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Initial
Assessment and
Management
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Objectives
Indentify Management Priorities. Apply principles of primary and
secondary survey. Institute appropriate resuscitation
and monitoring. Recognize value of patients history
and biomechanics of injury. Anticipate pitfalls.
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oncepts of Initial
Assessment Rapid Primary survey
Resuscitation
Adjuncts to primary survey !resuscitation "etailed secondary survey
Adjuncts to secondary survey
Reevaluation "efinitive care
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Initial Assessment
Primary survey and
resuscitation of vital
functions are donesimultaneously #
a team approach
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Preparation
Prehospital $ystem %ransport guidelines !protocols
On&line medical direction
Mobilization of resources
Periodic revie' of care
losest appropriate facility
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Preparation
Inhospital Preplanning essential
()uipment* personnel* services
$tandard precautions
%ransfer agreement
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$tandard Precautions
ap
+o'n
+loves Mas,
$hoe covers
+oggles!face $hields
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%riage
$orting of patients according to -
A"(s
Available resources
Multiple casualties
Mass casualties
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Primary $urvey
Adult* children* pregnant 'omen #
Priorities are the same /
A Air'ay 'ith c&spine protection reathing
irculation 'ith hemorrhage control
" "isability( (0posure!(nvironment
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$pecial onsiderations
%rauma in the (lderly
1thleading cause of death
2Physiologic reserve
omorbidities - "iseases!medications
Outcome depends on early*aggressive care
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Primary $urvey
&spine injury
Pitfalls
()uipment failure
Inability to intubate
Occult air'ay injury
Progressive loss of air'ay
Establish Patent Airway
Caution
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Primary $urvey
$uspect &$pine Injury
Spinal protection
C-spine X-ray when
appropriate
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Primary $urvey
reathing
Assess
O0ygenate 3entilate
Pitfalls
Air'ay vs ventilation problem 4 5atrogenic pneumothora0
!tension pneumothora0
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Primary $urvey
Assessment of Organ Perfusion
5evel of consciousness
$,in color and temperature Pulse rate and character
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Primary $urvey
irculatory Management
ontrol hemorrhage
Restore volume Reassess
Pitfalls
(lderly hildren
Athletes MedicationCaution
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Primary $urvey
"isability
Baseline neurologic evaluation
GCS scoring
Pupillary response
Observe for
neurologic
deteriorationCaution
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Primary $urvey
(0posure ! (nvironment
Completely undress the patient
Prevent
hypothermiaCaution
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Resuscitation
Protect and secure airway
entilate and o!ygenate
Stop the bleeding
igorous shoc" therapy
Protect from hypothermia
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Adjuncts to Primary $urvey
ital sign
#CG $BGs
%rinary Adjuncts Pulse
Output o!imeter
and CO
%rinary&gastric catheters
unless contraindicated
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Adjuncts to Primary $urvey
"iagnostic %ools Chest and pelvic
!-ray
'P(
%ltrasound
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Adjuncts to Primary $urvey
onsider (arly %ransfer
'o notdelay transfer for diagnostic
tests %se time before transfer for
resuscitation
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Reevaluate
Proceed to $econdary $urvey After - Primary survey completed
A" (s are reassessed
3ital functions are returning to
normal
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$econdary $urvey
)he
completehistory and
physical
e!amination
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$econdary $urvey
6ey omponents 7istory
Physical e0amination - 7ead&to&toe
8%ubes and finger in every orifice9
omplete neuro e0am
$pecial diagnostic tests
Reevaluation
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$econdary $urvey
7istory
A $llergies
M *edications
P Past +llnesses
5 (ast meal( #ventsnvironment
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$econdary $urvey
Mechanisms of Injury
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$econdary $urvey
7ead Complete neurologic e!amination
GCS score determination
Comprehensive eye&ear e!amPitfalls
%nconscious patient
Periorbital edema Occluded auditory canal
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$econdary $urvey
Ma0illofacial Bony crepitus&stability Palpable deformity
Pitfalls
Potential airway obstruction Cribriform plate fracture
,reuently missed in.ury
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$econdary $urvey
ervical $pine
Palpate for
tenderness Complete motor&
sensory e!ams
/efle!es C-spine imaging
Pitfalls
$ltered (OC forany reason
Other severe 0
painful in.ury
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$econdary $urvey
:ec, ;soft tissues< *echanism 1 Blunt
vs penetrating Symptoms 1 $irway
obstruction 0
hoarseness
,indings 1Crepitushematoma 0stridor
bruit
Pitfalls
'elayed symptoms and signs
Progressive airway
obstruction Occult in.uries
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$econdary $urvey
hest
+nspect
Palpate Percuss
$uscultate
X-ray
Pitfalls
#lderly
Children
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$econdary $urvey
Abdominal (valuation
Blunt trauma Penetrating trauma
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$econdary $urvey
Abdomen
+nspect0 auscultate0 palpate0 and percuss
/eevaluate freuently
Special studies
Pitfalls
2ollow viscus and retroperitoneal in.uries
#!cessive pelvic manipulation
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$econdary $urvey
Perineum
Rectum
3agina
Pitfalls
Contusions0 hematomas0
lacerations0 urethral blood
Sphincter tone 0 high 3riding
prostate pelvic fracture0
rectal wall integrity0 blood
Blood lacerations
%rethral in.ury in women0pregnancy
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$econdary $urvey
Musculos,eletal - (0treminities
Contusion 0 deformity
Pain Perfusion
Peripheral neurovascular status
X- rays as needed
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$econdary $urvey
Musculos,eletal - Pelvis
Pain on palpation
Symphysis width = (eg length uneual
+nstability
X-rays as needed
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$econdary $urvey:eurologic
$pine ! ord
omplete motor
and sensory e0ams
Imaging as
indicated
Refle0es
(arly neurosurgical
consultation
:$
>re)uentreevaluation
Prefent secondary
brain injury
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Adjuncts to $econdary
$urvey $pecial diagnostic test as indicated Pitfalls
Patient deterioration
"elay of transfer
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$econdary $urvey
:eurologic
Pitfalls
Incompleteimmobilization $uble = in IP 'ith manipulation
Rapid deterioration
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Reevaluation
Minimizing Missed Injuries
7igh inde0 of suspicion
>re)uent reeveluation andmonitoring
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Reevaluation
Pain Management
Relief of pain !an0iety as
appropriate
Administer intravenously
areful monitoring is essential
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"efinitive are
(ocal ,acility
44)ransfer agreements
44(ocal resources 44
44
)rauma Specialty
Center ,acility
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Record * 5egal
onsiderations oncise* chronologicdocumentation
onsent for treatment >orensic evidence
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?uestions
4
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$ummary
Primary $urvey
Resuscitation
Adjuncts $econdary $urvey
Adjuncts
"efinitive care
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