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Hello, everyone. It's great to have you join us today. Today is one of three. San Joy has actually committed to three talks for us. This is his first and this is gonna be on trauma. What's gonna happen is he's gonna give his talk. There's, er, he's gonna ask a couple of questions, er, in his talk where he'll want you to interact in the chat and give some answers and also all your questions as you know, go in the chat and he'll answer those at the end. Ok. As always feedback form, uh will be sent out once you've completed that, then your attendance certificate will be on your medal account. So without further ado I'm gonna hand you over to J Joy. All right. Hello. Good afternoon. Um, and a good whatever morning, evening night, wherever you are in the world, it's absolutely exciting to provide a talk on a, a subject very close to my heart as an emer medicine consultant. Um, you know, about trauma, um, trauma is quite important. It still happens globally. Uh Just to introduce myself as you said, I'm San Joy Barach. Uh You've seen my qualifications on the slide I'm a consultant, the Mercy Medicine, but also I'm a Director of Assessment for Institute of Medicine in Bolton University in the northwest of England, uh which, which is going to develop a med school now. Um So what we're gonna do is we got an hour to talk about trauma assessment and management. Now, um the the object, the learning objectives for this session as was laid out to you before you signed up was uh talking about assessment and intervention in trauma, uh safe ex education. Now, the only thing to say is that extrication in uni United Kingdom is carried out by a combination of fire rescue people. We don't get involved as clinicians. So I'm not going to talk about exec education. Um, the other thing was a fracture management. Now, I thought fracture in itself is a topic in itself and I'm going to speak to sue whether we can put up a separate block of teaching for fracture. Er, so I'm not going to, I'm going to touch on it but not go, er, details. I'm going to talk about the burns classification and initial care within the time available and bit of airway management as part of the burns. So, what are the objectives for today? What I, what I said is what I thought we'll do is we'll, we'll talk about the types of trauma, trauma is injury. Yeah. Er, now if we know the types of trauma, what are the causes of trauma. What, what causes there? Hello. All for those who are joining? Um, we'll have, we'll have the questions at the end, but you can put your questions in the chat box if you want and we'll address it at the end. Once we talk about the causes of trauma, then how do we initially assess and resuscitate? Now, this is major trauma. Ok. Uh, a minor trauma which we, which we'll talk about in a minute. Uh, don't need initial assessment, it needs assessment. It doesn't need resuscitation, but major trauma does need resuscitation. Ok. Once you've stabilize the patient through assessment and resuscitation, then we talk about secondary survey and I'll tell you what that means and we'll finish off by talking a bit about burn injury. We can't talk in details about burns, but um we'll, we'll touch the essential bits that's on the objective. OK. So in your chat box, if you can put in your opinion, what do you think the different types of trauma? How can you type, you know, classify trauma or what are the different types of trauma? If some, if if you could put in the chat box, nothing's coming through anyone. Obviously, I can't wait a long time. Burn fractures. Ok. So those are the causes of trauma. Penetrating, excellent ali uh Alex penetrating ally, open trauma, closed trauma, I mean, traumatic and nontraumatic, I think we'll move on. Brilliant. Excellent. Ok. So if you look at the pictures er, so basically we have a maj, we can have major trauma and minor trauma. So, major trauma. If you look at the, if you look at my cursor, er, it's a massive road traffic accident, we got paramedics, we got fire people, it's on the roadside. Er, major trauma is a trauma that affects, er, multiple anatomical areas. So head and uh, you know, massive head injury or serious chest injury, serious abdominal injury or a combination or more than one long bone fractures, like if a combination of femur and, and humerus, for instance, will cause a major trauma. A pelvic fracture is a major trauma. So, minor trauma are, if you look at where my cursor is a little cut to the toe, a cut of the finger or a sprain to the limb, that's, that's um that's minor trauma and also somebody's putting chemical radiation. Yes, those, those can result in it can result in both major and minor. So if it's a um you know, like a, a AAA nuclear plant that's exploded, that's a major trauma. Um, if a chemical has fallen into eye, that's a minor trauma. Ok. Now, within that, every trauma can be classified under these two categories. One a based on the mechanism. This is, this is based on the mechanism. You can get blunt force trauma where the trauma is caused by a blunt object. Ok. Now, uh, and, and you can see some examples on this slide. A a punch, a hit by a blunt object like a hammer or a baseball batt or even the road traffic accident, the chest hits the dashboard, er, or a fall where you land on the, on the, on the surface. And the other classification is penetrating. Now, globally, uh penetrating are of two types. Either you can get a stab injury and you can see this uh multiple stabs, you know, this, this, this, this person is still alive, I hope um multiple stab injuries and the other one is gunshot injuries. Now, depending where you are in the world. Um A a and, and you know, like in UK, we have much more uh blunt trauma and some stab injuries. Whereas if you go to the United States of America, there's a lot of gunshots injuries as well. Um If you, if you're involved, I, you know, if you look at globally the, the disaster zones, the wars and the conflicts there, you get a combination of blunt and penetrating. So I, I if you have a bomb blast, um then you have a blunt trauma uh by hitting something and you can get a shrapnel uh causing penetrating trauma. So you get a combination. Ok? Now, so be those being the mechanism anyone can put in, I think some of you has have put in what are the causes? What causes these major minor trauma or blunter penetrating? What, what are the causes? Can you think of uh in your chat box. Three of you burns. Ok. That's a cause you can get burns injury, you can get cold injury as well. Don't forget accidents. Yes. Brilliant. Alex Mucy accidents. Hussein crush injuries. Yeah. Ok. Brilliant. Uh, again accidents, er, road traffic accident, Hager um, burn frost bites. Yeah, cold injury. Ok. Thank you very much lightning. RT A and, and so