TRAUMA , RESUSCITATION, MCI, TRIAGE

Dr. Rajan Koju Click to edit Master subtitle style Resident, Surgery

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Trauma is the study of medical problems associated with physical injury. The injury is the adverse effect of a physical force upon a person. There are a variety of forces that can lead to injury, including thermal, ionising radiation and chemical; most injuries is mechanical,
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leading cause of death and disability

Mechanism of injury

Blunt: acceleration/ deceleration fall/RTA penetrating: weapons thermal and blast

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Initial assessment

Standarized and predetermined plan of identification and treatment of immediately life threatening conditions.

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Objectives

Identify priorities in assessing and managing trauma patient. Apply principles of ABCDE in primary and secondary survey. Guidelines and techniques of treatment . Correlation with medical history and mechanism of injury.
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Anticipation of pitfalls.

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 hemorrhage control D: disability, neurological status E: exposure

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Airway and C-spine

Always assume c-spine injury(c-spine protection) Check for foreign bodies, maxillofacial 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 threatening potentially Tension pneumothorax simple pneumothorax Flail chest hemothorax Massive hemothorax contusion Open pneumothorax 7/6/12 simple pulmonary cardiac injury

circulation

Hypotension= hypovolemia Assessment of organ perfusion: Level of consciousness Pulse rate and character Urine output Skin colour and temperature

1. 2. 3. 4.

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Circulatory management

Stop bledding Restore volume Reassess

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Disability

Rapid neurological evaluation of level of consciousness as well as pupillary size 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 threatening injuries as they are identified

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Adjuncts to primary survey

Obtained as part of primary survey: Vital signs ABG Pulse oxymeter Urinary/gastric catheters ECG During or after primary survey CXR and pelvic X-ray

1. 2. 3. 4. 5. .

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Re-evaluation

Primary survey and adjuncts completed ABCDE reassessed Progressive correction of vital functions

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Secondary survey(head to toe)

Patient history Head to toe examination Complete neurological examination Diagnostic tests Re-evaluation

Fingers and tubes in every orifice

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Definitive care

Transfer of patient to best suited closet medical facility after primary, secondary survey and resuscitation as well as necessary adjuncts have been completed Done in agreement with receiving doctor.

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Triage

It is the process by which the management of multiple patient casualties is prioritized. Patient with life threatening problems are treated first. Patient with the greatest chance of survival are managed first.

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walking

Y
N

Priority 3 delayed death N

Breathing Y

<10/>30 Respiratory Priority 1 rate immediate 10-29 >2 sec Capillary refill Priority 2 <2 urgent sec
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Life saving procedures on scene

Intubation Needle application Hemorrhage control (direct pressure/ tourniquet)

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Life saving first aid treatment

A: removal of debris, chin lift, jaw thrust, 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 mass casualties

Any hospital treating war wounded or serving as major surgical referral centre must be prepared to receive large numbers of casualties. A heavy influx of wounded arriving within short space of time can quickly overwhelm the available resources. An influx of wounded can occur at 7/6/12 any time without warning. It may be

Triage area

The ED may not be large enough to deal 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 the triage process Experienced, has understanding of trauma Understand how hospital functions Able to make clear decisions under stress.
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Triage leader decisions must be respected

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Triage categories

Category I : serious/ immediate resuscitate and immediate surgery. Those patients for whom urgent surgery is required and for those that have a good chance of recovery. Category II: secondary/ delayed can wait for surgery. Those patients that require surgery but not on an urgent basis. Fractures and head injuries.
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Category III : superficial/minimal walking wounded. Those patient that do not require hospitalization because their wounds are minor. Laceration, simple fracture. Category IV : supportive/expectant. Those patients that are so severely injured that they are likely to die. Penetrating head wounds, high spinal cord injuries, severe burn>60% BSA 7/6/12

COLOUR CODING

Category I RED Category II YELLOW Category III GREEN Category IV BLACK

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Triage process

Suspend routine operations and activities In arrival in the triage area each patient is assigned a triage number and a file The patient is quickly assessed and a triage category is assigned by the triage leader The patient is directed to a pre 7/6/12 determined area for treatment

Doctors and nurses assigned to the different categories carry out the treatment Operations are started in order of priority Patients are re-assessed and a new category may be assigned Ward and ICU spaces are created by shifting or discharging patients.

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Documentation during triage

Basic information: name, time of injury, 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 casualty events Allow flaws to be detected and modifications or improvements made.

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Planning for MCI

1. .

Surge capacity of hospital in MCI: Defined on the basis of : available surgical teams. Existence of specific surgical departments Number of operation room Number of ICU bed

. . .

National directive(UK) : 20 % of total 7/6/12 bed capacity, 2/3 ambulatory

Expansion of ER capacity: Immediate re-enforcement of personnel in ER Internal call-up via annoucement External call-up via mobile, group beepers.

1.

2. 3.

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Evacuation of ER: Rapid discharge of patients Transfer of patients to hospital wards Cessation of surgical operations Internal relocation of patients to evacuate surgical beds

1. 2.

. .

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Goal: saving maximum salvageable casualties while minimizing disabilities. Expectance : 10 % of casualties will need immediate surgery( within 2 hours of admittance).

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Continuous triage

Initial triage on scene Primary triage at entrance to hospital Ongoing triage within ER to determine needs: Imaging OT ICU

1. 2. 3. 4.

Hospitalization 7/6/12

Expanding capabilities of medical teams

Pre designation of roles in various MCI Preparation of checklists Training of personnel (strengthening specific professions: burns, orthopedics, trauma)

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Logistic sources

Allocation of stretcher carriers Storage of medical equipment in immediate vicinity of admitting sites Organizing equipment on mobile carts Early preparation of medical treatment charts Assignment of blood trustee to ER
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Thank you

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