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Pre-Hospital Management

Sudden Collapsed Patient

Trauma

Dr. Pritesh Vyas M.D. (Anesthesia)
Consultant Anesthetist & Intensivist

Causes of Sudden Collapse

• Head Injury / Major Trauma
• Massive Intracranial Event
• Infarct
• Hemorrhage
• Major Myocardial Infarction
• Pulmonary Embolism
• Poisoning
• Oral / Inhaled / Injected
• Insect / Snake Bite
• Chocking
• Convulsion

Dr. Pritesh Vyas (M.D.)

History & Clinical Examination

Brief history is important, do not waste more time
Ask for
• Current event
• Past / Present Other Major Illness
• Duration of Collapse / Unconsciousness
Look for
• Level of Consciousness
• Airway
• Breathing
• Pulse
• Cardiac Activity

The Chain of Survival

American Heart Association (AHA) first proposed the
phrase quot;the chain of survival”
• rapid access to medical care
• early basic life support (BLS)
• early defibrillation and
• early advanced cardiac life support (ACLS).


Check Responsiveness


„ABCD of Resuscitation‟

A. Airway
B. Breathing
C. Circulation
D. Defibrilation


Causes of Airway Obstruction


Adult Foreign Body Airway Obstruction


Back Blow in Chocking


Abdominal Thrust in CONSCIOUS Patient
(Heimlich maneuver)


Unconscious?

SHOUT FOR HELP
• CPR is always best done with more then one
persons

CALL AMBULANCE “108”
• Early initiation of ACLS
• Better infrastructure
• Expert help


Airway Assessment

“ Look, Listen & Feel”


Head Tilt & Jaw Lift


Jaw Thrust


Expired Air Resuscitation


Landmarks for Chest Compression


Position During Chest Compression


Assessment


Recovery Position


AMBU
(Artificial Mobile Breathing Unit)


Laryngoscope


Oropharyngeal Airway


Nasopharyngeal Airway


LMA (Laryngeal mask Airway)


Further Management

• Intravenous access with large bore (20G, 18G)
cannula
• Treat precepitating factor
• Manage Transfer
• Provide Supplemental Oxygen and IV fluids


List of necessary things

• Telephone
• Torch
• Stethoscope
• AMBU
• Oral / Nasal Airway
• 18 G, 20 G IV cannula
• IV set, Disposible Syringes
• IV fluids


Additional Facilities

• Laryngoscope & Endotracheal Tube / LMA
• Oxygen Cylinder
• Sucction Machine
• ECG Monitor with Defibrillator / AED
• Pulseoxymeter / Multipara Monitor


Pre-hospital Management of Trauma


What will you do?


Triage

The word triage derives from the French word
meaning “to sort.” When applied in a medical
context, triage involves the initial evaluation of a
casualty and the determination of the priority and level
of medical care necessary for the victim. The purpose
of triage is to be selective, so that limited medical
resources are allocated to patients who will receive
the most benefit


Triage Critaria
• Glasgow Coma Scale of 13 or less
• Systolic blood pressure of 90 or less
• Respiratory rate of 10 per minute or less, or greater than 29 per m
• Sustained pulse rate of 120 per m or more
• Head trauma with altered state of consciousness, hemiplegia, or uneven pupils
• Penetrating injuries of the head, neck, torso, and limbs proximal to the elbow or knee
• Chest trauma with respiratory distress or signs of shock
• Pelvic Fractures OR Two or more proximal long bone fractures
• Amputations above the wrist or ankle
• Limb Paralysis
• Combination of trauma with burns
• Mechanism of Injury and High Energy Impact like
• Fall of 20 feet or more
• Patient struck by a vehicle moving 20 MPH or more
• Patient ejected from a vehicle
• Vehicle rollover with the patient unrestrained
• High speed crash (initial speed of >40 MPH) with 20 inches of major front end deformity, 12
inches or more deformity into the passenger compartment
• Patient was a survivor of a MVA where a death occurred in the same vehicle

