If patient has pain say I cannot continue.
Most deaths occur in the golden hour which was the reason Primary survey was invented.
Differences in ATLS and normal history and Examination
1. No need for definitive diagnosis
2. No need for detailed history
Loss of airway kills quicker than loss of breathing which kills faster than circulation which in turn kills quicker than disability.
A-Airway
B-Breathing
C-Circulation
D-Disability
E-Exposure
One difference between a real life situation and OSCE is that a real trauma team has 12 members and in PLAB 2 it is only you and a nurse.
The second difference is that you cannot complete it in 5 minutes.
Assume a Cervical spine injury in all trauma patients.
There are two types of stabilization:
Hard Collar, Sand bags, and tape on forehead which should be attached to table itself.
Or
Inline immobilization which means holds head inline with body.
Listen for gurgling, Stridor and difficulty in breathing.
Look for Cyanosis and associated muscle usage.
Open the airway and take out foreign matter.
Airway not patent Chin lift
" " " " Jaw thrust
" " " " Guedel's airway
" " " " Oropharengeal intubation
Give 100 percent Oxygen in all patients except COPD give 24 percent.
If patient is talking tell then tell examiner patient's airway is Ok.
If nurse is present, tell her to immobilize cervical spine while you do airway check.
If patient is unconscious and GCS less than 7, then intubate straight away.
Breathing
If you do not sort out airway before breathing you will fail.
Do a quick Inspection, Palpation and Percussion.
Inspect trachea through collar if not then tell nurse to open collar.
Look for distended veins (for Cardiac tamponade), Open wounds, both sides moving equally.
If you dont know something for example how to decompress cardiac tamponade then say so. Dont make up stuff.
Management of Cardiac Tamponade
1. 100 percent oxygen
2. ECG leads
3.Long spinal needle just below Xiphisternum.Keep on aspirating from needle. Even 10-15 mm of blood will improve the patients condition drastically.
If you go too far and touch myocardium it will show on ECG.
Tension Pneumothorax
Put a Venflon in 2nd intercostal space .A whoosh of air comes out and patient feels better.
Eventually you will have to put in a chest drain which is treatment for both Pneumo and haemo thorax. If 1.5 liters or more is drained than you will have to do a thoracotomy.
Only when you have sorted out breathing can you move on to Circulation.
Circulation has 3 parts
1.heart Rate
2.BP
3.SKIN Color
If patient is hypotensive and tachycardic always assume unless proven otherwise that patient has hypotensive or hemorrhagic shock. Start fluids.
Tell the nurse
1. I/V Cannula large bore in both antecubital fossa.
2. 2 litersWarm Hartmanns solution straight away.
Leaking Tank concept
First look for external artery bleed
Clamps on arterial blood are contraindicated as you may damage arterial intima and later it may require surgical repair.
In arterial bleed all you need is pressure and in venous elevation and pressure.
Now look at other areas since chest already checked (in breathing) you now need to check abdomen.
Abdomen
Do Inspection, Palpation and Precussion.
If Diagnostic Peritoneal Lavage then the person doing it should be the same person taking the patient to theatre for laparatomy.
Check Pelvic FRACTURE. orthopaedics may put a put a fixator on pelvis and close it.
If you are not confident i doing the pelvic spring test than do not do it and say I will tell orthopaedics to do it.
Bilateral femoral FRACTURE put splints on and keep transfusing blood
If patient has normal HR/BP then no need to do Abdominal/ Pelvic examination
You cannot feel the Carotid if Cervical Collar is still on.
If Examiner tells you airway and breathing are normal then voice your thoughts saying as I have been told airway and breathing are normal then I am moving on to circulation.
Never assume Cervical spine is stable always stabilize first even if pt is sitting with collar on.
If you cannot see neck veins also open collar and check it.
Disability is next
1. Pupils and reaction to light
2. Response to verbal stimuli(alert)
Exposure
Completely expose the pt from head to toe and put on blankets
Adjuncts
1.Pulse Oximeter
2.BP Cuff
3.ECG
4.ABG if Respiratory Problem
5.Urinary and Gastric Catheter
Most Patients have delayed Gastric emptying.
Originally posted at http://www.rxpgonline.com/postt19492.html
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