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Um, a town called Basingstoke that is in the south of England. Um, and I'm gonna talk to you today a little bit about an introduction to trauma. Um, so let me just quickly share my screen and, uh, you'll be able to see my slides and then hopefully you can see a little bit about me as well. Just do that. Ok. Um, so, uh, why should I talk to you about trauma? World Trauma has really been my speciality for the last 40 years. Um I presently chair an organization you can see at the bottom of here called the Primary Trauma Care Foundation. And we teach trauma care in 85 low resource countries around the world, but I've also been president of the Orthopedic Trauma Society, um, and head of trauma education for the UK and Ireland. Uh, uh, so, well, hopefully you will get a little bit about this and, um, uh, a lot of that is done through, uh, the organizations you can see at the bottom here, uh, the British Orthopedic Association and, uh A O UK. Now we're gonna get a bit of all audience participation in this. So, um, uh, I hope that you are ready to uh uh to participate in all of this uh oops. Um and there will be an opportunity for some questions at the end. Um I am going to assume that most of you are undergraduates. Uh and this talk is going to be largely aimed at the undergraduates as an introduction. I'm doing another talk on the 29th of June, which will be uh taking things on a little bit further. For those of you who have an interest in trauma or who are doctors, there will be a little bit more detail later this month and then later this year, we are actually going to run a primary trauma care course, which I'll tell you about in a minute. Um, uh, for all of you to be able to attend, we're going to do it as a hybrid course, uh doing it online. And then for those of you that are able to attend a face to face session in London, uh we are going to run a face to face, er, er, skills station session in London uh in the autumn of this year. So watch this space and we'll keep you informed. Right. So let's get started. Um, this is an image. Uh I will talk a little bit about at the end of the, at the end of the talk, er, and it's what everyone thinks about when you start to think about trauma. But, um, I hope, er, you will see by the end of the talk. I hope this is an an image you will never see again. So let me give you a scenario. Um and this is a true scenario. So a major incident is declared we have a bomb that goes off in a city. There are multiple casualties and you as a medical student are called in because there are so many casualties. The system is overwhelmed and everyone gets allocated a patient. So you attend the emergency department in your hospital and here's your patient. Just 10 minutes after this, this incident. Uh This young lady is brought in, uh she's 15 years old, she can't talk, she's struggling to talk, she's struggling to breathe, she's obviously in pain and uh she has this obvious open tibial fracture. So have a little think about this park, your thoughts for a moment. Uh because I'm gonna come back to you in a minute. I'm gonna ask you your thoughts on how you're going to approach this young lady and you're on your own. But let's put this into a bit of perspective. Um Most of you unfortunately are attending this because of the the troubles that may be occurring with your own medical schools in your, in your own uh country. So let's put trauma into a global perspective. Trauma is what I call a forgotten pandemic. Um There are more people who are injured and die as a result of trauma than there are from all contagious diseases added together. So that's HIV, TB, malaria and COVID. If you add all of those together, they don't come close to the numbers affected by injury every year and yet injury and trauma does not get the same funding or, or attention. And we talk about the death, but actually, um uh there are uh far more people who are injured as a result of uh of uh trauma And there are 40 million people a year globally who are injured permanently and 100 and 50 million who are injured temporarily. And that causes an enormous loss of global GDP in this country. It probably is between 1.5 and 3% of GDP. But around the globe, talking about uh over 10 times that uh in low income countries. So in a, in a country that is struggling, it may be up to 30% of their GDP. And when we start to talk about those numbers, people tend to zone out. Uh the, the numbers are so great that it does not get the attention that uh you, you deserve. And so um let's put that in perspective. We're talking about the death of the entire population of the island of Ireland every year. And we're talking about entire Central America and the Caribbean getting injured every year, year on year, a year after year. And that gives you some idea of the perspective of the problem. Trauma is the leading cause of death for the 5 to 30 age group. And that is an issue because the vast majority of the world lives in countries where er, their population are under the age of 35. So the m, most of the world lives in low and middle income countries and most of those countries are uh young. So we're talking about the leading cause of death and we get focused on death. But as I said to you, um uh for every death, there are 97 people who aren't working nine in hospital and 88 managed at home and in low resource countries, uh uh the, the effects of trauma are dramatically different too in the UK, if you break your leg in England and you have a simple closed tibial fracture in England, we expect you to be back at work in six or seven weeks. But if you do it in Uganda, there was a beautiful study by done by the Vancouver group at ca at Macara University in Kampala. Looking at the effects of a simple closed tibial fracture in a working age man. And within 18 months, all of their Children were