Initial Assessment and Management in Trauma a short overview for doctors in general and intersted public.. Donate your blood and Do it Now

I have given some of the content in Red useful for general public and if you are not a doctor and do not want to know all these, at least go to the end of the blog and read the sentence in red and see if you can do it!

Initial Assessment and Management

Roadside

Think of the following scenarios in RTA as you may be a doctor or a general public nearby!

12 year old girl with headache and arm pain

65 year old grandfather with bilateral shoulder and arm pain

38 year old mother screaming in agony

45 year old father dead on arrival to a local hospital

A Middle aged man

History of RTA

Brought with

Pulse 90/mt

BP 140/90mm Hg

RR 25/mt

The sixteen year old

RTA in Vayalur Road

Rings his parents at 5 PM

Taken to few hospitals before

Brought to Kauvery

Not very alert

Initial management of Trauma is different

to what we learn in our Medical Schools where we are taught to take a detailed history, do examination and investigate and then come to a diagnosis before treating a patient

Why

Multiple casualties

Do not want to miss Important injuries

Do not want to miss important injury until it is too late

Do know how to be safe to yourself

It is OK to Call for Help

Standard Precautions

Cap

Gown

Gloves

Mask

Shoe covers

Goggles/face shields

The following is a synopsis of what you do in an emergency of trauma

The quick ten second assessment for anyone to follow on the roadside and at initial contact

I am "   " and

What is your name

Tell me what happened

If you get answers to the two questions, we can relax a bit as the airway is ok at present and not in severe shock or head injury

Airway and Cervical Spine

worry about the airway if

Patient is not talking

Noisy breathing

Secretions, FB, Loose tooth

The Chest is not moving

Get the airway sorted out first by

Establishing A Patent Airway 

or

Securing a Patent Airway

                                         
And How?

Establish a patent Airway by Clearing of Secretions and blood, ensure that theTongue not falling back by pulling the chin forward but do not bend the neck backwards, and the safer method would be to do jaw thrust

Use Airway Adjuncts

Give Oxygen

Adjuncts

B for

And the

Muscles and nerves to control

How to assess by looking for the

Symmetry of chest movement

Respiratory rate

Tracheal position

Percuss and auscultate

Manage B:what do you do

If chest is not moving at all?

If Chest is moving unequally?

If Hyperresonant or dull to percuss and no air entry to one side?

C for

Heart

Major Vessels

Organs: Brain, Heart, Kidney, skin

How to assess

Heart Rate

Blood Pressure

Skin: Colour, Sweating

Conscious level

Urine Output

Manage C

Restore Volume and Control Hemorrhage

IV Access

Fluids

Blood

Put it all together

A-----------------------------With ----Cervical spine protection

B------------------------------

C------------------------------

Reassess

Be ware in Children, pregnant women and Elderly

Be ware of Pulse oximetry reading BP

D

Disability

D for

Neurological Evaluation

GCS

Pupils

Localizing Neurological Signs

Serially Assess for deterioration

E for  Exposure / Environment

Watch for Hypothermia


Get the history as below

A Allergies

M Medications

P Past Medical/Surgical History/Pregnancy

L Last meal

E Events/Environment related to injury

Detailed assessment

History

Complete head-to-toe examination

“Tubes and Fingers in every orifice”

Complete Neuro exam

Special diagnostic tests

Reevaluation

Head To Toe Examination

Head

Neck

Chest

Abdomen and Pelvis and Perineum

Extremities

Spine and Neurological examination

Communicate with patient and others

Pain management

Maintain Records

Before transfer

To X ray

To CT scan

To theatre

To ICU/Ward

Summary

Quick Assessment and primary survey, use adjuncts

Treat to correct the problem as you find

Complete detailed assessment

Hope you found the above synopsis useful

Remember there are two life saving drugs in trauma, one is oxygen and the other is blood and both are available or should be made available widely. Oxygen is outside 

but

Donate your blood and Do it today

Thank You

Warm Regards, Chockalingam

Point of View, right or wrong, value of money!

