ABC\'s of Emergency

1. Polytrauma Frederick Mars Untalan MD

2. standard of care Advanced Trauma Life Support (ATLS) protocol Airway Breathing Circulation Disability Environment

3. History of the mnemonic 1957, Peter Safar[4] wrote the book ABC of Resuscitationwhich established the basis for mass training of CPR. 1962 training video called "The Pulse of Life" created by James Jude,[6]Guy Knickerbocker and Peter Safar. Jude and Knickerbocker, along with William Kouwenhouen[7] developed the method of external chest compressions, while Safar worked with James Elam to prove the effectiveness of artificial respiration.[8] Their combined findings were presented at annual Maryland Medical Society meeting on September 16, 1960 in Ocean City, and gained rapid and widespread acceptance over the following decade, helped by the video and speaking tour the men undertook. The ABC system for CPR training was later adopted by the American Heart Association, which promulgated standards for CPR in 1973.

4. First things First In the polytrauma patient, a number of injuries take higher priority than the craniomaxillofacial ones. life-preserving emergency procedures take precedence in extensive head or neck injury Craniomaxillofacial injuries need to be diagnosed, a treatment plan established, and a sequence fitted into the total treatment plan for the patient at an early stage.

5. TEAM (Trauma Evaluation And Management) TEAM introduces the concepts of trauma assessment and management to medical students during their clinical years. TEAM Program should satisfy the need for a standardized introductory course in the evaluation and management of trauma that can be taught to all medical students and multidisciplinary team members.

6. What is ATLS®? a systematic, concise training to the early care of trauma patients. It will provide the participants with a safe, reliable method for immediate management of the injured patient and the basic knowledge necessary to: Assess the patient's condition rapidly and accurately Resuscitate and stabilize the patient according to priority Determine if the patient's needs exceed a facility's capabilities Arrange appropriately for the patient's interhospital transfer (what, who, when, and how) Assure that optimum care is provided

7. Advanced Trauma Life Support a training program for doctors and Advanced Practice/Critical Care Paramedics in the management of acute trauma cases, developed by the American College of Surgeons. The program has been adopted worldwide in over 40 countries,[1] sometimes under the name of Early Management of Severe Trauma (EMST), especially outside North America. Its goal is to teach a simplified and standardized approach to trauma patients. Originally designed for emergency situations where only one doctor and one nurse are present, ATLS is now widely accepted as the standard of care for initial assessment and treatment in trauma centers. The premise of the ATLS program is to treat the greatest threat to life first. It also advocates that the lack of a definitive diagnosis and a detailed history should not slow the application of indicated treatment for life-threatening injury, with the most time-critical interventions performed early. However, there is mixed evidence to show that ATLS improves patient outcomes. Bouillon, B., Kanz, K.G., Lackner, C.K., Mutschler, W., & Sturm, J. The importance of Advanced Trauma Life Support (ATLS) in the emergency room [Article in German]. Unfallchirurg, 107(10), 844-850.

8. ABCDE of ENT Emergency A – Airway & Breathing B – Bleeding & Circulation C – Call D – D E - ENT

9. Primary Survey life-threatening injuries are identified simultaneously resuscitation is begun ABCDE A Airway Maintenance w/ Cervical Spine Protection BBreathing and Ventilation C Circulation with Hemorrhage Control D Disability (Neurologic Evaluation) E Exposure and Environment

10. Primary Survey A - Airway Maintenance with Cervical Spine Protection assess the airway. chin lift or jaw thrust. patient's mouth should be cleaned cervical spine -immobilised

11. Simple application for CPR A — Airway Unconscious patients In the unconscious patient, the priority is airway management, to avoid a preventable cause of hypoxia. Common problems with the airway of patient with a seriously reduced level of consciousness involve blockage of the pharynx by the tongue, a foreign body, or vomit. At a basic level, opening of the airway is achieved through manual movement of the head using various techniques, with the most widely taught and used being the "head tilt — chin lift", although other methods such as the "modified jaw thrust" can be used, especially where spinal injury is suspected,[16] although in some countries, its use is not recommended for lay rescuers for safety reasons.[15] Higher level practitioners such as emergency medical service personnel may use more advanced techniques, from oropharyngeal airways to intubation, as deemed necessary.[17] Conscious patients In the conscious patient, other signs of airway obstruction that may be considered by the rescuer include paradoxical chest movements, use of accessory muscles for breathing, tracheal deviation, noisy air entry or exit, and cyanosis.[18]

