1. حوادث شیمیایی و ارزیابی اولیه بیمار ترومایی
I. Speaker’s Notes:
The Occupational Safety and Health Administration (OSHA) requires employers to have a written Hazard Communication Plan. The plan demonstrates the employer’s commitment to helping employees work safely with the chemicals that are used in the workplace.
Today’s class will discuss the chemicals in the workplace, how to determine chemical hazards, and how to protect yourself from those hazards.
Copyright ã1999 Business & Legal Reports, Inc.

2. Close Encounters with Chemicals
We encounter chemicals almost every day
Filling your vehicle with gasoline
Cleaning the bathroom
Applying pesticides or insecticides
At work: Laboratory Chemicals, White Board Markers, White Board Cleaners, Copier Toner, Batteries, etc and possible exposure to paint, bathroom cleaners, etc.
Many chemicals can cause injury or illness if not handled properly.
I. Background for the Trainer:
Have the employees give examples of chemicals that they use at work and at home.
Ask the class if a chemical has ever caused them to feel sick (hangovers from too much alcohol don’t count).
Have they ever burned their skin or eyes with a chemical?
II. Speaker’s Notes:
These are all examples of why we are conducting this class. We want you to be able to work safely with hazardous chemicals at work and at home. As long as you understand the hazards and know how to protect yourself from those hazards, working with chemicals can be done safely.
Copyright ã1999 Business & Legal Reports, Inc.

3. Right to Know
You have a RIGHT TO KNOW about the hazardous chemicals you use on the job and how to work safely with those chemicals.
I. Speaker’s Notes:
OSHA has created the Hazard Communication Standard to help ensure your safety when working with chemicals.
The Hazard Communication Standard requires employee training to include:
A discussion of the operations at your company that use hazardous chemicals
How to detect the presence or release of a hazardous chemical
A discussion of the physical and health hazards of chemicals
How employees can protect themselves from the hazardous chemicals
This training module will cover the basics of all the required topics. Feel free to ask questions during the presentation if anything is unclear or needs further explanation.
Copyright ã1999 Business & Legal Reports, Inc.
Copyright ã1999 Business & Legal Reports, Inc.

4. Hazard Communication Standard
Chemical manufacturers must:
Determine a chemical’s hazards
Provide labels and MSDSs
I. Speaker’s Notes:
Chemical Manufacturers must:
Determine physical and health hazards of each product they make
Label all containers
Make and provide material safety data sheets (MSDS)
Employer’s must have and make the following available to employees:
A written hazard communication program
A list of the hazardous chemicals that the company uses
Material safety data sheets
Training that teaches employees:
About the Hazard Communication Standard
About chemicals that are used in the workplace
To recognize, understand, and use labels and MSDSs
To use safe procedures
Copyright ã1999 Business & Legal Reports, Inc.

5. HazCom Standard (cont.)
Employees must:
Read labels and MSDSs
Follow employer instructions and warnings
Identify hazards before starting a job
Participate in training
I. Speaker’s Notes:
As with any program, the Hazard Communication Standard will not be effective without the participation of all employees.
You should know where MSDSs are located and how to find the MSDS for a specific chemical. You should also know how to pull out important information such as the health hazards, symptoms of exposure, and how to protect against those hazards (i.e., using PPE).
Once you know what PPE to wear when using the chemical, you must follow the instructions and warnings on the MSDS or label. This means no shortcuts. Wear the required PPE.
Copyright ã1999 Business & Legal Reports, Inc.
Copyright ã1999 Business & Legal Reports, Inc.