We stayed in a hotel in chennai. The amount we had to pay was 2005.00. The person behind the desk was given 2100.00. He gave back 90.00 rupees and said that he did not have the change of five rupees to give the ninety five he owed us. hence I made him to give back the hundred and said to him to settle the bill with the 2000.00. He was perplexed and asked me about the five rupees I would owe him towards the 2005.00 bill.

 I said to him that the five rupees is as important to me as it is to him. It was fascinating to see the look on his face. I hope you got the point.   This is " the point of view or view point". This is where "right or wrong" goes a bit vague. It may be right for you but can certainly wrong for somebody else.

But what should one look for if the right applies to the majority of people who are not involved in the scenario and how would the majority would vote for. this is how the jury system works in the court of law in some countries. if you are a medico, please refer to Bolam theory.

 Short blog but hope had a message

 Best wishes Chockalingam

Vitamin D Deficiency in India may be endemic, Be ware, Campaign for Vitamin D food fortification, a study from Trichy

We have been monitoring Vitamin D levels on a consecutive cohort of patients presenting to our hospital. The unpublished results showed 70 out of 85 consecutive patients tested for Vitamin D are deficient in this vitamin. Alarming Eh!

What does it actually mean? Vitamin D is an essential vitamin for the function of all our tissues and the bone in particular. But remember Vitamin D helps in absorption of calcium and keeps the balance with phosphate in the blood and the bone. Calcium is essential for the function of the bone, muscles, heart and the brain and all the tissues of our body.

If this vitamin is deficient, one would feel tired, body pain, back pain in particular, fracture our bones more easily. This vitamin is fortunately synthesized in our skin should we sufficient sun exposure with UV rays. "Maalai muzhudhum Vilayattu endru Vazhakkappaduthi kollu pappa" was sung by Subramania Bharathiyar makes sense for our children. This vilayattu should be outdoors with exposure to sunlight and not in front of our computers.

Deficiency in Vitamin D is termed, as Hypovitaminosis D. Hypovitaminosis D is also prevalent in children and the elderly living in developing world such as Latin America. Risk factors for Hypovitaminosis D in developing countries are similar to those reported in Western countries and include extremes of age, female sex, winter season, dark skin pigmentation, malnutrition, lack of sun exposure, a covered clothing style and obesity (Arabi et al). 

In a tropical country such as India, it is customary to expect Vitamin D deficiency to be rare due to the abundance of sunlight.  The prevalence of Hypovitaminosis D is considerably high in low latitudes. A survey by pediatricians at New Delhi's Kasturba Hospital earlier this year showed the presence of rickets among city children (Mudur et al). 

Vitamin D deficiency when clinically apparent is picked up by the clinicians though the presentation may not necessarily to one sub specialty..  Although severe vitamin D deficiency leading to rickets or osteomalacia is rare in Brazil, a developing country, there is accumulating evidence of the frequent occurrence of subclinical vitamin D deficiency, especially in elderly people (Bandeira et al). 

This sub clinical deficiency makes it even more difficult to quantify the true incidence of Vitamin D deficiency unless an epidemiological study across the whole nation is carried out. This would not be a priority in the national health planning in a country like India especially when the test itself is cost prohibitive.

In developed countries, food fortification has proven an effective and low-cost way to increase the micronutrient supply and reduce the consequences of micronutrient deficiencies. Fortified foods provide most of the vitamin D in the American diet. For example, almost all of the U.S. milk supply is voluntarily fortified with 100 IU/cup. 

In Canada, milk is fortified by law, “with 35–40 IU/100 mL, as is margarine at ≥530 IU/100 g” (Well et all). Other dairy products made from milk, such as cheese and ice cream, are generally not fortified. Certain breakfast cereals often contain added vitamin D, as do several brands of yogurt, margarine, orange juice, and other food products. Both the United States and Canada mandate the fortification of infant formula with vitamin D: 40–100 IU/100 kcal in the United States and 40–80 IU/100 kcal in Canada (Well et all).

