1. Preparation

1. Preparation

• 1. Preparation

• 2. Triage

• 3. Primary Survey

• 4. Resuscitation

• 5. Secondary Survey

• 6. Continued postresuscitation monitoring and re-evaluation

• 7. Definitive care

Prehospital

• Prehospital

• Notify receiving hospital
• Closest appropriate facility
• Report pertinent information

• Inhospital

• Warmed IV solutions
• Ancillary departments notified
• Equipment made readily available
• Hospital personnel protection

Airway

• Airway

• Breathing

• Circulation

• Disability: Neurologic Evaluation

• Exposure/Environmental Control

Patency

• Patency

• Foreign bodies

• Facial Fractures

• Protect C-spine

Patency does not equal adequate ventilation

• Patency does not equal adequate ventilation

• Expose chest

• Auscultate

• Conditions that may acutely impair ventilation

• Tension pneumothorax
• Massive hemothorax
• Flail chest
• Rib fractures
• Open pneumo
• Pulmonary contusion

Hemorrhage control

• Hemorrhage control

• Two Key Elements

• 1. Level of Consciousness

• -AVPU

• -Glasgow Coma Score

• 2. Pulse

Control

• Control

• No hemostats

• Consider occult sources

AVPU

• AVPU

Verbal Response Motor response

• Verbal Response Motor response

• Oriented 5 Obeys 6

• Confused 4 Localizes 5

• Inappropriate words 3 Withdraws 4

• Incomprehensible sounds 2 Decortication 3

• None 1 Decerebration 2

• None 1

• Eye Opening

• Spontaneous 4

• To speech 3

• To pain 2

• None 1

Remove all clothes

• Remove all clothes

• Cover to prevent hypothermia

Airway

• Airway

• Oral
• Nasal- do not put in someone with facial trauma
• Endotracheal
• Surgical

• Breathing

• Supply O2
• Ventilate alveoli

Circulation

• Circulation

• Establish 2 large bore IVs
• Draw blood
• Vigorous IV therapy
• ECG monitoring
• Avoid hypothermia
• Evaluate PEA
• Other dysrhythmias

Catheters

• Catheters

• Urinary
• Rectal first
• Check for other signs of urethral injury
• Gastric
• Oral v.s. nasal placement

Monitoring

• Monitoring

• ABG’s
• Pulse oximetery
• Blood pressure
• ECG

Should not delay resuscitation

• Should not delay resuscitation

• AP pelvis

• AP chest

• Lateral C-spine

• Odontoid, AP C-spine

FAST scan

• FAST scan

• Focused Assessment Sonography in Trauma

• Ultrasound
• Pericardial sac (epigastric area)
• Hepatorenal fossa
• Splenorenal fossa
• Pelvis or Pouch of Douglas (bladder)

Head-to toe evaluation

• Head-to toe evaluation

• Vital sign evaluation
• Detailed neuro exam if not done in primary survey
• Special procedures

• “Tubes and fingers in every orifice”

A Allergies

• A Allergies

• M Medications

• P Past illnesses

• L Last meal

• E Events related to injury

• 1.Blunt

• 2.Penetrating

• 3.Burns

• 4.Hazardous Environment

A Allergies

• A Allergies

• M Medications

• P Past illnesses

• L Last meal

• E Events related to injury

• 1.Blunt

• 2.Penetrating

• 3.Burns

• 4.Hazardous Environment

Scalp

• Scalp

• Eyes

• Nose

• Mouth

• Bite occlusion

PITFALLS

• PITFALLS

• Hyphema

• Optic nerve injury

• Lens dislocation

• Head injury

• Posterior scalp laceration

Midline facial fractures

• Midline facial fractures

• Bite occlusion

• Bleeding

• Fracture repair can wait

I: Maxilla only transversely above the alveolar ridge

• I: Maxilla only transversely above the alveolar ridge

• Most common isolated

• II (pyramidal): Through nasal bone or nasal bone disarticulation with frontal bone

• Most common when associated with other fractures

• III (dislocated face): Through nasal bone, across floor of orbit, through lateral wall of orbit, zygomatic arch Rare

PITFALLS

• PITFALLS

• Pending airway obstruction

• Changes in airway status

• Cervical spine injury

• Exsanguinating midface fracture

• Lacrimal duct lacerations

• Facial nerve injuries

Must be immobilized

• Must be immobilized

• Inspection

• Palpation

• Auscultation (carotids)

PITFALLS

• PITFALLS

• C-spine injury

• Esophageal injury

• Tracheal or laryngeal injury

• Carotid injury (blunt or penetrating)

Visual evaluation (ant & post)

• Visual evaluation (ant & post)

• Palpate rib cage

• Sternal pressure

• Auscultation (heart & lungs)

• Chest xray

PITFALLS

• PITFALLS

• Tension pneumothorax

• Open chest wound

• Flail chest

• Cardiac tamponade

• Aortic rupture (widened mediastinum)

Frequently repeated exams

• Frequently repeated exams

• Inspection

• Palpation

• Normal initial exam does not rule out injury

• Peritoneal lavage v.s. CT scan v.s. U/S (FAST)

PITFALLS

• PITFALLS

• Liver or splenic flexure

• Deceleration injuries

• Hollow viscus, Lumbar spine

• Pancreatic injury

• Major intraabdominal vascular injury

• Renal injury

• Pelvic fractures

Contusions,Hematomas, Lacerations

• Contusions,Hematomas, Lacerations

• Urethral bleeding

• Rectal blood

• High riding prostate

• Sphincter tone

• Vaginal vault injuries (pelvic fractures)

PITFALLS

• PITFALLS

• Urethral injury

• Rectal injury

• Bladder injury

• Vaginal injury

Contusion

• Contusion

• Deformity

• Palpation

• Pelvic pressure and compression

• Vascular exam

• Neurologic exam

PITFALLS

• PITFALLS

• SPINE FRACTURES

• Fractures with vascular compromise

• Pelvic fractures

• Digital fractures

Immobilization of entire patient

• Immobilization of entire patient

• Reevaluate GCS

• Cranial nerve exam

• Motor exam

• Sensory exam

• Monitor frequently for changes in neuro status

• Assess O2 delivery if changes noted

• Early neurosurgical consultation

PITFALLS

• PITFALLS

• Increased intracranial pressure

• Subdural hematoma

• Epidural hematoma

• Depressed skull fracture

• Spine injury

• Beware of unconscious patient

Continuous reevaluation

• Continuous reevaluation

• Definitive care