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Mechanism of injury
High risk injury
o Penetrating injury to chest, abdomen, head, neck, groin
o Burns >15% facial injury + airway problems
o High energy impact:
Fall from 20ft height (2 tingkat); kalo children, double of his/her height
Velocity of crash >20 mph (50km)
Ejection of victim from vehicle
Rollover
Death of another person in same car
Low risk injury : blunt trauma
TRIAGE
Process of sorting the patients according to priority of tx
a) Mass casualty incident
b) 2 types: field / hospital
c) Categorized into - colour coding system
o Red life-threatening, critical, 1st priority, any issue with ABCD
A airway choking
B breathing tachypnea
C circulation shock, reduce consciousness level, hypoT
D disability semi-consciousness
o Yellow intermediate, semi-critical, cannot walk
o Green mild, pt can wait, G1 (elderly >60 , child <5 years) / G2 / G3 / G4 / G5
Breathing
Inspection
o bruises, bleeding, breathing pattern, RR, symmetrical chest movement, paradoxical chest
movement (during inhalation, chest compressed)
flail chest # 3 consecutive ribs
major ms diaphragm, internal intercostals ms
o open chest wound = sucking chest wound
apply 3 way occlusive dressing (in hospital setting)
if emergency chest tube!
Examination
o Palpate apex beat, chest expansion, tenderness, crepitation (air in btw soft ts; d/t torn
pleura)
o Percussion
Hyper resonance tension pneumothorax
Stony dullness pleural effusion
o Spring test - # ribs
o Auscultate - apex beat, heart sound, air entry, abnormal sound
Circulation
General
o Cold, clammy periphery, pallor, int/ext haemorrhage
Specific - Abdominal / Pelvic region
o bruises, laceration, abdominal distention, pelvic deformity, large hematoma, scrotal swelling,
bleeding at groin/ from anal/ meatal opening, open wound/ sucking (long bone)
o tenderness on palpation 9Q/4Q
o Pelvic spring test
Intervention
o Skin colour/ temperature/ BP/ CRT/ Pulse rate, rhythm, paradoxus
o Identify exsanguinated hage (bleeders)
o Apply cardiac monitor, pulse oximeter
Management
o Control bleeding site
o 2 large bore branula, GXM blood, Blood tranfusion
o Chest tube insertion
o Apply pelvic immobilization device - pelvic binders
Disability
Glasgow coma scale (EVM): mild 13-15/ moderate/ severe <8
Intervention AVPU
Limahabs-sofy
Assess pupil size, reactivity, equity
Neurological integrity - posture, limb movement, ms tone
Exposure
Make sure significant injury not missed
Examine thoroughly - expose head to toe
Avoid hypothermia esp in child blanket
Log roll
o Examine back, anal tone, whether neurogenic shock/not
ADJUNCT TO 1 SURVEY
U/S TAS, FAST (focus abdominal sonography in trauma)
ECG
Blood Ix - Dxt/ FBC/ GSH
Vital signs S = Symptoms
Xray chest, pelvic
A = Allergies
2 Tubes - Ryules/ CBD
M = Meds / Mechanism of injury
SECONDARY SURVEY - Re-evaluation P = PMH/ Pregnant?
Head to toe examination including neurological examination
Identify other injury L = Last meal
SAMPLE history
Any finding? appropriate ix E = Events surrounding the injury
DEFINITIVE CARE
Limahabs-sofy
Palpation flutter valve
Symmetry of movement unequal
Tenderness - rib fracture Do not tape on all sides --- may create
Crepitus - displaced fractures tension pneumothorax
Percussion
Resonant
Auscultation
Reduce air entry
Hypotensive
Flail chest Resp exam - Ensure adequate o2 supp
Inspection - Provide judicious fluid therapy
2 contigous ribs Chest wall - paradoxical movement,
- Administer adequate analgesic
fractured in 2 flail chest
places Palpation
Symmetry of movement unequal
Percussion
Resonant
Auscultation
Reduce air entry
WOUND CARE
Limahabs-sofy
- Wound = Any break in the continuity of body tissue
o Examples: grazes, burns, surgical incisions, stabs, leg ulcers, decubitus ulcers ( pressure
sores)
o Can be acute / chronic
Chronic pysiologically impaired in wound healing. Eg: bedsore
- Management
o ABCDE
o AMPLE hx
o Treat life-threatening injury 1st
o Remove ring, jewelery, clothing
o If amputated cover with moist NS (gauze) put in ice bag
- Wound assessment
o Mechanism of injury
o Age of injury
o Identify possible contamination / FB
o Assessment of extent wound many position
o Neurovascular compromise / tendon injury
o Need for tetanus
Wound
Clean Contaminated
ATT + Ig
No ATT ATT ATT
(toxoid)
- Wound examination
o Neutral position during injury
o Clenched fist injury tx as human bites
- Antibiotics
Limahabs-sofy
o Contaminated wound by debris, feces
o Puncture / bite
o Tissue destruction or in avascular area
o Neglected wound
o Overlying joint and cartilage
- Anesthesia (LA)
o 2 point discrimination differentiate numbness
o SBP comparison arterial injury
- Homeostasis
o Compress bleeding
o Skin
o Raneys clip (scalp)
o Figure of 8th suturing / horizontal mattress suture
o Chemical (LA + adrenaline)
o Physical gelatin, cellulose, collagen sponge
- Skin disinfection
o Suppress bacterial growth, but impair host defense
o Consist of: wound irrigation, ts debridement, FB removal
o Use NS, povidone
o Irrigation
Low pressure
0.5 PSI
About 1 gallipot
For clean wound, loose ts around scrotum & eyelids
High pressure
7 PSI
Syringe + 18G IV branula
For contaminated wound
- Debridement
o Prepare wound bed to facilitate good healing process
Autolytic
Mechanical
Irrigation
Wet to dry dressing
Excision
Biologic maggots
Limahabs-sofy
o Non inflammable, sterile
- Closure
o Primary closure acute, <24 hours, clean wound, suture / staple
o Delayed primary closure contaminated wound, after dressing then close it
- Healing
o 1st intention
o 2nd intention
- Suture
o Absorbable for mucosa
o Non-absorbable skin
o Interrupted VS continuous
Interrupted - if infected, easy to open up
o Ideal distant
0.5cm (face), 1cm (others)
o STO depends on site
Face: 3-5 days
UL & LL: 1 weeks (UL) 2 weeks (LL), joint area: max 2 weeks
- After care
o Keep dry
o Diabetic control
o Infected wound dressing!
o Compliance STO
Limahabs-sofy
BASIC LIFE SUPPORT
American Heart Associations Guideline for CPR and ECC (Emergency Cardiovascular Care)
Limahabs-sofy