MANAGEMENT AT THE SCENE OF ACCIDENT Dr. Mehtab Ahmed Pirwani DOST, LUMHS

1/006 DEFINITION 0F TRAUMA A term derived from the Greek for “WOUND” A term derived from the Greek for “WOUND” It refers to any bodily injury. It refers to any bodily injury. It defined as tissue injury due to direct effects of externally applied energy. Energy may be mechanical, thermal, electrical, electromagnatic or nuclear. It defined as tissue injury due to direct effects of externally applied energy. Energy may be mechanical, thermal, electrical, electromagnatic or nuclear. Included:burns, drowning, smoke, inhalation, Included:burns, drowning, smoke, inhalation, slip & fall. slip & fall. Excluded: poisoning/toxic ingestion. Excluded: poisoning/toxic ingestion.

Trauma Epidemiology Epidemiology –Leading cause of death in the first 4 decades –150,000 deaths annually in the US –Permanent disability 3 times the mortality rate –Trauma related costs exceed $400 billion annually in USA

The World Health Organization (WHO) predicts that by 2020 road traffic injuries will rank third in the causes of premature death and loss of health from disability (Peden et al., 2004).

Road traffic deaths and serious injuries show a peak incidence in young people between the ages of 17 (age of learning to drive) and 23.

Deaths as a result of trauma classically follow a tri- modal pattern, with three waves following the injury

Some 50 per cent of fatally injured casualties die from non-survivable injuries immediately, or within minutes after the accidents;

30 per cent survive the initial trauma, but die within 1–3 hours;

The remaining 20 per cent die from complications at a late stage during the 6 weeks after injury.

The initial mortality peak is usually due to non-survivable central nervous system or cardiovascular disruption.

Very few of these casualties can be saved. However, a small pro- portion die as a result of early airway obstruction and external hemorrhage, and these deaths can be pre- vented by immediate first-aid measures

The second peak of deaths during the first few hours after injury is most often due to hypoxia and hypovolemic shock. A significant proportion of these deaths can be avoided with an effective emergency medical service (EMS); hence, this period has been called ‘the golden hour’.

The third peak in the cumulative mortality rate within the 6 weeks is largely due to multisystem failure and sepsis. These complications of trauma need a high level of intensive care, but can be reduced by early and effective treatment during the casualty management.

PRE-HOSPITAL MANAGEMENT Essential elements include: 1. Organization. 2. Safety on scene. 3. Immediate actions and triage. 4. Assessment and initial management. 5. Extrication and immobilization. 6. Transfer to hospital.

Organization Provision of a pre-hospital EMS depends on economic resources, and varies from no provision in rural, low-income countries to sophisticated services linked to hospital care in developed economies. The EMS in most countries is based on ambulances crewed by medical technicians or paramedics

All emergencies are triaged by a team, which includes a doctor,

A doctor-led pre-hospital service leads to a 2.8-fold improvement in mortality for seriously injured patients. However the service is very expensive and demands a high number of experienced medical staff (Earlam, 1997).

Safety on scene and personal protective equipment Hospital doctors in acute specialties may be required to form part of a medical team to manage trauma cases on scene.

The scene of a traumatic incident is invariably hazardous, and the immediate priority for a doctor on scene is personal safety; if this is neglected, the doctor can become a casualty rather than a rescuer.

As a rule, personal protective equipment (PPE) must protect the head, eyes, hands, feet, limbs and body to an appropriate extent against physical, chemical, thermal and acoustic risks.

Immediate actions and triage In the event of multiple casualties, priorities are established by triage. Triage is a system of medical sorting originating from the Napoleonic battlefields to identify casualties in an order of priority for evacuation and treatment.

Assessment and initial management Once safety, command, communications and priorities have been established, patients can be given individual attention. This calls for an organized approach involving awareness, recognition and management (ARM).

AWARENESS Awareness of the environment, pattern of damage to a vehicle and the nature of the incident can help the attending doctor predict the likely injuries and facilitate their early recognition.

RECOGNITION Recognition of injuries is based on a rapid and systematic questioning and examination of the casualty. An immediate assessment is made of the air way, breathing and circulation – the ‘ABC’ of trauma assessment

An instant assessment can be made by questioning the patient and eliciting a verbal response; the ability to speak means that the brain is being perfused with oxygenated blood and hence the patient has a patent airway, is breathing and has an adequate circulation.

MANAGEMENT Management of injuries is prioritized on treating the most immediately life- threatening injuries first, traditionally following the ABCDE sequence.