if you move on, so this is, this is in the developing countries, in the developing countries, the one of the major causes of, uh, trauma is conflict. And if you look at here this is a war area. Currently, there's a war going on. If you remember in America, you know, many years ago there was a twin tower, uh, you know, um, a terrorist fight, airplane goes and hits the Twin Towers that kind of conflict in Afghanistan that can cause massive major trauma. Ok. As you can see about 40% then the next common is road traffic accidents, whether you call it road traffic collision. If you look at the top right, er, picture, there's a, you and it depends on the force, the vehicle. Um, you know how the, the impact has happened. Uh, now it can be two vehicles, it can be a vehicle and a person, uh, like a pedestrian or even person on a motorbike or in a push bike. So road traffic accidents and a push bike hitting a, a parked vehicle or a moving vehicle. Er, whatever. So the next common is road traffic accident. And again, you tend to have er, major trauma but you can get minor trauma as well depending on all those factors. The next common, about 13% is falls. Now falls again can be result in major trauma, depending on the height. So if it's a height, more than two m or twice your own height, you fall freely. Now be it from a, a scaffolding or a cliff or a mountain or on a ladder that can cause major trauma. But again, if you look at this picture where the girl has just slipped and er, caught the knee, um, that can cause a minor so falls can cause both types. Yeah. And the last bit, as I said, burns is the next common. About 8%. Now, burns again can be a major burn. So if somebody is burned, uh you know, a flame burn can be chemical burn, um, can be cold burn again, it can be major. If you look at this, somebody caught in this fire will have a major burn but somebody who's put the hand underneath very suddenly, awkwardly, unexpectedly, hot water, you get a scald, er, that's a minor burn. Ok. Again, so all of these causes can cause major and minor burns just to remember. Now, what does, so, so when you have these causes causing trauma, what do they result in? They result in either soft tissue injuries where? So you know what soft tissues are, the skin, the muscles, the ligaments and the subcutaneous fat. That's all the body is made of. If you remember from skin to bones, that's all the body is made of. So all those in structures that get injured, that's the commonest. They result in soft tissue injuries about more than 50%. Yeah. Then you can get abrasion. Abrasion is what we call grace where just a superficial layer of the skin gets injured. Yeah. And the next common is fractures and fractures. As somebody said in the chart box, uh or broken bones, it can be anywhere from head to toe. Um It can be a major fracture as I said, two long bones um or it can be a minor fracture like a fracture of the phalanx of the finger. So again, all of them can be major or minors. Ok? Now I'm, I'm going to concentrate now on major trauma. We've looked at the causes, we've looked at the mechanism. So what are you going to, how are you going to? So if you face eed or on a roadside, if you're going prehospital care, how are you going to initially assess and resuscitate? Uh what are the principles and methods that we use any idea? Bit on the chad box. Thanks for all that. Uh Putting the answers. Brilliant ABC. Brilliant, brilliant, more, fuck, fuck again, Ajmi Osama ABC. I think, I think we know that we uh if you ask me Ahmed. Yeah. Call for help. Excellent. A TLS. OK. So A TLS talks about um stop bleeding. Brilliant. OK. I I'll move on. Thank you so much. Thank you. Now, I, at my workplace in Ed, I sing. Uh I not sing. Sorry, I eat sleep and I, I think ABC D all the time. OK. Now, methodology uh before I come to ABC, what's the methodology of managing a major trauma? So some, what, what you do is a primary survey, then you resuscitate the primary servant resuscitation has to happen simultaneously. OK. So it's managed as a team if you're in a department in an er, or D emergency department as soon as a major trauma comes or even before the trauma arrives, er, a call is put out based on the information we receive from the ambulance and we have a trauma team in the hospital, multispecialty trauma team of experienced doctors who should have done the A TLS course and all of you who are interested in trauma. A TLS course is over the world. Now running I direct and instruct on a TLS course. So I would promote that. Go and do your A TLS course. Now, when they come, the team comes, there's a team leader and some other role players, they will start doing the primary serv and resuscitation. OK? And, and the doctors are roles are allocated once you've done that and you've identified and treated the primary serve injuries, then you do reassessment because what some, what you've treated can become worse so constantly you've got to reassess. Um, and then like, if you've done a procedure you've got to reassess is the procedure working. Once you've done that, then we do what's called secondary survey, which I'll come to that in a minute. Somebody's put up Xena. Um, and then as part of the secondary survey, you're going to decide, uh, the definitive care. Now, definite care could be patient, going to intensive care, could be theaters or could be a transfer to what we call in this day and age, we call it trauma center. Now, if you are in a trauma center, fine, if you're not in a trauma center in UK, there are uh a non trauma center, it's called a trauma unit, then you send the patient package them up, send them to trauma center. OK. So that's the methodology if you expand the primary survey. Now, this is the principle which all of you have been saying the first five letters of the alphabet, it's easy to remember. OK. And it's spoken, this language is common language spoken around the world. So if, if, if all of us, whoever goes to manage a major trauma, they will be speaking this language. OK? It's a common language. Uh And I'm going to expand that now using that A two E methodology. If you look at the bottom what I put in, it's an art form. To me, A RT is you assess each component, you recognize a problem in that component and you treat it right away. You cannot wait. So if there is an airway obstruction, you cannot go to B now because it's a team. If you're one person, you can only do what we call a vertical management. You do a sort it out, go to B sort it out. If you're a team, you do what's called a horizontal management. So a group manages a, a group manages B group manages C et cetera. Now, you, if you, if you find a problem, airway obstruction, you've got to open it, you've got to maintain it open. You cannot do, oh, I'll, I'll do it later and you seek help. Absolutely. Yeah. Uh