Professional Documents
Culture Documents
Page
(ThoughtsontheManagementoftheMultiplyInjured
Patient)
Aim: Togivepeopleaframeworkforthinkingaboutthemanagementofth
aculminationoftheteachingandexperiencesIgainedduringapast
ATLS: TheATLScourseitselfisanexcellentwayofpracticingthetheoreti
traumapatientstodoit.
Note:
ThisisnotmeantasashortcutwhichnegatestheneedtoreadtheA
don'treadtheATLSmanual.
PS:
Notethattheterm'ATLS'isaregisteredtrademarkofthe'American
GeneralPrinciplesofTrauma
Management
1.Thereisaneedforrapidevaluationofthetraumapatient.Timewastedcosts
2. Theabsenceofadefinitivediagnosisshouldneverimpedetheapplicationofe
3. Thefirst'GoldenHour'iscrucialtoboththeshortandlongtermsurvivalofth
4. Thereisaneedtoestablishmanagementpriorities:Thethingswhichwillkill
thepatientlateraremanagedlater.Thus,airwayproblemsaremanagedandtr
5. Alltreatmentmodalitiesshouldbegovernedbytheabidingprincipleof'First
OverviewofATLSProtocol:
(Stages&SubjectHeadings)
1.Preparation
2. Triage
3. PrimarySurvey(ABCDE)&Resuscitation
4. AdjunctstoPrimarySurvey&Resuscitation
5. ConsiderneedforPatientTransfer
6. SecondarySurvey(withAMPLEHistory)
7. ContinuedPostResuscitationMonitoring&Re
evaluation
8. TransfertoDefinitiveCare
1.PreparationEquipmentneededforPractice
Youshouldfamiliariseyourselfwithallthefollowingequipment.Youshould
beableexplaineachitem'suse,notonlyjustbyphysicaldemonstrationbut
alsobyverbaldescription.
GENERALEQUIPMENT
OneLivePatient(usuallyanactorwithcopiousbutexpertmake
uptoensurerealism)
OneNurseAssistant(whousuallyisaninexperiencedstudent)
OneCandidate(withlargeamountsofadrenalineinbloodstream
andsuitablyfastbeatingheart)
OneExaminer(tomakelifedifficultandgenerallythrowa
spannerintheworks)
UniversalPrecautions
Toilet+/Cigaretteforafterwards
CERVICALSPINEEQUIPMENT
LongSpinalBoard
HardCollarsofvarioussizes
Sandbags
Tapeforsecuringhead
Suction
Oxygen
Ventilator
Laryngoscopes(varioussizes&shapes)
BagandMaskwithReservoir
FlexibleBougie
TongueDepressor
Oropharyngeal/NasopharyngealTubes
Orotracheal/Nasotracheal/EndotrachealTubes
NeedleCricothyroidotomySet
FormalCricothyroidotomySet
Tracheostomyset(forchildrenunder12yrs)
SurgicalDrapes
10mlSyringes
Scalpel
AIRWAYEQUIPMENT
BREATHINGEQUIPMENT
Stethoscope
LargeBoreCannula
ChestDrainSetincluding:
Antisepticswap
LocalAnaesthetic
Scalpel
Dissectingforceps
ChestDrain
Tubing
Suitablecontainerwithunderwaterseal
StitchMaterial
Occlusivedressing
CIRCULATIONEQUIPMENT
PressureDressings&Swabs
Antisepticswaps
HypodermicNeedles
IntravenousCannulas
LongvenousCannulasforusewithSeldingersTechnique
Pericardiocentesisovertheneedlecannulas
VenousCutdownset
PeritonealDialysisCatheter
AdhesiveTape
Givingsets
Syringes
WarmedCrystalloid/Colloid/Blood
PASG:PneumaticAntiShockGarment
SetofResuscitationTrolleyDrugs
Lignocaine(+/Adrenaline)L/AInjection
LignocaineGelforCatheterisation
XylocaineSprayforOro/NasopharyngealL/A
Heparin
DRUGS
MISCELLANEOUSSTUFF
Resuscitationtrolley
Defibrillator
PulseOximeter
BloodPressureMonitor
CardiacMonitor
Capnograph
Normal&LowRangeThermometers
NasogastricTube
UrinaryCatheter
FastIntravenousInfuser/WarmerDevice
Ophthalmoscope&Otoscope
FractureSplints
GlasgowComaScaleChart
BroselowPaediatricResuscitationMeasuringTape
XRayViewingBox
WarmingBlanket
PolaroidCamera
Hammer&Nailstopreventtheparamedicswhobroughtthe
patientinfromleavingthedepartmentbeforetheyhavegivenan
amplehistory.
