1 - Initial Assesment and Management

INITIAL ASSESMENT MANAGEMENT

SYAFRI K.ARIF

Dept.of Anesthesiology,Pain Management and Intensive Care Faculty of Medicine Hasanuddin University

Makassar-Indonesia

INTRODUCTIONThe main role of the doctor is SAVING LIFE ALLEVIATE SUFFERINGAny doctors should have these competences.The main tool of saving life is “BASIC LIFE SUPPORT “

ACCIDENTS OR DISASTERSAccidents or disasters may occur

to : ANY WHERE ANY TIME ANY ONE

Well preparedness is very important ( soft-ware and hard-ware )

A medical condition that starts suddenly and requires immediate care

A life or limb threatening medical condition resulting from an injury or sickness that requires immediate treatment and, if left untreated, could result in permanent harm to the person.

What is “EMERGENCY” in Medicine ?

Conditions such as: heart attack, uncontrollable bleeding, loss of consciousness, convulsions, severe allergic reactions, poisoning, severe shortness of breath or difficulty breathing, or severe or multiple injuries, including obvious fractures.

Some Example of Emergency Conditions

The Cause of Death in US Traffic accidents are the third cause

of mortality after CVS and Cancer Disease of the young, leading cause

death age 1 to 40 years > 100,000 death /year in US Loss of productive work years Trauma management is expensive

Epidemiology of Trauma Death Trimodal patterns

Donald Trunkey50%

30%20%

sec hr days/week

%

Death

ATLS

Trauma Death First Peak

Death that occurs at impact or soon after the accident

50 % death Not preventable

severe head laceration, massive bleeding, heart injury etc.

Prevention of accidents enforcement,

education & awareness

Trauma Death Second Peak

Death within minutes to hours after injury

“ Golden Hours ” 30 % of death Life threatening

injuries involving airway, breathing , circulation

Trauma Death Airway

obstruction: tongue, secretion & blood, vomitus

difficult airway management Breathing & Ventilation

pneumothorax,heamothorax, penetrating chest injuries, flail chest

Circulation hemorrhage, cardiac tamponade

Second Peak Preventable Reflect

adequacy, efficiency of EMS in prehospital resuscitation

hospital emergency department resuscitation

definitive therapy

Third peak Third Peak

Death within days or week after injury

20 % death Sepsis or multiorgan

failure Reflects again efficiency

at resuscitation, definitive care, aggressive ICU care, prevention of infection and rehabilitation

INITIAL ASSESMENTInitial assessment include :1. Preparation2. Triage3. Primary Survey ( ABCDE )4. Resuscitation5. Secondary Survey ( Head to toe

evaluation )6. Definitive Care

1. PREPARATIONPreparation of the trauma patient

occursin two different clinical settings

1. PRE-HOSPITAL PHASE2. IN HOSPITAL PHASE

PRE HOSPITAL

Transportation is very important

Prehospital Trauma Resuscitation

Definitive care ? GOALS A clear airway, effective ventilation,

hemorrhage control & restoration of adequate blood volume

Pre hospital Care Ambulance Response

Time: Standard 50 % of all calls are

responded within 8 min.

95 % of calls within 14 min. (urban)

95 % of calls within 19 min. (rural )

Nolan JP, Pars. BJA 1997;79,226-240

Pre hospital Communication

Communication Vital between prehospital & in-

hospital trauma patient resuscitation

Prepare ED personnel well ahead

Activation of TRAUMA TEAM / DISASTER PLAN into action

2. Triage ‘trier’ sorting out Is the sorting of

patient based on the need for treatment

Triage Resuscitation Room Activation of trauma

team

Efficient method Trained doctors &

nurses Variety of tasks taken

simultaneously horizontal organization reduced time to life-

saving procedure by 50 %

Trauma Team-work

Trauma Team at Work “ Pit stop in a

formula 1 motor race ”

Managing trauma in a smooth and efficient manner

Do no further harm

3. The Primary Survey AAirway & cervical spine

control BBreathing & ventilation CCirculation &

haemorrhage control DDisability EExposure/Environment

Airway & Cervical Spine Control

Difficult Airway Goal

Keep airway patent

protect compromised airway

provide airway if none

Suspect: Unconscious

patients Injury above

clavicles Neck pain Weakness or

neurological deficit History of fall > 6 m

Cervical spine Fracture

Breathing & Ventilation Patient in increasing respiratory

distress, BLUE, BLUE, BLUE, BP DOWN, Not Recordable…...

Think :Tension Pneumothorax, haemotothorax, Flail chest, lung contusion, cardiac tamponade

Goals: Avoid Hypoxia, Hypercarbia. Bad for the Brain

TENSION PNEUMOTHORAX

Flail Chest

• Segmental ribs fracture of multiple ribs

• Panel moves in with inspiration and out with expiration

Cardiac Tamponade

Treatment of Cardiac Tamponade

Chest tubeMassive : > 1500 ml bloodDrainage: . 200 ml/hrCLAMPED CTUrgent thoracotomy

Hematothorax

Circulation Haemorrhage Control with Fluid therapy First Priority : Restore volume with fluid

(RL/NaCl 0.9% ) Second Priority :

Restore blood with WB and PRC transfusionto restore oxygen carrying capacity Remember : did not die of anemia but die of

hypovolemic shock Third Priority : Normalize coagulation status

FFP, Platelet, blood products

Disability ( Neurologic Evaluation ) Rapid Neurologic evaluation is

perform at the end of primary survey Simple Neurologic evaluation is AVPU

method A Alert V Responds to Vocal stimuli P Responds only to Painful stimuli U Unresponsive to all stimuli

4. Resuscitation Aggressive resuscitation and the

management of life threatening injuries Essential to maximize patient survial

Airway should be protect and secure Jaw thrust or Chin lift maneuver Definitive airway if needed

Breathing/ventilation and oxygenation Injured patient should received supplemental O2

Circulation Controlled bleeding by direct pressure or operative

intervention

End- Points of Resuscitation Traditional:

Achieved definitive care Blood Pressure/ cerebral perfusion

pressure/ ICP Heart rate Urine output

5. Secondary Survey Not begin until the Primary Survey is

completed Is Head to Toe evaluation

Head Maxillofacial Cervical spine and Neck Chest Abdomen Perineum / rectum / vagina Musculoskeletal Neurologic

6. Definitive Care Surgical intervention Transfer to higher trauma center

Conclusion Trauma continues to be the most

common cause of death BLS playing a big role in saving life in

pre-hospital phase or in hospital “Do No Further Harm” is the basic

principle of BLS ABCDE is a good guide to take

action.