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Hi guys. Sorry for the delay. Are you guys able to hear me out? Can you message in the chat box if you are able to hear me? Can you help me? Yeah. Ok. Yeah, that's fine then does it start? Hi. My name is Fahad Husan. And uh, today we'll be discussing about acute trauma assessment, basically primary and secondary surveys. It's not a detailed ATLS, but, uh, we'll go through just uh, an overview of acute trauma and uh assessment and how to do the primary and secondary surveys and what are the things to look out for and what are the things to keep an eye during the survey? So, uh, we'll start with the primary survey and, yeah. Uh, are you able to see my screen moving? Changing the slides? Yeah. Ok. Yeah. So, uh, with the primary survey in acute trauma, usually we hear about ABCDE and in here we do add AC four A as well or with a, uh to look for any catastrophic hemorrhage, maybe, uh some acutely bleeding, uh vessel or some a huge laceration which is actively bleeding and could, uh pose a threat uh to the life of a person who would have to immediately put some pressure with some gauzes and stop it, but that we have to focus on the airway along with the stabilizing the c spine. So for the airway, obviously, we'll have to see if a person is talking or not. The first step is to see if the person is talking to you. The airway is patent. If they are not talking to you, you could uh check for uh if they're semiconscious or conscious. So you could uh always uh check for maybe some gurgling sounds or uh just open their mouth and see if there's any blood, any vomiting, any other obstruction, maybe some foreign body, uh maybe some broken tooth or some other thing which is blocking the airway. Sometimes the tongue has fallen back back which can block the airway. So all these things that we need to consider while uh checking the airway of a person. Once we have made sure that airway is better, then we can move to breathing. But if it isn't, there's a problem, we need to clear that if you've got a broken tooth, there, any secretions, maybe some vomiting, some blood, we need to uh apply the suction and get and get them out of there to clear the airway. And if we are not confident the person is not able to maintain the airway, we need to move to the options of maybe nasopharyngeal airway or oropharyngeal airway. Uh along with some chin lift and jaw maneuvers. And if still, we are not able to maintain, we could uh contact the anesthetist and uh uh consider the options of laryngeal mask airway or the endotracheal tube as well. So once we're done with the airway, we flared it and we very confident that we can maintain it along with it. We have to focus on the C spine. That is a major thing to consider during uh the trauma injuries. So usually when the patients come in after some sort of trauma injury, uh we have to protect the c spine in A&E and the usual way to protect it is the cervical collar. And uh usually everybody is not uh familiar with the technique to apply the cervical collar or they're not trained to. So a crude method applied to is to, to uh uh put a couple of uh hard supports just uh uh besides their neck, could be some sandbags or uh if you uh see any, some uh hard blocks there just to immobilize the c spine movement. Uh And uh, until we are sure that there's no injury in the spine or we are able to manage it with the collar until then we can just immobilize the head with a couple of blocks and maybe taking the, the head just to keep it immobilized. And once, uh we are sure that we've uh maintain the airway, we are sure with the catastrophic hemorrhage and we uh protected the spine, then we'll move on to the breathing for the breathing part. As you're familiar would be focusing on the respiratory rate. Is the a person able to breathe normally if they are, what's the respiratory rate? And if it's normal, what are his saturations and do look uh look at the apparent injuries on the chest and do a quick respiratory examination to look for any uh pneumothorax, hemothorax or any respiratory distress signs. Uh And if there are, we have to move uh accordingly and to manage them. If there's drop in saturations, we have the oxygen. And uh if there's other things, pneumothorax, hemothorax, we'll be discussing them shortly how to go along with their management. And once we have uh we're done with the breathing part, then we go on to the circulation part in the circulation part. We assess uh the BP of the person, the pulses of the p person. First of all, we assess the uh the carotid pulse if you are able to feel that we can also check the peripheral pulses as well, just to make sure that uh we're able to uh get a good peripheral pulses as well and then assess the BP. Heart rate is the main thing in the circulation to assess. Usually, it gives us an idea that how are we doing with the circulatory