Primary Survey

[See Pocket Card]
Primary Survey (Rapid identification and management of immediately life-threatening injuries) 
A. Airway and cervical spine
  •   Assess, clear, and protect airway: Jaw thrust/chin lift, suctioning.
  •   Perform ET intubation with in-line stabilization for patient with depressed level of consciousness or inability to protect airway.
  •   Create surgical airway if there is significant bleeding or obstruction, or laryngoscopy cannot be performed.
B. Breathing
  •   Ventilate with 100% oxygen, monitor oxygen saturation.
  •   Auscultate for breath sounds.
  •   Inspect thorax and neck for deviated trachea, open chest wounds, abnormal chest wall motion, crepitus at neck or chest.
  •   Consider immediate needle thoracostomy for suspected tension pneumothorax.
  •   Consider tube thoracostomy for suspected hemopneumothorax.
C. Circulation
  •   Assess for blood volume status: skin color, capillary refill, radial/femoral/carotid pulse, blood pressure.
  •   Place two large-bore peripheral IV catheters.
  •   Begin rapid infusion of warm crystalloid solution, if indicated.
  •   Apply direct pressure to sites of brisk external bleeding.
  •   Consider central venous access if peripheral sites are unavailable.
  •   Consider pericardiocentesis for suspected pericardial tamponade.
  •   Consider left lateral decubitus position in late-trimester pregnancy.
D. Disability
  •   Perform screening neurologic and mental status examination, assessing:
    • Pupil size and reactivity
    • Limb strength and movement, grip strength
    • Orientation, Glasgow Coma Scale score
  •   Consider measurement of capillary blood glucose level in patients with altered mental status.
E. Exposure
  •   Completely disrobe the patient, inspect for burns, toxic exposures.
  •   Log-roll patient, maintaining neutral position and in-line neck stabilization, to inspect and palpate thoracic spine, flank, back, and buttocks.
Secondary Survey (Head-to-toe examination for rapid identification and control of injuries or potential instability) 
  Identify and control scalp wound bleeding with direct pressure, sutures, or surgical clips.
  Identify facial instability, potential for airway instability.
  Identify hemotympanum.
  Identify epistaxis or septal hematoma; consider tamponade or airway control if bleeding is profuse.
  Identify avulsed teeth, jaw instability.
  Evaluate for abdominal distention and tenderness.
  Identify penetrating chest, back, flank, or abdominal injuries.
  Assess pelvic stability, consider pelvic wrap or sling.
  Inspect perineum for laceration or hematoma.
  Inspect urethral meatus for blood.
  Consider rectal examination for sphincter tone and gross blood.
  Assess peripheral pulses for vascular compromise.
  Identify extremity deformities and immobilize open and closed fractures and dislocations.

A IRWAY

Trauma Pt.

Conscious Unconscious/Coma
OR
Noisy breathing
Extensive Maxillofacial Injury
"drowning in his own blood"

Airway present

Expanding Hematoma
        

Air Under skin of Neck


Secure Airway
(Orotracheal Intubation)


Cricothyroidotomy
OR
Percutaneous Tracheostomy (should be only done in an O.R.)

Nothing further Secure Airway
(Orotracheal Intubation)

Fiber optic Bronchoscopy w/ intubation



B REATHING

  1. Assess, respirations/oxygenation
  2. Check neck & thorax for

Management

  1. Ventilation w/100% O2 if
    • Apnea or poor ventilation
    • High spinal cord injury
    • Flail chest
    • Hypoxia w/o 100% non-rebreather mask
  2. Tracheal deviation
    • R/O Tension Pneumothorax
      • Immediate needle decompression (needle thoracostomy) if present
    • Possible tracheal fracture
      • Intubation may stabilize
    • Expanding neck hematoma
      • Intubate
  3. Sucking/open chest wounds
    • Place occlusive dressing taped on 3 sides
    • Place chest tube
  4. Flail Chest
    • Intubate & ventilate


C IRCULATION

C ontrol Bleeding

External Bleeding

  1. Apply direct pressure to wound 
    • May use saline soaked swab or pads
    • Do not rub or abrade wound
    • Tourniquets are contraindicated (pressure is superior to tourniquets)
    • Pressure points unproven & can compromise proven intervention of direct pressure
  2. Persistent bleeding w/ vessel diameter
    • >2 mm: suture ligature
    • <2 mm: electrocautery if applicable
  3. Bleeding diathesis: pack w/ type I gauze swabs
    • DO NOT remove gauze, add more gauze & continue to apply pressure
  4. Check for gross limb deformities
  5. Elevate wound (controversial)
    • Current studies have not established if elevation of wound helps or harms
    • Irrigate, disinfect (antibiotic creams have been shown to improve wound healing)
    • Re-examine w/in 24 hrs for 2° closure
    • Evacuating any hematoma

NO Obvious External Hemorrhage

  1. If no obvious external source
    • Probable hemorrhage into body cavity (internal bleed)
  2. Must assess
    • Chest
    • Abdomen
    • Retroperitoneum
  3. Consider pelvic fracture
  4. Assessment tools (for pts in hemorrhagic shock)
    • CXR, pelvic X-ray
    • FAST ultrasound scan
    • DPL
    • CT discouraged in unstable pt
    • Surgery

 

Estimation of Degree of Hemorrhagic Shock 
 
Class I II III IV
Blood Loss
(% blood volume)
<750 cc
(<15%) 
750-1500 cc
(15-30%)
1500-2000 cc
(30-40%) 
>2000 cc
(>40%)
Pulse   <100 >100 >120 >140
Blood pressure Normal Normal Decreased Decreased
Respiratory rate 20 30 35 >45
Capillary refill Normal Decreased Decreased Decreased
Urinary output 30 cc/hr 20 cc/hr 10 cc/hr None
Fluid replacement Crystalloid Crystalloid Crystalloid + blood Crystalloid + blood

 

Trauma Pt. in Shock
- Is the Chest involved?

NO
YES
Dx in this pt. is BLEEDING
Distended Neck Veins
High CVP

Collapsed Neck Veins
Unknown Site Of Bleed
Obvious Bleed
Trouble Breathing? Bleed in Abdomen

EMERGENCY
LAPAROTOMY
to stop bleeding

1. 2x16G IV lines. 1 in each arm.
(Child: Interosseus Cannulation of proximal tibia)
2.
1-2 L IV LR over 20 min.
3.
Cross & Type
4. CT Abd,
Physical to locate site of bleed.
5. 
Assess for surgical intervention (is pt. still bleeding or has it already stopped?)

1. