Trauma 2 PDF

Paramedic Science Health & Human Development 2 Trauma  WARNING This presentation contains a number of disturbing slides, images and videos that some people may find disturbing.  Definition “Trauma can be defined as an extrinsic force acting upon the b...

Paramedic Science Health & Human Development 2 Trauma  WARNING This presentation contains a number of disturbing slides, images and videos that some people may find disturbing.  Definition “Trauma can be defined as an extrinsic force acting upon the body.”  A PHTLS Approach So what is a PHTLS approach. PreHospital Trauma Life Support or (PHTLS) is the assessment and management tool that is used to deal with any trauma patient. Similar to an A-E Assessment or ALS Assessment. It is the most commonly used tool to assess Trauma Patients in the world. Initially formalised and created by the National Association of Emergency Medical Technicians (NAEMT). It is recognised by both the College of Paramedics and The Health & Care Professions Council as the preferred assessment tool for dealing with Trauma Patients.  PHTLS Primary Survey A PHTLS Primary Survey is not the same as a standard A-E Assessment. The PHTLS Primary Survey is a rapid assessment that should take no longer than a few minutes and is designed to identify and manage any acutely life-threatening problems that may be present early, before the patient deteriorates. *No observations are gained during this phase of the assessment.*  PHTLS Secondary Survey The PHTLS Secondary Survey as a more detailed analytical assessment of the patient. Considered more in line with a Head-to-Toe Assessment of the patient. Managing any injury found in the order of priority. Baseline observations will be gained and managed accordingly during the PHTLS Secondary Survey.  PHTLS PRIMARY SURVEY  PHTLS Primary Survey SCENE SAFETY Dynamic Risk Assessment Standard Infection Control Procedures (Consider Double Gloves for Assessment) Mechanism of Injury Number of Patients Additional Resources  PHTLS Primary Survey SCENE SIZE UP / GLOBAL OVERVIEW Visual Head to Toe Colour Appearance Position of the Patient Catastrophic Haemorrhage (Apply Tourniquet, 6cm proximal to injury) Adopt/Consider C-Spine Control Identify/Manages Time Critical Problem  PHTLS Primary Survey RESPONSE Checks ACVPU If Unconscious Check for pulse & Breathing to exclude TCA AIRWAY Visual Inspection Identify/Manages Time Critical Problem  PHTLS Primary Survey BREATHING Estimate the Respiratory Rate Apply High Flow O₂ Visual Inspection of the Palpation Auscultation Percussion Identify/Manages Time Critical Problem  PHTLS Primary Survey CIRCULATION Estimate Pulse, Rhythm & Strength Skin Colour / Temp / Texture Capillary Refill Peripheral / Central  PHTLS Primary Survey BLOOD ON THE FLOOR & 5 MORE External Blood Sweep checking natural hollows, then internal blood sweep. 1. Head 2. Thorax 3. Abdomen 4. Pelvis 5. Femurs Identify/Manages Time Critical Problem  PHTLS Primary Survey DISABILITY Pupillary Assessment Glasgow Coma Scale Abnormal Behaviour / Agitation Hypoxia / Drugs / Alcohol Pre-existing Condition Identify/Manages Time Critical Problem  PHTLS Primary Survey EXPOSE & EXAMINE Remove clothing to assess extremities Upper limbs PMS Lower Limbs PMS Maintain Dignity & Temperature Identify/Manages Time Critical Problem  PHTLS SECONDARY SURVEY  PHTLS Secondary Survey HEAD TO TOE EXAMINATION Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations & Swelling (DCAPBTLS) Head Face Pupillary Assessment (PERRLA)  PHTLS Secondary Survey AIRWAY Visual Inspection NECK Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations & Swelling (DCAPBTLS) Palpate C-Spine Apply Collar if Necessary Check for Jugular Vein Distension / Tracheal Deviation / Surgical Emphysema  PHTLS Secondary Survey CHEST Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations & Swelling (DCAPBTLS) Gain Full Respiratory Rate / Depth / Rhythm Gain SPO2 Visual Inspection Palpation Auscultation Percussion  PHTLS Secondary Survey ABDOMEN Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations & Swelling (DCAPBTLS) Palpate abdomen PELVIS Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations & Swelling (DCAPBTLS) If immobilised already no further handling Visual inspection for incontinence Check for priapism  PHTLS Secondary Survey BACK Only log roll if necessary EXTREMITIES Upper Limb Assessment including PMS Lower Limb Assessment including PMS Immobilised / Treated Appropriately  PHTLS Secondary Survey GAIN OBSERVATIONS Pulse Rate Blood Pressure Cap Refill ECG GCS Blood Glucose Temperature  PHTLS Secondary Survey HISTORY TAKING Gain SAMPLE Conduct SOCRATES / Manage Accordingly Social Hx Family Hx Identify appropriate