status? If the heart rate is above 100 120 we could be suspecting some sort of bleeding somewhere. Uh So which is a good or a initial indicator of a person may be heading towards the shock. So it would give us heads up to maintain a person's uh circulatory status, maybe get some good fluids and look for the site of bleeding and try to stop it. And with the circulation also involves the uh fluid balance as well just to pass the catheter and uh assess the urine output as well as the person that gives us an indication how they are doing in uh respect of the circulation. And uh we could do an ECG as well just to check the status of the heart. So once we are done with all these tests and we are sure that ok, the circulation is good or if there's anything and we have corrected them, then we can move on to the disability part D part. And this, the first thing is to check for uh ap visual status. If the person is alert or are responsive to the voice or the pain or they are still uh unconscious or confused, approved method to assess the gcs of the conscious status of the patient. So if um with that, we would also assess their pupillary response, quickly flashing lights in their eyes and they would be checking their uh capillary glucose as well alongside their temperature. You see that uh these things are all right. And once we're done with the, the part and uh we move on towards the E so, e uh stands for the exposure or everything else and will expose the them from head to toe and examine everything. So in uh essentially exposure or E part is overlapped with the secondary survey and sometimes it includes the secondary survey within itself just to move on to and uh the secondary survey and assess all the other things which are not part of the primary survey. And so once we're done with the primary service, then we'll move on to the secondary service, which is the main part of our presentation. So for the secondary survey, we usually have three major parts, take a quick history. The second one is to a head to toe examination and the third one is to rule out the what we call it, uh lethal six or the hidden six. These are the 612 condition. We just need to uh keep in our mind by doing the primary and secondary surveys. So we'll go down quickly one by one. So yeah, firstly taking a history. So while taking a history, we use a Pneumonic very, very useful Pneumonic. Uh the pi with a, we have to check the allergy status. Obviously, we're gonna give them some drugs and uh stuff to maintain them. So we do have to know that if there's any allergies uh to the person. And the then the next part is um, medication. Are they taking any medication regular, maybe, uh we need to stop that or maybe they are on blood thinners or stuff. So we just need to take a quick uh scan of their uh medical chart or maybe if there's a relative around just to ask about the medication. And then the next step is that talking about previous medical history? The similar thing with the medical history, maybe they've got some condition that could be worse. I know we need, which might need urgent attention along with our service as well. So we might as well ask about those medical conditions and then about the last meal, when was the last time they had any, had anything to eat or drink? And the last thing is then the event history that if they've had a trauma, how did this happen? What wa wa was it an high energy trauma or a low energy or if they just fell down? How much was the height? What was the mechanism of injury or was it an illness? And maybe there was some medical condition behind the fall or having this accident? So we need to just uh go through the events of injury just to make sense or make sure that there's nothing else going on in parallel or uh just for ourselves to make a better picture and uh plan our management ahead and once we're done with a quick history, we'll be moving on to the comprehensive uh, head to toe examination. So usually in secondary survey, we start from head, move on towards the toe. So with the head and neck examination would be assessing for any signs of trauma, including any bruises. If they've got any abrasions or lacerations around the head and neck region. Obviously, we'll be looking at the whole body for these things, but we will be starting from the head and neck of any visible deformities, any swelling or bleeding, But that would have to physically palpate as well, starting from the head, forehead and then uh they draw uh perorbital regions, nasal bridge cheeks and then go move on to the neck and then palpate the whole cervical spine as well, which we secured earlier just to make sure that the person hasn't got any injuries. And once we show that, ok, they haven't got any injuries to the spine and they palpated them for any tenderness. We could ask them to uh you know, show us the movements that every joint would have to ask