out of school because they were having to work to er keep the family in uh uh that fed and within 12 months that family was destitute. So we're talking about a big problem. Now, prior to COVID injuries and trauma were double the amount of um uh contagious diseases, but contagious disease got 36% of global healthcare funding and trauma got just 1% since COVID contagious disease gets over 60% of global healthcare funding and trauma gets significantly less. So um uh we need to be mindful of this in the, the uh uh the the way of the world. Um um Most of the trauma happens in the globe where most people live. I think most of you know that and images like this are pretty common and this is bubbles at depicting the population of the world right at this moment. But um those bubbles are going to change in the next 50 years. And the bubble in China is already reducing the bubble in India and uh Southeast Asia is increasing. The bubbles in Europe and North America are going to decrease. South America will increase slightly and then decrease. But the one that's going to dramatically change is Africa and there's going to be a big disparity between the provision of healthcare providers and the population of the world. But that's another talk. So I have a what I call the rough rule of 80 80% of the world's population lives in low and middle income countries. And 80% of that population is young, 80% of the world's trauma happens in those countries. And actually 80% of it happens on the road and 80% of that happens on two wheels. I'm afraid motorbikes are responsible for rather a lot of, of the trouble. Now, many of you are coming from places where unfortunately violence is, is a problem and you may think that violence is actually the major cause of, of trauma and it may well be from where you are at the moment. But actually in the global picture, it isn't war accounts for just 4% of global deaths. Uh, murder and suicide actually account for almost a quarter of global deaths. And remember these are deaths when you talk about injury, the, the picture is very different and, and road trauma accounts for uh, uh considerably more. So we know that if we train you, it's very, very cost effective to, uh, train you to look after trauma victims is 100 and 35 times more cost effective than giving antiretrovirals for HIV. So we know that if we can train you properly, we're gonna, we're gonna get a good result and we know if we do that properly, that, er, the wo has shown that we can prevent half of all trauma deaths and a third of all disabilities. Um, uh, uh, if we do trauma care properly now, there are 8 billion people in the world right at the moment and 5 billion of them, 63% of the global population does not have access to uh, uh, surgery, uh to either surgery, obstetric trauma or anesthetic care. And that's a problem. And at last year's world health Assembly, there wasn't a single surgical topic on the agenda. Now, that's outrageous that promoted a lot of discussion and a few of us got a bit hot under the collar. I even wrote a paper about this and I'm pleased to say that the trauma right organization at the World Health Organization, which is known as Ki and I sit on this organization, the Global Alliance for care of the injured was very successful two weeks ago at this year's World Health Assembly and Trauma and surgery is now very, very much back on the, the global agenda and, and that is the only right and proper, but I'm sorry to say that um trauma remains the single largest unaddressed global health care issue. And I hope like me, you'll get interested in this and perhaps want to do something about it. Ok. So let's go back to our young lady, let's think about our young lady. So we've got a 15 year old girl. She's seen 10 minutes after the injury to her leg, she's struggling to talk, she's struggling to breathe, she's in pain and she's got this open tibial fracture, right? I'm gonna stop sharing uh my screen and um I, I'll come back to it in a minute and what I want you to do is uh I want you to um put your cameras on, turn your er, sound on and er shout out, come on, I wanna hear from you. What do you think is gonna be the way to look after this. Er, poor young lady. Uh, so let's have some ideas. What are we gonna do for this young girl who's come in? Can't talk, can't breathe in pain and has got an open tibial fracture. Got your hands up, go for it. Uh, first we check the ABC S, the airway breathing and circulatory system, like you said, she's, like you said, she's not breathing. So first we have to check the patency of the airway. Excellent. All right. Don't stop that. Well done. Anyone else got any thoughts? Yes. Um Ensure exposure. Yup. Well done. What do you mean by that shams? Um uh like uh trying to expose other parts that might be um infected by uh affected by this incident? OK. Cool. All right. Excellent. Anyone else got any thoughts? Give her anesthesia? Say I missed that. Sorry. Give her anesthesia. Uh So you would, you would anesthetize her straight away? Yes. Why would you do that because of pain? All right, you might do that. There might be other reasons that you might want to do that, but that's not an unreasonable thing. OK. One more, one more thing as that you got your hand up again. Top man. Well, you said uh she came with a fracture. So if there is a bleeding, we have to stop the bleeding as well. OK. Good. All right. Well done. All right. So you've obviously all got some really, really good ideas on all of this, well done. And I can see that you already understand some of the concepts around all of this. All right. So let's go back to this young lady and let's start to think about things. So when we start to talk about trauma, um there should be three things in your mind and they are in this order and they're always in this order. Number one, you save life. Number two, you save limb. Number three, you're