trauma Pathway  Traumatic Brain Injury Traumatic Brain Injury (TBI) is a disruption in the normal function of the brain that can be caused by a blow, bump or jolt to the head, the head suddenly and violently hitting an object or when an object pierces the skull and enters brain tissue. Observing one of the following clinical signs constitutes alteration in the normal brain function: Loss of or decreased consciousness Loss of memory for events before or after the event (amnesia) Focal neurological deficits such as muscle weakness, loss of vision, change in speech Alteration in mental state such as disorientation, slow thinking or difficulty concentrating Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of damage to the brain. Mild cases may result in a brief change in mental state or consciousness. Severe cases may result in extended periods of unconsciousness, coma, or even death.  Intracranial Pressure (ICP) Cushing’s triad refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain. Cushing’s triad consists of bradycardia (also known as a low heart rate), irregular respirations, and a widened pulse pressure. A widened pulse pressure occurs when there is a large difference between the systolic blood pressure (the blood pressure when the heart is contracting) and the diastolic blood pressure (the blood pressure when the heart is relaxing). If C-Collar has been applied, it should be loosed slightly to reduce the risk of ICP  Skull Fractures There are 4 main types of Skull Fractures, They are: Linear skull fractures. This is the most common type of skull fracture. In a linear fracture, there is a break in the bone, but it does not move the bone. These patients may be observed in the hospital for a brief amount of time, and can usually resume normal activities in a few days. Usually, no interventions are necessary. Depressed skull fractures. This type of fracture may be seen with or without a cut in the scalp. In this fracture, part of the skull is actually sunken in from the trauma. This type of skull fracture may require surgical intervention, depending on the severity, to help correct the deformity.  Skull Fractures Diastatic skull fractures. These are fractures that occur along the suture lines in the skull. The sutures are the areas between the bones in the head that fuse when we are children. In this type of fracture, the normal suture lines are widened. These fractures are more often seen in new born’s and older infants. Basilar skull fracture. This is the most serious type of skull fracture, and involves a break in the bone at the base of the skull. Patients with this type of fracture frequently have bruises around their eyes and a bruise behind their ear. They may also have clear fluid draining from their nose or ears due to a tear in part of the covering of the brain. These patients usually require close observation in the hospital.  BATTLE SIGNS (Mastoid Ecchymosis)  RACOON EYES (Bi-Lateral Periorbital Ecchymosis)  Skull Fractures Epidural hematoma. Epidural hematomas occur when a blood clot forms underneath the skull, but on top of the dura, the tough covering that surrounds the brain. They usually come from a tear in an artery that runs just under the skull called the middle meningeal artery. Epidural hematomas are usually associated with a skull fracture. Subdural hematoma. Subdural hematomas occur when a blood clot forms underneath the skull and underneath the dura, but outside of the brain. These can form from a tear in the veins that go from the brain to the dura, or from a cut on the brain itself. They are sometimes, but not always, associated with a skull fracture. Skull Fractures Brain Injury  Concussion Concussion is also often referred to as mild head injury, minor head injury or mild traumatic brain injury (mTBI). Regardless of the terminology used, the occurrence of a head injury in these cases causes the brain to shake back and forth inside the skull, causing mild damage. Concussion is commonly caused by falls, road crashes, assaults and sports accidents. While most mild head injuries result in no long-term damage to the brain, it can cause temporary disruption to brain function that can last for at least a number of weeks. Mild head injury/concussion is defined by: Loss of consciousness of less than 30 minutes (or no loss of consciousness) Post-traumatic amnesia (PTA) of less than 24 hours after injury (this is a period where people are confused, act strangely and are unable to remember what has just happened) It is important to note that only around 10% of reported mild head injuries/concussions involve a loss of consciousness – so it’s important to not solely rely on this as an indicator.  