6. Chemical Hazards Physical Hazards: Health Hazards: Flammable Explosive
Reactive
Health Hazards:
Corrosive
Toxic
I. Speaker’s Notes:
Most people understand and recognize physical hazards and know how to protect themselves against them (e.g , no smoking near the propane tank). However, few people recognize and understand chemical hazards and, therefore, do not know how to protect themselves. Sometimes the effects of a hazardous chemical are not felt immediately; therefore, appropriate precautions are not taken.
Physical hazards include: fires or explosions, sudden release of pressure, or reactivity (e.g., when a chemical can burn, explode, or release gases after contact with water, air, or other chemicals). Have employees give examples (from both work and home) of each of the categories listed under physical hazards.
Flammable: Acetone, propane, gasoline, paints
Explosive: Compressed gas cylinders, aerosol cans
Reactive: Mixture of bleach and ammonia
Health hazards include: illnesses or other health problems that could develop as a result of overexposure to a chemical. Short-term effects include headache, dizziness, skin irritation. Long-term effects may be liver or lung damage or even cancer. Have employees give examples (from both work and home) of each of the categories listed under health hazards.
Corrosive: Nitric acid, many strong household cleaners
Toxics: Pesticides, benzene in gasoline, many solvents, lead
Copyright ã1999 Business & Legal Reports, Inc.
Copyright ã1999 Business & Legal Reports, Inc.

7. Routes of Entry Skin and eye contact Inhalation Swallowing
Penetration (skin absorption)
I. Speaker’s Notes:
Skin and eye contact: Irritation (e.g., itchiness, blisters) caused by solvents, degreasers, soaps; burns caused by corrosives; internal reactions (e.g., toxins) caused by hydrocarbon solvents; and allergic reactions (e.g., hives) caused by chromates or nickel
Inhalation: Headache, nausea, dizziness, lung damage
Swallowing: This usually means contact with food or smoking, not openly drinking a hazardous chemical. Nausea, vomiting, dizziness, liver or kidney damage
Penetration: The introduction of a chemical with a needle
Copyright ã1999 Business & Legal Reports, Inc.
Copyright ã1999 Business & Legal Reports, Inc.

8. Chemical Exposure Dosage Acute effects Chronic effects
I. Speaker’s Notes:
Dosage: The MSDS will list the dosage, or exposure level, allowed for each hazardous chemical. These exposure levels are typically called Permissible Exposure Level (PEL) as set by OSHA or Threshold Limit Value (TLV) as recommended by ACGIH (American Conference of Governmental Industrial Hygienists) and refer to the quantity of hazardous chemical that an average employee can safely be exposed to in an eight-hour work day. This is just like your doctor telling you to take one pill every eight hours. If you take two pills in an eight hour period, you are technically overdosing and could suffer some side effects. The company works to maintain exposure levels below these levels with engineering controls, ventilation, PPE, etc.
Acute effects: These are short-term effects or symptoms that disappear once the victim is no longer exposed to the chemical. They include rashes, burns, respiratory irritation, and poisoning.
Chronic effects: These are long-term effects that develop over a long period of exposure. They include allergies, lung or liver damage, cancer, etc.
Copyright ã1999 Business & Legal Reports, Inc.
Copyright ã1999 Business & Legal Reports, Inc.

9. Personal Protective Equipment
Dust masks and respirators
Glasses, goggles, and face shields
Hearing protection
Gloves
Foot protection
Head protection
Aprons or full-body suits
I. Background for the Trainer:
Discuss areas in your company in which the following PPE would be used. If several different types of the PPE are offered, discuss each type.
II. Speaker’s Notes:
Dust masks and respirators: Used when working in environments with hazardous dusts, vapors, liquids, or gases. Remember, anyone who uses a respirator as part of the normal job function must be involved in a respirator training program.
Glasses, goggles, and face shields: Used when working around equipment that cuts, grinds, shears, etc., and also when working with hazardous liquids that may splash. Remember, regular prescription glasses do not meet the requirements of safety glasses. Obtain prescription safety glasses.
Hearing protection: Used when working with noisy equipment or in a high noise area. Remember, employees who must work in a high noise area (as defined by OSHA) must be involved in a hearing protection program.
Gloves: There are many types of gloves to protect from many hazards including but not limited to hazardous chemicals.
Foot protection: Used when working with hazardous chemicals that may splash onto the feet.
Head protection: Might include hard hats or hoods to protect from chemical splashes or exposure.
Copyright ã1999 Business & Legal Reports, Inc.

