31.presentation team for medical student.pptx

8/20/2019 31.Presentation TEAM for medical student.pptx

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#oal $ Principles of Trauma Care

• Rapid, accurate, and physiologic

assessment• Resuscitate, stabilize, and monitor by

priority•

Prepare for transfer to definitive care• Teamwork for optimal, safe patient care


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%b"ectives

• Describe fundamental principles of initial

assessment and management• !dentify correct se&uence of management

priorities•

Describe appropriate techni&ues ofresuscitation


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%b"ectives

• 'ecogni(e value of patient)s history• *nderstand importance of in"ury

mechanism• !dentify concepts of team+or, in caring for

in"ured patient


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The -eed for Early TEAM

• Leading cause of death in ages . through //• Disabilities e0ceed deaths by ratio of 1 .• Trauma2related cost 3 4/55 billion per year• Lac, of public a+areness for in"ury

prevention


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!n"ury Prevention

A

B

C

D

E

Analy(e in"ury data

Build local coalitions

Communicate the problem

Develop prevention activities

Evaluate the interventions


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Trimodal Death Distribution


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TEAM Principles

• Treat greatest threat to life first•

Definitive diagnosis less important• Physiologic approach• Time is of the essence•

Do no further harm• Team+or, re&uired for TEAM to succeed


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TEAM Approach

A

B

C

D

E

Air+ay +ith c2spine protection

Breathing $ ventilation $ o0ygenation

Circulation Stop the bleeding6

Disability 7neuro status8

E0pose $ Environment $ body temp


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TEAM Se&uence

'apid primary survey ABCD 9 Ad"uncts

Detailed secondarysurvey $ reevaluation :ead2to2toe 9 Ad"uncts

Definitivecare

Safe transfer


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TEAM Se&uence and Team+or,

• Simultaneous primary survey

and resuscitation of vital functions

• Simultaneous secondary survey and reevaluation of vital functions


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;TEAM< =or, and Team+or,

TL Team Leader

A Air+ayManager

- -urse

. Assistant

> AssistantTogether Everyone Achieves More


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Prehospital Preparation

• Closest appropriate facility• Transport guidelines $ protocols• %n2line medical direction• Mobili(ation of resources• Periodic revie+ of care


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!nhospital Preparation

• Preplanningessntial

• Team approach• Trained personnel• Proper e&uipment• Lab $ 02ray

capabilities

• Standard precautions•

Transfer agreements• ?! program


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Standard Precautions

• Cap• #o+n• #loves• Mas, • Shoe covers•

#oggles $ faceshield


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•

%ther factors@ eg@ salvagebiliy


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Primary Survey

Priorities are the

Same for all !


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Primary Survey

A

B

C

D

E

Air+ay +ith C2spine protection

Breathing $ Life2threatening chestin"uryCirculation Stop the bleeding6

Disability $ !ntracranial mass lesion

E0pose $ Environment $ Bodytemp


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Special Considerations Children

• Leading cause of death• !mmature@ anatomic $ mechanical features• igorous physiologic response• Limited physiologic reserve• %utcome depends on early aggressive


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Special Consoderations Children

• Si(e@ dosage@ e&uipment@ surface area@ and

psychology• Air+ay Laryn0 anterior and cephalad@short tracheal length

•

Breathing Chest +all pliability@ mediastinal mobility


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Special Considerations Children

• Circulation ascular access@ fluid volume@

vital signs@ and urinary output• -eurologic omiting@ sei(ures@ and diffuse brain in"ury•

Musculos,eletal !mmature s,eleton@fracture patterns


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Special Consideration Pregnancy

• Anatomic $ physiologic changes modify

response to in"ury• -eed for fetal assessment• . st Priority Maternal resuscitation• %utcome depends on early@ aggressive care


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Special Considerations pregnancy

• #estation and position of uterus• Physiologic anemia• Pco>• #astric emptying• Supine hypotension• !soimmuni(ation• Sensitivity of fetus


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Special considerations Elders

• th leading cause of death• Diminished physiologic reserve and

response• Comorbidities Disease $ Medications• %utcome depends on early@ aggressive care