2.Triage.
Triageistheprioritisationorrankingofpatientsaccordingtoboththeir
clinicalneedandtheavailableresourcestoprovidetreatment.Theprocessis
basedonthesameABCprinciplesasexplainedbelow.
3.SummaryofPrimarySurvey&Resuscitation:
(Explainedinfulldetaillater)
AAirway&CervicalSpineControl
BBreathing&Oxygenation
CCirculation&HaemorrhageControl
DDysfunction&DisabilityoftheCNS
EExposure&EnvironmentalControl
4.AdjunctstoPrimarySurvey&Resuscitation:
Thesearevarioususefulmonitoringortherapeuticmodalitieswhich
supplementtheinformationalreadyobtainedusingclinicalskillsinthe
PrimarySurvey.
Theyinclude:
1.PulseOximeter
2. BloodPressure
3. CardiacMonitor/Electrocardiogram
4. ArterialBloodGases/EndTidalpCO2
XRaysChestXRay/Cervical
5.
Spine/Pelvis/Others
6. NasogastricTube&UrinaryCatheter
7. CoreTemperature
5.ConsidertheNeedforEmergencyPatient
Transfer.
Theparticularaccidentunitorhospitalwherethepatienthas
arrivedisnotalwaysthemostsuitableplaceforthedefinitive
careofthatpatienttobemanaged.Oncetheresuscitationis
wellunderwayandthepatientisstable,considerationshould
begiventotransferringthepatientelsewhere.Transfermay
betoanotherhospitalwhichismoregearedtotreatingthe
multiplyinjuredpatient(eg.alevel1traumacentre)orto
anotherfacilitywhichcanadequatelydealwiththeparticular
setofspecialisedinjurieswhicharepeculiartoyourpatient
(eg.aneurosurgicalunit).Transfermayalsobetoadifferent
departmentofthesamehospital(eg.theatres/radiology).In
anycase,patienttransferisoftenthetimeofgreatestperilfor
thepatientbecauseitisalltooeasyforthe'levelofcare'to
decline.Thechallengethereforeistoensurethatthislevelof
caredoesnotdeteriorateatanytime.Transfershouldalways
beassoonapossibleafterthepatientisstabilised.The
acquiringofspecialisedinvestigationsshouldnotholdupthe
transferofthepatientastheseinvestigationsareoftenmore
appropriatelyperformedintheunitwherethepatientistobe
transferred.
6.SecondarySurvey.
AfullAMPLEhistoryistakenfromanyonewhoknowsthe
relevantdetails.Thisoftenincludesboththefamilyandthe
paramedicswhobroughtthepatientin.Thisisfollowedby
completeheadtotoe&systemsexamination.Allclinical,
laboratory&radiologicalinformationisassimilatedanda
managementplanisformulatedforthepatient.Duringthis
timethereisaprocessofcontinuedpostresuscitation
monitoring&reevaluation.Anysuddendeteriorationinthe
patientshouldimmediatelypromptthedoctortoreturntothe
primarysurveyforareassesmentoftheABCDE's.
AMPLEHistory:
AAllergies
MMedicines
PPastMedicalHistory/Pregnancy
LLastMeal
EEvents/Environmentleadingtothecurrenttrauma
7.TransfertoDefinitiveCare
Thisisgovernedbythesameprinciplesaswerementionedaboveinthe
emergencytransferofpatients.Thelevelofcareshouldnotdeteriorate.
ThePrimarySurvey&
Resuscitation.
(Thisisthemainpartwhichistestedinthepracticalmoulages,sothisthe
partwillbecoveredinthegreatestdetail)
NOTEFIRST:
9ImmediatelyLifeThreateningInjuriesor
ConditionswhichshouldbepickedupinABCDE
andtreatedimmediately:
1.InadequateAirwayProtection
2. AirwayObstruction
3. TensionPneumothorax
4. Openpneumothorax
5. FlailChestwithHypoxia
6. MassiveHaemothorax
7. CardiacTamponade
8. SevereHypothermia
9.
SevereShockfromHaemorrhageUnresponsivetoFluid
Resuscitation.
