Initial
Initial Assessment and Management
Assessment and Management in trauma patients
Objectives
Apply principles of primary and secondary surveys
Identify management priorities
Institute appropriate resuscitation and monitoring procedures
Recognize the value of the patient history and biomechanics of injury Anticipate and manage pitfalls
Standard Precautions
Cap Gown
Gloves
Mask Shoe covers
Goggles / face shield
Initial Assessment
Primary survey and
resuscitation of vital functions are done simultaneously using a team approach.
Concepts of Initial Assessment
Primary Survey
Adjuncts
Definitive Care Reevaluation
Resuscitation
Reevaluation Detailed
Secondary Survey
Adjuncts
Quick Assessment
What is a quick, simple way to assess a patient in 10 seconds?
Quick Assessment
What is a quick, simple way to assess a patient in 10 seconds?
Identify yourself Ask the patient his or her name Ask the patient what happened
Appropriate Response Confirms
A B C
D
Patent airway
Sufficient air reserve to permit speech Sufficient perfusion to permit cerebration Clear sensorium
Primary Survey
A B C D E
irway with c-spine protection
reathing with adequate oxygenation irculation with hemorrhage control isability
xposure / Environment
Primary Survey
The priorities are the same for all patients.
Special Considerations
Trauma in the elderly
Pediatric trauma Trauma in pregnancy
Primary Survey
Airway
Establish patent airway and
protect c-spine
Pitfall s
Progressive loss of airway
Equipment failure
Occult airway injury
Inability to intubated
Primary Survey
Breathing
Assess and ensure adequate oxygenation and ventilation
Respiratory rate
Chest movement
Air entry Oxygen saturation
Primary Survey
Breathing
Pitfall s
Airway versus ventilation problem? latrogenic pneumothorax or tension pneumothorax?
Primary Survey
Circulation
Assess for organ perfusion Level of consciousness Skin color and temperature Pulse rate and character
Primary Survey
Circulatory Management
Control hemorrhage
Restore volume Reassess patient
Pitfall s
Elderly
Children Athletes Medications
Primary Survey
Disability
Baseline neurologic evaluation
Glasgow Coma Scale score
Pupillary response
Cautio n
Observe for
neurologic deterioration
Primary Survey
Exposure / Environment
Completely undress the patient
Cautio n
Prevent
Missed
injuries
hypothermia
Pitfall s
Resuscitation
Protect and secure airway Ventilate and oxygenate Stop the bleeding! Vigorous shock therapy Protect from hypothermia
Adjuncts to Primary Survey
ECG
Vital signs
ABGs Pulse
Urinary oximeter output Urinary / gastric catheters and CO unless contraindicated
2
PRIMARY SURVEY
Adjuncts to Primary Survey
Diagnostic Tools
Adjuncts to Primary Survey
Diagnostic Tools
FAST DPL
Adjuncts to Primary Survey
Consider Early Transfer
Use time before
transfer for resuscitation
Do not delay transfer
for diagnostic tests
What is the secondary survey?
The complete
history and
physical
examination
Secondary Survey
When do I start the secondary survey?
After Primary survey is completed ABCDEs are reassessed Vital functions are returning to normal
Secondary Survey
What are the components of the secondary survey? History Physical exam: Head to toe Complete neurologic exam Special diagnostic tests Reevaluation
Secondary Survey
History
A M P L E
llergies edications
ast illnesses
ast meal
vents / Environment / Mechanism
Secondary Survey
Mechanisms of Injury
Secondary Survey
Head
External exam Scalp palpation Comprehensive
eye and ear exam
Pitfall s
Unconsciousness
Periorbital edema
Including visual acuity
Occluded auditory canal
Secondary Survey
Maxillofacial
Bony crepitus Deformity Malocclusion
Pitfall s
Potential airway obstruction
Cribriform plate fracture
Frequently missed
Secondary Survey
Neck (Soft Tissues)
Mechanism:
Symptoms: Findings:
Blunt vs penetrating
Airway obstruction, hoarseness Crepitus, hematoma, stridor, bruit
Pitfall s
Delayed symptoms and signs
Progressive airway obstruction Occult injuries
Secondary Survey
Chest
Inspect Palpate Percuss Auscultate X-rays
Secondary Survey
Inspect / Auscultate Palpate / Percuss Reevaluate Special studies
Abdomen
Pitfall s
Hollow viscous injury Retroperitoneal injury
Secondary Survey
Perineum
Contusions, hematomas, lacerations, urethral blood
Rectum
Sphincter tone, high-riding prostate, pelvic fracture, rectal wall integrity, blood
Vagina
Blood, lacerations
Pitfall s
Urethral injury
Pregnancy
Secondary Survey
Pelvis
Pain on palpation Leg length unequal Instability X-rays as needed
Pitfall s
Excessive pelvic manipulation
Underestimating pelvic blood loss
Secondary Survey
Extremities
Contusion, deformity
Pain Perfusion
Peripheral neurovascular status
X-rays as needed
Secondary Survey
Musculoskeletal
Pitfall s
Potential blood loss Missed fractures Soft tissue or ligamentous injury
Compartment syndrome (especially with altered sensorium / hypotension)
Secondary Survey
Neurologic: Brain
GCS Pupil size and reaction Lateralizing signs Frequent reevaluation Prevent secondary brain injury
neurosurgical consult
Early
Secondary Survey
Neurologic: Spinal Assessment
Whole spine Tenderness and swelling Complete motor and sensory exams Reflexes Imaging studies
Pitfall s
Altered sensorium Inability to cooperate with clinical exam
Secondary Survey
Conduct an in-depth evaluation of
the patients spine and spinal cord
Neurologic: Spine and Cord
Early neurosurgical orthopedic consult
/
Secondary Survey
Neurologic
Pitfall s
Incomplete immobilization
Neurologic deterioration
Adjuncts to Secondary Survey
Special Diagnostic Tests as Indicated
Pitfall s Patient deterioration
Delay of transfer Deterioration during transfer Poor communication
How do I minimize missed
injuries?
High index of
suspicion
Frequent reevaluation
and monitoring
Pain Management
Relief of pain / anxiety as
appropriate
Administer intravenously Careful monitoring is
essential
Transfer
Which patients do I transfer to
a higher level of care?
Transfer
Which patients do I transfer to
a higher level of care? Those whose injuries exceed institutional capabilities:
Multisystem or complex injuries Patients with comorbidity or age extremes
Transfer
When should the transfer occur?
Transfer
When should the transfer occur? As soon as possible after stabilizing measures are completed:
Airway and ventilatory control Hemorrhage control (operation)
Transfer to Definitive Care
Local facility Transfer agreements Local resources Specialty Trauma facility center
Summary
Primary Survey
Adjuncts
Definitive Care Reevaluation
Resuscitation
Reevaluation Detailed
Secondary Survey
Adjuncts