gonna restore function and it's always in that order. So let's think about this young la lady. What is it that's gonna threaten her life? So as Azad said, you need to start thinking ABC and we'll come on to this in a moment. So the thing that's gonna trouble her is her airway and her breathing. If she is struggling to breathe, she isn't gonna survive very long unless you do something about that. It may be, she's struggling to ble breathe because she's in so much pain. But you need to ensure that her airway is patent and clear or that there isn't a major problem with her chest. She's got an open tibial fracture. And if you don't do something about that infection may intervene and that can threaten her life at a later stage. So what threatens her limb? Well, there is an open fracture. So is the blood supply going down to her foot intact? We don't know that yet. So does she have good circulation? The the wound is open, it will get infected unless you do something about it. And she's got AAA significant soft tissue injury. And as I always say, the definition of a fracture is a soft tissue injury that happens to have a broken bone beneath it. So you need to do something about that soft tissue injury, otherwise it isn't going to heal. And what about her function? We need this young lady to return to society to be a contributor to soI society again and not be a taker from society. So we got to think about healing of the soft tissues, think about healing of the bone. Once we've got that right to make it work, you've got to get that limb, the correct length, the correct alignment and the correct rotation. And we want those soft tissues to function again properly and don't forget, but she's suffered a serious injury with lots of other people being injured around her. There may well be some psychological sequelae from this that you need to factor in. All right. So as as I said, and a few of you very rightly said, and I'm delighted to hear that, you know about this. We think ABC de, you think about your alphabet and it's always in that order, airway breathing circulation, disability. And then as someone else very said, uh uh uh uh uh said, said, uh we're gonna expose and look for other injuries. Now, this concept came about, uh actually, not that long ago. Um It may be, feel, feel a long time ago to you, but it wasn't that long ago to me. And it was coined by the advanced trauma life support system and way back in 1976 and I actually attended the very first A TLS course in the UK in 1989 an A TLS is still the gold standard. And for those of you that can attend the course, it may be worth considering actually, if you're in Europe, in particular. Um, and you're in a high resource setting in Europe, the European trauma course really is now superseding A TLS and is actually, er, dare I say it a better course, er, it's a much better approach, it's a better run and, er, if you're in a high resource setting and you're able to attend the European Trauma course, the etc, uh I would recommend that over the A TLS but the A TLS and the, etc are really, really good courses but they're expensive and they're relatively didactic and they are uh talk about uh patients going into CT scanners, getting blood. And in many countries in the world, ct scanners are not available. Blood warners aren't available, they don't have blood available. And so the organization I chair and I'm the medical director of the Primary Trauma Care Foundation teaches exactly the same principles but in areas of the world where those resources are not available and we uh we um use what is available, what is appropriate and teach anyone and not just doctors, nurses, paramedics, teachers, police ambulance workers and members of the public. So when do patients die? Well, a lot of patients die within seconds or a few minutes of the trauma. And largely that's because of problems with the airway where the airway becomes blocked and people can't breathe or they have major chest injuries, serious head or spinal cord injuries or major blood vessel injuries, uh, that cause catastrophic hemorrhage. The picture you can see is unfortunately, of Princess Diana's car and when her car hit the wall of the tunnel in Paris, er, the deceleration was so much that her media stum moved forward at such great rate. She avulsed her pulmonary artery, uh, from her right lung and she bled to death very, very quickly. And unfortunately, her, her trauma uh, was probably unsurvivable. Um, the ones you can do something about are the ones that come in with serious head injuries, chest injuries that make it through the door. Um, and you can do something about that serious abdominal injuries and uh major fractures causing big blood loss. So you can do something about those. And then the ones that definitely we can do something about are the ones that happen later on due to s sepsis and organ failure. Now, in a mass casualty situation, like the scenario I gave you um we are often faced with many, many casualties and the term triage comes about and it actually comes from a French word uh trier meaning to sort. And it was coined by Baron Dominique Lara. And Lore was Napoleon's surgeon and he was the first surgeon who actually developed ambulances to take uh casualties off the battlefield. And he uh because he was overwhelmed, went on to triage uh the patients so that he would prioritize them depending on what he had available, the experience of the staff with him and the severity of the injuries and the number of people that are, are injured and that may change from event to event. So in a TLSETC and PTC that we start off with what we call the primary survey. So we do a rapid abc DEA rapid assessment of the that patient. You identify those lifethreatening injuries and you treat as you find. So you identify the injury and you do something about it. You don't move on until you've done something