NOTEALSO:
13PotentiallyLifeThreatening"NonObvious"
Injurieswhichshouldbeconsideredinthe
traumatisedpatient,butwhosemanagementcan
oftenwaituntilafterABCDEuntilthetimeof
definitivecare:
1.SimplePneumothorax
2. Haemothorax
3. PulmonaryContusion
4. TracheoBronchialInjury
5. BluntCardiacInjury
6. TraumaticAorticDisruption
7. DiaphragmaticRupture
8. MediastinalTraversingWounds
9. BluntOesophagealTrauma
10. Sternal/Scapular/RibFractures
11. RupturedLiverorSpleen
12. Ruptureofanabdominalorpelvicviscus
13. Anyotherchest/abdominal/orpelvicinjurieswhichhaveresultedinorgand
shock
HowtoapproachthePrimarySurveyandwhattodo
:
Thisnextsectionassumesyouareinamoulagescenarioandgoesthrough
yourpossibleactionsandreactionsinresponsetowhatyoufindwithyour
patient.
AAIRWAY&CERVICALSPINECONTROL
Sayyouarewearinguniversalprecautions.
Approachpatientfromheadsideandstabilisecervicalspineusing
inlineimmobilisation.Trytoavoidplacingyourhandsoverthe
patient'sears.
Introduceyourselfandreassurepatient.
AssesspreliminaryABCfrompatientsresponsetothis.
IFTHEAIRWAYISNOTATLEASTPARTIALLYSECURE,
thendefinitivecervicalspinecontrolwillhavetowait.Askthe
nursetotakeoverthefunctionofinlineimmobilisationofthe
cervicalspine,andMOVEONTOAIRWAYMANAGEMENT.
Don'tforgettocomebacktocervicalspinemanagementlater.
CERVICALSPINEMANAGEMENT:
Askforahardneckcollar.Measurethesizeofcollarby
measuringfromtheangleofmandibletothetopofshoulder/
trapezius.Thecollarshouldbethesamesizefromtheblack
markerpegtothebaseofthehardpartofthecollar.
ApplySandbagsandTape.
AIRWAYMANAGEMENT:
Inthetraumapatient,ifthepatientislikelytoneedintubation
eventually,thenearlyintubationispreferred,soastopreventthe
patientfromtiringandbecomingacidotic.
Suctionouttheairwayorremoveforeignbodiesifnecessary.
IFBREATHINGISSPONTANEOUSANDTHEPATIENTIS
CONSCIOUS,BUTAIRWAYISCOMPROMISEDBYPOOR
PHARYNGEALTONE/REDUCEDLEVELOF
CONSCIOUSNESS(GCS913):
Tryjawthrust/chinliftandaskforresponse.
Iftheresponseisgood,insertanoropharyngeal(Guedel)or
nasopharyngealairway.
Notes:
Theoropharyngealairwayismeasuredfromtheedgeofthemouth
tothetragusoftheear.
Thenasopharyngealairwayismeasuredfromthenostriltothe
tragusoftheear.Itsdiameterisalsoconvenientlyestimatedby
lookingatthepatient'slittlefinger.
Don'tattempttoinsertanasopharyngealairwayifthepatienthasa
headinjurywiththepossibilityofabasalskullfracture.
Assumingthepatientrespondstothis,applyoxygenusingaface
maskwithattachedreservoirbag.
Ifyouhaven'talreadydoneso,mostpatientsshouldnowhavetheir
neckimmobilisedwithahardneckcollar,sandbagsandtape.
IFTHESUPPORTIVEMEASURESABOVEHAVEFAILED,
ORIFPATIENTISUNCONSCIOUSWITHAGCSOF8OR
LESS,ORIFTHEPATIENTISAPNOEIC:
Thepatientneedsadefinitiveairway.
Callforananaesthetist.
IfthepatientisCOMPLETELYUNRESPONSIVE,itisnecessary
toproceedstraighttoendotrachealintubation.
MethodofENDOTRACHEALINTUBATION.
Preoxygenatewithbagandmask.
Theneckcollarwillneedtoberemovedduringintubationand
duringthistimeyourassistantmustprovideinlineimmobilisation
oftheneck.
Standingabovetheheadofthepatient,insertalaryngoscopeinto
theoropharynx,pushingthetonguetotheleft.Pullthescope
upwardsandawayfromyourselfuntilthevocalchordsbecome
visible.
