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Okay, so eyes, apartments being respect for one. Okay, good. Okay, s. So, um, I'm gonna be talking to your old bite the assessment off. Be looking specifically for me. And, uh, killer diagnoses on during their primary survey. Nine. And they're called the Six Colors on on a Z go three. This presentation. We're gonna talk about the recognition off the injuries before any imaging really occurs on. Then we're going to go through the immediate steps that any it's take to treat them. So that's a nice we pneumonic them at, um, f c on. This is one that's taught widely and drama courses and clean a TLS s. So it stands for very obstruction. Attention. Pneumothorax, open pneumothorax. Massive hemothorax flail segment on cardiac Tampa night a. DeLee. You want to identify? Um, treat all these issues before going for a CT trauma Siris. But there will be some times when you may not know that there's, ah, attention you monitor extra on. You know, it may be developing by the time I actually get to the CT scanner, or the hemothorax is small and then becomes mouse of by the time of C tape. But those circumstances a rare usually if one of these color diagnoses we're gonna happen. They're gonna happen earlier, on on on the initial primary assessment. So in terms of airway obstruction or disruption, there's no Monica that is used called 12, and I try and remember whenever I'm doing on their way assessment for for trauma patients. So looking up, trick your position. Uh, so let's see if it's deviated to one side, then that's going to give you a clue to attention pneumothorax or human? Thanks. Uh, if there any obvious wooden's there, then you may need to address those immediately. If there's a wind that actually has penetrated into the trachea, then you may actually teo intravenous through that wind, depending on on how it looks. But if you've had a stop, my call from the paramedics that have identified this this potential, then you want anesthetics and easy consultants at the head of the bed. So when they arrive in, you can make that assessment those whether they get a standard integration or ah, modified intubation or even front of Mac access. Uh, no, I airway obstruction may not happen immediately if you've got something like an expanding hematoma from, say, carotid artery rupture, Then the airway could progressively become more disrupted over time. If that's the kiss, you have an expanding pulse, little hematoma off the neck. Then they need to be interviewed immediately to secure the airway before it becomes a knish. You as in the picture. If they've got loads of bruising around there, you're gonna need to worry about it. Vascular entry, possibly even a large E l a tricky all damage. If you press over the larynx and you get lots of crepitus, then you may have a large enough fracture on a snail. It's sad when you're better on your C spine color. If you've got loads of distended neck veins that may give you on Dication is too, Um, you know, attention, you move the answer cardiac tamponade, and then the is do this every time. Other indications that there might be a way issues you've got paradoxical movement of the chest and abdomen whenever they're inspiring, or if there's a silent chest that will give you an indication. A swell. As the office stranger night the management wants you don't fade that there's an issue. Get oxygen on every single trauma patient. Um, Andi, start with your simple airway maneuvers. I If it's drama scenario, we're not going to do your head tilt chin left. So start off with John Thrust on airway suction to get any blood vomit secretions under there. If there's any solid material, then used some Miguel's forceps under direct vision to remove those and those pieces. If you need to step it up usually or referring Deal Airways or largely old mask airways of waiting that there's a friend deals on, uh, them. If the decision is that they need to be interviewed ID, you're gonna do it with your manual and nine stabilization by the most senior operator, which would most likely be on statics with a D is, uh, back up. Um, if everything goes to part, you may have to do the front of neck access. So planning nights, your airway, uh, plans Early on, If you've already escalated beyond Plan B, I would say Ask for crack a thorough doctor, make it to be at the bedside so that if he ever get into plant dear, he it's already there and available. So with attention, um, authorities, on the recognition of them can be difficult on by myself of missed one but very rare kiss on patients will often present with hypoxia. First, there's a lot of thinking that tension, um, authorities, The way they kill you is by kinking the great vessels and pinion teo shock from that point of view, but they quite often or hypoxic first on. Then they become tacking. I pretence it with the with the obstructive shock. If you're treating your shock with fluids, blood and they're not responding like they should do a consider that they have attention your mouth or ex distended neck veins. I don't think I've ever seen it with attention, but if it's there and you've seen on your airway assessment, keep it in mind. If they're hyper resident to percussion on on one side with decreased breath sides Hyperinflated on did consider that they have attention. You move in the setting off hypoxia on a shock. Um, don't rely on tricky deviation because it's very low and sign on. Most likely, you'll have everything else preceding it. So don't go look in front first, uh, night for the management. It's an immediate finger thoracotomy or needle decompression. Most trauma courses will advise finger thoracostomy first. Uh, nice. If you're not comfortable doing that, you can use middle. The compression a TLS does advised night that you did in the triangle of safety. So that's in the medics Ilary line on fifth intercostal space or fourth on The reason I preferred in a finger third cost me is because you've already then partially done the chest re in. But if you've got someone who is a boksic on day shark on, do you think it's attention you can do your finger thorough? Cost me to relieve the