about it because otherwise you're gonna be dealing with a dead patient and having done that, we then go on to what we call a secondary survey. So, um, uh you will take a history, we do a detailed head to toe examination in and document and sort all the injuries as they come and we will look at special investigations and management. And if you can get hold of this book, uh book called Top to toe trauma care. Uh, that was written by a great friend of mine, Professor Saed. Minna, er, who was professor of orthopedic trauma in, in Karachi in Pakistan. And I'm sorry to say Saed unfortunately died as a result of a head injury sustained in a road traffic accident. So, uh un unfortunately, er, uh, really awful and then at all times we are going to keep reassessing that patient, keep optimizing them. You're gonna document what you find and you communicate and we communicate in a standard fashion, which is now globally accepted. So we talk about the airway, the breathing, the circulation, disability exposure and what we've done at each of those and, and then you can hand over in a, an effective way so that you can then transfer that patient when they're stable. Ok. So let's work our way down and we're gonna talk a little bit about each of these and we'll do this in much more detail later in the year for those of you who can attend the uh the, the full primary trauma care course. Um uh So we're gonna talk about ABC S today. So let's start with the airway. And when we talk about the airway, we always combine that with cervical spine and I'll explain why in a second. So the very simple way of assessing the airway of a patient is can they speak to you if a patient can talk to you, you can be pretty confident that the airway is clear and that you do not need to do very much about the airway. But if they can't talk to you, uh, the, one of the first things you need to do is to look, to feel and to listen, to look at the airway. Is there something obviously obstructing it? And in the unconscious patient that may well be uh their tongue. If they're lying on their back, they may have swallowed their tongue and we'll talk about how you do something about that. Are they pink? Are they perfusing well, or are they blue if their conscious state is altered, if they're not with it? It may well be because they're not oxygenating problem because their airway is not uh patent. Are they obviously using their accessory muscles to breathe? And are they making sounds that make it obvious that the airway is blocked? So look for those airway obstructions. But also we'll come on to in a minute, serious chest injuries. So, are they having difficulty breathing because they've got a serious chest injury? And what you absolutely don't want to miss is a serious survival spine injury. If someone's got an x-ray like that and they've got an underlying serious uh neck injury, they may well be not breathing because of the serious survival spine injury. So we always approach the patient first with what we call uh the PTC handshake, your hands are out in front of you and you're gonna approach the patient holding their head, still controlling the cervical spine and getting protection on the cervical spine early, whether that be sandbags or fluid bags to the side or a rigid collar or ideally all of them and take them down. We're going to use basic airway maneuvers and then if those fail, we'll go on to advanced airway maneuvers. So those signs of obstruction are uh, serious noise. The patient's making snoring sounds, gurgling sounds or stridor. And, and hopefully, you've never heard Stridor, but once you hear it, you'll never forget it. The patients going. And uh they're obviously struggling to get breath in. They may be very agitated and if they're agitated and thrashing around, it may well be because they're in pain, but it may well also be because they're hypoxic because they're not ventilating properly. Look for movements of the chest that are, that are what we call paradoxical when they breathe in. Instead of the chest inflating, it deflates on one side, on one side, inflates the other side, deflates. And that is a sign of a serious chest injury, which we'll come on to in a minute and then cyano, they look blue. So what do you do? Well, having looked in the mouth and made sure that there's nothing actually physically obstructing the airway. Then you can do a simple chin lift, put your thumb under their chin and push it forward or put your hands behind the angle of the jaw and lift the jaw forward and that will bring the tongue out of the back of the mouth. And you'll be amazed how quickly that, that uh, relieves uh, the airway. Hopefully that makes a big difference to you. But if it doesn't, then you're going to put something into the airway to hold it patent. And that could be an oropharyngeal airway, which is often referred to as a gel airway gue uh Dal um uh which goes in over the back of the tongue to hold the tongue out of the back of the airway. Or there may be a nasopharyngeal airway which is inserted through the nose, uh directed towards the back of the throat that goes down to do exactly the same thing. And then we would use a bag valve mask to help that patient breathe so that you're actually getting some uh uh oxygen and air into them and we're getting no attach oxygen. Ok. So you've done something about the airway, let's start thinking about and looking at breathing. So, as I said, is the breathing normal, right? Uh have they got a normal respiratory rate and a normal respiratory rate is somewhere between about 15 and 20 breaths per minute. Um So is it very slow or is it very rapid? Uh have you got paradoxical movements of the chest? Are there obvious chest injuries and you need to look, feel and listen. So when you feel the chest is there crepitus around the chest. Are you feeling a very strange sensation under the skin of it crackling