Triage
A motor vehicle accident (MVA) took place at around 4 pm involving multiple casualties in a prehospital setting. It was reported that the vehicle was driving at an unknown speed when it left the road and collided with a concrete wall in the central reservation. The vehicle was found by a onlooker and the accident is thought to have occurred at 4pm. Ona arrival at the accident scene the time was recorded and quickly surveyed the scene by walking 360 degrees. The site was checked for any potential dangers for example, oncoming traffic, leaking fuel or fire, broken glasses and falling tree branches to ensure safety. After confirming the safety of the site and surrounding area, PPE was worn and a quick assessment of the casualties was done by conducting the Adult Triage Sieve (Carter, 2014). Further, assistance from the police, ambulance and rescue were requested using the ETHANE report (NSW Ambulance Intranet, 2015). This report is prepared to critically discuss the assessment and management of each of the casualties. The ABCDE approach is used for the purpose of assessment as well as management of all the three casualties separately as per the priority established through triage (Australian Resuscitation Council, 2016). The report also discusses the pathophysiology underlying each casualty’s signs and symptoms. Further, it is linked with their appropriate management. The objective of suitable trauma care is to stop early trauma mortality due to lack of oxygenation of vital organs or severe brain injury, or both. Lastly, the report is concluded with the key findings.
A triage would be performed in order to ascertain the priority among the three casualties as per the adult triage sieve (Smith, 2012) as shown in fig. 1.
None of the casualties were able to walk. So the next aspect to be checked is breathing. Casualty 2 (C2) and casualty 3 (C3) were able to breath properly but casualty 1 (C1) was short of breath so the command of “Open Airway” is expected to followed and when she starts to breathe, she is the immediate priority 1. Next respiratory rate is checked, C2 and C3 have RR between 10 and 29 but the RR of C1 is recorded to be 30, so she again becomes the immediate priority 1. Lastly, the pulse rate is measured which is under 120 for C1 and C2 but 120 for C3 so he becomes the immediate priority 1 in this case. So according to the triage sieve the order of care provision in this case of multiple casualty would be C1, C3 and lastly C2.
Casualty 1 who is a 35 years old female was semi-conscious and short of breath. Shortness of breath suggests partial airway obstruction as the entry of the air is diminished. Her decreased consciousness level is also a reason for airway obstruction.
Casualty 1
When the airway obstruction is not managed, it can quickly initiate cardiac arrest, so, it becomes the primary concern to clear airway and optimise breathing. For C1, head-tilt and chin-lift maneuver will be used to open the airway. However, protection of the cervical spine must be ensured (Austin, Krishnamoorthy, &Dagal, 2014). With the availability of suction equipment, suction of the airways will be done to eliminate the obstructions which could be blood in C1’s case. High-concentration oxygen will be provided using a mask with oxygen reservoir. Oxygen flow at around 15 L min-1 will be maintained. Because C1 is semi-conscious with a head injury intubation will be the optimal intervention to prevent secondary brain injury (Dash &Chavali, 2018). As it will control ventilation to optimise amount of oxygen going to the brain, otherwise CO2 will make the brain swell and secondary brain injury.
The respiratory rate of C1was counted to be 30/minute which is an indication of illness and a sign that the condition of C1 can worsen suddenly. The movements of the thoracic wall will be checked for symmetry and use of accessory respiratory muscles. Lungs will be auscultated. She must also be checked for other general signs of respiratory distress like sweating, central cyanosis, and abdominal breathing.
Since the breathing is inadequate assisted ventilation will be given to provide rescue breaths through bag mask ventilation.
Skin inspection can be significant in identifying the circulatory problems. Color changes, sweating, and a reduced degree of consciousness are indicators of lowered perfusion Thecolour of the hands and digits of C1 are checked along with the temperature. Heart should be auscultated with stethoscope. The heart rate of the patient was 115 bpm and blood pressure was 100/67mmHg. Low diastolic blood pressure is indicative of arterial vasodilation. Her reduced state of consciousness is also a sign of poor cardiac output (Nutbeam& Boylan, 2013). Haemorrhage from the forehead wound deep to bone is seen which shows slow oozing blood. For C1 additional neurological assessment might indicate signs of deterioration. As the injury to the forehead is obvious a brain injury is suspected, but the Cushing’s triad (bradycardia, irregular breathing and hypertension) is negative. Therefore, the likelihood of survival will be increased as opposed to positive Cushing’s triad (Nimmo, Howie & Grant, 2009).