Pathophysiology Signs & Symptoms Physical symptoms Headache Nausea or vomiting Fatigue or drowsiness Problems with speech Dizziness or loss of balance Loss of consciousness from several minutes to hours Persistent headache or headache that worsens Repeated vomiting or nausea Convulsions or seizures Dilation of one or both pupils of the eyes Clear fluids draining from the nose or ears Inability to awaken from sleep Weakness or numbness in fingers and toes Loss of coordination  Pathophysiology Signs & Symptoms Sensory symptoms Sensory problems, such as blurred vision, ringing in the ears, a bad taste in the mouth or changes in the ability to smell Sensitivity to light or sound Cognitive, behavioural or mental symptoms Loss of consciousness for a few seconds to a few minutes No loss of consciousness, but a state of being dazed, confused or disoriented Memory or concentration problems Mood changes or mood swings Feeling depressed or anxious Difficulty sleeping Sleeping more than usual Profound confusion Agitation, combativeness or other unusual behaviour Slurred speech Coma and other disorders of consciousness  Pathophysiology Treatment Follow JRCALC Guideline for Head Injury  Pathophysiology Spontaneous Pneumothorax Primary spontaneous pneumothorax is an abnormal accumulation of air in the space between the lungs and the chest cavity (called the pleural space) that can result in the partial or complete collapse of a lung. This type of pneumothorax is described as primary because it occurs in the absence of lung disease such as emphysema. Spontaneous means the pneumothorax was not caused by an injury such as a rib fracture. Primary spontaneous pneumothorax is likely due to the formation of small sacs of air (blebs) in lung tissue that rupture, causing air to leak into the pleural space. Air in the pleural space creates pressure on the lung and can lead to its collapse.  Pathophysiology Signs & Symptoms Spontaneous pneumothorax most commonly presents without severe symptoms. Patients with a collapsed lung may experience a sudden onset of the following symptoms: Sharp chest pain, made worse by a deep breath or a cough Shortness of breath A larger pneumothorax will cause more severe symptoms, including: Chest tightness Easy fatigue Rapid heart rate Bluish colour of the skin caused by lack of oxygen Nasal flaring Chest wall retractions  Pathophysiology Treatment Follow JRCALC Guideline for Thoracic Trauma  Pathophysiology Open Pneumothorax An open pneumothorax occurs when air accumulates between the chest wall and the lung as the result of an open chest wound or other physical defect. The larger the opening, the greater the degree of lung collapse and difficulty of breathing. A special type of open pneumothorax is a sucking chest wound. In the sucking chest wound, air is sucked into the thoracic cavity through the chest wall instead of into the lungs through the airways. This occurs because air follows the path of least resistance. A flap of skin allows air in but closes over preventing air from escaping. Uncorrected this can deteriorate into a tension pneumothorax.  Pathophysiology Signs & Symptoms Shortness of breath. Rapid, shallow breathing. Chest pain. Low blood pressure (shock) Pale, cool and clammy skin. Rapid heart rate. Restlessness. Anxiety. Surgical emphysema. Diminished/absent Breath Sounds. Hyperresonance.  Pathophysiology Treatment Follow JRCALC Guideline for Thoracic Trauma  Pathophysiology Tension Pneumothorax A tension pneumothorax is a severe condition that results when air is trapped in the pleural space under positive pressure, displacing mediastinal structures, and compromising cardiopulmonary function.  Pathophysiology Signs & Symptoms Shortness of breath. Rapid, shallow breathing. Chest pain. Low blood pressure (shock) Pale, cool and clammy skin. Rapid heart rate. Restlessness. Anxiety. Surgical emphysema. Diminished/absent Breath Sounds. Hyperresonance. Tracheal Deviation Away from affected side.  Pathophysiology Treatment Follow JRCALC Guideline for Thoracic Trauma if indicated for Needle Thoracocentesis and chest seal has been applied, it should be removed at this point.  Pathophysiology Haemothorax Haemothorax is a collection of blood in the space between the chest wall and the lung (the pleural cavity).  Pathophysiology Signs & Symptoms Shortness of breath. Rapid, shallow breathing. Chest pain. Low blood pressure (shock) Pale, cool and clammy skin. Rapid heart rate. Restlessness. Anxiety. Surgical Emphysema. Diminished/absent Breath Sounds. Hyporesonance.  