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Shalamar Trauma Support Module

Shalamar Trauma Support Module (abbreviated STSM) is a training program for medical providers in the management of acute trauma cases, which is refelection of ATLS developed by the American College of Surgeons. It has been tailored to the requirements of medical students and our set up. Similar programs exist for immediate care providers such as paramedics. The program has been adopted worldwide in over 60 countries, sometimes under the name of Early Management of Severe Trauma, especially outside North America. Its goal is to teach a simplified and standardized approach to trauma patients. Originally designed for emergency situations where only one doctor and one nurse are present, STSM is now widely accepted as the standard of care for initial assessment and treatment in trauma centers. The premise of the STSM program is to treat the greatest threat to life first. It also advocates that the lack of a definitive diagnosis and a detailed history should not slow the application of indicated treatment for life-threatening injury, with the most time-critical interventions performed early. However, there is no high quality evidence to show that STSM improves patient outcomes as it has not been studied.

 

Airway maintenance with cervical spine protection

 

The first stage of the primary survey is to assess the airway. If the patient is able to talk, the airway is likely to be clear. If the patient is unconscious, he/she may not be able to maintain his/her own airway. The airway can be opened using a chin lift or jaw thrust. Airway adjuncts may be required. If the airway is blocked (e.g., by blood or vomit), the fluid must be cleaned out of the patient's mouth by the help of suctioning instruments. In case of obstruction, pass an endotracheal tube.

 

Breathing and ventilation

 

The chest must be examined by inspection, palpation, percussion and auscultation. Subcutaneous emphysema and tracheal deviation must be identified if present. The aim is to identify and manage six life-threatening thoracic conditions as Airway Obstruction, Tension Pneumothorax, Massive Haemothorax, Open Pneumothorax, Flail chest segment with Pulmonary Contusion and Cardiac Tamponade. Flail chest, tracheal deviation, penetrating injuries and bruising can be recognized by inspection. Subcutaneous emphysema can be recognized by palpation. Tension Pneumothorax and Haemothorax can be recognized by percussion and auscultation.

 

Circulation with hemorrhage control

 

Hemorrhage is the predominant cause of preventable post-injury deaths. Hypovolemic shock is caused by significant blood loss. Two large-bore intravenous lines are established and crystalloid solution may be given. If the person does not respond to this, type-specific blood, or O-negative if this is not available, should be given. External bleeding is controlled by direct pressure. Occult blood loss may be into the chest, abdomen, pelvis or from the long bones.

As of 2012, use of rFVIIa is not supported by evidence. While it may help control bleeding, there is a risk of arterial thrombosis, and other than in those with factor VII deficiency, its use should be limited to clinical trials.

 

Disability/Neurologic assessment

 

During the primary survey a basic neurological assessment is made, known by the mnemonic AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive). A more detailed and rapid neurological evaluation is performed at the end of the primary survey. This establishes the patient's level of consciousness, pupil size and reaction, lateralizing signs, and spinal cord injury level.

The Glasgow Coma Scale is a quick method to determine the level of consciousness, and is predictive of patient outcome. If not done in the primary survey, it should be performed as part of the more detailed neurologic examination in the secondary survey. An altered level of consciousness indicates the need for immediate reevaluation of the patient's oxygenation, ventilation, and perfusion status. Hypoglycemia and drugs, including alcohol, may influence the level of consciousness. If these are excluded, changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise.

 

Exposure and environmental control

 

The patient should be completely undressed, usually by cutting off the garments. It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient privacy should be maintained.

 

Secondary survey

 

When the primary survey is completed, resuscitation efforts are well established, and the vital signs are normalizing, the secondary survey can begin. The secondary survey is a head-to-toe evaluation of the trauma patient, including a complete history and physical examination, including the reassessment of all vital signs. Each region of the body must be fully examined. X-rays indicated by examination are obtained. If at any time during the secondary survey the patient deteriorates, another primary survey is carried out as a potential life threat may be present. The person should be removed from the hard spine board and placed on a firm mattress as soon as reasonably feasible as the spine board can rapidly cause skin breakdown and pain while a firm mattress provides equivalent stability for potential spinal fractures.

 

Tertiary survey

 

A careful and complete examination followed by serial assessments help recognize missed injuries and related problems, allowing a definitive care management. The rate of delayed diagnosis may be as high as 10%.

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