Sliptheendotrachealtubethroughthevocalchords,ifnecessary
usingagumelasticbougie.Inflatethetube'sballoonsealand
connectthetubetoareservoired'bag&mask'orventilator.Some
patientsmaybesuffientlystablewiththeETtubeinsitutobreathe
spontaneouslywithouttheneedforbag&maskorventilator.
Ensurepositioningoftubeintracheabylisteningtothechest
(listentothelungapices,basesandoverthestomach).Final
confirmationcanbemadebyconnectingthetubetoacapnograph.
SecurethetubeusingacommerciallyavailableETtubesecuring
device.
Oncefinished,reestablishcervicalspinecontrolusingthehard
neckcollar,sandbagsandtape.
IfthepatientisSTILLPARTIALLYCONSCIOUSAND
RESPONSIVE,thenintubationwillneedtobecarriedoutby
'RAPIDSEQUENCEINDUCTION',usinganaestheticdrugs.The
procedureshouldonlybecarriedoutbypractitionerswhoarequite
familiarwithits'insandouts'(whichusuallyexcludeseveryone
exceptexperiencedanaesthetists).Ifyouaren'texperienced
enoughtoperformRSI,then'bag&mask'untiltheanaesthetist
arrives.
IFTHEACTIVEMEASURESABOVEHAVEFAILED,OR
THEREISPARTIALUPPERAIRWAYOBSTRUCTIONWITH
STRIDOR,ORTHEPATIENTISAPNOEICFROM
COMPLETEAIRWAYOBSTRUCTION:
PerformNEEDLECRICOTHYROIDOTOMYanddescribethis
method.
Alargeborecannulaisinsertedthroughthecricothyroid
membraneandisthenconnectedtohighflowoxygenat15litres/
minute.Inspiration/Expirationisachievedbyintermittently
holdingonesthumboverthesideofanopenYconnectorattached
tothecannula1secondinspiration,4secondsexpiration.The
patientcanonlybeadequatelyoxygenatedusingthismethod
forabout3045minutes.
Callforananaesthetist.
Finallyestablishdefinitiveairwaybyformalcricothyroidotomy
anddescribethismethod.
OTHERINDICATIONSFORADEFINITIVEAIRWAY
INCLUDE:
Severemaxillofacial/laryngeal/neckinjurieswithimpending
obstruction.Thepatientwillalmostcertainlyrequireasurgical
airway.
SevereClosedHeadInjurieswithareducedlevelofconsciousness,
ariskofaspiration,andtheneedforhyperventilation.
Ifyouhaven'talreadydoneso,apply100%oxygen.
AsknursetoapplyPulseOximeter,BloodPressureMonitorand
CardiacMonitor.Askhertotakereadingsfromallthesemonitors.
BBREATHING&OXYGENATION
Ifpatientsuddenlydeterioratesatanypoint,movebackandcheck
airwayagain.
Movedownneck.
AssessCarotidpulseforRate,Character&Volume.
CheckNeckveinsfordistension.
CheckforWounds,Laryngealcrepitus&Subcutaneous
emphysema.
CheckifTracheaiscentral.
Thenmoveontochest.
InspectforBruising/Asymmetryofexpansion.
Palpateanyareasofinterest.
CheckforSubcutaneousemphysemaandFlailchest.
PercussandAuscultatebothanteriorandlateralchestandaskfor
results.
IFPATIENTHASASIMPLEPHEUMOTHORAX:
Hyperresonantchest,reduced/absentbreathsounds,butneck
veinsdownandtracheacentral.
AskthenursetosetupformalChestDrainset.
Don'tinsertthechestdrainyet,butstatethatyouintendtoinsertit
later.
CHESTDRAININSERTION:
Drape&surgicallypreparethechest.
Ifthereistime,giveaninjectionoflignocainelocalanaesthetic.
Makeanincisioninthe5thintercostalspacejustanteriortothe
midaxillaryline,andjustabovetheupperborderofthe6thrib.
Bluntdissectdownthroughtheintercostalmuscles,untilthepleura
ispunctured.Clearawayadhesions,clotsorforeignbodiesusinga
fingersweep.
Clamptheproximalendofthechestdrainandthenadvanceitinto
thechesttothedesiredlength.
Connectthechestdraintoanunderwatersealapparatusandthen
unclampit.
Checkthedrainisfunctioningcorrectlythewatercolumnatthe
underwatersealapparatusshouldmoveuponinspirationand
bubbleduringexpiration.
