INITIAL ASSESMENT MANAGEMENT

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

INTRODUCTION
The main role of the doctor is SAVING LIFE ALLEVIATE SUFFERING Any doctors should have these competences. The main tool of saving life is BASIC LIFE SUPPORT

ACCIDENTS OR DISASTERS
Accidents or disasters may occur to : ANY WHERE ANY TIME ANY ONE Well preparedness is very important ( soft-ware and hard-ware )

What is EMERGENCY in Medicine ?

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.

Some Example of Emergency Conditions

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.

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 Trunkey
50% 30% 20%

ATLS

Death
%

sec

hr

days/week

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 ASSESMENT
Initial assessment include : 1. Preparation 2. Triage 3. Primary Survey ( ABCDE ) 4. Resuscitation 5. Secondary Survey ( Head to toe evaluation ) 6. Definitive Care

1. PREPARATION
Preparation of the trauma patient occurs in two different clinical settings

1. PRE-HOSPITAL PHASE 2. 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 & inhospital 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

Trauma Team-work

Efficient method Trained doctors & nurses Variety of tasks taken simultaneously

horizontal organization reduced time to life-saving procedure by 50 %

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

Airway & cervical spine control Breathing & ventilation Circulation & haemorrhage control Disability Exposure/Environment

Airway & Cervical Spine Control

Difficult Airway Goal

Keep airway patent protect compromised airway provide airway if none

Cervical spine Fracture

Suspect:

Unconscious patients Injury above clavicles Neck pain Weakness or neurological deficit History of fall > 6 m

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

Hematothorax
Chest tube Massive : > 1500 ml blood Drainage: . 200 ml/hr CLAMPED CT Urgent thoracotomy

Circulation
Haemorrhage Control with Fluid therapy First Priority : Restore volume with fluid (RL/NaCl 0.9% ) Second Priority : Restore blood with WB and PRC transfusion to restore oxygen carrying capacity

Remember : did not die of anemia but die of hypovolemic shock FFP, Platelet, blood products

Third Priority : Normalize coagulation status

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 Injured patient should received supplemental O2 Controlled bleeding by direct pressure or operative intervention

Breathing/ventilation and oxygenation

Circulation

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.