team for medical students.ppt
TRANSCRIPT
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TEAMProgram for Medical Students and Multidisciplinary Team Members Based on the ATLS Course for DocotrsCommittee on Trauma PresentsTrauma Evaluation And Management: Early Care of the Injured Patient
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Goal / Principles of Trauma CareRapid, accurate, and physiologic assessmentResuscitate, stabilize, and monitor by priorityPrepare for transfer to definitive careTeamwork for optimal, safe patient care
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ObjectivesDescribe fundamental principles of initial assessment and managementIdentify correct sequence of management prioritiesDescribe appropriate techniques of resuscitation
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ObjectivesRecognize value of patients historyUnderstand importance of injury mechanismIdentify concepts of teamwork in caring for injured patient
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The Need for Early TEAMLeading cause of death in ages 1 through 44Disabilities exceed deaths by ratio of 3:1Trauma-related cost > $400 billion per yearLack of public awareness for injury prevention
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Injury PreventionABCDEAnalyze injury dataBuild local coalitionsCommunicate the problemDevelop prevention activities Evaluate the interventions
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Trimodal Death Distribution
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TEAM PrinciplesTreat greatest threat to life firstDefinitive diagnosis less importantPhysiologic approachTime is of the essenceDo no further harmTeamwork required for TEAM to succeed
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TEAM ApproachABCDEAirway with c-spine protectionBreathing / ventilation / oxygenationCirculation: Stop the bleeding!Disability (neuro status) Expose / Environment / body temp
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TEAM SequenceRapid primary survey ABCD + AdjunctsDetailed secondarysurvey / reevaluation Head-to-toe + AdjunctsDefinitivecareSafe transfer
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TEAM Sequence and Teamwork Simultaneous primary survey and resuscitation of vital functions
Simultaneous secondary survey and reevaluation of vital functions
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TEAM Work and TeamworkTL Team Leader A Airway Manager
N Nurse
Assistant
2 AssistantTogether Everyone Achieves More
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Prehospital PreparationClosest appropriate facilityTransport guidelines / protocolsOn-line medical directionMobilization of resourcesPeriodic review of care
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Inhospital PreparationPreplanning essntialTeam approachTrained personnelProper equipmentLab / x-ray capabilities Standard precautions Transfer agreements QI program
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Standard Precautions Cap Gown Gloves Mask Shoe covers Goggles / face shield
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Other factors, eg, salvagebiliy
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Primary SurveyPriorities are theSame for all!
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Primary SurveyABCDEAirway with C-spine protectionBreathing / Life-threatening chest injuryCirculation: Stop the bleeding!Disability / Intracranial mass lesion Expose / Environment / Body temp
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Special Considerations: ChildrenLeading cause of deathImmature, anatomic / mechanical featuresVigorous physiologic responseLimited physiologic reserveOutcome depends on early aggressive
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Special Consoderations: ChildrenSize, dosage, equipment, surface area, and psychologyAirway: Larynx anterior and cephalad, short tracheal lengthBreathing: Chest wall pliability, mediastinal mobility
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Special Considerations: ChildrenCirculation: Vascular access, fluid volume, vital signs, and urinary outputNeurologic: Vomiting, seizures, and diffuse brain injuryMusculoskeletal: Immature skeleton, fracture patterns
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Special Consideration: Pregnancy
Anatomic / physiologic changes modify response to injuryNeed for fetal assessment1st Priority: Maternal resuscitationOutcome depends on early, aggressive care
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Special Considerations: pregnancyGestation and position of uterusPhysiologic anemia Pco2 Gastric emptyingSupine hypotensionIsoimmunizationSensitivity of fetus
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Special considerations: Elders5th leading cause of deathDiminished physiologic reserve and responseComorbidities: Disease / MedicationsOutcome depends on early, aggressive care
