dr. hany victor lecturer of anesthesia and icu etc instructor

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Dr. Hany Victor Lecturer of Anesthesia and ICU ETC Instructor Slide 2 Objectives Case presentation on poly-trauma patient. Discussion on the case Approach to poly-trauma patient Recommendation MCQ Slide 3 Case Male patient 28 years presented to the ER following a motor car accident 30 min ago complaining of chest pain, cut wound in the forehead with minimal bleeding and pain in the right forearm. By history the patient had a blunt trauma to the head and chest in the dashboard. Other previous medical history is irrelevant. Slide 4 On examination Airway: Clear Cervical Spine immobilization after neck examination with no major abnormality Breathing: RR: 20/min Equal air entry bilateral with no adventitious sounds. Tenderness over the sternum. SpO2: 95% on room air. Slide 5 Circulation: There is no major site of bleeding, vital signs include: HR: 100/min felt central and peripheral, equal on both sides. Blood pressure: 100/60 mmHg. Capillary refill time: 1.5 sec. Temp: 37.1C Neck veins not congested There is wound in the forehead 5X3 cm. Slide 6 Disability GCS 15/15 No loss of cons, no nausea or vomiting, no bleeding per orifices, no transient amnesia and no fits. Pupils are equal bilateral and reactive to light. Blood sugar 140 mg/dl. Exposure No major bleeding No major deformity Slide 7 Discussion on part one of the lecture Slide 8 Types of assessment 8 1.Primary Survey and resuscitation Identification of Life threatening conditions AcBCDE Approach 2.Secondary Survey Detailed head to toe examination Medical history All lab and radiology investigation ordered Management Plan Slide 9 Illinois EMSC9 PURPOSE OF THE INITIAL ASSESSMENT Identification of LIFE-THREATENING emergencies Assess Change - Reassess Initiation of LIFE-SAVING measures (CPR) Slide 10 5 second Round Illinois EMSC10 Pt is conscious or not Airway Ventilation Signs of massive external hemorrhage There is any deformity Skin color and temp with feeling pulse Slide 11 Illinois EMSC11 Primary Survey Airway/ Cervical Spine Control Breathing Circulation Disability (neurological) Expose Slide 12 Assessing Airway Is the airway: Clear and safe? At risk? Obstructed? Slide 13 Illinois EMSC13 AIRWAY INTERVENTIONS Jaw thrust Vs Head tilt. Deliver Oxygen (mask with reservoir). Use Rigid suction. Secure airway. Slide 14 5 Chest clues in the neck Wounds Distended neck veins Tracheal position Surgical emphysema Laryngeal crepitus Slide 15 Illinois EMSC15 CERVICAL SPINE STABILIZATION Place hands on either side of the head cervical collar.flv cervical collar.flv Maintain neck midline manual in line stabilization Slide 16 Breathing and ventilation Aims Support if inadequate Eliminate any immediately life threatening thoracic condition .. Slide 17 Breathing and ventilation Inspection Respiratory rate Effort of breathing Symmetry Wounds & marks Palpation Tender points, equal expansion Percussion No abnormal note Auscultation All lung zones Slide 18 Illinois EMSC18 BREATHING INTERVENTIONS If breathing is absent, start ventilation using: Simple Adjuvants (Airways) Bag valve mask with reservoir LMA ETT Slide 19 Fatal Chest conditions? Tension pneumothorax Open chest trauma Cardiac tamponade Flail chest Massive hemothorax Illinois EMSC19 Slide 20 Illinois EMSC20 CIRCULATORY ASSESSMENT Carotid pulse (absent or present) Capillary refill Skin color Skin temperature Sites of bleeding Slide 21 21 CIRCULATORY INTERVENTIONS If central pulse is absent, begin CPR Apply direct pressure to open wounds IV access (2 wide bore cannulae14/16G). Fluids (colloids Vs crystalloids) 20ml/Kg Peripheral Vs central line? Slide 22 Dysfunction of the CNS Aims Rapid neurological assessment Alert; Voice; Pain; Unresponsive Pupils Mini-neurological assessment GCS score / AVPU Pupils Lateralising signs Blood sugar Slide 23 23 Slide 24 Exposure and environment Aims Remove clothing to allow examination of entire patient Care when removing tight trousers Prevent hypothermia Patient dignity Remove spine board Slide 25 Dont Forget The Back Slide 26 Pause & check Are all immediately life- threatening injuries identified? Is all monitoring in place? Investigations ordered? Analgesia? Relatives informed? Non-essential team members disbanded? Slide 27 The well practiced trauma team should aim to complete the primary survey in less than 10 minutes Illinois EMSC27 Slide 28 Radiology Once the patient is stabilized the patient is sent to radiology for the survery: Cervical spine X-ray (AP and lateral view) Chest X- ray (Rib cage) Pelvis X-ray Abdomen and Pelvis U/S CT brain is ordered if there is suspicion of head trauma X-ray of extremities if fracture is suspected. Slide 29 Chest X-Ray Slide 30 Slide 31 Part 2 case Patient returned form the radiology department complaining of severe chest pain and could not lay down on his back for suturing of the cut wound in the forehead Patient received the following medication: 1500 cc of normal saline cefoperazone 1.5 gm IV Analgesia as Perfalgan 1gm IV followed by Pethedine 50 mg IM Slide 32 Labs were send for urgent Hb Patients Vital signs were: HR: 120/min Blood pressure 85-90/50-60 mmHg. CRT 2 sec SpO2:92 % On Room air. Patient still complains