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Primary Survey Air+ay

• Assess for air+ay patency• Snoring•

#urgling• Stridor• 'oc,ing chest +all motions•

Ma0illofacial trauma $ laryngeal in"ury

C2spinein"ury


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'esuscitation Patent Air+ay

•

Chin lift $ Modified "a+ thrust• Loo,@ listen@ feel•

'emove particulate matter• Definitive air+ay as necessary• 'easses fre&uently

C2spinein"ury


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'esuscitation Assess Breathing

• Chest rise and symmetry• Air entry• 'ate $ Effort• Color $ Sensorium

Tension $ openpneumothora0


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'esuscitation Breathing

• Administer supplemental o0ygen• entilate as needed• Tension pneumothora0 -eedle

decompression• %pen pneumothora0 %cclusive dreassing• 'eassess fre&uently


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Primary Survey Circulation

• Children• Elderly• Athletes• Pregnancy• Medication


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• -onhemorrhagic shoc,

2 Cardiac tamponade 2 Tension pneumothora0 2 -eurogenic 2 Septic 7late8


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• Assess organ perfusion 2 Level of consciousness 2 S,in color

2 Pulse rate and character


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Primary Survey CirculationAssess %rgan Perfusion

. Tachycardia

> asoconstriction> Cardiac output> -arro+ pulse pressure1 MAP1 Blood flo+


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'esuscitation Circulation

BleedingIT!

ind it6

-Direct pressure- %peration

- Avoid blind clamping


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• %btain venous access• 'estore circulating volume 2 'inger)s lactate@ .2> L 2 P'BCs if transient response or no

response• 'eassess fre&uently


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Consider• Tension pneumothora0 -eedle

decompression and tube thoracostomy• Massive hemothora0 olume resuscitation and tube thoracostomy• Cardiac tamponade Pericardiocentesis and direct operative repair


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Primary Survey Disability

• Baseline neurologic evaluation

%bserve for-eurologicdeterioration

-Pupillary response--eurosurgical consult as indicated


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Primary Survey #CS Score

• Eye opening 'ange . F /•

BEST Motor response 'ange . F G• erbal response 'ange . F • Score H 7E 9 M 9 8• Best score H .• =orst score H 1


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Primary Survey E0pose• Completely undress the patient• 'emove helmet if present• Loo, for visible $ palpable in"uries• Log roll@ protect spine

Preventhypothermia


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'esuscitation %vervie+

• !f doubt@ establish definitive air+ay• %0ygen for all patients• Chest tube may be definitive for chest

in"ury• Stop the bleeding6• > larger2caliber !vs• Prevent hypothermia


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Ad"unct *rinary Catheter• Blood• Decompress bladder• Monitor urinary output

- Blood at meatus- Perineal ecchymosis $ hematoma2 :igh2riding prostate


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Primary Survey Ad"uncts

Monitoring• ital signs•

AB#s• EC#• Pulse o0imetry• End2tidal C%>

Consider need for transfer

Diagnostic Tools• Chest $ pelvis 02ray• C2spine 02rays +hen appropriate• AST• DPL


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Secondary Survey Start After

• Primary survey completed• 'esuscitation in process• ABCDEs reassessed•

ital functions returning to normal


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Secondary Survey Iey Parts

• AMPLE history• Complete physical e0am :ead2to2toe• Complete neurologic e0am• Special diagnostic tests• 'eevaluation


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Secondary Survey :istory

A Allergies

M Medications P Past illnennes $ Pregnancy L Last meal E Event $ Environment


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Secondary Survey

Mechanisms of !n"uryAnatomy Physiology

Pattern of !n"ury

Mechanism of !n"ury


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Burn !n"ury

• !nhalation in"ury !ntubate and administer .55J o0ygen• Administer > F / mL $ ,g J BSA burn in >/ hours 79 maintenance in children8• Monitor urinary output• E0pose and prevent hypothermia• Chemical burn Brush and irrigate


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Burn !n"ury


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Burn !n"ury


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Cold !n"ury

• rostbite 'e+arm +ith moist heat 7/5 C8K +ait for demarcation

• :ypothermia Passive or active re+arming

• Monitor -ot dead until +arm and dead


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Secondary Survey :ead•

Complete neurologic e0am• #CS Score determination• Comprehensive eye $ ear

- *nconscious patient2 Periorbital edema2 %ccluded auditory canal


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Secondary Survey Ma0illofacial