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Special Conciderations: Elders 5th leading cause of death Diminished physiologic reserve and response Comorbidities: Diseases / Medications Outcome depands on early, aggressive care
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Primary Survey: Airway Assess for airway patency Snoring Gurgling Stridor Rocking chest wall motions Maxillofacial trauma / laryngeal injuryC-spine injury
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Resuscitation: Patent Airway Chin lift / Modified jaw thrust Look, listen, feel Remove particulate matter Definitive airway as necessary Reasses frequentlyC-spineinjury
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Resuscitation: Assess Breathing Chest rise and symmetry Air entry Rate / Effort Color / SensoriumTension / openpneumothorax
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Resuscitation: BreathingAdminister supplemental oxygenVentilate as neededTension pneumothorax: Needle decompressionOpen pneumothorax: Occlusive dreassingReassess frequently
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Primary Survey: Circulation Children Elderly Athletes Pregnancy Medication
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Primary Survey: CirculationNonhemorrhagic shock - Cardiac tamponade - Tension pneumothorax - Neurogenic - Septic (late)
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Primary Survey: CirculationAssess organ perfusion - Level of consciousness - Skin color - Pulse rate and character
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Primary Survey: CirculationAssess Organ PerfusionTachycardiaVasoconstriction2. Cardiac output2. Narrow pulse pressure3. MAP3. Blood flow
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Primary Survey: Circulation Children Elderly Athletes Pregnancy Medications
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Resuscitation: Circulation Bleeding?IT!Find it!Direct pressure Operation Avoid blind clamping
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Resuscitation: CirculationObtain venous accessRestore circulating volume - Ringers lactate, 1-2 L - PRBCs if transient response or no responseReassess frequently
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Resuscitation: Circulation
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Resuscitation: CirculationConsiderTension pneumothorax: Needle decompression and tube thoracostomyMassive hemothorax: Volume resuscitation and tube thoracostomyCardiac tamponade: Pericardiocentesis and direct operative repair
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Primary Survey: DisabilityBaseline neurologic evaluationObserve forNeurologicdeteriorationPupillary responseNeurosurgical consult as indicated
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Primary Survey: GCS ScoreEye opening: Range 1 4BEST Motor response: Range 1 6Verbal response: Range 1 5Score = (E + M + V)Best score = 15Worst score = 3
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Primary Survey: Disability
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Primary Survey: Expore Completely undress the patient Remove helmet if present Look for visible / palpable injuries Log roll, protect spinePreventhypothermia
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Resuscitation: OverviewIf doubt, establish definitive airwayOxygen for all patientsChest tube may be definitive for chest injuryStop the bleeding!2 larger-caliber IvsPrevent hypothermia
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Adjunct: Urinary CatheterBlood?Decompress bladderMonitor urinary output Blood at meatus Perineal ecchymosis / hematoma- High-riding prostate
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Adjuncts: Gastric Catheter Blood? Decompress urinary output Monitor urinary outout Blood at meatus Perineal ecchymosis / hematoma- High-riding prostate
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Primary Survey: AdjunctsMonitoringVital signsABGsECGPulse oximetryEnd-tidal CO2
Consider need for transferDiagnostic Tools Chest / pelvis x-ray C-spine x-rays when appropriate FAST DPL
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Secondary Survey: Start AfterPrimary survey completedResuscitation in processABCDEs reassessedVital functions returning to normal
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Secondary Survey: Key PartsAMPLE historyComplete physical exam: Head-to-toeComplete neurologic examSpecial diagnostic testsReevaluation
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Secondary Survey: History A Allergies M Medications P Past illnennes / Pregnancy L Last meal E Event / Environment
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Secondary Survey Mechanisms of InjuryAnatomyPhysiologyPattern ofInjuryMechanism ofInjury
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Burn InjuryInhalation injury: Intubate and administer 100% oxygenAdminister 2 4 mL / kg % BSA burn in 24 hours (+ maintenance in children)Monitor urinary outputExpose and prevent hypothermiaChemical burn: Brush and irrigate
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Burn Injury