of severe chest pain and received another 50 mg pethedine over 100 cc Normal Saline over 30 min Slide 33 Differential Diagnosis Slide 34 Slide 35 What Labs to order? What other radiological investigations to ask for? What other medications to give? Slide 36 Chest X-Ray Double aortic knob sign Diffuse enlargement of the aorta Tracheal displacement to the right Pleural effusion Pericardial effusion Cardiac enlargement Left apical opacity Fractured first or second ribs Mediastinal widening Slide 37 CT chest Slide 38 Aortograghy Slide 39 Slide 40 Slide 41 Final Diagnosis Traumatic aortic tear Slide 42 Slide 43 Traumatic Aortic Rupture These are found in victims of high-speed motor vehicle crashes and falls from great heights, and 85% of these injuries are due to blunt trauma. The majority (80-90%) of the patients die at the scene of the accident from massive blood loss. Of the patients reaching hospital alive, only 20% will survive without operation. The mortality remains high even after surgery. Slide 44 In cases of aortic rupture, the clinical presentation depends upon the site of injury. Patients with injury to the intrapericardial portion of the ascending aorta will usually develop a cardiac tamponade. Extrapericardial ascending aortic injury produces a mediastinal haematoma and a haemothorax, usually on the right side Slide 45 Rapid deceleration is believed to be responsible for damage to the aorta that most commonly occurs in the region of ligamentum arteriosum, just distal to the origin of left subclavian artery. Slide 46 Patients may show transient hypotension, which responds well to fluid therapy and further clinical signs may be absent. This may delay the diagnosis with catastrophic results should the aorta rupture completely. Thus a high index of suspicion should be kept in mind. Slide 47 Aortic disruption should always be suspected in patients with profound shock and who have no other external signs of blood loss and in whom mechanical causes of shock (tension pneumothorax and pericardial tamponade) have been excluded. Slide 48 Symptoms (if the patient is conscious) may include: Severe retrosternal pain Pain between the scapulae Hoarseness of voice (pressure from haematoma on the recurrent laryngeal nerve) Dysphagia Paraplegia or paraparesis Aortic dissection Vs ACS. Slide 49 The definitive investigation of choice is angiography or a CT angiogram of the aortic arch, the choice depending on local policy. Survival in patients who have their injury repaired surgically and who have remained haemodynamically stable during the repair is 90%. Slide 50 Minimally invasive repair using aortic stenting techniques are also being used Slide 51 MANAGEMENT OPEN PNEUMOTHORAX Ensure adequate airway 100% oxygen Seal open wound Load & Go IV access en route Notify Medical Direction Courtesy of David Effron, M.D. Slide 52 SEALING THE OPEN WOUND Asherman chest seal is very effective Slide 53 SEALING THE OPEN WOUND You can use impervious material taped on three sides Slide 54 TENSION PNEUMOTHORAX Slide 55 MANAGEMENT TENSION PNEUMOTHORAX Ensure adequate airway 100% oxygen Needle decompression if indicated Load & Go IV access en route Notify Medical Direction Slide 56 MCQ 1. Which of the following is true in regards to a traumatic aortic rupture? A.There is a 50% survival rate B.Immediate defibrillation is indicated C.Usually due to deceleration injury D.They are easily diagnosed in the pre-hospital setting Slide 57 3. What is the MOST likely abnormality that would be seen on chest x-ray in a patient with traumatic rupture of the aorta after blunt injury? (A) Obscuration of the aortic knob (B) Deviation of esophagus to the left (C) Fracture of the first or second rib (D) Apical cap (E) Superior mediastinal widening Slide 58 3. Male patient with intracerebral hemorrhage and intra-abdominal bleeding, the optimum blood pressure for this patient should be maintained around: A. 90 mmHg. B. 100 mmHg. C. 110 mmHg. D. 70 mmHg. Slide 59 4. The initial management of a poly-trauma patient should include the following order: A. Conscious level, secure airway, assess circulation, control cervical spine, assist ventilation and exposure. B. Secure airway, control cervical spine, assess circulation, follow up conscious level and assist ventilation and exposure. C. Secure airway, control cervical spine, assist ventilation, assess circulation, follow up conscious level and exposure. D. control cervical spine, secure airway, assist ventilation, assess circulation, follow up conscious level and exposure. Slide 60 5-Which of the following is the BEST screening test for detecting traumatic aortic injury in a stable patient? (A) Chest radiograph. (B) Computed tomography aortography. (C) Trans-thoracic echocardiography. (D) Test for unequal blood pressures in the upper extremities.. Slide 61 Recommendations All Trauma patients should be assessed using the universal AcBCDE approach. Management of Poly-trauma should include primary and secondary survey. Team work is standard in management of trauma patients. Routine investigation should be implemented as a protocol for our policy in Demerdash and ASUSH. High index of suspicion should be kept for aortic trauma in any posttraumatic chest pain. Slide 62 QUESTIONS? Slide 63 THANK YOU