10. Hazardous Materials First Aid
Eyes: Flush with water for 15 minutes
Skin: Wash with soap and water
Inhalation: Move to fresh air
Swallowing: Get emergency medical assistance
I. Background for the Trainer:
Discuss your company’s emergency procedures, so employees understand how to report and handle medical emergencies. Where are first-aid kits and emergency shower and eyewash stations located? Is the employee permitted to take another employee to the eyewash station, or does a person trained in first aid need to do this?
II. Speaker’s Notes:
This first-aid information is generic and will work for most chemicals. However, the chemical label and MSDS will provide the best first-aid information. An MSDS should accompany anyone who is going to see a medical provider because of exposure to a chemical.
Copyright ã1999 Business & Legal Reports, Inc.
Copyright ã1999 Business & Legal Reports, Inc.

11. Material Safety Data Sheets (cont.)
Health hazards
Routes of entry
Exposure levels
Symptoms of exposure
First-Aid and emergency information
I. Speaker’s Notes:
Health hazards is a very important section for you to read and understand. It is important to know the signs of overexposure and how a chemical can affect you.
Routes of entry: How can the chemical affect you? The main routes of entry are inhalation (breathing in vapors), skin absorption, and ingestion (swallowing).
Exposure levels: These are safety guidelines established by OSHA and ACGIH for the average adult. However, each person is affected differently. In fact, two people conducting the same work can be impacted differently. One person can become sick from a chemical while the other doesn’t feel anything.
Symptoms of exposure: If symptoms occur, there has probably been overexposure, and the employee should stop using the chemical and seek first aid.
First aid: This section will explain what actions should be taken to correct overexposure symptoms.
Copyright ã1999 Business & Legal Reports, Inc.
Copyright ã1999 Business & Legal Reports, Inc.

12. Material Safety Data Sheets (cont.)
Personal Protective Equipment (PPE)
Safe handling and storage
Spills and leaks
Compliance issues
I. Speaker’s Notes:
PPE: This section is crucial because it explains how employees can protect themselves from health hazards. The MSDS will provide guidance on skin, eye, hand, and respiratory protection. It may also suggest use of mechanical ventilation (e.g., a fan).
Safe handling: This section may suggest grounding chemical containers, keeping containers closed when not in use, storing away from incompatible materials and in a ventilated area, etc.
Spills and leaks: This section outlines steps to take in the event of a spill or leak. Never try to clean without the proper training.
Compliance issues: What are the disposal requirements for this chemical? Does the Department of Transportation have specific shipping restrictions? Is the chemical required to be reported under community right-to-know laws?
Copyright ã1999 Business & Legal Reports, Inc.
Copyright ã1999 Business & Legal Reports, Inc.

13. Hazard Communication Summary
Identify chemical hazards by reading labels and MSDSs
Follow warnings and instructions, or ask your supervisor if in doubt
Use the correct personal protective equipment
Practice sensible, safe work habits
Learn emergency procedures
I. Speaker’s Notes:
Here are the main points you should take away from this training session.
Copyright ã1999 Business & Legal Reports, Inc.
Copyright ã1999 Business & Legal Reports, Inc.

14. Initial Assessment and Management
1-1 Title Slide
Introduce the topic and explain to students that, based on their preparation for the course, a series of questions will be asked throughout the lecture. Their active participation and responses are expected.
Emphasize that this lecture summarizes the information provided throughout the course, and that all major components will be covered in depth during individual lectures, skill stations, and demonstrations.
Because you will use the slide show to emphasize key points, it is important to be familiar with every slide. Proper sequencing of questions and responses facilitates an interactive presentation.
Be sure to carefully manage the time allotted for this lecture.
Initial Assessment and Management

15. Chapter Statement
The primary survey should be repeated frequently to identify any deterioration in the patient's status that indicates the need for additional intervention.
ACS: Please add Notes for instructor.
1-2 Chapter Statement