and, and so that, and that's what you need. And if you need something you need, you, you tell the nurse can I have this? Now? I can't wait. OK. So that's primary service. We're gonna expand it a bit more brilliant. Now, in a TLS, they have borrowed it from the battlefield surgery. Basically, the principles have come from the, the battlefield front. Um The, the field hospital in Caba in Afghanistan where they use the methodology, they call C ABC D those who have heard about it. So see what has been, what was thought before that airway kills. The reason ABC D has come about is it was thought that airway kills the patient before breathing kills, before circulation kills and disability kills. But now it's been thought that if somebody has a catastrophic hemorrhage, blood is pouring out. And some examples like a AAA partial amputation, a complete amputation of a limb or a blood pouring out from a wound. If you don't stop that hemorrhage, the patient will die from blood loss, forget airway. So hence, the C ABC principle has come where the first thing is you look for catastrophic hemorrhage and there are means and ways where you can temporarily control it pending definitive uh they need definitive control by surgery. OK. I'll come to that in a minute. Once you've done that, then you assess the airway now airway because airway has got a neck c spine, it comes along with c spine, immobilization. So in a major trauma, you consider that the neck is injured, full stop and you go, you protect the neck, then go looking for what do I do to clear the neck and you do by clinic clinically radiologically, uh and neurologically, but that's later. Ok. That's not in the primary serv the primary survey. All you do is immobilize. Now, any any thoughts a quick chat, maybe one or two. How would immobilize the C spine? How do you immobilize the C spine? Ok. Mucy says, Mils, absolutely neck brace. Alex says so yes, Mils is manual in line immobilization where you put your hands on either side of the neck and you move the neck as one piece, ok? Now, if you can't stay there for all over or all the time. So somebody is putting collar blocks and bags and straps. Excellent. So there are three components. You put a well fitted hard collar, you put blocks on either side of the neck and you strap over the forehead and under the chin. Now, in, in some places where you don't have blocks, you can use um you know, like a fluid bags wrapped in a towel and, and you can, you can make it up. So and, and so you assess, you manage the airway and c spine, immobilize, just leave it immobilized at the moment. Now, you might have to take it out, take those contraptions off to manage airway. For instance, in that situation, you go back to mills. Yeah, once you sorted that out, then breathing and so breathing and ventilation go together. What I'm trying to say is a patent airway doesn't guarantee a normal breathing. Now, breathing means we are all breathing right now. You are taking 21% oxygen that 21% has to go through a patent airway into the lungs and then ventilate. Now, ventilation happens at the gas exchange level. Yeah. Now you can be breathing ok. But if the chest mechanics is impaired like multiple rib fractures or diaphragm is injured or intercostal muscles are injured, then the breathing will be affected and then ventilation may not happen or let's say the chest wall is ok, but the lung is injured and hence ventilation, the gas exchange doesn't happen then also um that needs to be sorted. So breathing and ventilation goes hand in hand. So what you need is high flow oxygen and the high flow means a mask with a reservoir bag connected to wall oxygen of 15 liters per minute. And that's what you start off with. Yeah, and you got to make sure the mask is missing a couple of observations. You need to monitor constantly. From this point of view is the respiratory rate because uh if they are in shock, tachy is important or they are uh the respiratory center is depressed, then then the respiratory will go down and the SP two which is oxygen concentration in the lungs. That's important. That gives you a measure of ventilation. It doesn't give you the measure, it doesn't give you uh the the assessment of gas exchange that you do through arterial blood gas, ok? Now, what we're trying to do in breathing and ventilation is trying to identify the lifethreatening chest injuries that will kill the patient right now, if you don't recognize and treat, they'll kill the patient. Ok. Now, um I'm I'm going to just ask um maybe one or two life-threatening chest injuries that you can think of and, and thanks for being interactive. Brilliant, really good. So there are six of them. You don't have to mention all 61 or two should do and I'll move on 10 pneumo thorax. Hussein. Absolutely superb. That's the first one, the top one flail chest. Ok. Thank you so much MOF mofa. I'll move on. Uh No, sorry. Hang on. Um Yeah. Ok. So, um just stay there for chex hemothorax. Brilliant. Ok. Ok. Now, once you've identified and treated it, then you move on to circulation. Now, in circulation, what you do is what you're trying to do is you identify is the patient in front of you in shock and in trauma shock means hemorrhagic shock, full stop. Ok. Now, there could be some non hemorrhagic shock causes as well. Ok. But majority of the shock cause is hemorrhage. Somebody patient is bleeding and the patient is can only bleed from the places that you can think of. They're lying in front of you. So where can they bleed from? There? There are, there's a rule called flow and four more. Now, there are five places where they can bleed from. So, flow means external hemorrhage where the blood is dripping on the flow and you and you look at is the bleeding, you look at all all over the place. The four more are three cavities and what are the three cavities? Chest, abdomen and pelvis and one more the the fourth one is long bone. So it no, no, no. There there can be external open hemorrhage or could be closed, hemorrhage, a fracture shaft of femur can bleed about two liters. A AAA shaft of humerus can bleed about a liter, that kind of thing. So what you're trying to do is you, you don't need to know the cause at this stage, identify through your heart rate and SBP um you know, and, and again, the first change that happens in a hemorrhagic shock is tachycardia provided, it's not an elderly patient. And remember this whole principle we are talking about is exactly the same, no matter what the age, what the sex is except you've got to remember the the pitfalls in a child, which we haven't got time to go through that pitfalls in a child, in an elderly, in a pregnant lady. Yeah. So common finding is tachycardia and that's when you say if they are cold and tachycardia they are in shock, you don't know the cause. It doesn't