12. Primary Survey B - Breathing and Ventilation chest must be examined tracheal deviation must be identified Life-threatening chest injuries tension pneumothorax, open pneumothorax flail chest hemothorax

13. Simple application for CPR B — Breathing [edit] Unconscious patients In the unconscious patient, after the airway is opened the next area to assess is the patient's breathing,[15] primarily to find if the patient is making normal respiratory efforts. Normal breathing rates are between 12 and 30 breaths per minute,[18] and if a patient is breathing below the minimum rate, then in current ILCOR basic life support protocols, CPR should be considered, although professional rescuers may have their own protocols to follow, such as artificial respiration. Rescuers are often warned against mistaking agonal breathing, which is a series of noisy gasps occurring in around 40% of cardiac arrest victims, for normal breathing.[15] If a patient is breathing, then the rescuer will continue with the treatment indicated for an unconscious but breathing patient, which may include interventions such as the recovery position and summoning an ambulance.[19] [edit] Conscious or breathing patients In a conscious patient, or where a pulse and breathing are clearly present, the care provider will initially be looking to diagnose immediately life-threatening conditions such as severe asthma, pulmonary oedema or haemothorax.[18] Depending on skill level of the rescuer, this may involve steps such as:[18] Checking for general respiratory distress, such as use of accessory muscles to breathe, abdominal breathing, position of the patient, sweating, or cyanosis Checking the respiratory rate, depth and rhythm - Normal breathing is between 12 and 20 in a healthy patient, with a regular pattern and depth. If any of these deviate from normal, this may indicate an underlying problem (such as with Cheyne-Stokes respiration) Chest deformity and movement - The chest should rise and fall equally on both sides, and should be free of deformity. Clinicians may be able to get a working diagnosis from abnormal movement or shape of the chest in cases such as pneumothorax or haemothorax Listening to external breath sounds a short distance from the patient can reveal dysfunction such as a rattling noise (indicative of secretions in the airway) or stridor (which indicates airway obstruction) Checking for surgical emphysema which is air in the subcutaneous layer which is suggestive of a pneumothorax Auscultation and percussion of the chest by using a stethoscope to listen for normal chest sounds or any abnormalities Pulse oximetry may be useful in assessing the amount of oxygen present in the blood, and by inference the effectiveness of the breathing

14. Primary Survey C - Circulation with Hemorrhage Control Hemorrhage Hypotension Hypotension Hypovolemic shock crystalloid solution type-specific blood, or O-negative if this is not available External bleeding is controlled by direct pressure. Occult blood loss may be into the chest, abdomen, pelvis or from the long bones. Chest or pelvic bleeding may be identified on X-ray. Bleeding into the peritoneum may be diagnosed on ultrasound (FAST scan), CT (if stable) or diagnostic peritoneal lavage.

15. Simple application for CPR C — Circulation Once oxygen can be delivered to the lungs by a clear airway and efficient breathing, there needs to be a circulation to deliver it to the rest of the body. [edit] Non-breathing patients Circulation is the original meaning of the 'C' as laid down by Jude, Knickerbocker & Safar, and was intended to suggest assessing the presence or absence of circulation, usually by taking a carotidpulse, before taking any further treatment steps. In modern protocols for lay persons, this step is omitted as it has been proven that lay rescuers may have difficulty in accurately determining the presence or absence of a pulse, and that, in any case, there is less risk of harm by performing chest compressions on a beating heart than failing to perform them when the heart is not beating.[20] For this reason, lay rescuers proceed directly to cardiopulmonary resuscitation, starting with chest compressions, which is effectively artificial circulation. In order to simplify the teaching of this to some groups, especially at a basic first aid level, the C for 'Circulation' is changed for meaning 'CPR' or 'Compressions'.[21][22][23] It should be remembered, however, that health care professionals will often still include a pulse check in their ABC check, and may involve additional steps such as an immediate ECG when cardiac arrest is suspected, in order to assess heart rhythm. [edit] Breathing patients In patients who are breathing, there is the opportunity to undertake further diagnosis and, depending on the skill level of the attending rescuer, a number of assessment options are available, including: Observation of colour and temperature of hands and fingers where cold, blue, pink, pale, or mottled extremities can be indicative of poor circulation Capillary refill is an assessment of the effective working of the capillaries, and involves applying cutaneous pressure to an area of skin to force blood from the area, and counting the time until return of blood. This can be performed peripherally, usually on a fingernail bed, or centrally, usually on the sternum or forehead Pulse checks, both centrally and peripherally, assessing rate (normally 60-80 beats per minute in a resting adult), regularity, strength, and equality between different pulses Blood pressure measurements can be taken to assess for signs of shock Auscultation of the heart can be undertaken by medical professionals Observation for secondary signs of circulatory failure such as oedema or frothing from the mouth (indicative of congestive heart failure) ECG monitoring will allow the healthcare professional to help diagnose underlying heart conditions, including myocardial infarctions