16. Objectives
Identify the correct sequence of priorities for assessment of a multiply injured patient.
Apply the principles outlined in the primary and secondary surveys to the assessment of a multiply injured patient.
Explain how a patient’s medical history and the mechanism of injury contribute to the identification of injuries.
Identify the pitfalls associated with the initial assessment and management of an injured patient and describe steps to minimize their impact.
Recognize patients who will require transfer for definitive management.
1-5 Objectives 1-10
Review the objectives with the students as provided on the slide.
Emphasize that ATLS has a unique language, including such terms as primary and secondary survey, ABCDEs, and definitive care. Those individuals who complete the course will speak the same language, and thereby communicate more effectively.
Primary and secondary survey will be defined.
Management priorities and their rationale will be discussed, including resuscitation and monitoring.
Recognize the possibility of pitfalls.
These objectives relate to the lecture/interactive discussion. There may be additional objectives related to this topic that will be covered in the skills station and the initial assessments. Please refer to the book for the complete list of objectives related to this topic.

17. Standard Precautions Cap Gown Gloves Mask Shoe covers
Protective eyewear / face shield
1-6 Standard Precautions
Standard precautions are one component of preparing for the patient in the hospital.
You may query what items are needed to protect the patient and the trauma team members.
Emphasize the need to protect the patient and trauma team members from communicable diseases.

18. Initial Assessment
Primary survey and resuscitation of vital functions are done simultaneously using a team approach.
1-7 Initial Assessment
We recognize that, when a team is present, many individuals accomplish disparate tasks simultaneously.
The ABCDE format serves the purpose of establishing priorities and helping the student to return to “A” (home base) whenever the patient’s condition worsens or the patient does not respond as anticipated during the initial assessment process.

19. Concepts of Initial Assessment
Initial assessment and management refers to the entire process of evaluating, treating, conducting a detailed head-to-toe evaluation, reevaluating the patient, and transferring that patient, as necessary, to a facility with the resources to provide optimal care.

20. What is a quick, simple way to assess a patient in 10 seconds?
Quick Assessment
What is a quick, simple way to assess a patient in 10 seconds?
1-9 Quick Assessment
What is a quick, simple method to assess the patient in 10 seconds?
After asking this question, allow the students adequate time to consider the most efficient way of assessing for a patent airway, sufficient respiratory reserve to speak, and the level of cognition to process the question and respond appropriately.
Answers appear on next slide.

21. What is a quick, simple way to assess a patient in 10 seconds?
Quick Assessment
What is a quick, simple way to assess a patient in 10 seconds?
Ask the patient his or her name
Ask the patient what happened
1-10 Quick Assessment

22. Appropriate Response Confirms
A Patent airway
B Sufficient air reserve to permit speech
C Sufficient perfusion
D Clear sensorium
1-11 Appropriate Response Confirms…
Emphasize the need for adequate cardiac output to ensure clear sensorium.
The patient who fails this simple test needs immediate attention.
Explain how the answers relate to A, B, C and D.
Inappropriate or no response requires urgent intervention.

23. Primary Survey
Airway with c-spine protection Breathing and ventilation Circulation with hemorrhage control Disability: Neuro status Exposure / Environmental control
1-12 Primary Survey
This is the student’s first encounter with the “ABCDEs,” so be sure to allow adequate time to discuss why the priorities are ordered in this manner.

24. The priorities are the same for all patients.
Primary Survey
The priorities are the same for all patients.
1-13 Special Considerations
Remind the students that there are special issues to consider with each of these types of trauma patients, but that the priorities remain the same.
Explain the rationale for special considerations:
Elderly – diminished reserve, cormobidity, meds → early decompensation.
Pediatric – early compensation, sudden deterioration – aggressive approach.
Pregnancy – 2 patients – best treatment is resuscitation of the mother.
Athlete – compensate because of reserve. Lack of tachycardia early.

25. Special Populations Elderly Infants and Children Pregnant Women Obese
Athletes
1-14 Special Considerations
Remind the students that there are special issues to consider with each of these types of trauma patients, but that the priorities remain the same.
Explain the rationale for special considerations:
Elderly – diminished reserve, cormobidity, meds → early decompensation.
Pediatric – early compensation, sudden deterioration – aggressive approach.
Pregnancy – 2 patients – best treatment is resuscitation of the mother.
Athlete – compensate because of reserve. Lack of tachycardia early.