because there's air got into the soft tissues. Um, listen for air entry and feel the trachea. Is the trachea deviated to one side or the other because that gives you an idea that the lung may have collapsed. So, as I said, check movement, respiratory, look for tracheal deviation. Are they using their muscles around their neck? Really? Trying to get more uh uh breath in and percuss the chest. If it's hyper resonant, there may be lots of air in that chest cavity. The lung has collapsed because the air is in the chest cavity or it's very dull, the chest is full of blood and there are lifethreatening injuries you need to be aware of around the chest. So, uh direct injuries to the airway that it has a vuls the trachea and obviously, those are serious, you're gonna need some serious help with that and they're really lifethreatening. But a tension pneumothorax is a pneumothorax, which if you look at this image on the top, if you can see my cursor, um there is the, the, the the this lung has completely collapsed and the trachea you can see over here, it's well and truly deviated over to the other side. And that is what is known as a tension pneumothorax. And if that goes on continuing, the other lung will collapse and the patient will, will succumb because there's no air getting in those need something doing about. You can have an open pneumothorax, what's known as a sucking chest wound. And we'll look at those in a second. If you look at this x-ray at the bottom, you can see lung field on one side and on the other side, you can see the lung field, but it's very white and that's because there's blood gone behind the lung. Um That's the patient lying down with blood behind the lung with a massive hemothorax. So that is also lifethreatening. A flail chest is when all the ribs are broken at the front and the back. And that's when you get paradoxical chest movements because as you breathe in, instead of the chest expanding the ribs expanding, there's nothing to hold them and they collapse down and serious lung contusions, direct injuries to the lung where the lung becomes directly bruised mean that the lung will not function. So, what are we gonna do? Well, you're gonna give oxygen, you're gonna assist with the ventilation. You're gonna get use that bag valve mask and you're gonna do something about that pneumo thorax and or hemothorax. So for the pneumo thorax, we do what's known as needle thoracocentesis and all of you can do this. It is not difficult. You get hold of the biggest needle you can find, you feel uh for the, the um zippy sternum, the angle of le at the base of your neck that's the top of the sternum, hold your hand, uh, one, the hand's breadth to the side and that's the middle of the clavicle. And then you feel down two rib spaces and in the middle of the clavicle, second, intercostal space, you take a big needle and you plunge it in and I'll tell you an amusing story about that in a minute. Um, and hopefully you'll get a big suck and rush of air and the patient will go and it'll make a big difference to their breathing as their lungs suddenly reinflate. And then that needs to be followed up with a formal chest drain as you can see all of this image at the bottom. So here's a picture of the needle going in and then the chest drain. And when we talk later in the year, we'll go and we'll have a, a skill station on putting in that chest dr um you may have an open pneumothorax where there's a big wound on the chest. Um And you have all the other sounds. It's hyper resonant. There may be a deviated trachea, but you've got an open wound. And what you need to do is you need to occlude that wound uh with some uh uh plastic type dressing, uh a little piece of plastic taped to the chest on three sides works very well because as they breathe in, uh the plastic will suck on to the side of the chest wall and won't allow further air into the chest. And then as they breathe out, the, the air that is in the chest will be expelled through the fourth side that you haven't taped to the chest wall. You've made a one way valve and then having done that, uh, you then need to get on and do the chest, right? Ok. So as someone else said, it may be that this young lady was, uh, uh going to bleed to death from her leg. That's unusual, but it's perfectly possible. And you, the thing next, things that are gonna kill you are serious um, uh, catastrophic bleeding and some of you may have attended a, an A TLS or similar course and you'll know, um, uh in, in high income countries and I was in the army for 20 years. We've actually changed this from ABC DE to C ABC DE because the majority of the casualties that come in um are, are going to have a patent airway. They would have died uh, at, at the scene of the uh, injury if they weren't, if their airway wasn't patent. So when they come in, when they're seriously injured, it's usually catastrophic hemorrhage. That is the main problem that we have to do something about. So you need to assess that patient is the patient in what we call shock, true clinical shock. They're not feeling disorientated. They are truly circulatory, uh, hemodynamically unstable. Is there obvious bleeding? Is there blood on the floor and you need to look for that blood. So look for that external bleeding and look for signs of shock. Have they got a rapid pulse? So an adult's pulse is hopefully somewhere between about 55 60 about 80. If it's above 100 that's uh tachycardia. So that's the first sign. Do they have poor capillary refill? When you squeeze the tip of their finger, it should go white and then go pink within two seconds. It takes longer than that. They've not perfusing their peripheries. Well, if you can't feel a radial pulse that says to me that your BP is below 90 millimeters of mercury. So if you can't feel a radial pulse, but you can feel a carotid pulse, they have got low BP by definition. So you