matter. You start the shock therapy or what shock the what is shock therapy? Any any any idea what is shock therapy in a trauma? Uh hemorrhagic shock? Any thoughts? OK, I'll, I'll move on. OK. Fluid resuscitation. Excellent. But before you put fluid, you need to do something you need intravenous access. Now, if you look at literature, they talk about big cannula so that lot of fluids can go through. Now, in a shock patient, you may not have vain enough to see a big cannula. So put a cannula and then fill the patient up with fluids. Um so cannula but take, before you start the fluids start, get some bloods out because you need blood grouping. Yes. Uh GVA you need blood cross match. You need full blood count or CBC. All the renal functions, kidney functions. If they have taken alcohol, uh send an alcohol level. If they are pregnant, then take a in a female patient send for pregnancy test. Um you know, if it's an abdominal trauma, send for an alas uh to rule out pancreatic injury. Once you've done that, then you start and the fluids is is crystalloid isotonic. Now remember in the past, a TLS used to recommend two liters to two wide vo cannula. They have stopped that now because they have realized that all it does, it causes problem with the clotting system in the patient because you want to, the patient's blood clot is their own best blood clot. So what you do is you do what's called hypotensive or balance resuscitation. So all you do is give small fluid challenge about 500 mils. Now, that fluid that you're giving has to be what they have to be. They have to be warm. Ok? They have to be warm, they can't be cold because hypothermia precipitates and makes the trauma worse and excellent Hussein warm, it has to be warm. So once you start the fluid, then you the, if they're in hemorrhagic shock, uh they're hypotensive, then you need bloods right. Now. Now when you send the bloods, you tell the blood back I need O negative. Now which is available. Now, some research uh has, has blood in the in the fridge. Um oh and then you need group specific because the full cross match takes about one hour. So you can't wait for that. Ok? Now, if they are bleeding, what you need is blood as soon as possible because by giving fluids, all you're doing is expanding the volume. But if they are bleeding, what you need is the oxygen carrying capacity to the vital organs, which fluid doesn't, the, the crystals doesn't. So you need, uh, and, and there's no role of colloids at this stage at all. Ok. Forget it. Um, then you start blood, the blood has to be warm and they carry oxygen to the vital organs. Ok? Once you start the, the shock therapy, then you go looking for, um, then you go, uh, then you go looking for the sites of hemorrhage and you, you saw what I said, the four sites. This is where you utilize the, the basic investigations. Maybe an ultrasound scan. The first a scan on the tummy a, a AAA scan on the chest, a pelvic uh x-ray, maybe uh to identify or a, or a lower or a, you know, a limb x-ray to identify the, the what you can do about those, those, those, those injuries. Yeah. And then you go down to disability. Now all you're doing here, you're not doing a detailed neurological assessment, you're doing a cross conscious level check using the Glasgow comscore that's gold standard. If you forget the glass of homo score, you can use what's called the AU scale. Um but it's good to memorize the gcs and you're looking at pupils, you're looking at the reaction, you're looking at the reaction. What you're telling yourself. Does the patient have an intracranial pathology that needs treating? And how can you diagnose that? You request a CT brain scan? Ok. Um Now, in this day and age in UK, certainly in trauma centers or in trauma units, what we do in major trauma is we do a whole body scan, ct scan from head to pelvis. That's what we do. We put the patient through a scanner because clinical assessment in a busy recess with multiple people can be observed ovarian. So that's so we do a quick life threatening, a two week assessment, send the patient for a scanner. OK. And then remember now, exposure happens simultaneously as the patient comes in the nurses cut the clothes. But remember if you cut the clothes, you're risking the patient for hypothermia. And you've got to keep an eye on the temperature because you don't want the patient to become hypothermic. Maybe they have, you know, if they have been in cold, they've been in rain. Um You know, it took time for ex education. So few things to remember the fluids are warm, the temperature of the room where they are should be warm um and cover them with warm clothes, warm blankets, uh et cetera. Ok. So that's a bit of detail on the ABC D going a bit more detail. So this is what you're going to do. What we need to do is under airway. You've got to give oxygen. Then if they're open, how would you know it's open, they're talking full sentences, you know, you ask John, are you OK? Um oh and and OK, they're not talking full sentences but they're making some sounds. So airway may be open. If they're not open, then you maintain the, then you open it and you know there are several methods, some basic methods, um jaw thrust, then you put some adjuncts like uh you don't put nasopharyngeal in the trauma probably oropharyngeal. But if they can't tolerate, then you might have to consider a definitive airway, especially the patients obtunded. Yeah, but you it's not enough just to put the airway, you've got to maintain it open. Yeah. And the b so some of you have mentioned um the lifethreatening, as you said, tension, pneumothorax, I can't go through in details, all of them. You need to know how to clinically, how to clinically. Yes, patient is talking ab absolutely right. How to clinically identify. There is no scope to identify these lifethreatening chest injuries by investigation. Ok. So clinical look, listen, feel cu ok. So look using the sensorium listen and then per us and then, and, and feel. Yeah. So tension pneumothorax, don't forget to feel the tricker. Uh You got to expose the chest at this point. Uh Look at the front and side, especially if there's a stab wound. Ok? And if there is a stab wound or a gunshot between in the front, in the middle, on either side of the sternum or on inside the scapula blade, then think you've got a, a cardiac trauma as well. Ok. The next one is somebody said hemothorax, I would like to qualify. It's a massive hemothorax. The massive hemothorax is where um you have about two liters of blood in one hemi Thax. Ok. The other one, the next one is open pneumothorax where you have a, an open wound caused by either penetrating or even blunt. And there's a sucking chest wound because the air is going in to the lung in the pleural space from outside because of pressure difference. And