Chapter 1Chapter 1

Initial Assessment Initial Assessment and and

managementmanagement

OBJECTIVESOBJECTIVES

Identify the correct sequence of priorities in assessing the Identify the correct sequence of priorities in assessing the multiply injured patientmultiply injured patient

Apply the primary and secondary evaluation surveys to Apply the primary and secondary evaluation surveys to assessment of the multiply injured patientassessment of the multiply injured patient

Apply guidelines and techniques in the initial resuscitative Apply guidelines and techniques in the initial resuscitative and definitive--case phaseand definitive--case phase

Anticipate the pitfalls associated with the initial assessment Anticipate the pitfalls associated with the initial assessment and management ( minimize their impact )and management ( minimize their impact )

Conduct an initial assessment survey on a simulated Conduct an initial assessment survey on a simulated multiply injured patientmultiply injured patient

CONCEPTS OF INITIAL CONCEPTS OF INITIAL ASSESSMENTASSESSMENT

PreparationPreparation TriageTriage Primary survey ( ABCDEs )Primary survey ( ABCDEs ) ResuscitationResuscitation Adjuncts to primary survey and resuscitationAdjuncts to primary survey and resuscitation Secondary survey ( head-to-toe evaluation and history )Secondary survey ( head-to-toe evaluation and history ) Adjuncts to the secondary surveyAdjuncts to the secondary survey Continued postresuscitation monitoring and reevaluationContinued postresuscitation monitoring and reevaluation Definitive care Definitive care

Repeat primary and secondary survey when finding Repeat primary and secondary survey when finding any deterioration in the patient’s statusany deterioration in the patient’s status

Primary survey and resuscitation are done Primary survey and resuscitation are done simultaneouslysimultaneously

PREPARATIONPREPARATION

PrehospitalPrehospital– Airway maintenanceAirway maintenance– Control of external bleeding & shockControl of external bleeding & shock– Immobilization of the patientImmobilization of the patient– Communication with receiving hospital & immediate transport Communication with receiving hospital & immediate transport

to the closest, appropriate facilityto the closest, appropriate facility– History taking ( include events )History taking ( include events )

InhospitalInhospital– Advanced planning ( especially massive casualty )Advanced planning ( especially massive casualty )– Equipment & personnelEquipment & personnel– Communicable disease protectionCommunicable disease protection– Transfer agreementsTransfer agreements

TRIAGETRIAGE

Sorting of patients according to ABCs and available Sorting of patients according to ABCs and available resourcesresources

Triages is the responsibility of prehospital Triages is the responsibility of prehospital personnelpersonnel

Not exceed the ability of the facility ==> treat life -- threatening patient firstNot exceed the ability of the facility ==> treat life -- threatening patient first

Exceed the capacity of the facility ( mass casualties ) ==> Treat the Exceed the capacity of the facility ( mass casualties ) ==> Treat the greatest chance of survival, with the less time, less equipment & less greatest chance of survival, with the less time, less equipment & less personnelpersonnel

PRIMARY SURVEYPRIMARY SURVEY

Adult / Pediatric priorities sameAdult / Pediatric priorities same Identified the life-threatening conditions and simultaneously Identified the life-threatening conditions and simultaneously

managedmanaged– A: Airway maintenance with cervical spine protectionA: Airway maintenance with cervical spine protection– B: Breathing and ventilationB: Breathing and ventilation– C: Circulation with hemorrhage controlC: Circulation with hemorrhage control– D: Disability ( Neurologic status )D: Disability ( Neurologic status )– E: Exposure / Environmental control: Undress the patient & E: Exposure / Environmental control: Undress the patient &

prevent hypothermiaprevent hypothermia

PRIMARY SURVEYPRIMARY SURVEY

Airway Maintenance with Cervical Spine ProtectionAirway Maintenance with Cervical Spine Protection– Oral foreign bodies, facial, mandibular, or tracheal / laryngeal Oral foreign bodies, facial, mandibular, or tracheal / laryngeal

fractures may result in airway obstructionfractures may result in airway obstruction– Assume C-spine injuryAssume C-spine injury

Multisystem traumaMultisystem trauma Altered level of consciousnessAltered level of consciousness Blunt injury above clavicleBlunt injury above clavicle

