1. Chapter 1 Initial Assessment and management

2. OBJECTIVES
Identify the correct sequence of priorities in assessing the multiply injured patient
Apply the primary and secondary evaluation surveys to assessment of the multiply injured patient
Apply guidelines and techniques in the initial resuscitative and definitive--case phase
Anticipate the pitfalls associated with the initial assessment and management ( minimize their impact )
Conduct an initial assessment survey on a simulated multiply injured patient

3. CONCEPTS OF INITIAL ASSESSMENT
Preparation
Triage
Primary survey ( ABCDEs )
Resuscitation
Adjuncts to primary survey and resuscitation
Secondary survey ( head-to-toe evaluation and history )
Adjuncts to the secondary survey
Continued postresuscitation monitoring and reevaluation
Definitive care

4. Repeat primary and secondary survey when finding any deterioration in the patient’s status
Primary survey and resuscitation are done simultaneously

5. PREPARATION Prehospital Airway maintenance
Control of external bleeding & shock
Immobilization of the patient
Communication with receiving hospital & immediate transport to the closest, appropriate facility
History taking ( include events )
Inhospital
Advanced planning ( especially massive casualty )
Equipment & personnel
Communicable disease protection
Transfer agreements

6. TRIAGE Sorting of patients according to ABCs and available resources
Triages is the responsibility of prehospital personnel

7. Not exceed the ability of the facility ==> treat life -- threatening patient first
Exceed the capacity of the facility ( mass casualties ) ==> Treat the greatest chance of survival, with the less time, less equipment & less personnel

8. PRIMARY SURVEY Adult / Pediatric priorities same
Identified the life-threatening conditions and simultaneously managed
A: Airway maintenance with cervical spine protection
B: Breathing and ventilation
C: Circulation with hemorrhage control
D: Disability ( Neurologic status )
E: Exposure / Environmental control: Undress the patient & prevent hypothermia

9. PRIMARY SURVEY Airway Maintenance with Cervical Spine Protection
Oral foreign bodies, facial, mandibular, or tracheal / laryngeal fractures may result in airway obstruction
Assume C-spine injury
Multisystem trauma
Altered level of consciousness
Blunt injury above clavicle
Pitfalls:
Difficult airway
Obesity: surgical airway cannot be performed smoothly
laryngeal fracture or incomplete upper airway transection

10. PRIMARY SURVEY Breathing and Ventilation
Airway patency  adequate breathing & ventilation
injury that may acutely impair ventilation
1. Tension pneumothorax
2. Flail chest with pulmonary contusion
3. Massive hemothorax
4. Open pneumothorax
above problems need to be identified in the primary survey and managed
Pitfall: Differentiation of ventilation problems from airway compromise may be difficult

11. PRIMARY SURVEY Circulation with Hemorrhage Control
Assess blood volume and cardiac output
level of consciousness
skin color
pulse
Bleeding control: direct manual pressure on the wound
Pitfall:
The response of elderly, children, athletes and others with chronic medical conditions to hypovolemia is different from normal people

12. PRIMARY SURVEY Disability ( Neurologic Evaluation )
Level of consciousness
A. Alert
V. Response to voice
P. Response to pain
U. Unresponsive
Pupils
Pitfall:
Lucid interval ( talk and die ) : EDH, frequent neurologic reevaluation can minimize this problem

13. PRIMARY SURVEY Exposure/Environmental Control
Undress patient completely
Protect from hypothermia
Pitfall:
early control of the hemorrhage is the best method to keep body temperature( early surgical intervention)

14. RESUSCITATION Protect/Secure airway & protect C-spine
Breathing/Ventilation/Oxygenation
Vigorous shock therapy
At last two large - caliber IV line
Crystalloid solution ( Ringer’s lactate 2~3 litter)
Type-specific blood
surgical intervention
Protect from Hypothermia : 39oC warm IV fluid
Urinary/gastric catheters unless contraindication

15. ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION
Monitor:
Ventilatory rate and ABGs/ end-tidal CO2
Pitfalls: Combative patients often extubate or bite endotracheal tube
Pulse oximetry
ECG & BP monitor
Temperature
urine output