you have a pneumothorax which needs treating. Ok. Flail chest, somebody has said now flail chest is not simple refracture. You have to have multiple refractures and each rib has to be broken in more than two places to get, give you a flail segment and the flail segment doesn't participate into the, into the respiratory excursion. And that's what results in what we call paradoxical breathing. Yeah. So, um and, and, and, and usually what they have is lung contusion. They can become hypoxemic, they might need definitive airway by intubation. Ok? Uh The next, the last one is cardiac tampon. I think somebody put in there cardiac tamponade. As I said, if you got a wound, you know, blunt trauma to the to the front of the chest or penetrating injury, front and back then think of cardiac uh Tana the cardiac tamponade clinically very difficult. Yeah, the book does say talk about Bextra, I won't go through that. But what we do these days is run what we call an echo in life support. So we bring an ultrasound scan, run it through the uh through the cardiac uh probe and look for, you know, cardiac ampulla. Now once you identify, you need to treat it and usually for lifethreatening chest injuries, all you need is a cannula and a drain. Obviously, you need the other recruitment to put a chest drain. Now I have we haven't got time to go through the details, but either you do needle thoracocentesis, you need to know the anatomical landmark and you need to know have the skill now to learn the skill. Either you you watch it, you do under supervision if you've done it already brilliant or and then you start doing yourself and also chest. Now this chest drain is an open chest drain. We have to cut, make an incision uh and it's a blunt dissection and you put the drain in. Yeah, you point the drain towards the apex towards the back of the lungs. Now and you watch what's coming out if you've got a gush of blood splashing on the floor or at one go or about 202 50 mils per hour. That patient needs a thoracic surgeon. Ok? Um You can, you can reuse the blood for patient called autotransfusion. You will need blood transfusion for the patient as well. Ok? So again, pneumothorax needs chest drain, cardiac tamar needs what's called a pericardiocentesis. But it's only a temporizing method. Ok. But the patient will need eventually a cardiothoracic surgeon. But if the patient is otherwise stable, think before you stick a a pericardiocentesis needle because if there is a clot sitting on your right atrium, patient's right atrium and you dislodge the clot with the pericardiocentesis, then the patient will bleed to death. I happened with 11 of the cases. Um we managed um coming to see, I said, you know, you need cannula. Now, if, if what would you do if you can't get a cannula, there's, you can't see a vein, you can't get a peripheral venous cannula, you can try central or even quicker than central. What is it? Absolutely Hussein, fantastic, intraosseous access and it's a skill you can save a life. Yeah. In adults, you put it in the head of the humerus just behind below that. And in kiddies, you put just under the uh uh you know, the an inferior part of the tibia um and it's brilliant. Ok. So intraosseous access, you can take marrow for testing. You can, the only thing is you infused by pressure in, in fluids, you can't run a drip because the pressure in the emissary veins are very, but you can survive. The patient can survive. Yeah, we, we had a, a child who was brought in drown, drowning injury and um we couldn't find any access. We put in, in, in two legs and 22 legs. Um intraosseous. The patient survived. We had to resuscitate. Patient was in cardiac arrest. Ok? So in C you, you, you put access, you take the bloods, as I've said, um you start the fluids now, then depending what, where you find the injury is, you might have to do certain things. So you remember C abc um exsanguinating hemorrhage. If blood is pouring out from the limb, you can put proximal to that tourniquet and there are custom made tourniquet, the, the, the army use surgeons use. And we keep those uh in our research in our, in our ed department. Yeah, if there is a wound that's bleeding, you can put a pressure. If it's too much of bleeding, then you might have to put a lots and lots and lots of dressing into the wound, not over into the wound. Pack it pressure bandage, lift it up if it's an arm or a leg. Yeah. Pelvis. If you suspect now any trauma, the best way to see a pelvic fracture is at the x-ray done at the roadside. Now, it doesn't happen. So when you see the x-ray or a uh you know, in recess, after the, after you stabilize the patient, you don't see a fracture, patient might have had a fracture. So what we're going to do is assume the patient still have a fracture and put a pelvic binder. They are a custom made binder. But if you don't have a custom made binder, which are, which are in the market, what you can do. We used to do that before we bought our own binders. We used to put a, a wide sheet. Yeah, around the pelvis underneath and bring it in front and tie it or bring the legs together internally, rotate and tie it. Ok. So there is always a method that you can still use. You can't sit and do nothing. Yeah. If a long bone is broken, what you need is, is splinting as soon as possible. Now, why do you need splinting? Because if a fracture is happen, ok, you need traction. Yeah. A traction splint because you want to realign because they overlap, you want to realign and you want to avoid soft tissue damage and by, by, by, by aligning it and also bleeding and also pain. So you need analgesia plus the traction spleen. This is only temporary. Now for hip, if you suspect there is a fracture and you see it on x-ray then the orthopedic surgeons can, can come and put an external fixator as a temporary, but the patient will need to go to theater eventually. Ok. Now, the you may not be able to stop the bleeding in the er or ed. So in that case, patient needs to go to theater. So you do the best you can, you can't stabilize pe you know, surgeons will sometimes come and say, oh we'll take to theater once you stabilize. Now, stabilization only will happen when you close the tap and the tap can only be closed in certain situations. In theater. You can see me talking, maybe my volume is a bit loud, but I am passionate about trauma care and that's you can see the passion and, and, and, and emotion coming out and, and, and I'm glad that I'm able to do this for you. Once you've done the C now you may not be able to do the D or, or, or a secondary survey because patients gone to theater. Ok? But let's say the patient hasn't, then you can run the patient. We don't only do CT brain scan, we do the whole body scan where we do the CT head, ct C spine, ct, chest, ct abdomen and ct pelvis, ok? And we talked