pressure and now you've transformed attention pneumothorax into Justin open pneumothorax on you. Don't then immediately have to place the dream because you've you've essentially treated the immediate life threatening injury. If there's another, then you can go and treat that come back and place the dream. When you have time some there's, ah, open, um, threats. His next dose, you may hear called a sucking chest wind. Uh, it's important when, um, anyone has any injuries to the back. You need the logroll them check out the chest because someone has been stabbed in the back on. You don't log rhythms. You won't find that that pneumothorax for a while. No, I have got a video here. Awfully demonstrations. Why, um, authorities on open your mouth Or is he's calls her spirit compromise. I kill people so pneumothorax. So as you can see here we have our lung in the bottle here. And so we know that when we are ventilating, inhaling, exhaling were manipulating the Has there been able to see the video of the moment? No. Let me see if I can, uh, share Teo the video. You will see that. Okay, open pneumothorax. So as you can see here, we have our lung in the bottle here. And so we know that when we are ventilating, inhaler and exhaling were manipulating the four AKs pressure the pleural space pressures and creating negative pressure to inhale and exhale. As you can see. Inhale, exhale, inhale, exhale. But if we have an open for it. So I just created a little hole here that could manipulating are open pneumothorax and open pneumothorax. And so look what happens when I try and deflate. Try inflate that blue. I can't create any negative pressure in the pleural space. If I can't create any negative pressure in the post space, then I'm not able to inflate this month appropriately. That's going to be a big problem. So that's why we want to try and seal it and make sure that we can create negative pressure in order to inflate that lump again. That's how and open your motor Actually a real big problem for not intervening. Okay, so back to the talk about pelvic fractures, the hell they can occur in rare inclusion. He's actually, if you're not wearing a seatbelt now we know what seatbelts. Sorry about that, right still after the presentation. So hopefully that is an indication is the white open Your new math or C's are so dangerous If the if the size of the hole is greater than two thirds the diameter off have the trachea than a rubber preference preferentially move through the chest wind rather than the trachea, so you don't have to have a wind that big. Maybe, you know, 23 centimeters before you will stop them bleeding through your airway on trying ventilated through that, that wouldn't on. So, uh, the management then try is a three sided occlusive dressing, and I lot of companies have, you know, branded occlusive dressing's I ever. If you don't have something like that, you can literally tip dine. Any can addressing across the wind, long as it's got three sides included on one side open. What that does is essentially create a one way valve where, when they and he'll the wind slam shut when they exhale, then their chest will push it. I threw the dressy on, then that will essentially reinflate their their lung on. Then when they're stabilized, then you can move on to have a formal chest re in night. That can go three different rib space. It cannot go through the wind itself, and you'll need to do a formal exploration off the wind before closure. The reason You don't get your chest or in through that window because, let's face it, it would be very handy because you've already got your tract. But there will be lots of dirt. It's a completely septic wind on if you stick a chest xray in through there, you're going to introduce infection into the little cavity. Um, okay, so with massive actually hemothorax, uh, this may not be a parent right quickly on your primary survey. But just like with the tension pneumothorax, you're gonna have decreased movement on that side. It may be hyperinflated be gonna have decreased signs. But this is where instead of the tension, you're more threats. We have high for residents to percussion. It's gonna be able residence. So in your tap on it, it's gonna sign dull. A massive in thorax is defined as blood loss more than 1500 mils at one single time point or more than 200 mils per our for two hours Night event If you know off Scot Langhart is a critical care am doc in America. His definition off massive hemothorax is whatever my blood that scares you. And I think that's ah more appropriate definition I if you have him a frax on one side and you place a tree and and it's just holding blood, I don't really need you to kind of the 1500 mils if its hose and blood on their unstable Yeah, get the master Transfusion protocol and kept blood back into them. Nine. If you do a soup plain chest, actually, then you may not actually see any blood whatsoever, because all pools behind the lung and spread right. So mass. It's a lot of blood. You're not going to get that white on. You need to 150 mills of blood before it'll actually be visible on interact chest X ray. So this is the sort of presentation where you might pick it up on your CT scanning. If you're doing a fast scan withdrawn designed, then you're more likely to pick up that there's a confusion. How are him thorax on one or both sides. It won't tell you how much fluid is there, but at least you'll you'll be aware of it. Treatment for, uh which again? Chest trim on I get blood into, um, really? Because if they're gonna be hemorrhaging 100 mils and are for a couple of bars or the dry and later and a half, you don't need a lot of packed red cells toe. Get the shackle it in volume back up night. There's always a worry about drinking too much blood quickly on what effect it'll have in the human dynamics. But every dream a blood right on you re expand the lung. You may actually tamponade any bleeding vessels so it might slow the rid of bleeding, but it's it's fine balance. The definitive treatment would be a thoracotomy. I if they go into a cardiac arrest, then they may need a CT resuscitated thoracotomy on. But we'll talk about that