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Burn Injury
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Cold InjuryFrostbite: Rewarm with moist heat (40 C); wait for demarcation
Hypothermia: Passive or active rewarming
Monitor: Not dead until warm and dead
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Secondary Survey: Head Complete neurologic exam GCS Score determination Comprehensive eye / ear - Unconscious patient- Periorbital edema- Occluded auditory canal
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Secondary Survey: Maxillofacial Bony crepitus / instability Palpable deformity Comprehensive oral / dental examsPotential airway obstruction - Cribriform plate fracture- Frequently missed injury
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Secondary Survey: C-spine Palpate for tenderness Complete motor / sensory exams Reflexes C-spine imaging- Injury above clavicles- Altered LOC- Other severe, painful injury
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Secondary Survey: Neck Blunt vs penetrating
Airway obstruction, hoarseness
Crepitus, hematom, stridor, bruitDelayed symptom / signs
-Progressive airway obstruction
-Occult injuries
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Secondary Survey: Chest Inspect, auscultate, palpate, percuss Reevaluate frequently Chest x-rays-- Missed injury- Chest tube drainage
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Secondary Survey: Abdomen Inspect, auscultate, palpate, and percuss Reevaluate frequently Special studies: FAST, DPL, CT Hollow viscus and retroperitoneal injury Excessive pelvic manipulation
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Secondary Survey Perineum Contusions, hematomas, lacerations, urethral blood
Rectum Sphincter tone, high-riding prostate, pelvic fracture, rectal wall integrity, blood
Vagina Blood, lacerations
Pregnancy
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Secondary Survey: MusculoskeletalPotential blood lossLimb or life threat (primary survey)Missed fracturesSoft-tissue or ligamentous injury
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Secondary Survey: MusculoskeletalOccult compartment syndrome (especially with altered LOC / hypotension)Examine patients back
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Secondary Survey: PelvisPain on palpationSymphysis width Leg length unequalInstabilityPelvic x-rays
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Pelvic Fracture Major source of hemorrhage Volum resuscitation Reduce pelvic volume External fixator Angiography / embolization
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Secondary Survey: CNSFrequent reevaluationPrevent secondary brain injuryImaging as indicatedEarly neurosurgical consultation
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Secondary Survey: SpineComplete motor and sensory examsImaging as indicatedMaintain inline immobilizationEarly neurosurgical consultation
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Secondary Survey: NeurologicIncomplete immobilizationSubtle in ICP with manipulationRapid deterioration
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Secondary Survey: AdjunctsBlood testsUrinalysisX-raysCTUrographyAngiographyUltrasonographyEchocardiographyBronchoscopyEsophagoscopyDo not delay transfer!
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Reevaluation: Missed InjuriesHigh index of suspicionFrequent reevaluationContinuous monitoringRapidly recognize patient deterioration
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Pain ManagementRelieve pain and anxiety as appropriateAdminister intravenouslyCareful patient monitoring is essential
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Safe TransferWhen patients needs exceed institutional resources. Use time before transfer for resuscitationDo not delay transfer for diagnostic testsPhysician-to-physician 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 AdjunctsSecondary Survey AdjunctsDefinitive careSafe transferResuscitationContinuousReevaluation
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SummaryDHeadTotoeBCA E One, safe way Do no further harm Treat greatest threat to life first Teamwork
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The End
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Supplement : The End
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STARTTRIAGE
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START TRIAGE
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START TriageRESPIRATIONSYESUnder 30/minNOPosition AirwayNOYESImmediate Non-salvageableOver 30/min ImmediatePERFUSIONCap refill> 2 secCap refill< 2 sec Control BleedingImmediateSTATUS MENTALFailure to followsimple commandsCan followSimple commandsImmediateDelayedRadial Pulse PresentRadial Pulse Absent*All Walking WoundedMINOR
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TEAMWORK in ER
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ER Layout
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TIME IS ESSENTIAL
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