can't feel a distal pulse. You can feel a central pulse. They have low BP. And if they've got an altered mental state, they're agitated, they're not really uh uh answering questions properly. They're, they're unconscious. You should think uh hemodynamic instability that they are clinically uh circulatory, shocked. So you need to do something about it and you need to look for it. And there's a saying in a TLS that there's blood on the floor and four more. So there's obvious signs of bleeding. It may be in that young lady. It was bleeding from her leg. That was the obvious proper uh problem that was going on um uh it may be um um sorry to say in my own hospital, we've had a patient bleed to death from a scalp wound. You can bleed profusely from the scalp. So look for that, but it may be that it's hidden that it's inside the chest. You got major hemothorax that, that it's hidden in the chest, that there's major bleeding in the abdomen or from a pelvic fracture or from your long bones and particularly from your femora. If you fracture one femur, you can lose uh 2 to 3 units of blood. If you fracture both femurs, you're losing five or six units of blood, you only got eight units of blood inside you. So bilateral femoral fractures is a problem. So be aware and you're gonna do something about it. So you're going to uh try and stop the bleeding most of the time that means applying direct pressure to the obvious sign of the bleeding. And if it's in a limb, you would apply a splint because holding that limb still allows the blood to try and clot don't need to worry about reducing a fracture, just get the limb still. And if that fails and only if that fails, would you apply a tourniquet and document very clearly and write on the tourniquet when it was applied because you've got a, a clinical critical finite time in which to do something about it. You need two large bore intravenous cannula inserted into somewhere in the body, ideally in the, in the arm. But often when the patient is very shocked, we will often just lift the legs up. So their jugular veins stick up and we stick cannula into the jugular veins. That's a quick way of getting fluid into the patient to open the peripheral circulation up. And we give intravenous fluid. Ideally, blood, people, patients don't bleed salty water, they bleed blood. So, ideally, we're gonna give them blood, but we can start off with Saline. Uh if nothing else is available. And ideally, you're going to put in a urinary catheter if possible and monitor the urinary output because that gives you an idea of how you're doing. So those are your rapid ABC S, you then would go on to disability and you assess the neurological function of, of that patient. And we use a uh an acronym APU A VPU. So is the patient awake? Um If they're awake, they're probably pretty good. Are the, are the patients only responding to your voice? You shout at them, they respond but they don't do much else. Do they only respond to pain? You press on their finger or you rub their sternum and they only respond to that or you do all of the above and nothing happens. The patient's unresponsive and then you need to look at that patient's pupil. So you document, they're either a VP or U look at the patient's pupils. Are they normal? Do they uh respond to light. So do they constrict or are they both dilated? Are they both very, very constricted? That might be as someone is uh indication that someone has actually had a big overdose of opiates or is one pupil blown and the other pupils small and restricted. And that gives you an idea of a serious head injury and which side of the head the injury is document that clearly time it and document it and then we're gonna go on to exposure and please, please, please don't forget temperature control and we'll explain why that's important in a moment. So, are there hidden injuries under the cloth, under the clothing? And uh that may be on the front? But we don't forget the back and we'll come to that in a moment. Um And it's really, really important to keep the patient warm. We have what we call the triad of death in trauma where the patient becomes cold. They're hypothermic, they become coagulopathic where you lose control of the clotting. And once you've lost control of the clotting, it's really difficult to stop them bleeding. And as a result of being cold and coagulopathic, they become acidotic and that makes a con a a AAA real problem in controlling the patient. And when you get those three, it's very difficult to uh rescue that patient. So that's your primary survey. ABC DE you monitor the patient. You may order some special investigations like a chest x-ray, a pelvic x-ray. Uh, and you're gonna do some procedures, you're going to do something to clear the airway. You're gonna, uh save the patient's life, uh, uh, decompressing a chest or putting a, a chest drain in for uh, uh a massive hemothorax or pneumothorax. And you're gonna give pain relief, preferably intravenously. And at any time if that patient becomes unstable or, uh uh and or if you move the patient from one place to another, when you hand the patient over, we always, always, always reassess ABC D at every time point because that patient can go off and you're not aware. So primary survey, systematic ABCDE done very rapidly in less than five minutes, you treat as you find and you repeat if they're unstable or on moving that patient and only when you've done that, do we go on to what we call the secondary survey? So the head to toe examination looking for everything else. Um And if at any time the patient goes off, you're going back to the primary survey and reassessing your ABC DE. So the first thing we do is we take a history and we have simple ways of taping history. And the, the two most common you'll hear are the acronym Ample or the acronym Aist. So, and Paul, you find out are they allergic to anything? Are