INITIAL ASSESMENT MANAGEMENT SYAFRI K.ARIF Dept.of Anesthesiology,Pain Management and Intensive Care Faculty of Medicine Hasanuddin University Makassar-Indonesia
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.