for patient with Life Threatening doctor must be required Life Saving
MEDICAL ACTION: ABCDE (primary) FGHI
Airway maintenance with cervical spine protection
- Upper airway (above vocal cords) managed adjunctively with chin lift/jaw thrust, suctioning, oral airway, nasopharyngeal airway, and laryngeal mask airway. The most common cause of airway obstruction in the unconscious patient is the tongue.
- Lower airway managed definitively with a cuffed tube in the trachea (orotracheal intubation, nasotracheal intubation, or surgical airway—cricothyroidotomy)
- Assume cervical spine injury in patients sustaining any blunt injury or penetrating injury above the chest.
- Intubation is indicated for airway protection (GCS < 9; severe maxillofacial fractures; laryngeal or tracheal injury; evolving airway loss with neck hematoma or inhalation injury) and as a conduit for ventilation (apnea, respiratory distress–tachypnea >30, hypoxia/hypercarbia).
Breathing and oxygenation
- Ensure adequate oxygenation (pulse oximetry) & ventilation.
- Provide supplemental oxygen.
- Assess breath sounds, chest percussion, chest wall excursion, and jugular venous distention.
- Re-expand alveolar volume:
- Tension pneumothorax (pneumothorax with hypotension) with needle decompression (second intercostal space, mid-clavicular line), followed by 32-36 French anterior chest tube
- Simple pneumothorax with 32-36 French anterior chest tube
- Open pneumothorax with occlusive chest wall dressing and 36 French anterior chest tube
- Massive hemothorax with 36 French posterior chest tubes en route to operating room
- Simple hemothorax with 36 French posterior chest tube
- Flail chest/severe pulmonary contusion with intubation and mechanical ventilation
Circulation and control external bleeding
- Assess for and stop external hemorrhage.
- Direct manual pressure.
- For traumatic amputation/severe mangled extremity, application of a tourniquet
- Assess for tissue perfusion.
- Cardiovascular: blood pressure, pulse, pulse pressure
- Pulmonary: oxygen saturation via pulse oximetry, respiratory rate
- Skin: color, temperature, capillary refill
- CNS: mental status
- Renal: urine output (normal 0.5 cc/kg/hr in adults, 1.0 cc/kg/hr in children, 2.0 cc/kg/hr in neonates)
- Gain vascular access.
- Two < 16-gauge peripheral intravenous catheters
- >9 French central (subclavian, femoral, or internal jugular) introducer catheters
- Intraosseous catheter
- Saphenous vein cutdown
- Administer initial volume.
- 2 L lactated Ringer’s
- If penetrating torso trauma, controlled resuscitation with minimal fluids until bleeding is controlled
- Assess for response.
- Responder: bleeding < 20%
- Transient responder: bleeding 20-40%, needs blood
- Non-responder: >40%, needs blood and intervention to stop internal bleeding
- Consider and intervene to stop hidden sources of bleeding.
- Chest: chest tube
- Pelvis: pelvic binder
- Long bone fracture: reduce and splint
- Posterior scalp laceration: whipstitch closure
- Maxillofacial trauma with swallowed blood: anterior/posterior nasal packing
- Blood left at the scene
- Consider non-hemorrhagic sources of shock
- Tension pneumothorax
- Cardiac tamponade
- Neurogenic shock (relative hypovolemia due to vasodilatation)
- No role for vasopressor agents in the initial management of traumatic shock
- Brief neurologic exam
- Level of consciousness: Glasgow Coma Scale
- Pupil symmetry and reaction to light
- Lateralizing signs
- Maintain airway, breathing, and circulation to prevent secondary brain injury.
- Temporize for evidence of increased intracranial pressure.
- Elevate head of bed.
- Mild hyperventilation to paCO2 = 35
- Mannitol (1 gm/kg)
- Neurosurgical consultation
Exposure with environtment control
- Assess temperature.
- Remove all clothing to facilitate access and examination.
- Maintain normothermia/prevent hypothermia: warm room, warm fluids, warm blankets.
All the circumstances that can lead to death soon.
- changes in the internal milieu homeostasis (acidosis-alkalo-sis, abnormal electrolyte levels)
- malfunctioning organs (heart, lungs, kidneys, liver, brain, sal. Digestibility)
REDUCTION OF CONSCIOUSNESS (non-physiological)
- VITAL SIGN:
R: abnormal – apneu
N: Bradi / Takikardia- Arrhythmias
T: Hypotension / Hypertension
t: Hypothermia / hyperthermia
- HYPOXIA SIGN :
Pale, cyanotic, pO2 <50 mmHg
- SIGNS OF SHOCK :
Reduction of conscioussness, Pale, Hypotension, akral COLD, tachycardia, Less urine
- INTERFERENCE homeostasis
Acidosis, alkalosis, Hipo / hyper: K, Na, Cl, Ca, Mg, PO4, glucose, Hiperuremik, Ketone object
Overdose various drug toxicity , LIQUOR etc.
- FAIL FUNCTION ORGAN
(ONE OR MULTIPLE)
- FAILED BRAIN
Coma, no breath, no cranial nerve reflexes
- HEART FAILURE
Decomp. Cardiac, Shock.
- LUNG & BREATH FAIL
Reduction of conscioussness, Breathing disorder, cyanotic, Hypoxia, Hipo / hypercarbia
- HEPATIC FAILURE
Odem anasarca, hipoalbumin, jaundice, various interference metabolism.
- GASTROINTESTINAL FAIL
No pasage digestive absorption or food
- KIDNEY FAILURE
Urine polyuria, oliguria, anuria, odem anasarca, change in level electrolyte, urea and creatinine