they taking anything or had any medications any past medical history or are they pregnant? When was their last meal because that may be relevant for surgery. And what were the events in the environment involved around the injury itself at miss is the age of the patient, the time of the injury, the mechanism of the injury, the injury that's been sustained and what are the symptoms that that patient has? So, in that secondary survey, we're gonna go from top to toe and we'll start with the head and neck and hopefully you won't get someone like this, um who has been and someone said, uh incubated because of a serious injury that neededed control. So you're gonna look at the scalp for bruising and lacerations, check the skull, look at the eyes, check the pupils, look at the ears and nose. Um, and look for CS F coming out of the ears or nose and, and we'll talk about that uh later, uh uh this month and later this year and then very carefully examine the facial bones. You're gonna look at the neck. Now, is there an obvious penetrating wound? Is there what we call subcutaneous emphysema? You get that crackling sensation or the neck is very swollen. Is the trachea deviated? And are there obvious swellings that are expanding? Even our late queen, did the PTC handshake, you're going to assume all the time that the neck is injured. And when we first approach the patient, the first thing we do is we put our hands on their head and we control the head and neck. So then that it is immobilized in a neutral position. First, do no harm. You're not gonna make the injury worse and then you'll go on to your neurological examination. So in the primary survey, we may do apu alert, vocal, painful or unresponsive, but you can then do a Glasgow coma score and we'll talk about this in more detail uh during the PTC course later in the year, but there's the Glasgow coma score and you're going to get this lecture there. You'll look at the ability for them to move. Limbs are the side symmetrical are, is the power normal. And there's a thing called MRC grading. The Medical Research Council grading where five is normal and zero is, is no motor function, test, sensation, test reflexes, compare side. Then we'll look at the chest abdomen and pelvis and we're gonna look feel and listen, we'll talk about pelvic injuries at another day. But what we don't do is you don't shake the pelvis around. We're gonna examine it because we want to be beware of, of the hidden bleeding within the chest abdomen and pelvis, the patient is shocked. It may well be there if you haven't found it, uh an obvious external bleeding and then you'll go and look at the limbs. Uh you know something like that. This is from a a gunshot wound uh is pretty obvious, but you're gonna look for deformity, bruising, laceration, the colors that are going on there. Uh uh If they, there isn't an obvious open injury, look for tenderness, check for the distal pulses. Uh Have they got circulation? Uh is that limb viable? And if not, you're gonna need to do something about it, check for power and sensation and there is an awful condition called compartment syndrome, which again, I will go through it another time, um which is something absolutely not to be missed and you can look it up uh uh uh uh after this talk and then during that secondary survey, we're gonna examine the back. So we're gonna log roll the patient and this needs four people to do it. We will practice it uh during uh the the face to face sessions uh where the person who is controlling the head and neck is the person in charge of rolling that patient over to examine the neck and the person at the top who is controlling it gives clear time and clear instruction. So we do it as AAA block role and we're not going to damaging anything else and he looked very carefully. So here's a chap whose injury wasn't obvious until we rolled him over and he was clinically shocked and he could not move his limb, his lower limbs and he'd been stabbed in his back. The stab wound had gone into his heart. Uh Yeah, he uh had bled into the to um his medial stum and pericardium and the stab wouldn't have gone through his spinal cord so that uh uh he was unable to move his legs and until we rolled him over, it wasn't obvious. So you're gonna document and communicate. All right. So we've done all of that. So let's go back to, are a young lady. Here's our young lady and now you've gone through your ABC DES, she's come in 10 minutes after her injury, she's struggling to talk, she's struggling to breathe, She's in pain. She's got this obvious open tibial fracture. So I hope now, now we've gone through that you, even as an undergraduate could approach this young lady systematically and look after her. And what would you do? Well, you're gonna do, look after her neck, we're gonna make sure that someone's looking after her neck. We're gonna check her breathing and chest is the airway blocked. And if there is there a, a deviated trachea and if there's hyper resonance, you might think about needle thoracocentesis to allow the, the lung to reinflate and or a chest drain. We almost certainly would get a chest x-ray because that's gonna give us some ideas. And then with her leg, a photograph speaks a, 100 words because once you've uh photographed it, we're gonna cover that wound up and you don't want to keep exposing the wound because that lets more bugs in. So you're gonna photograph it, you're gonna splint it because that will make it more comfortable and will stop any uh help to stop any further bleeding. You're gonna cover the wound so that it doesn't get secondarily infected and you're gonna give her some antibiotics and tetanus prophylaxis. So that we try and s uh uh stop any infection affecting the leg or her as a whole. We're gonna give her analgesia and having done all of that. You've, or hopefully got a patient who's now somewhat more stabilized and