Trauma: Initial Survey
Primary and Secondary Surveys
Dr. Jason Alexander Dr. Melanie Walker Huntington Memorial Hospital
Prehospital Phase
Prehospital information can be invaluable if available
Valuable Prehospital Information
Victim age Mechanism of injury Vital signs IV access Glasgow Coma Score Obvious injuries (eg. Open fractures, eviscerated bowel)
Additional Paramedic Information
Field blood loss Pre-hospital fluids
Primary Survey
A B C D E Should take no more than 2-5 minutes
Primary Survey
Airway management with cervical spine protection Breathing and ventilation Circulation with hemorrhage control
Primary Survey
Disability: Neurologic status Exposure/Environmental control: Completely expose patient
Glasgow Coma Scale (Adults)
Quick neurologic assessment which provides the information about:
Prognosis Victims ability to maintain patent airway on own
Best score in three categories Total<8 =need for intubation
Glasgow Coma Score (Adults)
Eyes
1= do not open 2= open to pain 3= open to voice 4= open spontaneously
Verbal
1= nonverbal 2= incomprehensible 3= inappropriate 4= confused 5= orientated 1= none
Motor
2= extends to pain 3= flexes to pain 4= withdraws to pain 5= localizes pain 6= follows commands
Best EYE +
Best VERBAL +
Best MOTOR
Airway Maintenance with Cervical Spine Protection
Attempt to get verbal response from patient Inspect for foreign bodies Assess for facial, mandibular, tracheal / laryngeal injuries Oxygen Maintain cervical spine precautions Quick Glasgow Coma Score Assessment
Airway
Jaw Thrust Maneuver
Place 2-3 fingers under each side of lower jaw angle Lift jaw upward and outward
Head tilt Chin lift Maneuver
Do not perform if cervical injury suspected
Airway: Head tilt Chin lift Maneuver
Infant
Head in neutral position Do NOT overextend head and neck
Child and adult
Head and neck slightly extended Line from chin to jaw angle perpendicular to floor
Use other hand's fingers under bony part of chin
Do NOT use thumb to lift chin Lift mandible upward and outward
Breathing and Ventilation
Directed at acutely life-threatening disease processes that impair breathing Observe respiratory rate and use of accessory muscles Listen for breath sounds Inspect chest for crepitus and open wounds
Breathing and Ventilation: Life-Threatening Insults
Tension Pneumothorax Open Pneumothorax Massive Hemothorax Flail chest with pulmonary contusion
Breathing and Ventilation: Tension Pneumothorax
Diagnosis
Absent breath sounds Tympanitic chest Distended neck veins Tracheal deviation
Treatment
Needle thoracostomy Tube thoracostomy
Breathing and Ventilation: Open Pneumothorax
Open thoracic wound causes immediate equilibration between intra-thoracic and atmospheric pressure
This leads to lung collapse
Close defect with large sterile occlusive dressing Remote placement of thoracostomy tube
Breathing and Ventilation: Massive Hemothorax
Diagnosis
Diminished breath sounds Dullness to percussion over thorax Shock
Treatment
Tube thoracostomy >1500cc output=Thoracotomy
Flail Chest with Pulmonary Contusion
Paradoxical movement between segment of chest wall with multiple contiguous rib fx and thorax Pulmonary dysfunction is due to the underlying pulmonary contusion and splinting secondary to discomfort Management is oxygen, pain control and if unable to maintain oxygenation, mechanical ventilation
Circulation with Hemorrhage Control
Three aspects of circulation
Control of external bleeding Efficiency of the cardiac pump Volume status (degree of shock)
Circulation with Hemorrhage Control
Must have adequate IV access Inadequate circulation is a clinical diagnosis augmented by vital signs. Young victims will often manifest a tachycardia when they are hypovolemic followed by hypotension Older patients or medicated patients may not be able to mount a tachycardia
Circulation with Hemorrhage Control
Significant bleeding can only be found in a few anatomic locations
Chest: Massive hemothorax Abdomen: Hemoperitoneum Retroperitoneal bleed Pelvis Secondary to major closed fractures (pelvis or femur)
Circulation and Hemorrhage Control
Additional locations of hemorrhage most often forgotten are:
Active external hemorrhage Hemorrhage in the field
Circulation and Hemorrhage Control
During the primary survey the goal is not to stop hemorrhage but to support the circulatory system with one exception This is done by rapid infusion of IV fluids Adult patients who do not respond to bolus of 2 liters IV fluids need blood products Do stop all active external hemorrhage
Disability: the Brief Neurologic Evaluation
Glasgow Coma Score (GCS): re-evaluate Orientation Any change in level of consciousness or depreciation in the GCS should prompt examiner to return to the beginning of primary survey
Exposure/Environmental
Important balance
Expose patient entirely to allow global assessment of patient as well as remove any detrimental coverings (eg. Wet clothes, smoldering coverings) Cover patient with warm blankets following exposure to prevent hypothermia
The Secondary Survey
Should not take more than 5 -10 minutes Examine patient from head to toe
The Secondary Survey
Head
Scalp Pupils Auditory canals Mouth
Neck
Trachea Neck veins
Chest
Clavicles Ribs Breath Sounds Heart Tones
The Secondary Survey
Abdomen Rectum
Prostate (in males) Sphincter
Genitalia Extremities
Bones Soft tissues
The Secondary Survey
Neurologic system
Reflexes Sensation Hemispheric function Spinal function
Assignment of Priorities
The goal in the first few hours after trauma is not to treat individual injuries but to determine and manage threats to the patients life
Assignment of Priorities
Airway management takes first priority Treatment of bleeding can be delayed for a few minutes if intensive resuscitation is necessary
Assignment of Priorities
Any injuries which would lead to complications or loss of function if diagnosis or treatment is delayed
peripheral vascular injuries, tendon and nerves injuries, eye injuries, amputations of limbs
Assignment of Priorities
Closed fractures, dislocation and small soft tissue wounds are the only lesions for which treatment can be delayed for several hours