trauma , resuscitation, mci, triage

7/31/2019 Trauma , Resuscitation, Mci, Triage

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TRAUMA , RESUSCITATION,

MCI, TRIAGEDr. Rajan KojuResident, Surgery


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Trauma is the study of medicalproblems associated with physicalinjury. The injury is the adverse effect

of a physical force upon a person.There are a variety of forces that canlead to injury,

including thermal, ionising radiationand chemical;

most injuries is mechanical,

leadin cause of death and disabilit


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Mechanism of injury

Blunt: acceleration/ decelerationfall/RTA

penetrating: weapons thermal

and blast


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Initial assessment

Standarized and predetermined planof identification and treatment ofimmediately life threatening

conditions.


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Objectives

Identify priorities in assessing andmanaging trauma patient.

Apply principles of ABCDE in primaryand secondary survey.

Guidelines and techniques of

treatment . Correlation with medical history and

mechanism of injury.

Anticipation of pitfalls.


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Primary survey

Rapid ABCDE

Resuscitation

Adjuncts Identical priorities for all patients


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Basic plan

A: airway with C-spine protection.

B: breathing

C: circulation and hemorrhagecontrol

D: disability, neurological status

E: exposure


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Airway and C-spine

Always assume c-spine injury(c-spineprotection)

Check for foreign bodies, maxillo-facial injury or fracture

Jaw thrust/chin lift

Oxygen 10 L/min via reservoir mask Definitive airway


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Breathing

Exposure of chest

Auscultation and percussion

Oxygenate ventilate


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Life threateningpotentially

Tension pneumothorax simplepneumothorax

Flail chest simple

hemothoraxMassive hemothorax pulmonarycontusion

Open pneumothorax cardiac injury


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circulation

Hypotension= hypovolemia

Assessment of organ perfusion:

1. Level of consciousness2. Pulse rate and character

3. Urine output

4. Skin colour and temperature


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Circulatory management

Stop bledding

Restore volume

Reassess


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Disability

Rapid neurological evaluation of levelof consciousness as well as pupillarysize and reaction.

A: alert

V: response to voice

P: response to pain U: unresponsive

GCS: eye: 1-4, motor: 1-6; verbal: 1-5


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Exposure

Completely undress

Examine front and back

Prevent hypothermia Warm room

Warm IV fluids

Cover patient


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Resuscitation

Aggressive resuscitation

Management of life threateninginjuries as they are identified


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Adjuncts to primary survey

Obtained as part of primary survey:

1. Vital signs

2. ABG3. Pulse oxymeter

4. Urinary/gastric catheters

5. ECG

. During or after primary survey

1. CXR and pelvic X-ray


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Secondary survey(head totoe)

Patient history

Head to toe examination

Complete neurological examination Diagnostic tests

Re-evaluation

Fingers and tubes in everyorifice


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Definitive care

Transfer of patient to best suitedcloset medical facility after primary,secondary survey and resuscitation

as well as necessary adjuncts havebeen completed

Done in agreement with receiving

doctor.


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Triage

It is the process by which themanagement of multiple patientcasualties is prioritized.

Patient with life threatening problemsare treated first.

Patient with the greatest chance ofsurvival are managed first.


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Y

N

N

Y 30

10-29 >2 sec


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Life saving procedures onscene

Intubation

Needle application

Hemorrhage control (direct pressure/tourniquet)


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Life saving first aidtreatment

A: removal of debris, chin lift, jawthrust, manual cervical stabilisation

B: mouth to mouth, mouth to nose,chest decompression

C: control of external hemorrhage,application of pressure dressing,fracture alignment and splintage


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Plan ahead for masscasualties

Any hospital treating war wounded orserving as major surgical referralcentre must be prepared to receive

large numbers of casualties. A heavy influx of wounded arriving

within short space of time can

quickly overwhelm the availableresources.

An influx of wounded can occur at

any time without warning. It may be


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Triage area

The ED may not be large enough todeal with an influx of patients.

Road access protection.

Crowd control (police).

Close hospital.

One way flow.


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Triage leader

The one person in charge of thetriage process

Experienced, has understanding oftrauma

Understand how hospital functions

Able to make clear decisions understress.


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Triage leader decisionsmust be respected


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Triage categories

Category I : serious/ immediateresuscitate and immediate surgery.

Those patients for whom urgent

surgery is required and for those thathave a good chance of recovery.

Category II: secondary/ delayed can

wait for surgery. Those patients thatrequire surgery but not on an urgentbasis. Fractures and head injuries.


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Category III : superficial/minimalwalking wounded. Those patient thatdo not require hospitalization

because their wounds are minor.Laceration, simple fracture.

Category IV : supportive/expectant.

Those patients that are so severelyinjured that they are likely to die.Penetrating head wounds, high spinal

cord injuries, severe burn>60% BSA


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COLOUR CODING

Category I RED

Category II YELLOW

Category III GREEN Category IV BLACK


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Triage process

Suspend routine operations andactivities

In arrival in the triage area eachpatient is assigned a triage numberand a file

The patient is quickly assessed and atriage category is assigned by thetriage leader

The patient is directed to a predetermined area for treatment


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Doctors and nurses assigned to thedifferent categories carry out thetreatment

Operations are started in order ofpriority

Patients are re-assessed and a newcategory may be assigned

Ward and ICU spaces are created byshifting or discharging patients.


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Documentation duringtriage

Basic information: name, time ofinjury, cause of injury, first aid given.

Vital signs: BP, Pulse, RR ,Neurological evaluation.

Diagnosis: concise and complete

Category of triage Complete pre operative orders


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Evaluation

Following each mock practice

Following each actual mass casualtyevents

Allow flaws to be detected andmodifications or improvementsmade.


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Planning for MCI

1. Surge capacity of hospital in MCI:

. Defined on the basis of : availablesurgical teams.

. Existence of specific surgicaldepartments

.

Number of operation room. Number of ICU bed

. National directive(UK) : 20 % of total

bed capacity, 2/3 ambulatory


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Expansion of ER capacity:

1. Immediate re-enforcement ofpersonnel in ER

2. Internal call-up via annoucement

3. External call-up via mobile, group

beepers.


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Evacuation of ER:

1. Rapid discharge of patients

2. Transfer of patients to hospitalwards

. Cessation of surgical operations

. Internal relocation of patients toevacuate surgical beds


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Goal: saving maximum salvageablecasualties while minimizingdisabilities.

Expectance : 10 % of casualties willneed immediate surgery( within 2hours of admittance).


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Continuous triage

Initial triage on scene

Primary triage at entrance to hospital

Ongoing triage within ER todetermine needs:

1. Imaging

2. OT

3. ICU

4.

Hospitalization

E di biliti f


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Expanding capabilities ofmedical teams

Pre designation of roles in variousMCI

Preparation of checklists

Training of personnel (strengtheningspecific professions: burns,orthopedics, trauma)


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Logistic sources

Allocation of stretcher carriers

Storage of medical equipment inimmediate vicinity of admitting sites

Organizing equipment on mobilecarts

Early preparation of medicaltreatment charts

Assignment of blood trustee to ER


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Thank you

trauma , resuscitation, mci, triage

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