26. Primary Survey Airway Establish patent airway and protect c-spine
Pitfalls
Occult airway injury
Progressive loss of airway
Equipment failure
Inability to intubate
Establish patent airway and protect c-spine
1-15 Primary Survey: Establish patent airway and protect c-spine
Concerns regarding the c-spine may be new to those students who are familiar with cardiac life support procedures, but have not taken the ATLS Course.
Emphasize the need to protect the c-spine during airway management, especially avoiding the ACLS head-tilt maneuver.
You may then query the students about what pitfalls they may encounter with managing the airway or, depending on available time, caution the students to avoid these pitfalls.

27. Primary Survey Breathing and Ventilation Respiratory rate
Chest movement
Air entry
Oxygen saturation
Assess and ensure adequate oxygenation and ventilation
Primary Survey: Assess and ensure adequate oxygenation and ventilation
Emphasize the need to attend to adequate oxygenation and ventilation in the injured patient, recognizing that altered chest wall mechanics may be new to those doctors who have taken only the cardiac life support course.
Emphasize that, if the patient is receiving high-flow oxygen, adequate oxygenation is no guarantee of adequate ventilation.

28. Primary Survey Breathing and Ventilation Pitfalls
Airway versus ventilation problem?
Iatrogenic pneumothorax or tension pneumothorax?
1-17 Primary Survey: Assess and ensure adequate oxygenation and ventilation
Emphasize the need to attend to adequate oxygenation and ventilation in the injured patient, recognizing that altered chest wall mechanics may be new to those doctors who have taken only the cardiac life support course.
Discuss how interventions may lead to pneumothorax and tension pneumothorax (referring to the role of positive pressure ventilation).

29. Primary Survey Circulation (including hemorrhage control)
Level of consciousness
Skin color and temperature
Pulse rate and character
Assess for organ perfusion
1-18 Primary Survey: Assess for organ perfusion
Emphasize the reasons for assessing for signs of inadequate tissue perfusion instead of focusing on the patient’s blood pressure.
Explain how generalized hypoperfusion manifests itself by the signs on the slide.

30. Primary Survey Circulatory Management Pitfalls Control hemorrhage
Restore volume
Reassess patient
Elderly
Children
Athletes
Medications
1-19 Primary Survey: Circulatory Management
Emphasize the need to control hemorrhage or stop the bleeding.
Also emphasize that the patient may require the students about what pitfalls they may encounter with managing the airway or, depending on available time, caution the students to avoid these pitfalls.
Explain that hemorrhage is the major source of hypoperfusion in the trauma patient and the prime goal is to identify and stop the hemorrhage.
The different responses of the elderly, child and athlete to hypoperfusion and the effect of medications such as B-blocker should be discussed.

31. Primary Survey Disability Caution Baseline neurologic evaluation
Glasgow Coma Scale score
Pupillary response
Observe for neurologic deterioration
1-20 Primary Survey: Disability
Emphasize that it is essential to identify neurologic injury using the tools of GCS score and pupil response early in order to avoid secondary brain injury, identify surgically correctible lesions rapidly, and provide a baseline GCS score to identify trends and changes.

32. Primary Survey Exposure / Environment Caution Pitfalls
Completely undress the patient
Prevent hypothermia
Pitfalls
1-21 Primary Survey: Exposure and Environment
The ‘E’ of the ABCDEs.
Emphasize the need to completely undress the patient to adequately assess the entire patient, while at the same time preventing hypothermia.
Explain the need to examine the patient completely to avoid missed injuries.
Missed injuries

33. Resuscitation Protect and secure airway Ventilate and oxygenate
Stop the bleeding!
Crystalloid / blood resuscitation
Protect from hypothermia
1-22 Resuscitation
Emphasize that treatment is administered at the time the life-threatening problem is identified and that assessment and treatment during the primary survey and resuscitation phases of the initial assessment process often are done simultaneously.