16. Primary Survey D - Disability (Neurologic Evaluation) AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive). A more detailed and rapid neurological evaluation is performed at the end of the primary survey. level of consciousness, pupil size and reaction, lateralizing signs & SCI. Glasgow Coma Scale a quick method to determine the level of consciousness, and is predictive of patient outcome.

17. Primary Survey E - Exposure / Environmental control The patient should be completely undressed Hypothermia in the emergency department. Warm Intravenous fluids warm environment Maintain Patient privacy

18. Secondary Survey head-to-toe evaluation complete history and physical examination reassessment of all vital signs. Each region of the body must be fully examined. X-rays indicated by examination AmalMattu; DeepiGoyal; Barrett, Jeffrey W.; Joshua Broder; DeAngelis, Michael; Peter Deblieux; Gus M. Garmel; Richard Harrigan; David Karras; Anita L'Italien; David Manthey (2007). Emergency medicine: avoiding the pitfalls and improving the outcomes. Malden, Mass: Blackwell Pub./BMJ Books. pp. 60. ISBN 1-4051-4166-2

19. recovery position an airway management technique for assisting people who are unconscious, or nearly so, but are still breathing. It is frequently taught alongside CPR in first aid. An unconscious person (GCS <8) cannot be trusted to maintain his or her own breathing. Many fatalities occur where the original injury or illness which caused unconsciousness is not inherently fatal, but where the unconscious person suffocates for one of these reasons. This is a common cause of death following unconsciousness due to excessive consumption of alcohol. When an unconscious person is lying face upwards, there are two main risk factors which can lead to suffocation: Fluids, possibly blood but particularly vomit, can collect in the back of the throat, causing the person to drown. When a person is lying face up, the esophagus tilts down slightly from the stomach toward the throat. This, combined with loss of muscular control, can lead to the stomach contents flowing into the throat, called passive regurgitation. Fluid which collects in the back of the throat can also flow down into the lungs; stomach acid can attack the inner lining of the lungs and cause aspiration pneumonia. It's possible to achieve limited protection of the airway by tilting the head back and lifting the jaw. An unconscious person will not remain in this position unless held constantly, and crucially it does not safeguard against risks due to fluids. In the recovery position, the force of gravity will allow any fluids to drain. The chest is also elevated from the ground, making breathing easier. lateral recumbent position

20. When to use the recovery position unconscious person who does not need CPR those who are too inebriated to assure their own continued breathing victims of drowning victims of suspected poisoning (who are liable to become unconscious).

21. Putting a victim in the recovery position / lateral recovery position."[ Checking carotid pulse If spinal or neck injuries are possible They should be moved to a recovery position only when it is necessary to drain vomit from the airway. "HAINES modified recovery position" (High Arm IN Endangered Spine.) one of the patient's arms is raised above the head (in full abduction) to support the head and neck. Less neck movement (and less degree of lateral angulation) than when the lateral recovery position is used, and, therefore, HAINES use carries less risk of spinal-cord damage. Pregnant victims always rest on her left side Victims with torso wounds wounds closest to the ground to minimize the possibility of blood affecting both lungs, resulting in asphyxiation.