Suturethetubeinplaceusingapursestringsutureandthenapply
anadhesivenongaspermeabledressingtothesite.Applythe
dressingto3outof4sidesofthedraintube.
Finallyreexaminethechestandobtainanearlychestxray.
IFNECKVEINSDILATED,TRACHEADEVIATED,
ABSENTORREDUCEDBREATHSOUNDSANDCHEST
HYPERRESONANT,THENTHINK
'TENSIONPNEUMOTHORAX':
AsknursetosetupformalChestDrainset.
Inthemeantime,performNeedleThoracostomyandcheckfor
hissingsound.Leavetheneedlethoracostomyopen.
Reexaminechestandaskforresponse.
Ifpatientstabilises,thenleaveformalchestdrainuntillater.
Iftheydon'tstabilise,performanotherNeedleThoracostomyand
proceedstraighttoformalChestDraininsertion.
Describethismethod.
IFPATIENTHASEVIDENCEOFCHESTTRAUMA,
DILATEDNECKVEINS,MUFFLEDHEARTSOUNDS,AND
DECREASEDARTERIALBLOODPRESSURE(POSSIBLY
EVENPULSELESSELECTRICALACTIVITY)(BECK's
TRIAD),THENTHINK'PERICARDIALTAMPONADE':
ProceedstraighttoNeedlePericardiocentesis.
Describethismethodandcheckforresponse.
NEEDLEPERICARDIOCENTESIS:
Monitorthepatient'svitalsignsandECGbefore,during&after
theprocedure.
Drape&surgicallypreparethexiphoidarea.
Usea#16gauge15cmneedle,3waytap,anda20cmsyringe.
Puncturetheskin12cmbelowandlateraltotheleftxiphi
chondraljunction,pointingtheneedleatanangle45totheskin
andaimingforthetipoftheleftscapula.
Advancetheneedleuntilthereisaflushbackofblood,andatthis
pointwithdrawasmuchbloodaspossible.
Iftheneedleisadvancedsothatitpenetratesthemyocardium,the
ECGpatternwillchange,producingwildSTTsegmentvariation
andwidened/enlargedQRScomplexes.Ifthisoccurs,theneedle
shouldbewithdrawnslightlyuntiltheECGpatternreturnsto
normal.
Itissometimesnecessarytoleaveacannulainsituforrepeat
aspirations,andsoheretheneedlemaybechangedtoaplastic
cannulausingtheSeldingertechnique.
IFPATIENTISHYPOXIC,SHOCKED,HASASTONY
DULLCHEST,ABSENTBREATHSOUNDSANDA
TRACHEADEVIATEDAWAYFROMTHISSIDE,THEN
THINK'MASSIVEHAEMOTHORAX':
Establishintravenousaccessusingtwolargeborecannulas.
Proceedimmediatelytoinsertionofchestdrain.
IFPATIENTHASAFLAILCHESTANDISHYPOXIC:
Earlyintubationisessential.
PerformOrotrachealintubationyourselfpreferablyby'Rapid
SequenceInduction'orcallforananaesthetisttodoit.
IFPATIENTHASANOPENPNEUMOTHORAX:
Coverthisopeningwithanocclusivedressing.
Securethedressingwellsoastopreventairleaks.
ProceedstraighttoChestDrain,placingthedrainwellawayfrom
thewoundoftheoriginalopenpneumothorax.
CCIRCULATION&HAEMORRHAGE
CONTROL
AsknursetorepeatmeasurementsofOxygenSaturation,Blood
Pressure&Pulse.
Palpatethepatientsheadandhandslookingforsignsof
'shock'.Thisisdefinedasinsufficientorganperfusionand
oxygenation.Itissuspectedinapatientwithcold,clammy,pale,
peripherallyshutdownextremities.
MoveontoAbdomen&Pelvis.
ABDOMEN:
Inspectabdomenforinjuriesordistension.
Palpateabdomenforanymassesorsignsofperitonism.
Considerabdominalpercussion&auscultation.
Iftherearesignsofabdominalbleeding,askthenursetofastbleep
theoncallsurgeonandaskthemtocometocasualty.
Askthenursetostatethatyouhaveaclinicallyshockedpatientin
casualtywhoyoususpecthasabdominalbleeding,whoyouarein
theprocessofresuscitating,butwhomayurgentlyneedtobetaken
totheatreforlaparotomy.