16. X-RAY AND DIAGNOSTIC STUDIES
Can’t delay or interrupt the primary survey and resuscitation
Trauma series ( portable X-ray ): CXR, C-spine/ lateral view, pelvic AP view
A negative or inadequate c-spine x-ray can’t exclude cervical spinal injury
Sonography / DPL
Pitfalls: obesity ( Sonography and DPL are difficult )

17. CONSIDER NEED FOR PATIENT TRANSFER
Referring doctor -to -receiving doctor communication
Closest appropriate hospital

18. BEFORE SECONDARY SURVEY
Complete primary survey
Establish resuscitation
Normalization of vital functions

19. SECONDARY SURVEY History taking Complete neurologic exam.
Head-to-toe evaluation
Roentgenograms
Special procedure
Tubes and fingers in every orifice
Re-evaluation

20. SECONDARY SURVEY History A. Allergies M. Medications currently used
P. Past illness / pregnancy
L. Last meal
E. Events / Environment related to injury

21. HISTORY Mechanisms of injury
Blunt
Automobile collisions
Seat belt usage
Steering wheel deformation
Direction of impact
Ejection of passenger form the vehicle
Burns and Cold injury
Inhalation injury and CO. intoxication in fire field
Hazardous environment
Penetrate
Anatomy factors
Energy transfer factor
Velocity and caliber of bullet
Trajectory
Distance

22. SECONDARY SURVEY Physical Examination Head entire scalp and head eye:
pupil
visual acuity
EOM
foreign body ( soft contact lens….)
Pitfalls:
Severe facial swelling or unconsciousness p’t still need eye exam.

23. SECONDARY SURVEY Physical Examination Maxillofacial
No airway obstruction or massive bleeding ==> treat later
Midfacial fracture ==> R/O cribriform plate fracture
Pitfalls:
Some facial bone fracture is difficulty identified early ==> reassessment is crucial

24. SECONDARY SURVEY Physical Examination C-spine and Neck
Maintain immobilization
Complete evaluation
Complete radiology study
Cautions helmet removed
Penetrating injury: Not be explored in the emergency department; explored & treat in the operative room
Pitfalls:
Blunt injury to Neck: Carotid artery intima injury or dissection ( delay onset )
Immobilization ==> decubitus ulcer

25. SECONDARY SURVEY Physical Examination Chest Pitfalls:
Poor tolerance to minor pulmonary trauma in elderly patients
A normal CXR can’t role out chest injury in children

26. SECONDARY SURVEY Physical Examination Abdomen
Identify a surgical abdomen is more important than doing a specific diagnosis ==> early consult surgeon
Close observation & frequent reevaluation of the abdomen
DPL, sonography, abdomen CT
Pitfalls:
Excessive manipulation of the pelvis should be avoid ==> just do pelvic x-ray
Retroperitoneal organs ( pancreatic & hollow organ ) are very difficult to identify

27. SECONDARY SURVEY Physical Examination Perineum / rectum / vagina
Perineum: Contusions, hematomas, urethral bleeding…….
Rectum: Sphincter tone, high riding prostate, blood…..
Vagina: Blood, laceration
Pitfalls:
Female urethral injury is difficult to detect

28. SECONDARY SURVEY Physical Examination Musculoskeletal
Extremities / pelvis: Contusion, deformity, pain crepitation, abnormal movement
Vascular: Assess all peripheral pulses
Spine: Physical findings, mechanism of injury

29. SECONDARY SURVEY Physical Examination Neurologic Determine GCS score
Re-evaluate pupils
Sensory / motor evaluation
Maintain immobilization
Prevent secondary CNS injury ( keep stable vital signs, avoid increased ICP and treat IICP )
Early neurosurgical consultation
Pitfalls:
Intubation should be done expeditiously and as smoothly as possible ( Intubation will increase ICP )

30. REEVALUATION New findings / deterioration / improvement
High index of suspicion ==> early diagnosis & management
Continuous monitoring
Pain relief

31. DEFINITIVE CARE
Trauma center
Closest appropriate hospital

32. RECORDS AND LEGAL CONSIDERATIONAS
Records: Concise, chronologic documentation
Consent for treatment
Forensic Evidence: preserve the evidence

33. SUMMARY Initial assessment & management of multiply injured patient
Primary survey ( ABCDEs )
Resuscitation & monitor ( life-threatening problems )
Secondary survey ( head-to-toe, history )
Definitive care ( early consultation, surgical intervention or transport )