Pathophysiology Treatment Follow JRCALC Guideline for Thoracic Trauma  Pathophysiology Tamponade Cardiac tamponade happens when the fluid sac around your heart fills with blood or other fluid, putting pressure on your heart. Because of the pressure, your heart can’t fill up with blood, reducing how much blood your heart can pump and ultimately causing a drop in blood pressure. Trauma and certain diseases can cause cardiac tamponade. If not treated, it is always fatal.  Pathophysiology Tamponade Beck’s triad is a collection of three classic clinical signs associated with cardiac tamponade. The triad was originally described in 1935 by the American cardiothoracic surgeon Claude Beck and includes the presence of low blood pressure, distension of the jugular veins, and muffled or diminished heart sounds on cardiac auscultation. Although the presence of the complete triad is highly suggestive of cardiac tamponade, only a small number of cases present with all the elements of Beck’s triad at diagnosis.  Pathophysiology Signs & Symptoms Cardiac tamponade that happens quickly can cause the following symptoms: Sharp pain in the chest. The pain may also radiate or extend to nearby parts of the body like the abdomen, arm, back, neck or shoulder. It may also get worse when you breathe deeply or cough. Trouble breathing or breathing rapidly. Fainting, dizziness or light headedness. Changes in skin colour, especially going pale, gray or blue-tinted skin. Heart palpitations (where you become unpleasantly aware of your heartbeat). Fast pulse. Jaundice (yellowing of the skin or eyes caused by liver problems). Altered mental status. A person with this will not be acting like themselves and may act confused or agitated. Cardiac tamponade that happens more slowly may also cause these symptoms: Shortness of breath. Swelling in the abdomen or legs. Fatigue or tiredness. Chest discomfort that typically gets better when you lean forward or sit up  Pathophysiology Treatment Follow JRCALC Guideline for Thoracic Trauma  Pathophysiology Flail Chest Flail chest — defined as two or more contiguous rib fractures with two or more breaks per rib — is one of the most serious of these injuries and is often associated with considerable morbidity and mortality. It occurs when a portion of the chest wall is destabilized, usually from severe blunt force trauma.  Pathophysiology Signs & Symptoms Paradoxical movement: When someone with this injury inhales and the rest of the chest expands, a flail segment will sink inward. On the other hand, when the rest of the chest contracts on an exhale, the flail segment bulges outward. Severe chest pain Dyspnoea Cyanosis Tachycardia Tachypnoea Cyanosis Bruising, inflammation, and sensitivity in the injured area are also expected.  Pathophysiology Treatment Follow JRCALC Guideline for Thoracic Trauma  Pathophysiology Blunt Force Trauma Blunt trauma, also known as non-penetrating trauma or blunt force trauma, refers to injury of the body by forceful impact, falls, or physical attack with a dull object. Penetrating trauma, by contrast, involves an object or surface piercing the skin, causing an open wound. Blunt trauma can be caused by a combination of forces, including acceleration and deceleration (the increase and decrease in speed of a moving object), shearing (the slipping and stretching of organs and tissue in relation to each other), and crushing pressure. Blunt trauma can generally be classified into four categories: contusion, abrasion, laceration, and fracture. Contusion—more commonly known as a bruise—is a region of skin where small veins and capillaries have ruptured. Abrasions occur when layers of the skin have been scraped away by a rough surface. Laceration refers to the tearing of the skin that causes an irregular or jagged-appearing wound. Lastly, fractures are complete or partial breaks in bone. Such injuries can often occur in motor vehicle crashes, sports injuries, physical assaults, and falls.  Pathophysiology Blunt Force Trauma  Pathophysiology Penetrating Trauma Penetrating trauma is an injury caused by a foreign object piercing the skin, which damages the underlying tissues and results in an open wound. The most common causes of such trauma are gunshots and stab wounds. Clinical features differ depending on the injured parts of the body and the shape and size of the penetrating object. Penetrating Injuries can either be a result of high velocity or low velocity injuries.  