about temperature control and not forgetting patients who are traumatized, their blood sugar drops. So do a quick BM check and if the sugar is down, give some glucose, that's a quick treatment. So that's primary survey and resuscitation. Once you've stabilized or you've send the patient for definitive care to the theaters, to the intensive care or to the trauma center. That's where the, the, the secondary survey starts. Yeah. So secondary survey very quickly is reassessment. You constantly reassess. Ample is a very quick history. Yeah. Can anyone think of ample? What ample stands for time is running out? So I've got to be quick. A for aller allergies. M for medi medication patient is on p past medical history. Any medical conditions. Um L is last meal in case they have to go to theater and ease event. Ok. Now what secondary survey basically is, you've got to assess and using your sensorium again. Look, feel, listen and special test. Yeah, events. You do a head to toe and front and back. If you only examine the front, then you won't be able to comp you only do 50% of the assessment. Ok? You have to do front and back. Now, how do you assess the back? If it's a spine injury suspected, then you do what we call a log roll. Can you see log roll where about four people, one holding the head and three people holding the rest of the body will roll to one side. Usually the non injured side and another person will assess the whole back, not just the spine, the spine, the back of every part of the body head thorax, abdomen and the limbs. Ok. Then only you'll be able to identify those potential injuries that will kill them later. Not now, later. So it's important. Ok. I'll finish it off. Now. Uh, with burns very quickly to say burns can be major. You saw the pictures, major burns are usually from explosion, from a fire. Um, it can be major chemical burns or even major. Um, you know, if you're caught in a, uh in a avalanche on a, on a ski slope, then it's a major coal burn. You can get minor burns like a scald or a, you know, a little fire like a candle, you burn your finger so it can be major and minor. The reason I say that is that assessment and treatment is different major burns assessment and is exactly the same as a major trauma. So you go through ABC, especially if the airway potentially is burned. Ok? And, and uh minor burns doesn't need that kind of assessment. The treatment is different as well. Ok. So let's see. So management again, as I said, you need to do initial assessment based on that A two V assessment, I'll come to the airway burns in a minute, ok? Oxygen 100% especially if there is a suspicion of inhalation injury. Ok. Again, you need fluids because the patient is losing, what do they lose, they lose plasma. So you need to, you don't need colloids, you still need resuscitation crystalloids. How much. You would give initial fluid, you start 500 mils, then calculate the fluids based on a formula. I'll come to that in a minute. You probably will know already burns cause pain. They need strong analgesia. Now this is not paracetamol. This is opiate analgesia given intravenously or intra. Yeah, using the morphine sulfate by titrating to the response. Ok. Two things to remember in burns, airway burns which can kill inhalation, burn inhalation injury, especially if they have been an enclosed room with smoke. Yeah, so what are the signs of I'll come to that airway in a minute. So in terms of fluids, when you've given the resuscitation fluid, then what you do, you have to calculate two things, three things. Actually you need, you need a patient's weight, you need the surface area of the burn and major burns, surface area you measure by couple of rules. Yeah, there's a formula called uh Wallace's rule of nine, ok? Or there's a London Browder chart that gives you the percentage. So now remember when you calculating the percentage, you don't consider the erythema. If it's only red, that's not in the percentage if they have blistered or the skin has lost, that's those are the areas that you consider surface area, then you need the depth. Ok? The depth is more for, for treatment but for fluid, you need the weight and the surface area and there's a formula called Parkin's formula commonly used. It's uh 4% per percentage of burns per bo kilo body weight. Now, that amount of fluid, ok? That amount of fluid is over 28 4 hours. The first half you give in the first eight hours, the eight hours doesn't start from the time you see the patient starts when you've given when the patient started the burns. So if they come four hours later or two hours later, you uh you have to give more fluid more quickly, the next eight hours and the next half in the next 16 hours and then you reassess. Ok? Now, in terms of depth uh is important for treatment of the burns, the wound treatment of the wound. So what are the depths that you're aware of any thoughts very quickly? OK. I think I, I think I'll have to move on. You can put, you can keep putting it. So the depth. Yeah, 1st and 3rd degree. Excellent. OK. So uh the depths are superficial. There's one. So the there are different classifications in degrees as you can see who says 1st, 2nd and 3rd or superficial, which is only the redness, especially given an example is, is exactly Zins is superficial. So um like sunburn where you only see redness edema, then you get partial thickness where it's the skin has peeled off, you get blistering, it's painful and the sensation is present. OK? Um then is deep burn. OK? The deep burn is where the superficial skin layer is gone, it's gone into the deeper layers of the skin and they are full thickness. So they are incensed. They don't have sensation and they need skin grafting. OK. The other thing to say about major burns. Um If the, if the surface area is more than 10 or 15% partial thickness or more than 10% full thickness, that's a major burn means they need, if a burn needs fluid resuscitation, that's a major burn. Ok. Loss of sensation, partial deep. Yes. OK. You can, you can um you can classify that way and the other one is 1st, 2nd and 3rd degree. So first degree is superficial. Second is partial thickness and third degree is full thickness. Yeah. Now, airway burns is very important because patient can get killed if airways lost, you've lost the patient. So how can you suspect or what can you see which will tell you? Oh, the patient has got airway burns any thoughts very quickly? Can we get the slides? Ok. I'll leave you to sue. Probably. Yes. Ok. Anyway, um Charring. Ok. Charring. So, Charring is a feature of full thickness burn. Yeah, full thickness. Excellent. Anything else remember airway burn? So you're thinking of face suit, suit, wear suit in the mouth. So open the mouth suit in the mouth or black tongue suit in the tongue. That's a feature of airway