Dilawaiz Nadeem MCh Orth, MD, FRCS (Ed) Trauma & Orth Professor /Consultant Orthopaedic Surgeon SIMS / Services Hospital, Lahore Find Online Presentations &

Time After Injury

PreventionTriage Primary survey Secondary survey StabilisationTransfer Definitive care

Priority depends on  experience  resources  severity of injury

Primary Survey - a swift check of vital functions A-B-C-D-E - treat problems as you find them Secondary Survey - a systematic examination of structure and function to make sure you do not miss anything important Stabilisation and transfer for definitive treatment in the hospital or referral elsewhere ? Phases of acute trauma care

 Primary Survey ( ABCDE ) Resuscitation and its adjuncts Consider Need for Transfer  Secondary Survey ( Head to Toe Evaluation) Tubes and Fingers in every orifice  Definitive Care

 To introduce the elements of primary survey  To understand when to perform the primary survey 7

 Airway  Breathing  Circulation  Disability  Exposure 14

 Look, listen, feel  Colour  Conscious state  Accessory muscle use

 Airway obstruction  Chest injuries with breathing difficulties  Cervical spine injury

 Clear mouth  Chin lift / Jaw thrust  Oro / Nasopharyngeal Airway  Intubation  Cervical spine care 16

 Air movement  Respiratory rate

 Tension pneumothorax  Massive haemothorax  Open pneumothorax  Flail chest  Lung contusion

 Oxygen (if available)  Artificial ventilation  Decompress pneumothorax  Darin haemothorax 19

 Cardiac output  Blood volume  External haemorrhage

 Intra-abdominal injury  Intra-thoracic injury  Long bone fracture  Pelvic fracture  Penetrating injury  Scalp wounds 22

 Stop bleeding  Large bore intravenous access x 2  Blood for crossmatch and Hb  Administer IV fluids

 Pupils  Check awareness A Awake V Verbal command response P Responds to pain U Unresponsive 24

 Undress for thorough assessment  Prevent hypothermia 25

 Cervical spine (lateral)  Chest  Pelvis 26

If patient is, or becomes, unstable 27

 Rapid sequential look  2 minutes  Treat as you find  Repeat at any time if unstable 29

Objectives  To understand how and when to perform the secondary survey 72

 Thorough head to toe examination  On completion of primary survey  When ABC’s are stable  Aim to find any injury that may threaten life or limb  Return to primary survey if any deterioration 73

 Scalp (bruising, lacerations)  Skull (tenderness, depression)  Eyes (pupils, fundi, lens, conjunctiva)  CSF or blood from ear, nose, mouth 74

 Assume neck is injured  Immobilise in neutral position 75

 Penetrating wounds  Subcutaneous emphysema  Tracheal deviation  Neck veins 76

 Glasgow Coma Score  Motor Function  Sensation  Reflexes 77

 Inspection  Palpation  Percussion  Auscultation  CXR (if not done, and if possible)  ECG ( if available) 78

 Potentially Difficult  Beware “hidden haemorrhage”  Look, listen, feel  Remember rectal examination 79

 Penetrating wound  surgical exploration  Blunt trauma - naso/orogastric tube  Urinary Catheter if no meatal blood  Reassess frequently 80

 Look: deformity, bruising, laceration  Feel: tenderness, pulses  Remember compartment syndrome 81

Don’t forget the back! 82

 4 people  Airway/neck controller in charge  Clear timing and instructions  Allows back examination 83

 In secondary survey if not already done  Chest  Cervical spine - all 7 vertebrae + T1  Pelvis  Others as indicated by examination 84

? 85