them to give us the range of movement. So every joint, uh we'll have to assess that for the neck. We could ask them to flex it, extend it and lateral flexion as well. So once we have, we have, we made sure that there's no injuries to head and neck, then we'll move on to the chest and do a full chest examination. Uh Similarly, just uh looking at the chest for any signs of uh again, for any bruising, swelling or any deformities, any problem with the breathing and quickly palpating for any tenderness along along the ribs or uh then uh if there's no tenderness, we have to auscultate them as well. Uh just to rule out the pneumothorax and hemothorax. If there's nothing in chest, then we'll move on to the abdominal examination. Similarly, the inspection for any visible deformities, any visible bruising, any signs of hemorrhages or maybe some swelling, then we'll move on to the palpation of would be palpating for any tenderness, rigidity anywhere or any signs of internal bleeding. We could see some hemorrhages around certain areas of the abdomen, uh maybe periumbilical or maybe right hypochondria or left hypochondrial or maybe in the flank. So we, we would have to palpate for the or bones and then the uh liver spleen kidneys in the flanks and then bladder as well. So after palpating these regions, we've made sure. Ok, if there's any injury in the abdomen, do we need to get any investigations or do we need to just uh move on to the pelvis? Same thing will have to do with the pelvis, assess for any stability, uh assess for the stability and uh any signs of fracture. Usually, you can see the bruising and uh lacerations, swelling around the pelvis as well. You have to palpate all the pelvic bones, eyelid crusts, uh coming immediately as well, uh doing uh palpating the pelvic bones as well. And then going behind and uh pelvi in the sacrum to see if there's any uh fractures or tenderness. Just to see that if there's anything of concern, uh uh we can move on to the further imaging or maybe if there's an unstable pelvis and you can feel uh the instability with your just pelvis and the bone moving around, you could give them a pelvic binder for a temporary stabilization and go for the imaging and then assess them in detail. And after assessing the pelvis, you could uh ask the person to sit up and uh check their extremities and back as well. So for the extremities, you could ask them to lift them up, lift the, lift the arms up in the air and then individually ask them to move their joints, the sho shoulder joints for rotational movements, flexion extension, abduction adduction. Similarly with the wrist and elbows and the fingers as well. Every joint you have to ask them to move and then physically palpate for all, all over the joints and the long bones as well. Just to make sure that there's not any tenderness, any bruising or any deformities, there's any suspicion of any injuries you could ask for the further investigation or x-rays simi similar things you have to do with the lower limbs as well. And once you are uh uh done with assessing any injuries, you do have to palpate the peripheral puls in your upper limbs and lower limbs as well just to make sure that they are neurovascularly intact and there's nothing going inside, uh, uh in the limbs. And once you're done with it, ask them to sit up and make sure that you palpate the whole back and the spine as well. Starting from above cervical, thoracic lumbar and sacral spine to look for any injuries. If there's any suspicion of any tenderness, any bruising or any pro pain around any region, you could ask for further x-rays and investigation to make sure that there's not any fractures. So moving on, these are some sort of uh injuries we could uh see for in the eyes. This is maybe uh uh an orbital fracture or maybe some soft tissue injuries around the eyes. This would warrant us to go for the X rays. This is a specific battle sign just behind the air lobe. This is a sign of uh base of skull fracture. You could also see if there's any bleeding through the ears and through the nose or maybe some uh um CSF just clear fluid coming through the nose that would also give you a hint of all the base of skull fracture. So you'll be thinking about getting a CT head as well. These are some abdominal images of the bruising. You could uh see all kinds of bruising in the abdomen just by looking at it. You could have an idea, maybe sometimes a person is uh wearing a seatbelt and they could have a sign of bruising along that line. If they've got any splenic or liver injury, they could have bruising at the those specific sites like right or left hypochondria. And similarly, with the bladder injuries, the bruising could be and uh hypogastric region as well. So you'd have to specifically look at, look and palpate the regions for specific things uh and the bruising in those regions. So, moving on once we've assessed