In Europe, countries such as Finland have it mandatory to fortify the milk and milk products since 2003.[ Laaksi et al 2006]. Countries such as United Kingdom, Ireland, Scotland, Australia, and similar countries do not require fortification of foods though they allow optional fortification of staple foods such as breakfast cereals and margarine.

However majority of countries in the world do not use Fortification of foods to prevent Vitamin D deficiency. India is one of them.

Most of the studies have reported vitamin D deficiency in specific groups and speciality of medicine. This is a cohort study across all specialities in a multi speciality Hospital which helps us to understand the true incidence in patients attending a hospital. 

However we feel from this study of a very high incidence of clinical Vitamin D deficiency from a select group of patients presenting to a hospital may only be the tip of the iceberg. Even though an epidemiological study across the whole nation will truly reflect the real situation, would not be cost effective. 

As food fortification has rarely been used in the developing countries, we strongly recommend this as a cost effective option. It would be appropriate for a developing country like India as the risk factors for Vitamin D deficiency are the same as a developed country.

The cohort group showed a very high percentage of abnormality for a single test in a clinical situation. With the possibility of sub clinical Vitamin D deficiency, this study highlights the need for either a multi centric study to assess the true incidence in General population or 

simply Vitamin D fortification. 

Now what should we do? We need to campaign to the Government to bring on mandatory food fortification. This would reduce the incidence of this endemic in not only children but also the growing old age popuation who are often confined indoors. We are not going to get any support from the industry as the pharmaceutical companies are happy in selling vitamin D and Calcium supplements and making more money. 

We like to think that we should be taking medicines for every ailment, but in fact a lot of these ailments are preventable and this Vitamin D deficiency is one of them.

Please refer to the link on the side for the calcium rich foods that we can have but we need Vitamin D to help us to absorb the calcium from our diet.

Something to think about!

Best Wishes

Chockalingam

Wrist Arthroscopy at Kauvery Hospital Trichy in an young fit Defence Personnel

Technology has been rapidly catching up with our lives or one can say that our life has recently been spent catching up with the technology.

One should read the History of 20th century and especially the last twenty years of this century where great strides have been made in the technological revolution.



Medicine has been rather slow in catching up, but boy has it not caught up with it! Radiology, interventional, optics in scopy, computers in navigating surgery and robotics and so on and so forth.

The subject of this blog is arthroscopy which is a technique of viewing the inside of the joint to diagnose and more importantly to treat the joint ailments. Knees and shoulders are now optimally treated with arthroscopic techniques details of which we can go into another day.

The lesser known joints where this technique is useful are the wrists, elbows and ankles. A national security cadet had a wrist injury which caused him to be limited in his use of his left wrist and hand. he was unable to open a bottle by screwing the cap out. Of course he was not able to use the rifle which is essential in his line of duty.

The Magnetic resonance Imaging which shows the soft tissues well was performed on his wrist. this showed a torn cartilage. As you know the X rays which are used show only the bones. Majority of joint problems are to do with the cartilage and the ligaments which do not show on the X rays.

The availability of the technique of arthroscopy enabled us to look into his wrist without cutting it open and confirm the torn cartilage. The technology also allows us to repair the cartilage and in six weeks he was a happy person able to use his wrist as normal.

Now when i started training in Orthopaedics, we were excited to see the inside of the knee with a telescope, let alone do something inside. At present, "the advent of fibreoptics, high definition camera, power instruments and coablation techniques helping us to treat patients like this cadet in a second tier city in India" is remarkable.

Hats off to the Technology and Kudos to Kauvery Hospital in providing the technology to the people of Trichy and the surrounding Districts!

Best wishes

Chockalingam