1. Chapter 1

2.  Apply principles of primary and secondary surveys  Identify management priorities  Institute appropriate resuscitation and monitoring procedures  Recognize value of patient’s history and biomechanics of injury  Anticipate pitfalls

3.  How do I prepare for a smooth transiiton from the prehospital to the hospital environments?  What is a quick, simple way to assess the patient in 10 seconds?  What is the secondary survey and when does it start?

4.  How can I minimize missed injuries?  Which patients do I transfer to a higher level of care?  When should the transfer occur?

5. Primary survey Resuscitation Reevaluation Detailed secondary survey Reevaluation Definitive care Adjuncts

6.  Primary survey and resuscitation of vital functions are done simultaneously in a team approach

7.  Transport guidelines/protocols  Online medical direction  Mobilization of resources  Periodic review of care  Closest, appropriate facility

8.  Preplanning is essential  Equipment, personnel, services  Standard precautions  Prearranged transfer agreements

9.  Cap  Gown  Gloves  Mask  Shoe covers  Goggles/face shield

11.  Triage is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately.  Sorting of patients according to ◦ ABCDEs ◦ Available resources

12.  Identify yourself  Ask the patient his/her name  Ask the patient what happened

13.  A – patent airway  B – sufficient air reserve to permit speech  CD – clear sensorium If no response, proceed with rapid primary survey.

14.  A – Airway  B – Breathing/ventilation/oxygenation  C – Circulation: Stop the bleeding  D – Disability (neuro status)  E – Expose/environment/body temperature

15.  Trauma in the elderly  Pediatric trauma  Trauma in pregnant women

16.  Establish patent airway ◦ Protect c-spine ◦ Pitfalls?  Equipment failure  Inability to intubate  Occult airway injury  Progressive loss of airway

17.  Assess and ensure adequate oxygenation and ventilation  Pitfalls ◦ Airway vs ventilation problem? ◦ Iatrogenic pneumothorax or tension pneumothorax

18.  Level of consciousness  Skin color and temperature  Pulse rate and character

19.  Circulatory Management ◦ Control hemorrhage ◦ Restore volume ◦ Reassess parameters  Pitfalls? ◦ Elderly ◦ Children ◦ Athletes ◦ Medication

20.  Disability ◦ Baseline neurologic evaluation ◦ GCS scoring ◦ Pupillary response  Observe for neurologic deterioration

21.  Exposure/Environment ◦ Completely expose the patient  Prevent hypothermia

22.  Protect and secure airway  Ventilate and oxygenate  Stop the bleeding  Vigorous shock therapy  Protect from hypothermia

23. ADJUNCTS Vital Signs ABGs/Pulse oximeter ECG Catheters/ Output

24.  Diagnostic tools

25.  FAST (Focused Assessment Sonography in Trauma)  DPL (Diagnostic Peritoneal Lavage)

26.  Consider Early Transfer ◦ Do not delay transfer for diagnostic tests ◦ Use time before transfer for resuscitation

27.  The complete history and physical examination.

28.  After ◦ Primary survey is completed ◦ ABCDEs are reassessed ◦ Vital functions are returning to normal

29.  History  Physical exam: Head-to-toe  “Tubes and fingers in every orifice”  Complete neurologic exam  Special diagnostic tests  Reevaluation

30.  History A=Allergies M=Medications P=Past illnesses L=Last meal E=Events/environment

31.  Mechanisms of injury

32.  HEAD ◦ Glascow Coma Score (GCS) ◦ Neuro exam ◦ Comprehensive eye and ear exam  Pitfalls? ◦ Unconsciousness ◦ Periorbital edema ◦ Occluded auditory canal

33.  Maxillofacial ◦ Bony crepitus ◦ Deformity ◦ Malocclusion  Pitfalls ◦ Potential airway obstruction ◦ Cribriform plate fracture ◦ Frequently missed

34.  Cervical spine ◦ Tenderness ◦ Complete motor/sensory exams ◦ Reflexes ◦ Imaging studies if warranted  Pitfalls ◦ Altered consciousness ◦ Inability to cooperate with clinical exam

35.  Neck (soft tissues) ◦ Mechanism: Blunt vs penetrating ◦ Symptoms: Airway obstruction, hoarseness ◦ Findings: Crepitus, hematoma, stridor, bruit

36.  Neck (soft tissue): Pitfalls ◦ Delayed symptoms and signs ◦ Progressive airway obstruction ◦ Occult injuries

37.  Chest ◦ Inspect ◦ Palpate ◦ Percuss ◦ Auscultate ◦ (aka IPPA) ◦ Obtain X-rays if indicated

38.  Abdomen ◦ IAPP – in this case, auscultation is done before percussion ◦ Reevaluate ◦ Special studies (CT>FAST>DPL)

39.  Abdomen: Pitfalls? ◦ Hollow viscus injury ◦ Retroperitoneal injury ◦ Excessive pelvic manipulation

40.  PeritoneumContusions, hematomas, lacerations, urethral blood  RectumSphincter tone, high- riding prostate, pelvic fracture, rectal wall integrity, blood  VaginaBlood, lacerations  Pitfalls? Urethral injury in women, pregnancy

41.  Musculoskeletal: Extremities ◦ Contusion, deformity ◦ Pain ◦ Perfusion ◦ Peripheral neurovascular status ◦ X-rays as indicated

42.  Musculoskeletal: Pelvis ◦ Pain on palpation ◦ Symphysis width increasing ◦ Leg length unequal ◦ Instability

43.  Musculoskeletal: Pitfalls? ◦ Potential blood loss ◦ Missed fractures ◦ Soft-tissue or ligamentous injury ◦ Compartment syndrome

44.  Neurologic: Brain ◦ GCS score ◦ Lateralizing signs ◦ Frequent evaluation ◦ Imaging as indicated ◦ Prevent secondary brain injury  Early neurological consult

45.  Neurologic: Spinal cord ◦ Complete motor and sensory exams ◦ Imaging as indicated ◦ Reflexes  Early neurological/orthopedic consult

46.  Special diagnostic tests as indicated  Pitfalls: ◦ Patient deterioration ◦ Delay of transfer ◦ Missed injuries: High index of suspicion

47.  Relief of pain/anxiety as appropriate  Administer IV  Careful monitoring

48.  Those whose injuries exceed institutional capabilities  When do I transfer? ◦ As soon as possible after stabilizing ◦ Avoid needless delay

49.  Primary survey  Adjuncts  Resuscitation  Secondary survey  Adjuncts  Definitive care