burn. Difficulty breathing. Yes. Ok. That inhale smoke. Ok. Breathing problem. What other features we've got to move on here they are. So again, you're looking at the patient facial edema, yeah, suit in the mouth, suit in the tongue, hair burned. So nasal hairs, eyebrows, facial hairs are burned. That's a feature of airway burn, facial burn. So burns on the face or swelling or blistering. That's a feature of facial burn or if it's gone into the larynx, there'll be ho uh that kind of noise coming out. So hoarseness after a facial burn or airway burn is airway injury. The, the reason you've got to be identifying or suspecting is you need the airway to protection and the way to protect the airway is a definitive airway. What I mean is uh endotracheal intubation by a specialist through drugs because you can't shove a tube in because they'll gag on it, they'll choke on it. So you got to give medications to paralyze the patient and put a tube in because the sooner you do it the better because if you lose the airway, you can't, they swell up in the larynx, you can't stick an airway. What you gonna do, then you can't get a tube in patient, stopping breathing, cryo G one superb. So you do what's called a cricothyroidotomy, which is not a tracheostomy, which is done by the NT surgeons. This is between the cricoid cartilage and thyroid cartilage. There's a membrane, you make a cut, you put a tracheostomy tube, you connect it to a ventilator. That's what you might have to do. But if you are well vigilant, you might be able to avoid that. Ok. So you call the anesthetic. So you call the anesthetics ASAP asap as soon as possible. And last one is in, if you suspect inhalation injury from the story, then remember lots and lots of oxygen because they can have carbon monoxide poisoning. And how do you diagnose that? Do a quick venous blood gas and you look for, uh, cob carboxyhemoglobin and do a chest x-ray maybe. Um, and then you, the treatment is just oxygen. Now, I think that's me done. Um, my next slide is, uh, the summary. So what we've done in this last hour or so, we've discussed types of trauma, you know, I could have carried on talking but time doesn't allow me, er, and you can't finish everything in, in trauma. As I said, I couldn't go, you know, I couldn't do the fractures. For instance, we discussed causes of trauma. We cause we, we discussed initial assessment, resuscitation, the principles we talked about secondary survey and a bit about burn injury. Uh su says, so that's, that's me done. Um, it's, er, question time now. Uh, I think we've got about 9, 10 minutes. Wow. I wonder if we've got any questions you covered an awful lot. Was that ok? Yeah, perfect. And I would love to have you talk on fractures. I don't know if anyone else would, but I would be delighted. So if you put one up so I can organize that, we can sort that. So does anyone have any questions? We have to give them a few moments um to pop anything do another session like this? Thank you. You're just gonna get praised now, aren't you? And it's, it's, you know, the audience is global. This is fantastic. So there is feedback, you will be sent at five o'clock, you will get a feedback form in your email. Please fill out. Um Please communicate other things. You might want to learn that Sandra can actually teach. Thank. Thank you. Please fill that out. Um And then your attendance certificate will be on your medal account. We have another event next week. Bear with we sany is joining us next week he is going to be doing. Is it, is it toxicology? Yeah, that's the 13th. Yeah. So Sandro's event next week is right here. Um Hope to see some of you there. Yes, we do. Question. There's a question, there's a question. There is a question. I know they're going so quick, aren't they? What is the clinical distinction between inhalation injury and an actually suspected airway burn? Is neb adrenaline useful? OK. Thank you Jose for the question. So the clinical distinction, I if it's a suspected airway injury, you will visibly see features of airway burns and if the burn goes as far as the larynx, you will get hoarseness. Now that's, that's burn caused by phlegm, if the smoke goes into the lungs, if you think about it, they have inhaled the smoke, that's inhalation injury. Now, inhalation injury also is talked about I in, in, in the, in the question of burns, that's what inhalation injury is. You, you inhale the smoke. Um I I know smokers inhale smoke but that doesn't cause the inhalation injury. It has to be a massive enclosed area, burns and they get that's how most, most of the burns kill patients die from inhalation injury, you know, rather than actually flame burns. But I mean, people, people can succumb to that. Um, neb adrenaline. Um I don't think there's any role, I'm not aware of any studies. Um, but what you need is a definite airway for airway burns, you stick a tube in as soon as you pos as soon as possible for inhalation injury. There's not much of treatment. Um, you just give a lot of oxygen and you hope it'll, it'll, the co HB will eventually be displaced and the patient will get better. Hope that answers your questions soon. Perfect. It looks like it does. He says, ok, that makes sense. Thank you so much. Carly has a question. If someone has damage control surgery and then goes to the ward, how long is optimum between that surgery and definitive surgery? Er, so damage control surgery. The term Carly, thanks for the question again. That term has come from battlefield surgery. The field hospitals. That's where they do damage control surgery. It does happen also. So I I if, if some, if somebody's bleeding, let's say the belly is full of blood, the liver is lacerated, you cannot carry on further assessment. You have to stop and take the patients to theater. So all you're doing is damage control. So the the belly is opened up, you, you suck the bladder, you pack pack pack, you're not doing repair of the liver. Um, the patient goes to the ward and then, um, in terms of how long is the optimum time asap, as soon as the patient's stabilized, the next operating theater, the patient needs to go for definite surgery. Or if the, let's say the, the, the place where the damage control surgery has happened is not a liver center. There's no expertise. Then with that packing patient can be transferred to the liver center for defin surgery so that can take a bit of time. Hope that answer your question, Kly and thanks for all the other. Thank yous. You've got a lot of thank yous there. Ok. Osama asks doc you said in, in past they said, oh, hang on. You said in the past they used two wide bore cannula in shock therapy. Why not now? No? Ok. It's so, so it still says if you look at the A TLS manual, they still recommend the two big bow cannula. What I said is life is different. Practical, real