34. Adjuncts to Primary Survey
Vital signs
ECG
ABGs
PRIMARY SURVEY
Pulse
oximeter
and CO2
Urinary
output
1-23 Adjuncts to the Primary Survey
Emphasize that adjuncts are done selectively, depending on the patient’s spectrum of injuries and physiologic responses.
Urinary / gastric catheters
unless contraindicated

35. Adjuncts to Primary Survey
Diagnostic Tools
1-24 Adjuncts to Primary Survey
The primary purpose of these adjuncts during the primary survey is to determine where occult bleeding may be occurring that is not obvious on clinical exam.
Emphasize the need to determine the source of shock.
Portable chest and pelvic x-rays in the emergency department are the ONLY x-rays obtained during the primary survey. Previous editions of the course included lateral cervical spine x-rays, but this film is now obtained selectively and at the appropriate time, based on the doctor’s judgment.
These x-rays assist in identifying the cause of shock in “C” of the A, B, C’s of the primary survey.
(X-rays courtesy of Dr. Ray McGlone, A&E Consultant, Royal Lancaster Infirmary; UK.)

36. Adjuncts to Primary Survey
Diagnostic Tools
FAST
DPL
1-25 Adjuncts to Primary Survey
Explain the role of FAST and DPL (not generally used) in assessing for a source of hemorrhage.

37. Adjuncts to Primary Survey
Consider Early Transfer
Use time before transfer for resuscitation
Do not delay transfer for diagnostic tests
1-26 Adjuncts to the Primary Survey: Consider Early Transfer
Emphasize that the time to initiate the transfer process is when the need is recognized. Therefore, the need to transfer must be considered early. The sooner the need is recognized and communicated, the more efficiently it occurs.
In addition, transfer should not be delayed to perform the secondary survey or to perform diagnostic tests such as CT scans. The time spent waiting for transportation to arrive should be spent stabilizing the patient.
Early identification of the need for transfer and prompt transfer should not await conduct of unnecessary diagnostic tests.

38. The complete history and physical examination
Secondary Survey
What is the secondary survey?
The complete history and physical examination
1-27 What is the secondary survey?
Expand upon the definition of the secondary survey after eliciting students’ responses.

39. Secondary Survey When do I start the secondary survey? After
Primary survey is completed
ABCDEs are reassessed
Vital functions are returning to normal
1-28 Secondary Survey: When do I start it?
These slides transition the student to the secondary survey.
Emphasize that issues identified during the primary survey have been addressed and reevaluated before proceeding to the secondary survey.

40. Secondary Survey Components of the secondary survey History
Physical exam: Head to toe
Complete neurologic exam
Special diagnostic tests
Reevaluation
1-29 Secondary Survey: What are the components of the secondary survey?
You may use these items as a summary of the discussion on the components of the secondary survey.
This slide also serves as an introduction to each component of the secondary survey.
Discuss the components of the secondary as outlined emphasizing the need for re-evaluation.

41. Secondary Survey
History
Allergies Medications Past illnesses / Pregnancy Last meal Events / Environment / Mechanism
1-30 Secondary Survey: History
Introduce this simple mnemonic for obtaining an “AMPLE” or complete patient history.

42. Secondary Survey Mechanisms of Injury
Ask the students how the mechanism of injury can influence the type and pattern of injury sustained.

43. Secondary Survey Head Pitfalls External exam Scalp palpation
Comprehensive eye and ear exam
Include visual acuity
Pitfalls
Unconsciousness
Periorbital edema
Occluded auditory canal
1-32 Secondary Survey: Head
You may query the students about what to examine and/or evaluate during the examination of the injured patient’s head.
Describe the components as depicted on the slide and how the pitfalls may complicate the assessment.

