Early Assessment and Management of Trauma Frank Stening Australia Specialists Without Borders Seminar in Surgery Rwanda, September 2010

Objectives Identify management priorities Understand concept of Primary and Secondary Survey Institute appropriate resuscitation and monitoring within first minutes Recognize the value of the patient’s history and mechanism of injury Anticipate pitfalls

KEY QUESTION How do we minimise MISSED injuries ? How do we improve survival rates ? ( Who needs transfer When do they need transfer )

Concepts of Initial Assessment Rapid primary survey Resuscitation Adjuncts to primary survey/resuscitation Detailed secondary survey Adjuncts to secondary survey Re-evaluation Definitive care

INITIAL MANAGEMENT AND ASSESSMENT 1. Preparation 2. Triage 3. Primary survey (ABC’s) 4. Resuscitation 5. Secondary survey (Head-to-toe) 6. Continued post resuscitation monitoring and re-evaluation 7. Definitive care

Initial Assessment Primary survey and resuscitation of vital functions are done simultaneously = a team approach

Triage Sorting of patients according to: ABCDEs Available resources Multiple casualties Mass casualties

A quick, simple way to assess the patient in 10 seconds Identify yourself Ask the patient his / her name Ask the patient what happened

... an appropriate response suggests: Patent airway Sufficient air reserve to permit speech Clear sensorium Now proceed to a rapid primarysurvey

Primary Survey Adults, paediatric, pregnant women Priorities are the same! A Airway with c-spine protection B Breathing C Circulation with haemorrhage control D Disability E Exposure / Environment EMST

Special Groups to Consider Children Elderly Pregnant women

Primary Survey Establish Patent Airway  Beware C-spine injury  Pitfalls  Equipment failure  Inability to intubate  Occult airway injury  Progressive loss of airway Caution

Breathing Oxygenate Assess Ventilate Caution Primary Survey Pitfalls  Airway vs ventilation problem?  Iatrogenic pneumothorax/ tension pneumothorax

Primary Survey Assessment of Organ Perfusion Level of consciousness Skin colour and temperature Pulse rate and character

Circulatory Management Control haemorrhage Restore volume Reassess Caution Primary Survey Pitfalls  Elderly  Athletes  Children  Medications

Disability Baseline neurologic evaluation – GCS scoring – Pupillary response Caution Primary Survey Observe for neurologic deterioration

Exposure / Environment Completely undress the patient Caution Primary Survey Prevent hypothermia

Adjuncts to Primary Survey Vital signs Adjuncts ABGs Pulse oximeter and CO 2 Urinary/gastric catheters unless contraindicated Urinary output ECG

PRIORITY PLAN X-RAYS (should be used judiciously and should not delay resuscitation) Lateral cervical spine AP chest AP pelvis

Adjuncts to Primary Survey Diagnostic Tools Chest and pelvic x-rays DPL Ultrasound

Secondary Survey What is secondary survey? – Available history and head-to-toe examination When do I start? – After primary survey complete – After ABCDE’s re-assessed – Vital functions are returning to normal

Secondary Survey Key Components History Physical examination: Head-to-toe “Tubes and fingers in every orifice” Complete neuro exam Special diagnostic tests Re-evaluation

Secondary Survey History A Allergies M Medications P Past illnesses L Last meal E Events / Environment

Secondary Survey Mechanisms of Injury

Secondary Survey Head Complete neurologic exam GCS score determination Comprehensive eye exam Pitfalls – Unconscious patient – Periorbitaloedema – Occluded auditory canal

Secondary Survey Maxillofacial Bony crepitus/stability Palpable deformity Pitfalls – Potential airway obstruction – Cribriformplate fracture – Frequently missed injury

Secondary Survey Cervical Spine Palpate for tenderness Complete motor/sensory exams Reflexes C-spine imaging Pitfalls – Altered LOC for any reason – Other severe, painful injury

Secondary Survey Neck (Soft tissues) Mechanism: Blunt vs penetrating Symptoms: Airway obstruction, hoarseness Findings: Crepitus, haematoma, stridor, bruit  Pitfalls  Delayed symptoms/signs  Progressive airway obstruction  Occult injuries

Secondary Survey Chest Inspect Palpate Auscultation Percussion X-rays  Pitfalls  Elderly  Children

Secondary Survey Abdomen Inspect, auscultate, palpate, and percuss Re-evaluate frequently Special studies Pitfalls – Hollow viscus and retroperitoneal injuries – Excessive pelvic manipulation

Secondary Survey PerineumContusions, haematomas, lacerations, urethral blood RectumSphincter tone, high-riding prostate, pelvic fracture, rectal wall integrity, blood VaginaBlood, lacerations PitfallsUrethral injury in women, pregnancy

Secondary Survey Musculoskeletal: Extremities Contusion, deformity Pain Perfusion Peripheral neurovascular status X-rays as needed

Secondary Survey Musculoskeletal: Pelvis Pain on palpation Symphysiswidth  Leg length uneven X-rays as needed

Secondary Survey Musculoskeletal Pitfalls – Potential blood loss – Missed fractures – Soft-tissue or ligamentous injury – Occult compartment syndrome (especially with altered LOC/hypotension)

Secondary Survey NEUROLOGIC Spine / Cord Complete motor and sensory exam Imaging as indicated Reflexes CNSFrequent re-evaluationPrevent secondarybrain injuryCNSFrequent re-evaluationPrevent secondarybrain injury

Secondary Survey Neurologic Pitfalls – Incomplete immobilisation – Subtle  in ICP with manipulation – Rapid deterioration

Re-evaluation Minimising Missed Injuries High index of suspicion Frequent re-evaluation and monitoring

Re-evaluation Pain Management Relief of pain/anxiety as appropriate Administer intravenously Careful monitoring is essential

PRIORITY PLAN DEFINITIVE CARE After identifying the patients injuries, managing life threatening problems and obtaining special studies

SUMMARY 1. Primary survey 2. Resuscitation Adjuncts 3. Secondary survey 4. Definitive care