is what we call packaged and ready to be transferred. So you're gonna call help and you're gonna get some senior help and refer her on. And if you can do all of that, you get four marks in my book. So there we go. As I said, at the beginning, this is an image I hope you would never see to that image. To me says that um uh that you haven't done the resuscitation very well and it was all pretty awful. And if you follow the ABC des, you do it in a systematic way. You have a team approach, everyone approaching it properly. You will have AAA good outcome. All right, I'm gonna stop that. Uh We've got a few minutes left for some questions. Um I can see some things in the chat. Um uh Can't see anything in the chat at the moment. Uh asking specific questions. Anyone got any questions? Yes. A a crack crack on unmute yourself and turn your camera on. Go off, go for it. You want my camera on Yeah, watch over go for it. Uh The cushion is regarding with the DNA. Sometimes when the P uh patients come in and some uh and we save them like we try to do everything, we check the ABC S and we put them in the IC U. But then they say, oh I have a DNA and I, so we can say we can't know what from an unconscious patient like you signed a DNA. Our job was to just to do whatever in an emergency situation was to save. Correct. So, because there are issues where there, because there are issues that might uh people have sued the paramedics and the doctors as well. That, that will, you know, if, if someone has opted not to be resuscitated, then um you don't know that until someone tells you otherwise. Um and you, you will not be successfully sued and you can forget that you can just carry on until someone tells you to stop. Jas you had a, a question. Yes, I actually asked the questions you if that's ok, go for it. Um uh during the ABC S like um as I'm going through the ABC S, um the letter D stands for disability, what sort of disability am I looking for in? Um you're documenting neurological injury? So you're starting at the top with your apo, are they alert? Do they only respond to voice? Do they only respond to pain? Are they unresponsive that's in your primary survey and then in the secondary survey, you're gonna do a Glasgow coma score and then you're gonna do a peripheral neurological examination to see that is one limb not moving as well as the other. Is it a stroke? Um, uh, have they had a serious neurological injury? A a brachial plexus injury? So that one arm isn't working as well as the other or the same in the leg and you work your way down. Does that make sense? Oh, yeah, it does. Um My, my second question is um what is uh it's regarding GCS score? So what is uh the role of the GCS score during um resuscitation of of, of the patient? Good question. Um uh There is good evidence that if someone has a GCS score of less than nine, that they may well have a serious head injury and they may well be a patient who is better off being intubated and ventilated early because you will then lower the intracranial pressure uh quicker and earlier and like um make it more likely that they will suffer less of a neurological injury that make sense. Oh, yes. Thank you very much. Cool. Anyone else got any questions? Just shout out or stick your hand up doctor. There's one question in the chart it says um in the disability, if he's awake, should I complete a VP or move to the next? Yeah, so uh yeah, good question. Um uh So if the patient's awake and can respond to you then move on. You can do a Glasgow coma score. You can do a full peripheral neurological examination. So if they, they're awake and alert, yeah, you can move on. Absolutely. Anyone else. Uh One last one from you as had. Uh Yes, it's uh regarding the basic life support uh question uh different countries have different approach. Even different airports have different approach. Regarding the basic life support in which when we start chest compressions and some people say, ok, it's been more than 10 minutes. It's been more than 17 minutes and we have to consider it uh that or the patient is clinically dead, but some people continues it and uh some people say that the patient is unconscious for more than a time period and which has caused also many problems regarding uh some people are deliberately like even the paramedics with good intention. So, uh a doctor with good intention. So my very, my very short answer to you is you keep going until someone senior tells you to stop. And in my book, that's a minimum of 20 minutes and possibly 30 minutes. Uh But that's for another uh course and we'll do cover it in the uh primary trauma care course later this year. Ok. Well, I think you've got another lecture coming up relatively soon. I'm sure you need to grab a, a drink or something else. Um I hope you've enjoyed this talk um, uh, for those of you who are really bored, I'm giving another talk later today on femoral neck fractures. So we'll drill down into a little bit of, uh, day to day trauma. Um, we got another lecture on trauma later this month and we'll talk about trauma in a little more detail. And then, as I said, later in the year, um, there will be, uh, for those of you who can, uh, a, uh, uh, a primary trauma care course that will run over two days that we will do, uh, both hybrid. We'll do it online. Uh, we'll do lectures and discussions online and then we'll run some face to face, um, uh, skill stations being able to incubate patients, put chest drains in all of that, uh, fun and games. Uh, so you can get good practice at it. So I hope you've enjoyed it. Have a good rest of the day and I'll see you about, uh, three o'clock this afternoon. Right? Thanks. Thank you very much, doctor. Really appreciate the lecture and I hope, I hope everyone can finish the feedback form in the chat that I've posted twice and we've got a lecture starting in five minutes. Have a lovely day. Goodbye.