Primary intervention should be of stopping the bleeding which will improve the sweating and paleness. Hypotension is a significant unfavorable clinical indication (Bose, Hravnak, & Pinsky, 2015). An IV (intravenous) line should be attained quickly so that saline infusion can be started immediately. Heart rate and and BP must be reassessed every 5 min and the target should be to attain patient’s normal BP. Direct manual pressure can be applied to stem visible bleeding.
C1 is found in a semi-conscious state. Pupils should be examined for size, equality and sensitivity to light.Various methods can be utilised for quick initial assessment of the C1’s conscious level. The AVPU method involves Alert, responds to Vocal stimuli, responds to Painful stimuli or Unresponsive to all stimuli (Kheirabadi, Tabeshpour, &Afshari, 2015). C1 was found semi-conscious, alert to vocal stimuli and alert to painful stimuli. Further, limb movements must be examined to check for possible signs of lateralization.
Casualty 2
The above mentioned ABCs should be reviewed and treated as the best immediate treatment for patients with a primary cerebral condition is stabilization of the airway, breathing, and circulation. It is essential that hypoxia and hypotension is excuded and if identified then should be treated. She must be reviewed regularly at frequent intervals, as deterioration can take place quickly and she can be lucid following a substantial head injury before deterioration.
C1 should be examined properly which can be done through full exposure of the body. Body temperature should be measured. A head to toe clinical examination must be done for signs of trauma, skin rashes and signs of DVT. It was found that she has bruises over chest and abdomen. Chest bruises suggest that the patient suffered injury over chest area and it could be a reason for high RR. She has an obvious and significant forehead wound most likely be due to her direct contact with steering, dashboard and airbag (Eid& Abu-Zidan, 2007). This could result in severe head trauma, possible brain damage like subdural hematoma and cerebral tissue inflammation. An increase in intracranial pressure and lowered brain functions must be checked (Como, Smith &Grabinsky, 2012). Injury to the internal organs of the chest is also possible due to compression from the seatbelt or huge impact from steering wheel and airbag that might have caused internal organs to hit their hard internal structures (Dickson, 2004).
It is essential that her dignity is respected and heat loss is minimised. Assess the body temperature (Rull, 2014). The bruises must be attended to by applying antiseptic and bandages.
Casualty 3 who is a 60 years old male was found sobbing. He was conscious which was an indicator of a patent airway.
On assessing C3, it was found that he was diaphoretic and pale which are the general signs of respiratory distress. His respiratory rate was also 28 which indicate that the condition of patient may worsen suddenly.
Assisted ventilation will be performed by providing rescue breaths. It can be done with or without using a barrier device.
C3 exhibited active haemorrhage from groin due to the penetration of piece of metal. On heart auscultation, the heart rate was recorded to be 120 bpm. Blood pressure was hypotensive 90/45mmHg. C3’s comparatively lower diastolic blood pressure is suggestive of arterial vasodilation as in anaphylaxis or sepsis (Eduardo Vilar Gomez, Bertot, Garcia, Rodriguez, & Perez, 2014).
C3 should be made to sit comfortably by removing the seatbelt. The piece of metal should be removed carefully, bleeding should be stopped and the wound should be covered. A bolus of 250 mL of warmed crystalloid solution over less than 15 min should be given. It will raise the preload and thereby increase organ perfusion because it is raising arterial pressure. Heart rate and BP should be reassessed regularly, aiming for the target > 100 mmHg systolic. An IV (intravenous) line must be attained as quickly as possible and infusion should be started.
Seatbelt must be removed and C3 must be made to sit comfortably. He should be assessd for signs like symmetry and dilation of pupil, damaged or lack of light reflexes, and weakness. He should also be checked for motor function of limbs for lateralising signs.
Casualty 3
It is essential that hypoxia and hypotension is excluded and if identified then should be treated. Further the ABCs should be reviewed so that the debilitating symptoms are improved.
Clothes should be removed keeping in mind the dignity of the patient to enable conduction of a detailed physical examination. Body temperature must also be assessed by touching the skin or by utilising a thermometer.