– Pitfalls:Pitfalls: Difficult airwayDifficult airway Obesity: surgical airway cannot be performed smoothlyObesity: surgical airway cannot be performed smoothly laryngeal fracture or incomplete upper airway transectionlaryngeal fracture or incomplete upper airway transection

PRIMARY SURVEYPRIMARY SURVEY

Breathing and Ventilation Breathing and Ventilation – Airway patency Airway patency adequate breathing & ventilation adequate breathing & ventilation– injury that may acutely impair ventilationinjury that may acutely impair ventilation

1. Tension pneumothorax1. Tension pneumothorax 2. Flail chest with pulmonary contusion2. Flail chest with pulmonary contusion 3. Massive hemothorax3. Massive hemothorax 4. Open pneumothorax 4. Open pneumothorax above problems need to be identified in the primary survey and above problems need to be identified in the primary survey and

managedmanaged– Pitfall: Differentiation of ventilation problems from airway Pitfall: Differentiation of ventilation problems from airway

compromise may be difficultcompromise may be difficult

PRIMARY SURVEYPRIMARY SURVEY

Circulation with Hemorrhage Control Circulation with Hemorrhage Control – Assess blood volume and cardiac outputAssess blood volume and cardiac output

level of consciousnesslevel of consciousness skin colorskin color pulsepulse

– Bleeding control: direct manual pressure on the woundBleeding control: direct manual pressure on the wound– Pitfall:Pitfall:

The response of elderly, children, athletes and others with The response of elderly, children, athletes and others with chronic medical conditions to hypovolemia is different chronic medical conditions to hypovolemia is different from normal peoplefrom normal people

PRIMARY SURVEYPRIMARY SURVEY

Disability ( Neurologic Evaluation ) Disability ( Neurologic Evaluation ) – Level of consciousnessLevel of consciousness

A. AlertA. Alert V. Response to voiceV. Response to voice P. Response to painP. Response to pain U. UnresponsiveU. Unresponsive

– PupilsPupils– Pitfall:Pitfall:

Lucid interval ( talk and die ) : EDH, frequent neurologic Lucid interval ( talk and die ) : EDH, frequent neurologic reevaluation can minimize this problemreevaluation can minimize this problem

PRIMARY SURVEYPRIMARY SURVEY

Exposure/Environmental Control Exposure/Environmental Control – Undress patient completelyUndress patient completely– Protect from hypothermiaProtect from hypothermia

– Pitfall:Pitfall: early control of the hemorrhage is the best method to early control of the hemorrhage is the best method to

keep body temperature( early surgical intervention)keep body temperature( early surgical intervention)

RESUSCITATIONRESUSCITATION

Protect/Secure airway & protect C-spine Protect/Secure airway & protect C-spine Breathing/Ventilation/OxygenationBreathing/Ventilation/Oxygenation Vigorous shock therapyVigorous shock therapy

– At last two large - caliber IV lineAt last two large - caliber IV line– Crystalloid solution ( Ringer’s lactate 2~3Crystalloid solution ( Ringer’s lactate 2~3 litter)litter)– Type-specific bloodType-specific blood– surgical interventionsurgical intervention

Protect from Hypothermia : 39Protect from Hypothermia : 39ooC warm IV fluidC warm IV fluid Urinary/gastric catheters unless contraindicationUrinary/gastric catheters unless contraindication

ADJUNCTS TO PRIMARY SURVEY ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATIONAND RESUSCITATION

Monitor:Monitor:– Ventilatory rate and ABGs/ end-tidal COVentilatory rate and ABGs/ end-tidal CO22

Pitfalls: Combative patients often extubate or bite Pitfalls: Combative patients often extubate or bite endotracheal tubeendotracheal tube

– Pulse oximetryPulse oximetry– ECG & BP monitor ECG & BP monitor – TemperatureTemperature– urine outputurine output