• Bony crepitus $ instability• Palpable deformity• Comprehensive oral $ dental e0ams

-Potential air+ay obstruction2 Cribriform plate fracture2 re&uently missed in"ury


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Secondary Survey C2spine• Palpate for tenderness• Complete motor $ sensory e0ams• 'efle0es• C2spine imaging - !n"ury above

clavicles

2 Altered L%C2 %ther severe@ painful in"ury


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Secondary Survey -ec, •

Blunt vs penetrating

• Air+ay obstruction@ hoarseness

• Crepitus@ hematom@ stridor@ bruit

-Delayed symptom $ signs

2Progressive air+ay obstruction

2%ccult in"uries


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Secondary Survey Chest• !nspect@ auscultate@ palpate@ percuss• 'eevaluate fre&uently• Chest 02rays

-- Missed in"ury2 Chest tube drainage


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Secondary Survey Abdomen• !nspect@ auscultate@ palpate@ and percuss• 'eevaluate fre&uently• Special studies AST@ DPL@ CT

•

:ollo+ viscus and retroperitoneal in"ury• E0cessive pelvic manipulation


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Secondary Survey•

Perineum Contusions@ hematomas@lacerations@ urethral blood

• 'ectum Sphincter tone@ high2riding prostate@ pelvic fracture@ rectal +all integrity@ blood

• agina Blood@ lacerations

Pregnancy


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Secondary Survey Musculos,eletal

• Potential blood loss• Limb or life threat 7primary survey8• Missed fractures•

Soft2tissue or ligamentous in"ury


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Secondary Survey Musculos,eletal

• %ccult compartment syndrome

7especially +ith altered L%C $ hypotension8• E0amine patient)s bac,


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Secondary Survey Pelvis

• Pain on palpation• Symphysis +idth• Leg length une&ual• !nstability• Pelvic 02rays


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Pelvic racture• Ma"or source of

hemorrhage• olum resuscitation• 'educe pelvic volume• E0ternal fi0ator• Angiography $

emboli(ation


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Secondary Survey C-S

• re&uent reevaluation• Prevent secondary brain in"ury• !maging as indicated•

Early neurosurgical consultation


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Secondary Survey Spine

• Complete motor and sensory e0ams• !maging as indicated• Maintain inline immobili(ation•

Early neurosurgical consultation


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Secondary Survey -eurologic

• !ncomplete immobili(ation• Subtle in !CP +ith manipulation• 'apid deterioration


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Secondary Survey Ad"uncts

• Blood tests• *rinalysis• 2rays• CT•

*rography• Angiography

• *ltrasonography• Echocardiography• Bronchoscopy•

EsophagoscopyDo not delay transfer6


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'eevaluation Missed !n"uries

• :igh inde0 of suspicion• re&uent reevaluation• Continuous monitoring•

'apidly recogni(e patient deterioration


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Pain Management

• 'elieve pain and an0iety as appropriate• Administer intravenously• Careful patient monitoring is essential


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Safe Transfer

=hen patient)s needs e0ceed institutional

resources• *se time before transfer for resuscitation• Do not delay transfer for diagnostic tests• Physician2to2physician communication


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Transfer to Definitive


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Emergency Preparedness

• Simple plan• Command

structure• Disaster triage scheme•

Traffic control system


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Summary

Primary Survey Ad"uncts

Secondary SurveyAd"uncts

Definitive care

Safe transfer 'esuscitation

Continuous'eevaluation


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Summary

D:ead

Totoe

B C

A

E

• %ne@ safe +ay•

Do no further harm• Treat greatest threat to life first• Team+or,


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The End


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Supplement

The End


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STA'TT'!A#E


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STA'T T'!A#E

STA'T Triage*A +a ,in& +o(nded


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RESPIRATIONS

YES

Under30/min

NO

Position Airway

NO YES

Immediate Non-salvageable

Over30/min

Immediate

PERFUSION

Capref

" se#

Capref$ " se# Contro

% eedin&

Immediate

STATUSMENTAL

'ai (re to )o owsimp e #ommands

Can )o owSimp e #ommands

Immediate

*e ayed

Radial Pulse PresentRadial Pulse Absent

MINOR


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TEAM=%'I in E'


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E' Layout


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T!ME !S ESSE-T!AL

31.presentation team for medical student.pptx

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