them, uh this is usually sums up the secondary survey, but obviously, we'll have to just quickly go through the conditions. Uh We have to keep in mind doing the ABCDE and then the secondary survey. Uh So what do we call the lethal six are airway obstruction, tension, pneumothorax, open pneumothorax and a massive p hex cardiac temp. And these are the six thing uh which could prove potentially fatal on spot. So we should uh keep them at the top priority while doing the A two E assessment. As we already discussed about the airway assessment, we have to uh check for the signs of obstruction, maybe some stridor sound or inability to speak. There could be some foreign body trauma or after trauma, maybe some uh blood vomiting, loose toes or maybe tongue falling back, blocking the airway. Once it was the, when you see any blocking, you have to clear it, using the appropriate technique as we discussed already, maybe had uh T man along with that. If not, then using the nasopharyngeal or oropharyngeal airways or laryngeal mask airways. If we are still unsuccessful, we have to consider uh uh the other things maybe talk to the anesthetist about uh doing the intubation and maintaining the airway going forward. So, uh the other thing uh about uh Lasix is the tension pneumothorax. This is the accumulation of uh air in the pleural space which could be causing pressure on the lungs and not letting it expand. And it could also, if it's a massive pneumothorax, it could be potentially compressing the heart as well. Usual signs are respiratory distress, dyspnea, tachypnea. And if it's a mess pneumothorax and having an effect on the circulation, you could have a patient with a low BP hypertension as well. And while, while you are assessing, you could uh uh while you're uh auscultating the test, you, you won't have any breath sounds on the affected side and there would be tracheal deviation towards the opposite side because that all the pressure on the lungs will be pushing the trachea towards the other side. And uh the management for attention pneumothorax is the immediate needle decompression, which you would be doing in the second intercostal space in the midclavicular line. And then the definitive management would be the chest tube and the axilla and safety triangle in the fifth intercostal space. And yeah, this is the X ray for pneumothorax. If you, you can see that this is the black shadow and vascular marking. And this is the lung shadow which has been compressed with all the air leaking from the lung and accumulating here and just compressing it and causing all the respiratory symptoms. So, uh this is a condition we should have in mind while assessing the airway. The other one is another thing, pneumothorax, another variety of pneumothorax, which is uh which happens in the open chest injury, maybe there's a wound, maybe a gunshot or a stabbing wound out from outside. And while patient is breathing, that uh could suck air from outside and it could start accumulating just like this around the lungs and could compress the lungs. Uh And during the assessment, there would be a visible wound and then obviously, the person would be presenting with the signs of respiratory distress. And for the management of this urgently, we could apply uh an occlusive dressing, we call it a three way dressing and this is what uh we apply. We close it on the three third, three side with the tape and we leave one side open. So once a patient is breathing in, this uh dressing would get sucked in with the negative pressure and would occlude that opening and would prevent the outside air to go in. And once they are expiring air from inside would get pushed out through this opening. We have left open. So this could potentially give us that window to get the appropriate team involved and uh do the definitive management of maybe just maybe thoracotomy depending on the assessment. Uh So yeah, the next thing would be a massive hemato is one of the other conditions if they've uh had a massive injury and maybe some uh lung trauma or maybe some vessel injury within the chest cavity with good pleural cavity. And uh the blood starts accumulating there. Uh It will present with the signs of hypovolemic shock with tachycardia hypertension. You would have absent or decreased breath, sound at the level where the blood is accumulating. You would also see outside chest wheezing and trauma. The management for this would be immediate chest tube insertion for the drainage of blood. And in parallel to that, we have, we do have to resuscitate the patient with fluids and blood transfusions and contact the cardiothoracic surgeons for the definitive management. Moving on with the, the last thing with the little six is cardic tamponade, which is the compression of heart due to accumulation of blood. Once they uh during the injury, if they've ruptured or maybe there's a leakage in the muscular