These are the outlines of the topic:
Prehospital resuscitation
Hospital resuscitation
Primary survey
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey
Head to toe examination
Imaging
FAST
Radiograph
CT scan
Tertiary survey
Review investigation result
Review treatment
Reevaluate patient
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For prehospital resuscitation, it involve:
1.Evaluation of the scene
2.Initial assessment, which involve:
-Airway
-Breathing
-Circulation
Cervical spine protection is maintained throughout the assessment. Airway is cleared, jaw thrust menauver can be used to open up the airway while maintaining the cervical spine protection.
After that we should check for breathing adequacy, rescue breathing might be needed if the breathing is not adequate.
Next, check the circulation, palpate for peripheral and central pulses, check skin colour and temperature, and also capillary refill time.Any obvious bleeding should be attend - apply direct pressure and dressing.
3.Rapid assessment, which includes head to toe examination to look for injuries
-Extremities injuries are splinted
-Suspected pelvic fractures are stabilized with pneumatic antishock garment
-Suspected back injury need full spinal immobilization
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Now we move to hospital resuscitation. This involve primary, secondary and tertiary survey.
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| Trauma assessment sheet consist of primary and secondary survey |
Primary survey
Primary survey involve assessment:
-Airway
-Breathing
-Circulation
-Disability
-Exposure
Clear the airway from any foreign body that may cause obstruction. We may use chin lift or jaw thrust menauver to open up the airway, however usually jaw thrust is more useful as we also want to maintain the cervical spine protection in trauma case. We may need to put oral airway to prevent the tongue from occluding the oropharynx. In some circumstances, we might need to intubate patient. Indication for intubation for trauma patient are: GCS of 8 or less,Hemodynamically unstable, Multiple injuries, involving head and neck. In some cases, intubation is not successful or unable to maintain the airway,in these cases, we might need to use laryngomask airway or cricothyroidotomy
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| head tilt chin lift |
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| jaw thrust |
After airway is maintained, we proceed with breathing assessment. This involve checking the respiratory rate, usage of accessory muscle, presence of cyanosis, chest wall assymmetry, percussion and auscultation. In this assessment we want to detect any life threatening injuries which are: Tension pneumothorax, Open pneumothorax, Flail chest, Massive hemothorax . Once we have manage the life threatening injuries involving breathing, we can proceed with circulation assessment.
Check blood pressure, pulse rate and volume, colour, temperature, and CRT. Secure at least 2 large bore cannula at antecubital fossa. In some cases, patient might need central line for more rapid fluid infusion. Fluid resuscitation will depend on patient condition. In the trauma patient, hypovolemic shock is the most common cause of shock due to the hemorrhage. Therefore knowledge of hypovolemic shock classification is very important to determine the aggressiveness of resuscitation. Generally, resuscitation with 2L of crystalloid is recommended, followed by blood if indicated. Patient with minimal blood loss <20% will require minimal volume of fluid to stabilize their blood pressure. 20 - 30% blood loss will require at least 2L of crystalloid but blood may not be required. Blood loss >30% usually require blood transfusion. Patient who stabilize initially but then become hemodynamically unstable usually have ongoing bleeding and require further investigation and/or operative intervention as the sources of hemorrhage need to be identified and stopped : external wound, or contained in body cavities (hemothorax, cardiac tamponade, intraabdominal, retroperitoneal, pelvic), or surrounding fractured bone. After these measures has been taking care of, we can now move to assess disability.
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| Pericardiocentesis for cardiac tamponade |
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| Pelvic binder to control hemorrhage |
Under disability assessment, we should check for pupillary response, level of consciousness, any gross neurological deficits of all 4 extremities.This assessment is important to detect and to determine severity of head injury. Spine should be checked for deformities and tenderness, using log roll menauver for spinal protection. Anal tone and bulbocavernous reflex should be checked as well during this menauver, as spinal shock can be a complication of spinal injury in trauma patient.
Under exposure section, all clothing should be removed from the patient to do full examination. Patient with hypo or hyperthermia need to return to normothermia. The patient should be removed from the source of exposure as soon as possible. In cold exposure, gradual rewarming is preferred to avoid risk of dysrythmias. Patient with thermal burns should have any burned clothing rapidly removed to prevent further injury. Patient who alleged contaminating agent exposure should have the agents removed from their skin by irrigation. The skin should be constantly reexamined to make sure no further continuation of the injury process
To be continued....