22. Variations Nearly all first aid organizations use "ABC" in some form 'ABCD' (designed for training lay responders in defibrillation) 'AcBCDEEEFG' (the UK ambulance service version for patient assessment).

23. Variations DR ABC One of the most widely used adaptations is the addition of "DR" in front of "ABC", which stands for Danger and Response “protect yourself before attempting to help others” then ascertaining that the patient is unresponsive before attempting to treat them, using systems such as AVPU or the Glasgow Coma Score "The primary survey" St John Ambulance. http://www.sja.org.uk/sja/first-aid-advice/lifesaving-procedures/primary-survey.aspx

24. Variations DRsABC A modification to DRABC is that when there is no response from the patient, the rescuer is told to Shout for help "Cardio Pulmonary Resuscitation"Centre for Excellence in Teaching and Learning. http://www.cetl.org.uk/learning/print/cpr-print.pdf

25. Variations ABCD Defibrillation— The definitive treatment step for cardiac arrest Disability or Dysfunction[— Disabilities caused by the injury, not pre-existing conditions Deadly Bleeding (Differential) Diagnosis Decompression Cayley, William E, Jr (2006-05-01). "Practice guidelines: 2005 AHA guidelines for CPR and Emergency Cardiac Care“.American Family Physician. http://www.aafp.org/afp/20060501/practice.html Primary Trauma Care. Primary Trauma Care Foundation. 2000. ISBN 0-95-39411-08 http://av.rds.yahoo.com/www.primarytraumacare.org/PTCMain/Training/pfd/PTC_ENG.pdfRetrieved 2008-12-20. "Emergency First Aid with Level C CPR". Western Canada Fire & First Aid Inc. http://www.wcff.ca/crs-emrgfirstaid.htm. Retrieved 2008-12-20. "Cardiac Arrest associated with Pregnancy“ Circulation 112: 150–153. 2005-11-28. http://www.comtf.es/doc/RCP/CIRCULATIONPregnancy.pdf. Retrieved 2008-12-20. "Resuscitation. Revival should be the first priority". Postgraduation Medical Journal 89 (1): 117–20. January 1991. ISSN 0032-5481

26. Variations ABCDE Expose and Examine Environment Escaping Air — Checking for air escaping, such as through a sucking chest wound, which could lead to a collapsed lung. Elimination Evaluate Primary Trauma Care. Primary Trauma Care Foundation. 2000. ISBN 0-95-39411-0-8 http//www.primarytraumacare.org/PTCMain/Training/pfd/PTC_ENG.pdf. Retrieved 2008-12-20 Accident Compensation Corporation (June 2007). Management of burns and scalds in primary care. New Zealand Guidelines Group. http://ngc.gov/summary/summary.aspx?view_id=1&doc_id=11509 "Resuscitation. Revival should be the first priority". Postgraduation Medical Journal 89 (1): 117–20. January 1991. ISSN 0032-5481

27. Variations ABCDEF Fundus — pregnancy Family (in France) — indicates that rescuers must also deal with the witnesses and the family, who may be able to give precious information about the accident or the health of the patient, or may present a problem for the rescuer. Fluids — A check for obvious fluids (blood, cerebro-spinal fluid (CSF) etc.) Fluid resuscitation Final Steps — Consulting the nearest definitive care facility "Resuscitation. Revival should be the first priority". Postgraduation Medical Journal 89 (1): 117–20. January 1991. ISSN 0032-5481 Accident Compensation Corporation (June 2007). Management of burns and scalds in primary care. New Zealand Guidelines Group. http://ngc.gov/summary/summary.aspx?view_id=1&doc_id=11509 "Pediatric clinical practice guidelines for nurses in primary care". Health Canada. http://www.hc-sc.gc.ca/fniah-spnia/pubs/services/_nursing-infirm/2001_ped_guide/chap_10c-eng.php. Retrieved 2008-12-21

28. Variations ABCDEFG Go Quickly! — A reminder to ensure all assessments and on-scene treatments are completed with speed, in order to get the patient to hospital within the Golden Hour Glucose — The professional rescuer may choose to perform a blood glucose test, and this can form the 'G' or alternately, the 'DEFG' can stand for "Don't Ever Forget Glucose"