layer of the heart and the blood could leak from the cardiac cavities into the pericardium parallel to the heart. And it would put pressure on the heart and uh prevent it from expanding with full strength. And then the contraction would be uh less and less powerful and usually it presents with the classic triad with the uh hypotension muffle heart. So heart sounds on auscultation and jugular venous dis uh distension as well. You could see the jugular veins uh visibly while you're uh assessing the patient. And there would be pulsus paradoxus, although it's difficult to assess, but it is one of the signs which is the decreased systolic BP during inspiration. So, uh usually the best try it is the giveaway for uh cardiac tampon art. And you do have to, they look uh on the lookout for that. If you've uh we are suspecting that you could immediately do an echo or move on to the pericardiocentesis, which is like a thoracocentesis. When we release the tension, pneumothorax, needle decompression, it's a decompression of the heart, but we have to suck the a aspirate that fluid collecting around the myocardium within that pericardial region. And the definitive treatment would be pericardiectomy, which would be the cardiothoracic surgeon. This is an approximate picture of uh pericardial and this is we usually go to uh in between the uh rib cage and ZZ process at a 30 angle, aiming at the left mid clavicle and puncture the heart for the pericard and disease. And the other thing for uh uh the lethal fix is flail chest, fla chest is when the uh the patient has got multiple reflexes on the same side. These rib fractures could cause up uh segment of the chest to move paradoxically, which is the opposite of the normal aspiration moved during inward during the inspiration and outward during the expiration and you would have pain and tenderness over the fracture legs. And uh this paradoxical pattern is because uh the ribs are moving, uh the they have been fractured and they're moving inward and outward. And also the pain once the patient tries to inspire, they have sudden pain and then they suddenly won't inspire and exhale. Uh And the major management for this is the pain management with the uh oral and IV pain or maybe some nerve blocks or some local patches as well. Usually they are enough. But if the patient is not able to maintain his normal saturation of breathing with pain management, then we might have to put them on mechanical ventilation until that uh pain has subsided and we have stabilized them. Uh The other six things to keep in your mind while doing the primary and secondary survey are these things we call them the hidden six because they don't usually give you sudden or subtle hints which the other six condition give you and you can pick them up. But these are the things which are, which are usually ignored or are kept hidden are present late until it's uh too late or maybe the patient is too unstable. So we do have uh have to keep them in mind and be looking for them actively during our primary and secondary survey. So they are thoracic aortic disruption, tracheobronchial disruption, myocardial contusion, diaphragmatic rupture, esophageal disruption and primary confusion we quickly go through them. The first one is uh thoracic aortic disruption. Usually aorta is teared due to a pressure injury, maybe high energy trauma. And once that is tiered, usually the patient presents with instability, low BP. And then once you assess the BP, you'd have two different readings between two different arms and uh on the chest X ray, you would see the Biden mienum and uh you'd also see the signs of shock along with that. This is the X ray showing wider venous. Usually you don't see this shadow as well. You can see that this shadow is from the disruption of uh aorta, maybe some blood accumulating in that space. Once you suspect that uh you have to immediately stabilize the patient with some fluids and aggressive management along with keeping their BP in check. And you have to consult the vascular surgery for definitive management because it's a condition which could just tell the patient within minutes. And uh yeah, moving on with the trach bronchial disruption. It is also a dis disruption in the chest at the same level. If they've got a chest injury, high energy trauma or maybe some penetrating injury to the trachea or bronchi. Usually, patient would present with the signs of respiratory distress, stridor and there would be signs of subcutaneous emphysema as well. You could uh see it during your uh palpation of the chest as well. But the definitive way to assess it to do the CT scan of the chest. And once, uh, you've, uh, picked it up, you have to maintain the airway with the intubation. If it's, uh, at a lower level, maybe you'd have to contact, uh, the ent for uh a surgical airway or tracheostomy possibly and doing a repair for this injury as