Trauma Primary and Secondary Survey
Sarah Pearson Emergency Department Consultant Queens Hospital, Burton
Trauma Resuscitation
Aim
Structured approach to the assessment of severely injured patient and institution of lifelifepreserving therapy
Trauma
Structured Approach
rapid primary evaluation ABC . resuscitation of vital function more detailed secondary assessment emergency treatment initiation of definitive care
Trauma Assessment & Resuscitation
Technically longitudinal progression of events In reality often parallel or simultaneous
Treat problems as they are found
Trauma Assessment
Primary Survey
A B C D E
airway & cervical spine control breathing & oxygen therapy circulation & haemorrhage control disability & neurological status exposure & environment
DEFG
don t ever forget glucose
Trauma Assessment
A - airway and C-spine control C
direct clearance / gentle suction position to establish patent airway check adjuncts and definitive airway if used C - spine immobilisation
Pitfalls Beware of struggling patient paralysed patient unknown laryngeal # or airway transection Finger sweep
Trauma Resuscitation
Airway Manoeuvres
Definitive airway
jaw thrust chin lift head tilt
ETT (oral or nasal)
Surgical airway
needle cricothyroidotomy (jet insufflation ) surgical cricothyroidotomy (mini(mini-tracheostomy) tracheostomy
Adjunts
OroOro-pharyngeal airway NasoNaso-pharyngeal airway
Trauma Assessment
B- Breathing with oxygen therapy
chest wall and abdominal inspection check for air shift palpation, percussion and auscultation high flow oxygen
Pitfalls
airway compromise equipment failure
Trauma Resuscitation
Breathing with oxygen therapy
patent airway established with continuous CCspine protection supplemental oxygen given - mask or catheter assist breathing if necessary bag & mask chest decompression if tension pneumothorax is suspected attach monitors pulse oximeter
Most fatal chest injuries
A T O M F C
Airway transection/rupture Tension pneumothorax Open pneumothorax Massive haemothorax Flail segment Cardiac tamponade
Trauma Resuscitation
Indications for intubation and ventilation
Impending airway compromise Inadequate support from bag & mask Prolonged ventilation needed controlled ventilation needed
Trauma Assessment
C - circulation and haemorrhage control
level of consciousness colour, pulse,capillary refill , B.p look for obvious bleeding ensure patent intravenous(IV) access possible
largest
Pitfalls
poor correlation of b.p with cardiac output tachycardia in athletes occult bleeding
Trauma Resuscitation
Circulation
control bleeding by direct pressure or operative intervention two good IV accesses + fluid therapy Consider inter-osseous needles if IV is difficult intercutcut-downs may be necessary take blood for baseline tests, GXM and BM monitor urinary output
Trauma Assessment
disability
A - Alert V - responds to Voice P - responds to Pain U - Unresponsive GCS may be used Pupils Posture haemorrhage or drugs lucid interval
Pitfalls
Trauma Assessment
E - Exposure and Environmental control
completely undress with minimal movement keep patient warm and decent
Pitfalls
massive infusion of cold fluids may worsen already existing hypothermia
Trauma Resuscitation
Adjuncts to Primary survey & Resuscitation
Monitoring
vital signs arterial gases urinary output
X-rays (trauma series)
CXR Lateral C-spine C Pelvis
Trauma Resuscitation
More Adjunts
Other diagnostic studies
Focused assessment sonography in trauma(FAST) Computerised tomography(CT) Diagnostic peritoneal lavage(DPL)
Gastric tube (nasal or oral) Urinary catheter
Trauma
Secondary Survey
head to toe assessment with due consideration to the already identified injuries But
primary survey must be completed resuscitative efforts must be well established and continued patient should be demonstrating normalisation of vital functions review ABC if any deterioration is noted during secondary survey
Trauma
Secondary Survey
History -AMPLE A - allergies M - medications P - past medical history L - last meal E - events/environment relating to injury
Trauma
History
Details about events and environment
Source
Vehicular accident Fall from height Assault including suicide(think NAI) Blunt Penetrating burns and cold
Type
other hazardous environment
Trauma
Secondary Survey
Examination
head and face Neck chest abdomen Perineum Back log roll Limbs Neurology
*Use as framework for recording notes
Trauma
Secondary Survey
Log roll
5 people must be a clear leader must give clear instructions
Note: May be done earlier to relieve pressure from spinal board
Trauma
Definitive care
Referral Safe transfer or retrieval
Trauma Resuscitation
Trauma Resuscitation
Summary
Simple concept of trauma management Sequence of assessment and resuscitation Essential initial imaging in trauma System of recording notes in trauma