29. Variations AcBC additional (small) 'c' in between the A and B, standing for 'cervical spine' or 'consider C-spine'. potential neck injuries to a patient, as opening the airway may cause further damage unless a special technique is used. Occupational First Aid. Level 5. Further Education and Training Awards Council. July 2008. http://www.safetyireland.com/occupational_first_aid_fetac.pdf. Retrieved 2008-12-21

30. Examination of the Maxillofacial Region Once the patient has been stabilized and cleared for cervical spinal cord injuries, the physician can begin to evaluate the maxillofacial region. If possible, the history of events surrounding the injury should be obtained because it can provide clues to the type of injuries the patient could have. For example, a sharp, penetrating injury is more likely to injure nerves and major vessels than is blunt trauma, which is more likely to result in fractures of the facial skeleton. Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000

31. Examination of the Maxillofacial Region Do you see " double"? binocular diplopia can indicate internal or periorbital fractures. It should be considered a nonspecific symptom, however, because it can also be caused by other things, most commonly periorbital edema. monocular diplopia might indicate an injury to the globe, for which ophthalmologic consultation is necessary. Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000

32. Examination of the Maxillofacial Region Are there any areas of numbness on your face? Any neurosensory deficit usually indicates a skeletal fracture has occurred surrounding the bony canals/grooves/foramina, through which the branches of the trigeminal nerves exit. Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000

33. Examination of the Maxillofacial Region Does your bite feel " normal"? Most mandibular and/or maxillary fractures are associated with the subjective feeling that the bite is not "normal." The location of premature contact of the teeth can help to direct the clinician to the site of fracture. Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000

34. Examination of the Maxillofacial Region Which areas on your face hurt? Although this question seems basic, one could find a patient who points to a location that is not swollen or bruised, such as the preauricular area, in the case of a condylar process fracture of the mandible. Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000

35. Examination of the Maxillofacial Region Does it hurt when you open your mouth? Where? The presence of pain when one attempts functional movements of the mandible can indicate that skeletal fractures have occurred, although contusions of the temporomandibular joint can also produce pain in the absence of skeletal fractures. If pain is present, however, its location helps to determine underlying fractures. For instance, preauricular tenderness with mandibular movement could indicate a condylar process fracture. Pain at the angle of the mandible could indicate a fracture in that location. Pain in the cheek region when one attempts to open the mouth could signify a zygomaticomaxillary complex fracture Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000

36. The clinical evaluation of the maxillofacial region must be organized and sequential and should be performed prior to ordering radiographs and other images. The head and neck examination must be methodical, or significant injuries can be missed. The maxillofacial examination must include the following components: Soft tissues Nerves Skeleton Dentition Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000

37. "inside out and bottom up." One approach organizes the examination from "inside out and bottom up." Following this recommendation, the oral cavity is inspected first for lacerations or penetrating injuries. The tongue is frequently lacerated and can produce profuse bleeding. Soft tissue injuries should be explored for tooth fragments and other foreign bodies. Areas of soft tissue swelling and ecchymosis are noted because they can indicate underlying skeletal fractures. Lacerations of the attached gingiva around the teeth or palate also can indicate an underlying fracture. Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000

38. An examination of the maxillofacial skeleton involves inspection and palpation. Injuries in the maxillofacial area can be associated with massive edema, which makes evaluation of the underlying skeleton difficult; however, bony contours should be palpated for irregularities and tenderness (discussed in their specific regions). One should always inspect carefully any fluid exiting the nose in case it could be cerebrospinal fluid (CSF). The presence of CSF rhinorrhea indicates disruption of the anterior cranial base, most commonly at the cribriform plate of the ethmoid bone associated with naso-orbitoethmoid fractures, or from disruption of the posterior wall of the frontal sinus. Areas of "numbness" on the face should make one suspect disruption of the sensory branch of the trigeminal nerve from skeletal fractures Edward Ellis III, DDSUniversity of Texas Southwestern Medical Center Emergency Medicine Clinics of North AmericaVolume 18 • Number 3 • August 2000

39. Star of Life Preserve Life Prevent Further Injury Promote Recovery. 6 stages of high quality pre-hospital care: Early Detection Early Reporting Early Response Good On Scene Care Care in Transit Transfer to Definitive Care[

40. Polytrauma Frederick Mars Untalan MD