Pathophysiology Penetrating Trauma Follow JRCALC Guideline for Penetrating Chest Trauma and Chest Seal  Pathophysiology Abdominal Injuries A ruptured spleen can occur when there’s damage to the spleen’s surface. The spleen is an organ located in the upper left side of the abdominal cavity, underneath the rib cage. It plays an important role in filtering blood by removing old or damaged cells and debris, as well as in helping the body fight infections. Splenic rupture may result in internal bleeding that can be life threatening if not treated promptly. Pathophysiology Pathophysiology  Pathophysiology Pelvic Injuries Pathophysiology Pelvic Injuries A pelvic fracture is a break in one or more of your bones in your pelvis. Pelvic fractures are an uncommon type of fracture that can range from mild to severe. While mild pelvic fractures usually don't require surgery, severe fractures have to be fixed with surgery. Pelvic fractures are often unstable and can be life threatening. Pathophysiology  Pathophysiology Signs & Symptoms Experiencing pain in groin, hip and/or lower back. Experiencing more intense pain when walking or moving legs. Experiencing numbness or tingling in groin area or legs. Experiencing pain in abdomen. Having a difficult time urinating. blood in urine or stools Having a difficult time walking or standing. Splayed feet Depending on severity more serious symptoms may occur.  Pathophysiology Treatment Follow JRCALC Major Pelvic Trauma Guideline Pathophysiology  Pathophysiology Mid Shaft Femur Fracture Femoral shaft fractures are common, especially in high- energy trauma, with an incidence of around 4 per 10000 person-years. The femur is the longest bone in the body and a highly vascularised bone, due to its role in haematopoesis. The bone is supplied by penetrating branches of the profunda femoris artery, therefore large volumes of blood (up to 1500ml) can extravasate if fractured.  Pathophysiology Signs & Symptoms Severe and sharp pain. Inability to put weight on the injured leg. Swelling. Bruising. Pain on touching the thigh that worsens with movement. Deformity. Numbness in the thigh, lower leg, ankle, foot, knee.  Pathophysiology Treatment Follow JRCALC Limb Trauma Guideline  Pathophysiology Crush Injuries Crush injury is the result of physical trauma from prolonged compression of the torso, limb(s), or other parts of the body. The resultant injury to the soft tissues, muscles, and nerves can be due to the primary direct effect of the trauma or ischemia related to compression.  Pathophysiology Treatment Follow JRCALC Major Pelvic Trauma or Limb Trauma Guideline  Pathophysiology Compartment Syndrome Compartment syndrome occurs when pressure rises in and around muscles. The pressure is painful and can be dangerous. Compartment syndrome can limit the flow of blood, oxygen and nutrients to muscles and nerves. It can cause serious damage and possible death. Compartment syndrome occurs most often in the lower leg. But it can also impact other parts of the leg, as well as the feet, arms, hands, abdomen (belly) and buttocks.  Pathophysiology Trauma Triad The trauma triad of death is a medical term describing the combination of hypothermia, acidosis, and coagulopathy. This combination is commonly seen in patients who have sustained severe traumatic injuries and results in a significant rise in the mortality rate. Commonly, when someone presents with these signs, damage control surgery is employed to reverse the effects. The three conditions share a complex relationship; each factor can compound the others, resulting in high mortality if this positive feedback loop continues uninterrupted. Severe bleeding in trauma diminishes oxygen delivery, and may lead to hypothermia. This in turn can halt the coagulation cascade, preventing blood from clotting. In the absence of blood-bound oxygen and nutrients (hypoperfusion), the body's cells burn glucose anaerobically for energy, causing the release of lactic acid, ketone bodies, and other acidic compounds into the blood stream, which lower the blood's pH, leading to metabolic acidosis. Such an increase in acidity damages the tissues and organs of the body and can reduce myocardial performance, further reducing the oxygen delivery.  Pathophysiology Trauma Triad Pathophysiology  Pathophysiology Drowning Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. This process is a continuum beginning with respiratory impairment as the victim's airway goes below the surface of the liquid (submersion) or when water splashes over the face (immersion). If the victim is rescued at any time, the process of drowning is interrupted, resulting in a non-fatal drowning. Any submersion or immersion incident without evidence of respiratory impairment (aspiration) should be considered a water rescue rather than a drowning. Terms such as 'near-drowning', 'dry or wet drowning', 'active and passive drowning', 'secondary', and 'delayed onset of respiratory distress' should not be used. BMJ, 2022  Pathophysiology Treatment Follow JRCALC Immersion and Drowning Guideline  Pathophysiology Burns There are three classifications of burns, they are: Superficial burns First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long- term tissue damage is rare and usually consists of an increase or decrease in the skin colour. Partial thickness burns Second-degree burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful.  