44. Secondary Survey Maxillofacial Bony crepitus Deformity Malocclusion
Pitfalls
Bony crepitus
Deformity
Malocclusion
Potential airway obstruction
Cribriform plate fracture
Frequently missed
1-33 Secondary Survey: Maxillofacial
Students should be instructed to check mid-face stability, dental occlusion, and contraindications for nasogastric tubes.
Discuss how these findings could be missed and the need for accurate assessment.

45. Secondary Survey Neck (Soft Tissues) Pitfalls
Mechanism: Blunt versus penetrating
Symptoms: Airway obstruction, hoarseness
Findings: Crepitus, hematoma, stridor, bruit
Pitfalls
Delayed signs and symptoms
Progressive airway obstruction
Occult injuries
1-34 Secondary Survey: Neck (soft-tissues)
You may query the student about they should look for during the examination of the injured patient’s maxillofacial area.
Review the mechanism, symptoms and presentation of neck injuries and the pitfalls.

46. Secondary Survey Chest Inspect Palpate Percuss Auscultate X-rays
The photograph shows an unrestrained passenger who was thrown into the dashboard.
Ecchymosis of chest wall from blunt trauma.
Review how the chest is evaluated during secondary survey, including appropriate imaging studies.

47. Secondary Survey Abdomen Pitfalls Inspect / Auscultate
Palpate / Percuss
Reevaluate
Special studies
Pitfalls
Hollow viscus injury
Retroperitoneal injury
1-36 Secondary Survey: Abdomen
Review how the abdomen is evaluated during secondary survey, including appropriate imaging studies.
The lap portion of the belt appears to have been applied incorrectly.
You may wish to emphasise the use of x-ray for pelvic assessment
Remind the students that the back also is a part of the torso and requires examination.
Appropriate spine precautions and protection must be taken whenever the patient is suspected of having a spinal cord or vertebral injury.
Emphasize the elements of physical examination of the abdomen, the need to reevaluate and the role of special studies (contrast studies) in the hemodynamically normal patient.
Review how hollow viscus and retroperitoneal injuries can be easily missed.
Photograph used with the permission of Trauma.org; Bradley R. Davis, MD, wound 0005b;

48. Secondary Survey Perineum Rectum Vagina Pitfalls
Contusions, hematomas, lacerations, urethral blood
Rectum
Sphincter tone, high-riding prostate, pelvic fracture, rectal wall integrity, blood
Pitfalls
Vagina
1-37 Secondary Survey: Perineum/Genitalia
Inspect for injury.
If injury is present, emphasize the need for vaginal and rectal exam looking for pelvic fracture.
Prior to Foley catheter placement, evidence for injury necessitates a digital prostate exam.
Outline the importance of identifying the abnormalities depicted on the slide.
Discuss the need to identify and diagnose urethral injury.
Urethral injury
Pregnancy
Blood, lacerations

49. Secondary Survey Pelvis Pitfalls Pain on palpation Leg length unequal
Instability
X-rays as needed
Pitfalls
1-38 Secondary Survey: Pelvis
Review how the pelvis is evaluated during secondary survey, including appropriate imaging studies.
Emphasize the need to avoid pelvic manipulation in patients with unstable pelvic fractures that can cause hemorrhage.
Present the findings suggesting bony pelvic injury and its risk of massive hemorrhage as well as the need to avoid excessive manipulation which could worsen hemorrhage as well as pain.
Excessive pelvic manipulation
Underestimating pelvic blood loss

50. Secondary Survey Extremities Contusion, deformity Pain Perfusion
Peripheral neurovascular status
X-rays as needed
1-39 Secondary Survey: Musculoskeletal Trauma—Extremities
Review how the extremities are evaluated during secondary survey, including appropriate imaging studies.
Explain the importance of not missing these findings.

51. Secondary Survey Musculoskeletal System Pitfalls Potential blood loss
Missed fractures
Soft tissue or ligamentous injury
Compartment syndrome
1-40 Secondary Survey: Musculoskeletal Trauma—Pitfalls
Emphasize the potential for hidden hemorrhage, compartment syndrome, missed fracture, and soft tissue injury.

