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

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

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 = AllergiesM = MedicationsP = Past illnessesL = Last mealE = 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

Peritoneum Contusions, hematomas, lacerations, urethral blood

Rectum Sphincter tone, high-riding prostate, pelvic fracture, rectal wall integrity, blood

Vagina Blood, 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