on board of subsequent venues I delayed their stabilize on Once have been through the CT scanner. You may see where the bleeding pointers much kiss called and sand to the royal on cardio thoracic six could be notified on. Don't take a patient from for a media thoracotomy, I feel segments. These are sometimes tricky to pick up clinically there to find his fractures off. Two or more contiguous ribs, up two locations, almost ribs. So, for example, and fractures on ribs six ounce, seven on the left hand side with fractures anteriorly on posteriorly. So you get this segment of chest, which has paradoxical movement when you're breathing. In a caveat to that is that only works if they're breathing spontaneously. If you've interviewed them, you'll have them on positive pressure ventilation on. So that will correct the paradoxical movement so you won't know about it. I ever They will quite often be picked up on CT scanning if they've got a lot of bruising over the chest wall and you pop yet over those bones and you feel burning crepitus the not usually a good indication that there's a fracture there. I'm going to show you another video off a flail segment on this is quite obvious. Okay, so maybe just time change it over. You said they're okay. So So you can see by dramatically there that there's a feel segment. There's a defined portion off that chest wall, which is completely sucking in. Um, so I don't think anyone would be able Teo mistake that, uh, close that dying okay, as so with feel segments depends on the size on high compromised respect. Realize they are at the most important thing is analgesia. Lots of it. A nice and early on. A lot of our trauma patients will be getting morphine straight off the bat. Sometimes make academy with feel safe in specifically, it's good to give them a regional anesthesia so you can have a chat with anesthetics if they haven't already been at The bedside is part of the tropical. They can do all sorts of regional on the CT anesthesia Introvert abril, paraspinal Erector speak and I Stratus Interior would be one of the best ones for this on. Essentially, that will take away the peon, unlike them to breathe deeper on M pre the ventilation. Sometimes the may need live again. It helps to reduce the paradoxical movement off the chest wall. I've never seen it personally being used for a field segment, but it's possible. One of the key things is that you need to keep a close eye on them over several ours because, as as the peon builds up on, they start to tire. They won't breathe deeply on then on. That actually can go into your respiratory failure on the main it in together at that time on. So you want to know early if they're gonna feel get that trip and almost prophylactically, so keeping them in resource, you know, for several hours after the initial primary survey just for ventilatory observation is warranted on. They will need sounds, the respiratory it, but but checking the Risperdal effort on That's where you need someone actually be looking at their chest and looking at how the patient is doing not just recording numbers and on having an art lane and place would be very beneficial for these sorts of patients because you're gonna wanna check serial a beegees on a BG may tell you I had a time that they're tiring before clinically it becomes apparent on that's when you can get anesthetics involved. Planet, um, elective interview tree. And so some of them. Um, so this is for anyone who has handed with an option probe. You tend to get a cardiac tamponade more with penetrating traumas rather than blunt on. It doesn't take that much blood before you actually get tablet 75 mills is enough to do it. It doesn't cause is obstructive shock on the classic description is backs. Try at That's distended Anacins. Um uh, inaudible or difficult to hear heart sounds, muffled heart signs And on, uh, yeah, from hypertension night. With the advent of ultrasound, you can actually pick the diagnosis up a lot sooner. But the time they get distended acciones muffled heart signs, which are you going to hear in a trauma setting and resource before shock set? It's difficult, But if you get the scanner on on, you say you something, just think. And these videos big pocket of blood around the heart. Then you know what what the diagnosis is. And sometimes they have pulses, paradoxus, electrical, our ultimate off turn ons on all these sort of things. But, um, again, unreliable signs. So because tension, um thanks also presents with obstructive shock to stand in activations, it could be difficult to distinguish. It's not the top of everything differential less when ever have chest trauma. So, uh, I would I would advocate personally that you got a trauma in with chest pain. Gets under through on echo probe on heart and see if they're screwed. I management fluids. Teo, keep They're circulating. Volume is as good as possible. Try and get the radio trim. And the right ventricles full of fluid is possible. So you can actually get some cardiac. I put eggs. That's what the problem is. They're right. Intria on ventricle has been squashed closed, so can't fell with fluids. Thean ish ulcer able izing treatment is a pericardiocentesis. No, If you don't have ah, a specific pericardiocentesis kit, then don't worry. A Central Inc it will do. All you really need is a long cannula on a long needle on a lot of guts on day. That'll that'll do the job for you. Ideally, it should be under ultrasound guidance. But it doesn't have to be, have you? If you have to do a blind, then you go Just lose a few sternum just to the left him in the temperature needle towards the tip off the patient scapula. And as soon as you have blood aspirin on. Usually it's a very rapid recovery. Um, because if only 75 mills is needed to cause tamponade, if you take 20 mils at it, that you should see an immediate improvement and BP on the heart rate night defendant treatment is part peri cardio me on. Or if they go into, um, a rest authority got me on again. New will cover that. This is talk later on. So does anyone have any questions about any of the sex killers? Move, Doctor. Right. So far. Especially. All right, sure. So