Other Criteria

• Age of less than 5 years old, or over 55 years old
• History of cardiac disease, respiratory disease, insulin
dependent diabetes, cirrhosis, or morbid obesity
• Pregnancy
• Immunosuppressed patients
• Patients with bleeding disorders, or patients on
anticoagulants
• Burns of greater than 30% of body surface area in
adults, or 15% body surface area in children
• Burns of the head, hands, feet, or genital area
• Inhalation injuries
• Electrical burns
• Burns associated with multiple trauma or severe medical
problems


Glasgow Coma Scale
Feature Response Score
Eye Opening Spontaneous 4
To speech 3
To pain 2
None 1
Vrebal Response Oriented 5
Confused conversation 4
Words inappropriate 3
Sounds incomprehensible 2
None 1
Best Motor Response Obeys commands 6
Localizes pain 5
Flexion normal 4
Flexion abnormal 3
Extended 2
None 1


ABCDE of Trauma Management

A. Airway maintenance with cervical spine protection
B. Breathing and ventilation
C. Circulation with hemorrhage control
D. Disability; neurologic status
E. Exposure/Environment (completely undress the
patient and prevent hypothermia)


Initial Evaluation of Trauma

• Level of consciousness
• History
• Clinical Examination
• Haemostasis
• Immobilization
• Supplemental Oxygen if needed
• IV Fluids
• Analgesics, Antibiotics


Level of Consciousness

CONSCIOUS UNCONSCIOUS
Follow further line of trauma Check for need of CPR
management • YES – Start CPR first
AMPLE Survey
• NO
• Allergies
• Secure Airway
• Medications currently being
taken by the patient • Check Vital Signs
• Past illness and operations • Not Good ? - Correct
first
• Last meal
• Events and Environment
• Good? - Follow
related to the injury further line of trauma
management

History

• Time of Trauma
• Mode of injury
• Change in level of consciousness
• Amount of blood loss
• Pregnancy – if female
• Other pre-existing medical disorders
• Drug history
• Medicine
• Intoxication – drugs, alcohol, poisons


Clinical Examination
• Level of consciousness
• Vitals
• General Examination from head to toe
• Quick Systemic Examination
• RS – Air Entry, Chest Movements, Chest
Compression
• CVS – S1, S2, Murmur, Rhythm
• AS – Wounds, Bruises, Distention, Pelvic
Compression
• CNS – GCS, Orientation, Pupils, Limb Movements


Haemostasis

Control any active visible bleeding with
• Pressure
• Bandage
• Tourniquet
• Pressure Points
• Suture (if possible)


Key Points in Fracture Management

• Never try to correct deformity yourself
• Apply sterile dressing over open wound
• Haemostasis
• IMMOBILIZATION
• Limbs – any solid slab
• Neck – hard cervical collar


Supportive Treatment

• Large bore IV line (18 G, 20 G)
• IV Fluids
• Analgesics
• Wound Dressing
• Antibiotics
• Oxygen Support
• Arrange safe transfer
• Police Inform


Small but important lines

• Never remove penetrating foreign body
• If Female – ask about pregnancy
• Secure IV line – Two lines better
• X-Ray, CT Scan
• Blood Samples – Lab. Tests
• Cross-matching
• Inform Refferal Hospital in advance with proper
records – saves time
• Reassessment


Critical Trauma Patient
 Inadequate or threatened airway
 Impaired ventilation as demonstrated by the following:
 Abnormally fast or slow ventilatory rate
 Hypoxia (Spo2 <95% even with supplemental oxygen)
 Dyspnea
 Open pneumothorax or flail chest, Suspected pneumothorax
 Significant external hemorrhage or suspected internal
hemorrhage
 Abnormal neurologic status, GCS score ≤13
 Seizure activity
 Sensory or motor deficit
 Penetrating trauma to the head, neck, or torso. or proximal to
the elbow and knee in the extremities
 Amputation or near amputation proximal to the fingers or toes


Any trauma in the presence of the following
is critical

• History of serious medical conditions
(e.g., coronary artery disease, chronic
obstructive pulmonary
disease, bleeding disorder)
• Age >55
• Hypothermia
• Burns
• Pregnancy

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