Chapter 1
Apply principles of primary and secondary surveys Identify management priorities Institute appropriate resuscitation and monitoring procedures Recognize value of patient’s history and biomechanics of injury Anticipate pitfalls
How do I prepare for a smooth transiiton from the prehospital to the hospital environments? What is a quick, simple way to assess the patient in 10 seconds? What is the secondary survey and when does it start?
How can I minimize missed injuries? Which patients do I transfer to a higher level of care? When should the transfer occur?
Primary survey Resuscitation Reevaluation Detailed secondary survey Reevaluation Definitive care Adjuncts
Primary survey and resuscitation of vital functions are done simultaneously in a team approach
Transport guidelines/protocols Online medical direction Mobilization of resources Periodic review of care Closest, appropriate facility
Preplanning is essential Equipment, personnel, services Standard precautions Prearranged transfer agreements
Cap Gown Gloves Mask Shoe covers Goggles/face shield
Triage is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. Sorting of patients according to ◦ ABCDEs ◦ Available resources
Identify yourself Ask the patient his/her name Ask the patient what happened
A – patent airway B – sufficient air reserve to permit speech CD – clear sensorium If no response, proceed with rapid primary survey.
A – Airway B – Breathing/ventilation/oxygenation C – Circulation: Stop the bleeding D – Disability (neuro status) E – Expose/environment/body temperature
Trauma in the elderly Pediatric trauma Trauma in pregnant women
Establish patent airway ◦ Protect c-spine ◦ Pitfalls? Equipment failure Inability to intubate Occult airway injury Progressive loss of airway
Assess and ensure adequate oxygenation and ventilation Pitfalls ◦ Airway vs ventilation problem? ◦ Iatrogenic pneumothorax or tension pneumothorax
Level of consciousness Skin color and temperature Pulse rate and character
Circulatory Management ◦ Control hemorrhage ◦ Restore volume ◦ Reassess parameters Pitfalls? ◦ Elderly ◦ Children ◦ Athletes ◦ Medication
Disability ◦ Baseline neurologic evaluation ◦ GCS scoring ◦ Pupillary response Observe for neurologic deterioration
Exposure/Environment ◦ Completely expose the patient Prevent hypothermia
Protect and secure airway Ventilate and oxygenate Stop the bleeding Vigorous shock therapy Protect from hypothermia
ADJUNCTS Vital Signs ABGs/Pulse oximeter ECG Catheters/ Output
Diagnostic tools
FAST (Focused Assessment Sonography in Trauma) DPL (Diagnostic Peritoneal Lavage)
Consider Early Transfer ◦ Do not delay transfer for diagnostic tests ◦ Use time before transfer for resuscitation
The complete history and physical examination.
After ◦ Primary survey is completed ◦ ABCDEs are reassessed ◦ Vital functions are returning to normal
History Physical exam: Head-to-toe “Tubes and fingers in every orifice” Complete neurologic exam Special diagnostic tests Reevaluation
History A=Allergies M=Medications P=Past illnesses L=Last meal E=Events/environment
Mechanisms of injury
HEAD ◦ Glascow Coma Score (GCS) ◦ Neuro exam ◦ Comprehensive eye and ear exam Pitfalls? ◦ Unconsciousness ◦ Periorbital edema ◦ Occluded auditory canal
Maxillofacial ◦ Bony crepitus ◦ Deformity ◦ Malocclusion Pitfalls ◦ Potential airway obstruction ◦ Cribriform plate fracture ◦ Frequently missed
Cervical spine ◦ Tenderness ◦ Complete motor/sensory exams ◦ Reflexes ◦ Imaging studies if warranted Pitfalls ◦ Altered consciousness ◦ Inability to cooperate with clinical exam
Neck (soft tissues) ◦ Mechanism: Blunt vs penetrating ◦ Symptoms: Airway obstruction, hoarseness ◦ Findings: Crepitus, hematoma, stridor, bruit
Neck (soft tissue): Pitfalls ◦ Delayed symptoms and signs ◦ Progressive airway obstruction ◦ Occult injuries
Chest ◦ Inspect ◦ Palpate ◦ Percuss ◦ Auscultate ◦ (aka IPPA) ◦ Obtain X-rays if indicated
Abdomen ◦ IAPP – in this case, auscultation is done before percussion ◦ Reevaluate ◦ Special studies (CT>FAST>DPL)
Abdomen: Pitfalls? ◦ Hollow viscus injury ◦ Retroperitoneal injury ◦ Excessive pelvic manipulation
PeritoneumContusions, hematomas, lacerations, urethral blood RectumSphincter tone, high- riding prostate, pelvic fracture, rectal wall integrity, blood VaginaBlood, lacerations Pitfalls? Urethral injury in women, pregnancy
Musculoskeletal: Extremities ◦ Contusion, deformity ◦ Pain ◦ Perfusion ◦ Peripheral neurovascular status ◦ X-rays as indicated
Musculoskeletal: Pelvis ◦ Pain on palpation ◦ Symphysis width increasing ◦ Leg length unequal ◦ Instability
Musculoskeletal: Pitfalls? ◦ Potential blood loss ◦ Missed fractures ◦ Soft-tissue or ligamentous injury ◦ Compartment syndrome
Neurologic: Brain ◦ GCS score ◦ Lateralizing signs ◦ Frequent evaluation ◦ Imaging as indicated ◦ Prevent secondary brain injury Early neurological consult
Neurologic: Spinal cord ◦ Complete motor and sensory exams ◦ Imaging as indicated ◦ Reflexes Early neurological/orthopedic consult
Special diagnostic tests as indicated Pitfalls: ◦ Patient deterioration ◦ Delay of transfer ◦ Missed injuries: High index of suspicion
Relief of pain/anxiety as appropriate Administer IV Careful monitoring
Those whose injuries exceed institutional capabilities When do I transfer? ◦ As soon as possible after stabilizing ◦ Avoid needless delay
Primary survey Adjuncts Resuscitation Secondary survey Adjuncts Definitive care