauma Patients 4 quadrant has been examined. Right Hypochondrium Hepatorenal Area Left Hypochondrium Splenorenal Area Cardiac Window- To see the Heart: Cardiac Tamponade Suprapubic Region- Bladder Region 79. Disability : Rapid Neurological Examination Performed Includes: The Patients Level of Consciousness, PupillarySize & Pupillary reaction. Best : GCS GCS: Comprises 3 component: Eye opening, VerbalResponse and Motor Response. GCS: Predictor for pts outcome particularly the BestMotor Response. 80. GCS: Eye OpeningResponse ScoreEye Opening Spontaneously 4Eye opening on Verbal Response 3Eye opening on Painful Stimuli 2Eye opening - None 1 81. Verbal ResponseResponse ScoreFully Conscious 5Confused 4Inappropriate words 3Incomprehensive words 2None 1 82. Motor Response: Best PredictorResponse ScoreObeys Commands 6Localize the Pain 5Withdrawal( Normal Flexion) 4Abnormal Flexion( Decorticate) 3Extension( Decerebrate) 2None 1 83. GCS Total Score(EVM) is 15, Minimum is 3 Predictor to decide the prognosis: Motor Response is the Best to decide outcome: If GCS is less than 8 Go for definitive airway i.eIntubation If GCS : 12-15 ( Mild), 9-12( Moderate), 3-8( Severe) HeadInjury. 84. Exposure/ Environments Completely Undress the Patients by cutting offhis/her garments. Purpose: To Facilitate a through examination &assessment. Prevent from Hypothermia: Cover with Warm Blanket Give only Warm IV Fluid. 85. PREVENTION/SOLUTION Follow the TRAFFIC RULE( Speed limit,Helmet wearingAvoid drinking while driving, stop talking on mobile, donotovertake,apply safety belt, avoid triple loading on bike etc. Empowered citizen. Save TIME=Save LIFE. Assessment ,Treatment as well Transport-Simultaneously. 86. Home Message RTA- Big issue for developing country like India Max death is due to ignorance of Pre-Hospital Care. Airway with C-spine protection is 1st step of primary survey Scene Safety is the first priority & assessment is the next. Triage is the top priority in mass casuality 87. Home message Helmet & Foreign Body removal , Jaw Thrust/Chin Liftmaneuver , Cervical collar application can be done easily atscene site. In Advanced setting May proceed for Airway & ET Intubation Time is critical in trauma so only AMPLE history is required. Hypothermia should be prevented to break the triad of death. Chest tube is the TOC in most of chest trauma 88. Home Message Hemorrhage is the commonest cause of death in trauma In BTA- Spleen is the MC organ injured Direct Pressure is the first steps to stop any bleeding. FAST is very useful in detecting intra-abdomial bleed GCS: Best prognostic indicator in HI Patients 89. Thank You &