PELVIS:
PalpatethePelvis.
Applybothlateralandanteroposteriorspringingforcesontothe
anteriorsuperioriliacspinesandfeelforabnormalmobilityor
crepitus.Onlyperformthisexaminationonce.
Askexaminerwhetherthepelvisisstableorunstable.
Iftherearesignsofafracturedpelvis,askthenursetofastbleep
theorthopaedicsurgeononcallandaskthemtocometocasualty.
Askthenursetostatethatyouhaveaclinicallyshockedpatientin
casualtywhoyoususpecthasanunstablefractureofthepelvis,
whoyouareintheprocessofresuscitating,butwhorequires
urgentstabilisationwithapelvicexternalfixator.
GiveconsiderationtotheuseofaPASGPneumaticAntiShock
Garmentorinternallyrotatethehips(whichmaycloseanunstable
openbookpelvicfractureandlimitthebleeding).
Trytogetapelvisxraybeforetheorthopaedicsurgeonarrives,
providedthisdoesn'tinterferewiththerestofyourresuscitation.
LIMBS:
Quicklymoveontothelimbs,cuttingoffclothesasnecessary,and
examiningforthepresenceofobviousdeformityorsofttissue
haematoma.
Anysourcesofexternalhaemorrhageshouldimmediatelybe
stemmedbyapplyingdirectpressureandwrappinginabandage.
IfthereareOpen(Compound)Fractures,thentheseshouldbe
photographed,andthenimmediatelypackedwithaBetadine
soakedbandageanddirectpressureapplied.Askthenursetostand
bywithintravenousmorphine,atetanusinjectionandintravenous
antibiotics(usuallycefuroxime&metronidazole).The
orthopaedicteamshouldbeinformedandaskedtoattendtheA&E
department.
FLUIDRESUSCITATION:
Havingexaminedthebodyforpotentialsourcesofhaemorrhageas
wellasstemminganyareasofoverthaemorrhage,fluid
resuscitationshouldbegininearnest.
Youneedtoplacetwolargebore(#14gauge)intravenous
cannulas,oneineachcubitalfossa.
BloodshouldbeaspiratedintoasyringeforFBC,U&E,and
CrossMatch.Askthenursetoensurethatthesampleisrushedto
thelab.Askfor24unitsofONegativeBlood,24unitsof
TypeSpecificBlood,and24unitsofCrossmatchedBlood,
dependingontheindividualcircumstances.
Ifcannulationisunsuccessful,thenalternativesincludetheother
cubitalfossa,thefemoralvein,thesubclavianvein,theexternal
jugularvein,theinternaljugularvein,oravenouscutdownforthe
greatsaphenousvein.
Immediatelysetup1litreofwarmedHartmannsforeachofthe
twocannulasandrunthroughusingafastinfuser.Thiscantake1
2minutestorunin.
Inchildrenunder6years,intraosseousinfusionisthepreferred
methodofaccessafter2unsuccessfulattemptsatcannulation.In
infants,scalpveinsmaybetried,andinneonatestheumbilical
veinoftenprovidesexcellentaccess.Thevolumeoftheinfusion
bolusinchildrenis20mls/kgandthiscanberepeated2or3times
dependingonresponse.
AskthenursetorepeatOxygenSaturation,BloodPressure,Pulse
&RespiratoryRate.CheckalsotheTemperature.
Accordingtoresponse,500mlsofcolloidcanthenbeinfused
througheachcannula,or(morelikely)intheabsenceofaclinical
improvement,the2unitsofONegativebloodwhichhavejust
arrivedfromthelabshouldbegivenusingthefastinfuser.Ifthe
patientcanwait10minutesfortypespecificblood,thenthisis
preferable.
CheckforClinicalResponse.
Ifthepatientfailstorespond,orinitiallyresponds
butsubsequentlydeteriorates,youshouldreflecton
thevariouspossiblecausesofthisstateofaffairs:
1.GobackandcheckAirway&Breathing.
2. ThepatientcouldbeBLEEDINGfasterthanyouarereplacingblood.Thesep
3. ThepatientcouldbeHYPOTHERMICandthereforemayberespondingmore
4. ThepatientcouldbeinCARDIOGENICSHOCK:Heretheheartpumpisfail
andactappropriatelyifrequired.ConsiderearlyCVPmonitoring.