life is different what the book says. So if you face a shock patient, if you can get a white bow, cannula, brilliant. The reason white bow is if you imagine a cannula, if you those who've seen it is the length, it has got a length and it's got a AAA width. And the rate of fluid is based on this law of physics called the law. So the shorter and thicker the cannula, the faster the fluid. But to get a AAA big candela which is a size 14 or a size, you need a big vein, a shocked patient, the veins are all flat, are collapsed so you can keep trying. You. So what I do and I'll so whatever I've said to all of you today, that's my practice. I would not say anything that I don't preach, don't, don't practice myself. So I would get a cannula, whatever candy I can get an 18 or I've, I've also used a pediatric cannula to get some fluids in. Then the veins get filled up or go side by side an intraosseous cannula and then get a bigger cannula. So I'm not saying don't uh that's the reason. Hope, hope that makes sense to you. Sarah says, please do the fracture session as soon as possible. It's up to sue. Oh, we'll get you fitted in San Joy. We'll have, we'll have a chat and we'll see what we can fit in next. San Joy has committed to two more events. They're on a Friday. The next one is a toxicology and then the one after that is the 20th, which is respiratory emergencies. Ok. So he has committed to three events for us already, but we'll get him for some more. A question. There is do, what's the ratio of packed sales to fresh frozen plasma transfusion for massive hemorrhaging given? Thank you very much for that. I don't think I, I've mentioned that as I was doing the talk, if you've got a hemorrhagic shock or, or you know, or a or a traumatic shock but not hemorrhages. So say tension, pneumothorax, traumatic can give you shock. Ok. Cardiac tampon not can give you shock. So if you've got a hemorrhagic shock where they are bleeding, what we do is and I think that's pretty much everywhere you asked for major hemorrhage protocol activation so that the hospital knows about it as soon as you activate it, what comes through his own negative blood and you get uh uh bad red cells, fresh, frozen, fresh, frozen uh frozen plasma. I think the ratio is one is to one. So you get one red cell, one plasma that way um until, until you are but but remember giving tons and tons of red cells or plan FFP you what you need is is not enough. What you need is to close that up. So you imagine the tap in your house in your kitchen or wherever if you keep it open, the water will run out your waste and, and here you've got to close the tap. You've got to stop the bleeding no matter how and otherwise patient will die. So no point giving, giving, giving you, you can give afterwards to re re replace it, but you need to close the tap. Yeah. Close the tab. Absolutely. I think I saw something else. Where was it? It was about io Yes. When should we use IO? OK. So I um has in trauma uh has come in. So I, you used to be in a sick child most commonly used in the sick kids where you could get shocked, usually septicemia. So meningococcal septicaemia. Now what is being said is you try two attempts, only two attempts in a shocked patient in trauma, hemorrhage or trauma, hemorrhagic shock. Two attempts at peripheral cannula, forget central can. So you can get central cannula in the, in the neck veins, internal jugular or subclavian or femoral. But that takes time. You need to do it by ultrasound. Forget that you go straight for IO. In fact, if you ask me, if the patients start shocked and clapped out, you can't see a vein, I can get somebody, I I can delegate somebody to try cannula. I'll be doing the intraosseous at the same time because one thing you have to remember that in this assessment phase, resuscitation phase time is of essence, time is ticking off we talk about the golden hour we have, I mean, did mention it. Golden hour is an hour where you can make a difference to the trauma victim patient. But the hour people have a misconception. They think that it starts from the time I see the patient, the hour has started from the roadside. Ok. So if they come an hour later, hour is gone, if they come half an hour, you got half an hour, but do the best you can. Ok. So as soon as possible, uh, put the IO in and there's no harm because, you know, at least you've given some fluids. I think that's it. Thank you ever so much. Obviously you can see how well, oh, hang on. Ahmed said is it used in adults? Yes. Yes. I think G one has said something. There was, what's the reason G one said something about I end commonly in the Children in IV Cannula was taken. So, yes. Ahmed. G has already answered your question. It is used in adults. The needles are a bit different, they're longer. And the anatomical landmark is the reason I can't show it to you. It's just underneath the head of humerus. The, the pro the need. The reason you need bigger can a bigger needle is, remember there's a deltoid muscle here. You've got to go through the muscle and you hit the bone at a direct 90 degrees. And in this, in when, when I was training, we used to use a manual needle, we used to twist it, twist it, twist it and then go in into the marrow. But now we use guns. It's a drill. So the drill is connected to the needle, you go through the muscle, hit the bone, stop and use, you put the drill on and as soon as you feel a give it's in the marrow, you stop, the needle is in the marrow cavity and then you, you take it, it disconnect the, the, the, the, the drill or it's made, it's revolutionized shock therapy. It has so sounds painful. It is painful. But I think you can give some local anesthetic through the needle. But in a patient who is shocked out, they are pretty much semiconscious and it takes seconds. It just takes seconds. Brilliant. Well, I think we, I think we're done. We're still getting some. Thank you. And people can't wait for your next session. So no pressure. This session, actually, we had 240 42 people registered for it, which is an incredible amount of people. So um brilliant. We, we will love to see you with your next on our next session. What I'll do is I'll get this catch up sorted out. It'll be ready probably at the beginning of next week at some point and we'll put the slides up at the same time. So, can you be there for two seconds or we'll stay here? Sandra. We'll stay here. We'll just say goodbye to everyone. Goodbye. That was useful and whatever I've said, apply it at your workplace and you will make a difference to the trauma patient. They're waiting for you. Brilliant. Well, we'll say goodbye. Have a great weekend, everyone. Uh, we have another event tomorrow, I believe. Um, and then sun enjoys is same time next week. Can you just book in for that one? All right. Take care everyone. Bye.