It is essential that after examining C1 adequate measures are taken to prevention of heat loss by using warming equipment or clothing.
Casualty 2 who is a 55 years old male was laying in the ditch 4 meters behind the vehicle. When he was found screaming in pain. He was fully conscious which was another indicator of a patent airway.
C2 is responding in a normal voice, which suggests that his airway is patent. Therefore, No airway adjunct is currently needed for C2 because also he is alert.
C2 will also be checked for the signs of respiratory distress. Lungs ausculatationmust be done and respiratory rate must be counted.
C2 also demonstrated the RR of 26/minute which is high.
Heart auscultation will be performed with the help of stethoscope. The heart rate was 115 bpm. The blood pressure was measured to be 105/75 mmHg. The peripheral and central pulses must be assessed for presence, speed, frequency and equality. With a heart rate of 115 beats per minute, respiratory rate of 26 and blood pressure of 105/75mmHg, C1’s body may be compensating for hypovolemia (Pacagnella et al., 2012). However, tachycardia and tachypnoea could also be due to the severe pain experience by C1 (evidenced by the fact that C2 is screaming in pain) from the suspected fracture or dislocation of the legs. Left leg is swollen till mid-thigh and grossly deformed which shows edema. Fracture is common in MVA as the body is impacted by kinetic forces. The patient is alert and screaming in pain which shows a sound level of consciousness. An immediately occuring swelling after the injury indicates substantial haemarthrosis, which is bleeding occurring because of damage to a bone or ligament (Gupte& Mart, 2013). The neurovascular status of the limb should be monitored regularly.
Primary survey should be done first to rule out the life-threatening injutries, then secondary survey must be done to check for limb-threatening injuries before before focusing on soft-tissue damage sustained by the leg. Lower limb should be stabilizied. The open wounds should be covered up with saline-soaked sterile gauze. Pain to the legs can be managed through traction splinting in order to stabilize the legs in case of fractures. Moreover, pain relief such as morphine is appropriate for pre-hospital pain management in suspected fractures (Parkers & Rodgers, 2015). However, it is important to continue assessing airway patency, respiratory rate, level of consciousness and sedation levels, as these can be affected post morphine administration (Bendall, Simpson, & Middleton, 2011).
AVPU method can be utilized to assess the level of consciousness quickly. In this method C2 will be graded as alert (A), voice responsive (V), pain responsive (P), or unresponsive (U). C2 was found alert and pain responsive. Pupillary light reflexes must be examined. C3’s blood glucose can also be checked. If the level of consciousness is decreased because of low blood glucose, it can be fixed rapidly by administering glucose orally or infusing it through IV line.
The patient should be made to sit comfortably. The above mentioned ABCs should be reviewed and treated as the best instant management for patients with a primary cerebral condition is maintaining the airway, breathing, and circulation (Thim, Krarup, Grove, Rohde, &Løfgren, 2012).
Patient should assessed by undressing him but hypothermia should be prevented. As his left leg is grossly deformed and swollen to mid-thigh, his clothes need to be cut off. Signs of trauma, bleeding, skin reactions (rashes), needle marks, etc, must be observed from head to toe. The quick and repetitive acceleration-deceleration must have impacted C2’s body and there is a possibility that he might have sustained serious injuries as he was not restrained. It further implies that he could have injured his internal organs.
After examination, attend to prevention of heat loss with warming devices, warmed blankets, etc.
Conclusion:
To assess and manage the critically injured patients in a motor vehicle accident is a difficult task in a pre-hospital setting and therefore, needs a quick and organised approach. It is important to do a 360 degree walk around the injury scene in order to check for any potential signs of danger and ensure safety. Further, in case of multiple casualties, prioritisingshould be done using a tool such as the Adult Triage Sieve. It will be useful in sorting out casualties as per their severity so that suiatble assistance can be ascertained using the ETHANE report. Further, the handing over the report of Basic and Advance Life Support to hospital authorities would require the use of an evidence based handover tool (Shelton & Sinclair, 2016), such as ABCDE approach so that all the aspects of the injuries can be communicated effectively. The pre-hospital care should also give recommendations with respect to further diagnosis. It can prove to be significant in verifying any suspicions originating from continuous assessment prior to reaching the hospital and lower the the risk of mortality and improve the health outcomes for the casualties.
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