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INITIAL ASSESMENT

MANAGEMENT
SYAFRI K.ARIF
Dept.of Anesthesiology,Pain Management and Intensive Care
Faculty of Medicine Hasanuddin University
Makassar-Indonesia

INTRODUCTION
The main role of the doctor is
SAVING LIFE
ALLEVIATE SUFFERING
Any doctors should have these
competences.
The main tool of saving life is
BASIC LIFE SUPPORT

ACCIDENTS OR DISASTERS
Accidents or disasters may occur to
:
ANY WHERE
ANY TIME
ANY ONE
Well preparedness is very important
( soft-ware and hard-ware )

What is EMERGENCY in Medicine ?


A medical condition that starts suddenly and
requires immediate care
A life or limb threatening medical
condition resulting from an injury or
sickness that requires immediate
treatment and, if left untreated, could
result in permanent harm to the person.

Some Example of Emergency Conditions

Conditions such as: heart attack,


uncontrollable bleeding, loss of
consciousness, convulsions, severe allergic
reactions, poisoning, severe shortness of
breath or difficulty breathing, or severe or
multiple injuries, including obvious fractures.

The Cause of Death in US

Traffic accidents are the third cause


of mortality after CVS and Cancer
Disease of the young, leading cause
death age 1 to 40 years
> 100,000 death /year in US
Loss of productive work years
Trauma management is expensive

Epidemiology of Trauma
Death

Trimodal patterns

ATLS

Donald Trunkey
50%
30%

Death
%

sec

hr

20%

days/week

Trauma Death

First Peak
Death that occurs at
impact or soon after the
accident
50 % death
Not preventable
severe head
laceration, massive
bleeding, heart
injury etc.
Prevention of accidents

enforcement,
education &
awareness

Trauma Death

Second Peak

Death within
minutes to hours
after injury
Golden Hours
30 % of death
Life threatening
injuries involving
airway, breathing ,
circulation

Trauma Death

Airway
obstruction: tongue, secretion & blood,
vomitus
difficult airway management
Breathing & Ventilation
pneumothorax,heamothorax, penetrating
chest injuries, flail chest
Circulation
hemorrhage, cardiac tamponade

Second Peak

Preventable
Reflect

adequacy, efficiency of EMS in


prehospital resuscitation
hospital emergency department
resuscitation
definitive therapy

Third peak

Third Peak

Death within days or


week after injury
20 % death
Sepsis or multiorgan
failure
Reflects again efficiency
at resuscitation,
definitive care,
aggressive ICU care,
prevention of infection
and rehabilitation

INITIAL ASSESMENT
Initial assessment include :
1.
Preparation
2.
Triage
3.
Primary Survey ( ABCDE )
4.
Resuscitation
5.
Secondary Survey ( Head to toe
evaluation )
6.
Definitive Care

1. PREPARATION
Preparation of the trauma patient
occurs
in two different clinical settings

1. PRE-HOSPITAL PHASE
2. IN HOSPITAL PHASE

PRE HOSPITAL
Transportation is very
important

Prehospital Trauma
Resuscitation

Definitive care ? GOALS

A clear airway, effective ventilation,


hemorrhage control & restoration of
adequate blood volume

Pre hospital Care

Ambulance Response
Time: Standard
50 % of all calls are
responded within 8
min.
95 % of calls within 14
min. (urban)
95 % of calls within 19
min. (rural )

Nolan JP, Pars. BJA


1997;79,226-240

Pre hospital
Communication

Communication
Vital between prehospital & inhospital trauma patient
resuscitation
Prepare ED personnel well
ahead
Activation of TRAUMA TEAM /
DISASTER PLAN into action

2. Triage

trier sorting out


Is the sorting of
patient based on the
need for treatment
Triage

Resuscitation Room
Activation of trauma
team

Trauma Team-work

Efficient method
Trained doctors &
nurses
Variety of tasks taken
simultaneously

horizontal organization
reduced time to lifesaving procedure by 50
%

Trauma Team at Work

Pit stop in a
formula 1 motor
race
Managing trauma
in a smooth and
efficient manner
Do no further
harm

3. The Primary Survey

Airway & cervical spine


control
Breathing & ventilation
Circulation &
haemorrhage control
Disability
Exposure/Environment

Airway & Cervical Spine


Control

Difficult Airway
Goal

Keep airway
patent
protect
compromised
airway
provide airway if
none

Cervical spine Fracture

Suspect:

Unconscious
patients
Injury above
clavicles
Neck pain
Weakness or
neurological deficit
History of fall > 6 m

Breathing & Ventilation

Patient in increasing respiratory


distress, BLUE, BLUE, BLUE, BP
DOWN, Not Recordable...
Think :Tension Pneumothorax,
haemotothorax, Flail chest, lung
contusion, cardiac tamponade
Goals: Avoid Hypoxia, Hypercarbia.
Bad for the Brain

TENSION PNEUMOTHORAX

Flail Chest
Segmental ribs fracture
of multiple ribs
Panel moves in with
inspiration and out with
expiration

Cardiac
Tamponade

Treatment of Cardiac
Tamponade

Hematothorax
Chest tube
Massive : > 1500 ml blood
Drainage: . 200 ml/hr
CLAMPED CT
Urgent thoracotomy

Circulation
Haemorrhage Control with Fluid therapy
First Priority : Restore volume with fluid
(RL/NaCl 0.9% )
Second Priority :
Restore blood with WB and PRC transfusion
to restore oxygen carrying capacity

Remember : did not die of anemia but die of


hypovolemic shock

Third Priority : Normalize coagulation status

FFP, Platelet, blood products

Disability
( Neurologic Evaluation )

Rapid Neurologic evaluation is


perform at the end of primary survey
Simple Neurologic evaluation is
AVPU method
A Alert
V Responds to Vocal stimuli
P Responds only to Painful stimuli
U Unresponsive to all stimuli

4. Resuscitation

Aggressive resuscitation and the


management of life threatening injuries
Essential to maximize patient survial

Airway should be protect and secure

Breathing/ventilation and oxygenation

Jaw thrust or Chin lift maneuver


Definitive airway if needed
Injured patient should received supplemental O2

Circulation

Controlled bleeding by direct pressure or operative


intervention

End- Points of
Resuscitation

Traditional:

Achieved definitive care

Blood Pressure/ cerebral perfusion


pressure/ ICP
Heart rate
Urine output

5. Secondary Survey

Not begin until the Primary Survey is


completed
Is Head to Toe evaluation

Head
Maxillofacial
Cervical spine and Neck
Chest
Abdomen
Perineum / rectum / vagina
Musculoskeletal
Neurologic

6. Definitive Care

Surgical intervention
Transfer to higher trauma center

Conclusion

Trauma continues to be the most


common cause of death
BLS playing a big role in saving life
in pre-hospital phase or in hospital
Do No Further Harm is the basic
principle of BLS
ABCDE is a good guide to take
action.

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