X-RAY AND DIAGNOSTIC STUDIESX-RAY AND DIAGNOSTIC STUDIES

Can’t delay or interrupt the primary survey and resuscitationCan’t delay or interrupt the primary survey and resuscitation Trauma series ( portable X-ray ): CXR, C-spine/ lateral view, Trauma series ( portable X-ray ): CXR, C-spine/ lateral view,

pelvic AP viewpelvic AP view A negative or inadequate c-spine x-ray can’t exclude cervical A negative or inadequate c-spine x-ray can’t exclude cervical

spinal injury spinal injury Sonography / DPLSonography / DPL

Pitfalls: obesity ( Sonography and DPL are difficult )Pitfalls: obesity ( Sonography and DPL are difficult )

CONSIDER NEED FOR PATIENT CONSIDER NEED FOR PATIENT TRANSFERTRANSFER

Referring doctor -to -receiving doctor communicationReferring doctor -to -receiving doctor communication

Closest appropriate hospitalClosest appropriate hospital

BEFORE SECONDARY SURVEYBEFORE SECONDARY SURVEY

Complete primary surveyComplete primary survey

Establish resuscitationEstablish resuscitation

Normalization of vital functionsNormalization of vital functions

SECONDARY SURVEYSECONDARY SURVEY

History takingHistory taking Complete neurologic exam.Complete neurologic exam. Head-to-toe evaluationHead-to-toe evaluation RoentgenogramsRoentgenograms Special procedureSpecial procedure Tubes and fingers in every orificeTubes and fingers in every orifice Re-evaluationRe-evaluation

SECONDARY SURVEYSECONDARY SURVEY

History History – A. AllergiesA. Allergies– M. Medications currently usedM. Medications currently used– P. Past illness / pregnancyP. Past illness / pregnancy– L. Last mealL. Last meal– E. Events / Environment related to injuryE. Events / Environment related to injury

HISTORYHISTORYMechanisms of injuryMechanisms of injury

BluntBlunt– Automobile collisionsAutomobile collisions

Seat belt usageSeat belt usage Steering wheel deformationSteering wheel deformation Direction of impactDirection of impact Ejection of passenger form the vehicleEjection of passenger form the vehicle

Burns and Cold injuryBurns and Cold injury– Inhalation injury and CO. intoxication in fire fieldInhalation injury and CO. intoxication in fire field

Hazardous environmentHazardous environment PenetratePenetrate

– Anatomy factorsAnatomy factors– Energy transfer factorEnergy transfer factor

Velocity and caliber of bulletVelocity and caliber of bullet TrajectoryTrajectory DistanceDistance

SECONDARY SURVEYSECONDARY SURVEY

Physical ExaminationPhysical Examination– HeadHead

– entire scalp and headentire scalp and head– eye:eye:

pupil pupil visual acuityvisual acuity EOMEOM foreign body ( soft contact lens….)foreign body ( soft contact lens….)

– Pitfalls:Pitfalls:Severe facial swelling or unconsciousness p’t still Severe facial swelling or unconsciousness p’t still need eye exam.need eye exam.

SECONDARY SURVEYSECONDARY SURVEY

Physical ExaminationPhysical Examination– MaxillofacialMaxillofacial

No airway obstruction or massive bleeding ==> treat laterNo airway obstruction or massive bleeding ==> treat later Midfacial fracture ==> R/O cribriform plate fractureMidfacial fracture ==> R/O cribriform plate fracture

Pitfalls:Pitfalls:Some facial bone fracture is difficulty identified early ==> Some facial bone fracture is difficulty identified early ==> reassessment is crucialreassessment is crucial

SECONDARY SURVEYSECONDARY SURVEY

Physical ExaminationPhysical Examination– C-spine and NeckC-spine and Neck

Maintain immobilizationMaintain immobilization Complete evaluationComplete evaluation Complete radiology studyComplete radiology study Cautions helmet removedCautions helmet removed Penetrating injury: Not be explored in the emergency Penetrating injury: Not be explored in the emergency

department; explored & treat in the operative roomdepartment; explored & treat in the operative room

Pitfalls:Pitfalls:Blunt injury to Neck: Carotid artery intima injury or Blunt injury to Neck: Carotid artery intima injury or dissection ( delay onset )dissection ( delay onset )