Pathophysiology Burns Full thickness burns Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. The burn site appears white or charred. There is no sensation in the area since the nerve endings are destroyed. Burns affecting 10 percent of a child's body and those affecting 15 to 20 percent of an adult's body are considered to be major injuries and require hospitalization and extensive rehabilitation.  Pathophysiology Treatment Follow JRCALC Guideline for Burns and Scalds  Pathophysiology Hypothermia Hypothermia is defined as a core body temperature below 35°C. It is a potentially life-threatening condition and a reversible cause of cardiac arrest. Primary hypothermia is due to environmental exposure, with no underlying medical condition causing disruption of temperature regulation. Secondary hypothermia results from a medical illness lowering the temperature set-point.  Pathophysiology Hypothermia  Pathophysiology Signs & Symptoms Shivering Slurred speech or mumbling Slow, shallow breathing Weak pulse Clumsiness or lack of coordination Drowsiness or very low energy Confusion or memory loss Loss of consciousness Bright red, cold skin (in infants)  Pathophysiology Treatment Follow JRCALC Hypothermia Guideline  Pathophysiology Heat Stress Heat stress is a mild form of heat illness, characterised by the features below (refer to Table 3.58). This level of heat disorder is often self-managed, but if left untreated can progress to more serious conditions.  Pathophysiology Heat Exhaustion A less severe heat illness than heat stroke, lacking the defining neurological symptoms of this condition. Symptoms are mainly due to excess fluid loss and electrolyte imbalance.  Pathophysiology Heat Stroke A ‘systemic inflammatory response’ to a core body temperature >40°C in addition to a change in mental status and organ dysfunction (European Resuscitation Council Guidelines).  Pathophysiology Signs & Symptoms Check JRCALC Heat Related Illness for each Sign & Symptoms for each condition.  Pathophysiology Treatment Follow JRCALC Guideline for Heat Related Illness  Acid Attack The use of corrosive substances in an assault. Corrosive substances include acids, such as sulphuric acid, but also alkaline or caustic chemicals such as sodium hydroxide. These attacks often cause chemical burns to the skin and eyes. Care of victims of acid attack NHS estimated treatment costs of £34,500 for those requiring specialist burns treatment, eye care, rehabilitation and mental health support. NHS England released First Aid guidance to the public for how to manage acid attacks appropriately: Report - Remove - Rinse Survivor of acid attack – Katie Piper  Acid Attack Treatment Follow JRCALC Burns and Scalds Guideline  Traumatic Amputation ‘An injury to an extremity that resulted in immediate separation of the limb or will result in loss of the limb as a result of accident or injury’ (Jorge, 2020) Usually result from accidents factory, farm, power tool or road traffic accidents. Partial amputation occurs when some soft tissue connection remains intact. Depending on how severe the injury is the partially severed extremity may or may not be able to be reattached.  Traumatic Amputation Treatment Follow JRCALC Limb Trauma Guideline  Teeth Avulsion Avulsion of permanent teeth is one of the most serious dental injuries and prognosis is dependent on the actions taken at the place of injury and promptly after avulsion. Immediate replantation is the best treatment at the place of the injury occurring. Only permanent teeth should be replanted, primary teeth should not be replanted.  Teeth Avulsion Treatment Find the tooth and pick up by the crown, avoid touching the root. If the tooth is dirty, wash it briefly (max 10 seconds) under cold running water and reposition it. Once the tooth is back in place ask the patient to bite down on a handkerchief to hold it in position. If unable to be replanted, place the tooth in a glass of milk or another suitable storage medium e.g. saline. The tooth can be transported in the mouth, keeping it inside the lip or cheek. Caution should be taken if the patient is very young as they may swallow the tooth. Avoid storage in water.  Shock in Trauma Shock is characterised by a decreased oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilisation leading to cellular and tissue hypoxia. It is a life-threatening condition of circulatory failure and most commonly presents as hypotension (systolic blood pressure