CLINICAL LESSON Co-organized by GORNA & The Greek Society of Surgery
«INJURED PATIENT MANAGEMENT: FROM SITE OF ACCIDENT
TO DEFINATE CARE»
Trauma is the number one cause of death during the first four decades of life (ages 1-44years). It represents the 60% of childhood mortality and a globally is one of the biggest financial, social and health problem. Almost 30% of deaths due to trauma will take place in the first 4 hours. Rapid and efficient specialized pre-hospital and hospital care could reduce that percentage (Time is a killer). This is exactly what defines the “golden hour”, inside its time frame most of the critical problems must be tackled, before the trauma patient tolerance and reserves are exhausted (Golden hour-optimize the chance of survival).
The management of the patient comprises a) pre-hospital care b) in hospital management c) rehabilitation and social reintegration.
- PRE-HOSPITAL MANAGEMENT
In case of multiple injuries patents survival estimation is crucial (Triage). Triage is the categorization of trauma patients according to their requirements for treatment in combination with the available recourses. During pre-hospital care the ABCDE algorithm is implied to manage patients. Special care must be taken in maintaining an open airway, control of external bleeding and shock, patient immobilization and transfer to the nearest trauma center.
- IN-HOSPITAL MANAGEMENT
Is comprised by the initial assessment and care in the emergency department and the definite care in the operating room or the intensive care unit. This requires rapid primary survey and simultaneous resuscitation of vital functions and thorough secondary survey and assessment and at the end final definite care.
- Primary survey and resuscitation in the Emergency department
Recognition and management of fatal injuries is a priority. This is the reason why the ABCDE algorithm is implied in the primary survey, established by the A.T.L.S. program (Advanced Trauma Life Support).
A “Airway” Airway maintenance with cervical spine protection and Ο2
B “Breathing” Control of Breathing and ventilation
C “Circulation” Control of circulation with external hemorrhage control
D “Disability” and neurologic status
E “Exposure/Environmental control” Completely Undress the patient, but prevent hypothermia
In continuation, form of management is dependent by the hemodynamic status and the need for surgical intervention
A patient who is hemodynamically stable, if there is no requirement for surgical intervention and according to the severity of the injuries will be transferred for definitive care to the High Dependency or the Intensive care Unit.
Hemodynamically stable patient, who is in need of surgical intervention, will be transferred to the operating room and then to HDU or ICU.
Hemodynamically unstable patient who doesn’t need surgical intervention will be transferred to ICU.
Hemodynamically unstable patient who needs surgical intervention will be transferred immediately to the operating room for “damage control” intervention to avoid the establishment of the “lethal triplet”. That triplet comprises: hypothermia, metabolic acidosis, clotting derangement and further degradation of the patient.
In the present course and with the aid of actors playing the role of patients, we will mainly focus in pre-hospital care and initial management in the hospital emergency department.