Immobilization ==> decubitus ulcer Immobilization ==> decubitus ulcer

SECONDARY SURVEYSECONDARY SURVEY

Physical ExaminationPhysical Examination– ChestChest

Pitfalls:Pitfalls:– Poor tolerance to minor pulmonary trauma in Poor tolerance to minor pulmonary trauma in

elderly patientselderly patients– A normal CXR can’t role out chest injury in A normal CXR can’t role out chest injury in

children children

SECONDARY SURVEYSECONDARY SURVEY

Physical ExaminationPhysical Examination– AbdomenAbdomen

Identify a surgical abdomen is more important than doing a Identify a surgical abdomen is more important than doing a specific diagnosis ==> early consult surgeonspecific diagnosis ==> early consult surgeon

Close observation & frequent reevaluation of the abdomenClose observation & frequent reevaluation of the abdomen DPL, sonography, abdomen CTDPL, sonography, abdomen CT

Pitfalls:Pitfalls:– Excessive manipulation of the pelvis should be avoid Excessive manipulation of the pelvis should be avoid

==> just do pelvic x-ray==> just do pelvic x-ray– Retroperitoneal organs ( pancreatic & hollow organ ) Retroperitoneal organs ( pancreatic & hollow organ )

are very difficult to identifyare very difficult to identify

SECONDARY SURVEYSECONDARY SURVEY

Physical ExaminationPhysical Examination– Perineum / rectum / vaginaPerineum / rectum / vagina

Perineum: Contusions, hematomas, urethral Perineum: Contusions, hematomas, urethral bleeding……. bleeding…….

Rectum: Sphincter tone, high riding prostate, Rectum: Sphincter tone, high riding prostate, blood….. blood…..

Vagina: Blood, lacerationVagina: Blood, laceration

Pitfalls:Pitfalls:Female urethral injury is difficult to detectFemale urethral injury is difficult to detect

SECONDARY SURVEYSECONDARY SURVEY

Physical ExaminationPhysical Examination– MusculoskeletalMusculoskeletal

Extremities / pelvis: Contusion, deformity, pain Extremities / pelvis: Contusion, deformity, pain crepitation, abnormal crepitation, abnormal

movement movement Vascular: Assess all peripheral pulsesVascular: Assess all peripheral pulses Spine: Physical findings, mechanism of injurySpine: Physical findings, mechanism of injury

SECONDARY SURVEYSECONDARY SURVEY

Physical ExaminationPhysical Examination– NeurologicNeurologic

Determine GCS scoreDetermine GCS score Re-evaluate pupilsRe-evaluate pupils Sensory / motor evaluation Sensory / motor evaluation Maintain immobilizationMaintain immobilization Prevent secondary CNS injury ( keep stable vital signs, Prevent secondary CNS injury ( keep stable vital signs,

avoid increased ICP and treat IICP )avoid increased ICP and treat IICP ) Early neurosurgical consultationEarly neurosurgical consultation

Pitfalls:Pitfalls:Intubation should be done expeditiously and as smoothly Intubation should be done expeditiously and as smoothly as possible ( Intubation will increase ICP )as possible ( Intubation will increase ICP )

REEVALUATIONREEVALUATION

New findings / deterioration / improvementNew findings / deterioration / improvement

High index of suspicion ==> early diagnosis & High index of suspicion ==> early diagnosis & managementmanagement

Continuous monitoringContinuous monitoring

Pain reliefPain relief

DEFINITIVE CAREDEFINITIVE CARE

Trauma center Trauma center

Closest appropriate hospitalClosest appropriate hospital

RECORDS AND LEGAL RECORDS AND LEGAL CONSIDERATIONASCONSIDERATIONAS

Records: Concise, chronologic documentationRecords: Concise, chronologic documentation

Consent for treatmentConsent for treatment

Forensic Evidence: preserve the evidenceForensic Evidence: preserve the evidence

SUMMARYSUMMARY

Initial assessment & management of multiply injured Initial assessment & management of multiply injured patientpatient

Primary survey ( ABCDEs )Primary survey ( ABCDEs )

Resuscitation & monitor ( life-threatening problems )Resuscitation & monitor ( life-threatening problems )

Secondary survey ( head-to-toe, history )Secondary survey ( head-to-toe, history )

Definitive care ( early consultation, surgical intervention Definitive care ( early consultation, surgical intervention or transport ) or transport )