5. ThepatientmaybePREGNANT.Ifmoderatelyorheavilypregnantwomena
Cava.Suchpatientsshouldbebolsteredsothattheyarelyingslightlyontheir
shouldbecarriedoutearlierratherthanlaterintheresuscitation.
6. ThepatientmaybeinNEUROGENICSHOCK:Thisoccurswithspinalcord
resultsinaclinicalpictureofhypotensionwithouttachycardiaorperipheralva
thejudicioususeofvasopressors.EarlyCVPmonitoring&SwanGanzpulm
7. SEPTICSHOCK:Thisisuncommonintheearlyperiodfollowingtraumabut
wherethewoundhasbeencontaminatedwithdirtyexogenousdebris,especial
tachycardia,pyrexiaandcutaneousvasodilation.
Alltheabovearetreatedbygenerousvolume
replacementalongwithdefinitivetreatmentofthe
causeoftheshock.
OtherConsiderationsintheDiagnosis&Treatment
ofShock.
1.OLDAGEElderlypatientshaveless'physiologicalreserve':Theyarelessa
decreasedbloodflowandhypoxiaassociatedwithshock.Thelungsarelesse
stimulusofthestresshormonesAldosterone,AntiDiureticHormone&Cortis
elderlypatienttopaymeticulousattentiontovolumeresuscitation,andthepla
devicesshouldbeplacedearlierratherthanlater.
2. YOUNGAGEChildrenandbabieshaveanespeciallyhighphysiologicalres
percentagesoftheirbloodvolume.Howeverwhenthepercentageofbloodlo
precipitously.Thelessonhereisthatchildrenmaystillhavenormalvitalobse
3. ATHLETESAlthletesmayhaveanincreasedbloodvolumeofupto1520%
lowerthanunfitindividuals.Thesefactsmeanthattheusualclinicalsignsof
4. PREGNANCYWomenhaveahigherplasmavolumeduringpregnancy.Ca
minute.Minuteventilationincreasesalso(primarilyduetoanincreaseinthe
increasethephysiologicalreserveofthemotherandmeanthatsignsofhypov
eveninmoderateshock,themothermaybequitewell,thefoetusmayactually
cardiotocographicmonitoringareoftenrequiredatanearlystagetominimise
5. DRUGSVariousdrugscanaffectthebody'sresponsetostress.Betablocke
picture.Diureticusecausesarelativehypovolaemiawhichmayimpairthebo
6. HEADINJURIESThebrainhasaveryhighdemandforoxygenandsoseco
blood.TheCerebralPerfusionPressureisequaltotheMeanArterialBloodP
pressure,orbyanincreaseinintracranialpressure.Headinjuriesmayincreas
cerebrospinalfluid.Subarachnoidhaemorrhageincreasesintracranialpress
CSFfrombeingreabsorbedbackintothevenoussystem.
Thereareanumberofconflictingprocessesintheheadinjuredpatientthatma
resuscitationwillresultinhypotensionwherasoverenthusiasticvolumeresusc
pressure.Thekeyaspectsintheoptimalmanagementoftheheadinjuredpatie
intubationtoassistwithhyperventilation,andearlyconsultationwithanexper
DDYSFUNCTION&DISABILITYOFTHE
CNS
AnAVPUorGCSassessmentiscarriedout.
Thepatient'spupilsareexaminedforsize,symmetry&reactiontolight.
Theconsensualpupillaryreflexcanalsobetestedhere.
AVPUAssessment:
AAlert
VRespondingtoVoice
PRespondingtoPain
UUnresponsive
GlasgowComaScale(GCS):
EyeOpening
4Spontaneous
3ToSpeech
2ToPain
1NoEyeOpening
BestVerbalResponse
5Orientated
4ConfusedConversation
3InappropriateWords
2IncomprehensibleSounds
1NoResponse
BestMotorResponse
6Obeyscommands
5Appropriatelocalisingresponsetopain
4Withdrawalresponse
3Abnormalflexionresponse(DecorticateRigidity)
2Extensionresponse(Decerebraterigidity)
1NoResponse
EEXPOSURE&ENVIRONMENTAL
CONTROL
Here,anyclotheswhichhaven'talreadygoneareremoved.
Careisstilltakentoprotectallareasofthespinefromundue
movement.
Finally,thepatientiscoveredwithablanketorothersuitable
warmcoveringtopreventhypothermia.
Hereendeththelesson!!