Concepts of ATLS Concepts of ATLS Treat the greatest threat to life first Treat the greatest threat to life first The lack of a definitive diagnosis should never impede the application of an indicated treatment The lack of a definitive diagnosis should never impede the application of an indicated treatment A detailed history is not essential to begin the evaluation A detailed history is not essential to begin the evaluation “ABCDE” approach “ABCDE” approach

Initial Assessment and Management An effective trauma system needs the teamwork of EMS, emergency medicine, trauma surgery, and surgery subspecialists An effective trauma system needs the teamwork of EMS, emergency medicine, trauma surgery, and surgery subspecialists Trauma roles Trauma roles –Trauma captain –Interventionalists –Nurses –Recorder

Trauma Team

Primary Survey Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms ABCDEs of trauma care ABCDEs of trauma care –AAirway and c-spine protection –BBreathing and ventilation –CCirculation with hemorrhage control –DDisability/Neurologic status –EExposure/Environmental control

Airway How do we evaluate the airway?

A- Airway Airway should be assessed for patency Airway should be assessed for patency –Is the patient able to communicate verbally? –Inspect for any foreign bodies –Examine for stridor, hoarseness, gurgling, pooled secretions or blood Assume c-spine injury in patients with multisystem trauma Assume c-spine injury in patients with multisystem trauma –C-spine clearance is both clinical and radiographic –C-collar should remain in place until patient can cooperate with clinical exam

Airway Interventions Supplemental oxygen Supplemental oxygen Suction Suction Chin lift/jaw thrust Chin lift/jaw thrust Oral/nasal airways Oral/nasal airways Definitive airways Definitive airways –ETI for comatose patients (GCS<8)

Difficult Airway

Breathing What can we look for clinically to assess a patient’s ‘breathing’ status? What can we look for clinically to assess a patient’s ‘breathing’ status?

B- Breathing Airway patency alone does not ensure adequate ventilation Airway patency alone does not ensure adequate ventilation Inspect, palpate, and auscultate Inspect, palpate, and auscultate –Deviated trachea, crepitus, flail chest, sucking chest wound, absence of breath sounds CXR to evaluate lung fields CXR to evaluate lung fields

Flail Chest

Subcutaneous Emphysema

Breathing Interventions Ventilate with 100% oxygen Ventilate with 100% oxygen Needle decompression if tension pneumothorax suspected Needle decompression if tension pneumothorax suspected Chest tubes for pneumothorax / hemothorax Chest tubes for pneumothorax / hemothorax Occlusive dressing to sucking chest wound Occlusive dressing to sucking chest wound If intubated, evaluate ETT position If intubated, evaluate ETT position

Chest Tube

C- Circulation Hemorrhagic shock should be assumed in any hypotensive trauma patient Hemorrhagic shock should be assumed in any hypotensive trauma patient Rapid assessment of hemodynamic status Rapid assessment of hemodynamic status –Level of consciousness –Skin color –Pulses in four extremities –Blood pressure and pulse pressure

Circulation Interventions Cardiac monitor Cardiac monitor Apply pressure to sites of external hemorrhage Apply pressure to sites of external hemorrhage Establish IV access Establish IV access –2 large bore IVs –Central lines if indicated Cardiac tamponade decompression if indicated Cardiac tamponade decompression if indicated Volume resuscitation Volume resuscitation –Have blood ready if needed –Level One infusers available –Foley catheter to monitor resuscitation

D- Disability Abbreviated neurological exam Abbreviated neurological exam –Level of consciousness –Pupil size and reactivity –Motor function –GCS »Utilized to determine severity of injury »Guide for urgency of head CT and ICP monitoring

GCS EYEVERBALMOTOR Spontaneous 4 Oriented 5 Obeys 6 Verbal 3 Confused 4 Localizes 5 Pain 2 Words 3 Flexion 4 None 1 Sounds 2 Decorticate 3 None 1 Decerebrate 2 None 1

Disability Interventions Spinal cord injury Spinal cord injury –High dose steroids if within 8 hours ICP monitor- Neurosurgical consultation ICP monitor- Neurosurgical consultation Elevated ICP Elevated ICP –Head of bed elevated –Mannitol –Hyperventilation –Emergent decompression

E- Exposure Complete disrobing of patient Complete disrobing of patient Logroll to inspect back Logroll to inspect back Rectal temperature Rectal temperature Warm blankets/external warming device to prevent hypothermia Warm blankets/external warming device to prevent hypothermia

Always Inspect the Back

Disposition of Trauma Patients Dictated by the patient’s condition and available resources i.e. trauma team available Dictated by the patient’s condition and available resources i.e. trauma team available –OR, admit, or transfer Transfers should be coordinated efforts Transfers should be coordinated efforts –Stabilization begun prior to transfer –Decompensation should be anticipated Serial examinations Serial examinations – Regain of consciousness –Abdominal exams for documented blunt trauma –Pulmonary contusions with blunt chest trauma

Summary Trauma is best managed by a team approach (there’s no “I” in trauma) Trauma is best managed by a team approach (there’s no “I” in trauma) A thorough primary and secondary survey is key to identify life threatening injuries A thorough primary and secondary survey is key to identify life threatening injuries Once a life threatening injury is discovered, intervention should not be delayed Once a life threatening injury is discovered, intervention should not be delayed Disposition is determined by the patient’s condition as well as available resources. Disposition is determined by the patient’s condition as well as available resources.

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