The Initial Assessment OF THE MULTIPLY INJURED PATIENT

Objectives 1.Identify the correct sequence of priorities in the assessment of an injured patient 2.Outline the components of the primary and secondary surveys 3.Explain the techniques used in the initial resuscitation phase.

Introduction The initial assessment aims: Rapid assessment Rapid life preserving therapy Prevents further damage to the patient. It consists of: Preparation Triage Primary survey Resuscitation Secondary survey Continued resuscitation Definitive care

Preparation and Triage Preparation A.Pre-hospital Phase  Hospital notification  Airway maintenance, control external bleeding, immobilization and transportation. B.In-hospital phase  Fluids and equipment  Adequate and appropriate personnel  Universal precaution Triage Sorting patients based on the need for treatment and the available facilities.

Primary Survey A Airway with Cervical Spine Control BBreathing and ventilation CCirculation D Disability: neurological status EExposure/ Environmental control

A Airway with cervical spine control Assume C-spine injury in all patients Assess airway compromise  Is the patient talking or Apnoeic  Look for signs of:  Agitation and aggression  Foreign bodies, dislodged teeth  Facial fractures and injuries to the neck (trachea and Larynx).  Listen for abnormal breathing sounds, stridor or hoarseness.  Feel for the movement of air. DO NOT MOVE THE NECK

A Airway with cervical spine control Management: 1. In-line immobilization of the neck and triple neck support 2. Remove foreign body and suction 3. Administer oxygen 100% 4. Chin lift and jaw thrust manoeuvres 5. Oro-pharyngeal air way Definitive airway A cuffed tube in the trachea connected to a ventilator. (oro-tracheal, naso-tracheal, surgical airway) Indication: 1. Apnoea 2. Protection against aspiration 3. Expected impending air obstruction 4. Head injury requiring hyperventilation 5. Failure to maintain an airway or adequate oxygenation

B Breathing 1. Determine centrality of the trachea and apex beat 2. Look for symmetrical expansion and respiratory rate. 3. Look for obvious contusion, laceration or flail segments. 4. Listen for movements of air: normal, absent or decreased 5. Listen for heart sounds: normal or muffled 6. Recognise specific life-threatening conditions: Action: 1. Oxygen supplementation 100% reservoir mask. 2. Treatment of specific disease entities. 3. Definitive air-way and assisted ventilation. 1.Tension pneumothorax 2.Flial chest with pulmonary contusions 3.Open pneumothorax 4.Massive hemothorax

C Circulation 1. Assess the severity of blood loss: 2. Conscious Level: if confused indicates 30-40%, 2L blood loss 3. Skin colour: dusky colour indicates at least 30% blood loss 4. Blood pressure: may be maintained in up to 30 % loss 5. Pulse: Carotid or femoral  If rapid may indicate hypovolaemia or pain and anxiety.  Irregular pulse may indicate cardiac contusion  Look for narrow complex tachy.  Be aware of differences due to age and physiological status. 6. Look for obvious source of bleeding Action: 1. 2 large bore cannulae established at the antecubital fossa 2. Draw blood for cross-match and base line lab investigations and pregnancy tests. 3. Rapid administration of warmed crystalloid solution 4. Administer type specific or O negative blood if patient not responsive 5. Prevent hypothermia 6. Start ECG monitoring

D Disability AAlert V Responsive to verbal stimuli P Responsive only to painful stimuli U Unresponsive Altered level of consciousness may indicate: a. Head injury b. Shock c. Hypoxia d. Drug/ Alcohol

At the End of the Primary Survey 1. Assessment and management of:A,B,C,D is completed. 2. ABG 3. ECG, pulse oximeter, BP Cuff placed 4. Urinary catheter and Naso-gastric tube inserted 5. X rays requested: 1. AP chest 2. AP pelvis 3. Lateral C-spine 6. Consider system involvement and surgical specialities required. 7. Consider need for patient transfer

AMPLE Key terminology AAllergies MMedication PPast illnesses LLast Meal EEthanol/ Drug abuse Mechanism of Injury  Vehicle: Stationary / Slow or High Speed  Pedestrian / Passenger (front or back) / Driver  Head-on / Side impact / Rear impact collision  Restrained / Unrestrained  Helmets  Role over accident  Thrown out of the car.