well. Uh The next one is myocardial contusion. A as we've discussed earlier that there is, uh, there was a peri uh pericardial effusion which was giving uh as a cardic tampon. So it's a less severe type of that, that we've had a chest injury, but it has uh given the myocardium a contusion. Now the leakage uh and usually it's a bruising after a blunt chest trauma, patient could present with chest pain, some arrhythmias or cardiac dysfunction. Um It won't be as uh acute or as dangerous as the cardi tampon heart. But obviously, if there's a contusion to the myocardium patient would have some ecg changes maybe or later on could have uh signs of heart failure. So we do have to keep in mind and uh keep patient observing and do the cardiac monitoring and serial serial ECGS just to make sure that uh patient doesn't deteriorate and the treatment would be according to the status of the patient may and we'll have to treat the symptoms and support and the fluid therapy. Next one is uh diaphragmatic rupture. It's also it could be due to the up pressure trauma to your abdominal wall or a thoracic wall. And once the there is a tear in the diaphragm, what would happen is your uh abdominal organs could just herniate through that opening or tear into your chest cavity. And which was would cause the person to have a respiratory distress, abdominal pain. And the, the most uh convincing sign would be some bowel sounds in the chest because of maybe stomach or in the sts in the chest cavity. You could uh have uh more diagnosis with the imaging like chest X ray and CT scan to confirm the diagnosis and the intervention would be the surgical repair of diaphragm. And in the meanwhile, you could uh uh maintain the oxygen and respiration of the person until they would have the definitive repair of maybe the injured organs or the diaphragm. And the next one is esophageal rupture. Uh uh The mechanism is also the same, maybe some uh uh trauma to the chest, some foreign foreign body injection or maybe sometime a patient uh inject some acid or uh an alkali poisoning. All these could cause esophageal disruption. Signs of esophageal disruption are sepsis, presenting with metasis, fever, chest pain, difficulty swallowing, dis if there's any uh a disruption, it could be similar to uh the aortic disruption. You would see me as well. If there's leaking of any content from the esophagus, you would see the X ray appearance similar to previous one. We just saw uh to diagnose, we could do a CT scan with some oral contrast and you'd see the leakage of that contrast into the chest and mid and you can diagnose uh and confirm the diagnosis with that. Obviously, for the management, you'd have to keep the patient the mouth. Uh from that moment on, you could have to put them on uh temporarily for uh TPN and then maybe some later on some uh long term no enteral feeding tubes. And that would need a surgical involvement for the repair of esophagus as well as the maintenance of uh they're treating as well. And the last uh condition to keep an eye during your uh primary and secondary service would be a pulmonary contusion, which is a bruising or any injury to your lung tissue would usually be caused by uh blunt trauma to your chest. Again, the signs would be respiratory distress, chest pain, or maybe some hemoptysis. If there's any bleeding within uh the lungs, uh to confirm again, you'd have to get the chest x rays and the CT scan would give you a definitive diagnosis. The interventions would be to give the oxygen therapy, pain management and mo monitor the patient for worsening signs. Maybe to uh just to look for the signs of pneumonia or acute respiratory distress. If the patient seems to be going, then we will need to be proactive and prevent the prevent those infections. So, in summary, yeah, we have to start our primary and secondary survey with ac catastrophic hemorrhage. Then go through ABCD with, along with A, we have to maintain the cervical spine, go through B CDE and then start from head to toe. All the, you have to expose all the body and inspect and palpate for any tenderness, injuries or any signs of trauma, bleeding or bruising, starting from head to neck, going all the way to the extremities. And we do have to keep nasal six and the hidden six in our mind so that we don't miss anything, uh which could cause uh any damage or which could uh cause our patient to deteriorate later on. Uh So yeah, this is it from our session today if uh anyone's got any questions. Uh Yeah. So thank you all for attending the session. Hopefully, you would have enjoyed it. And uh if we haven't covered anything, you could uh leave your comments in the feedback link which Arnab has sent you guys in the groups as well. And uh, he's been that link in the chat section of this session as well. Uh Do give us the feedback to improve other sessions. Thank you, everyone. See you in the next session.