52. Secondary Survey Neurologic: Brain GCS Pupil size and reaction
Lateralizing signs
Frequent reevaluation
Prevent secondary brain injury
1-41 Secondary Survey: Neurologic—Brain
Note the need for an in depth evaluation of the patient’s central nervous system status and frequent documented reevaluation.
Emphasize prevention of secondary brain injury by avoiding hypotension and hypoxia.
Emphasize need for continued assessment to detect deterioration and the need to prevent secondary brain injury by maintaining oxygenation and perfusion.
Early neurological consult

53. Secondary Survey Neurologic: Spinal Assessment Pitfalls Whole spine
Tenderness and swelling
Complete motor and sensory exams
Reflexes
Imaging studies
Pitfalls
Altered sensorium
Inability to cooperate with clinical exam
1-42 Secondary Survey: Neurologic—Spinal Assessment
Review how the spine and spinal cord function is evaluated during the secondary survey, including appropriate imaging studies.
Review patient conditions that impair evaluation.
Emphasize that the entire spine must be assessed and detailed neurologic assessment is necessary.

54. Secondary Survey Neurologic: Spine and Spinal Cord
Conduct an in-depth evaluation of the patient’s spine and spinal cord
1-43 Secondary Survey: Neurologic—Spine and Cord
Emphasize the need to carefully evaluate the patient’s entire back and take precautionary/protective measures when logrolling the patient.
Early neurological /
orthopedic consult

55. Secondary Survey Neurologic Pitfalls Incomplete immobilization
Subtle changes may predict acute deterioration.
Emphasize the need for serial reevaluation.
Explain how incomplete immobilization can lead to neurologic deterioration.
Incomplete immobilization
Neurologic deterioration

56. Adjuncts to Secondary Survey
Special Diagnostic Tests as Indicated
Pitfalls
Patient deterioration
Delay of transfer
Deterioration during transfer
Poor communication
1-45 Adjuncts to Secondary Survey
These include specialized radiographic studies.
Emphasize that adjuncts should NOT delay appropriate transfer to definitive care.

57. How do I minimize missed injuries?
High index of suspicion
Frequent reevaluation and monitoring
1-46 Missed Injuries
Emphasize that meticulous attention to detail, integrated with clues from the mechanism of injury and physical findings, and continued reassessment, are the best methods to avoid missed injuries.
Some institutions conduct a “tertiary” survey within 24 hours of admission to assess for missed injuries.
Missed injuries are avoided by frequent re-evaluation , monitoring and having a high index of suspicion.

58. Pain Management Relief of pain / anxiety as appropriate
Administer intravenously
Careful monitoring is essential
1-47 Pain Management
Emphasize the need for judicious relief of pain associated with careful patient monitoring.
Careful monitoring is required.

59. Which patients do I transfer to a higher level of care?
Pose the question to the students and discuss their response and go to the next slide.

60. Transfer to Definitive Care
Which patients do I transfer to a higher level of care?
Those whose injuries exceed institutional capabilities:
Multisystem or complex injuries
Patients with comorbidity or age extremes
1-49 Which patients do I transfer?
Emphasize who needs transfer, the mechanics and rules of transfer, and the importance of doing it efficiently.

61. Transfer to Definitive Care
When should the transfer occur?
1-50 When to transfer?
Elicit responses from the audience. Answers appear on next slide

62. Transfer to Definitive Care
When should the transfer occur?
As soon as possible after stabilizing measures are completed:
Airway and ventilatory control
Hemorrhage control (operation)
1-51 When to transfer?
Define what degree of stabilization is needed at minimum prior to transfer.
Emphasize the need to avoid delay and unnecessary tests.
Discuss the stabilization of the patient using the A, B, C system.

63. Transfer to Definitive Care
Local Facility
Transfer Agreements
Local Resources
1-52 Transfer to Definitive Care
Use this slide to summarize transfer to definitive care.
Emphasize the need for established transfer agreements and relationships.
Trauma Center
Specialty Facility

64. Questions? ?
1-54 Questions
Ask for questions from the students and then pause, allowing the students adequate time to form and ask their questions.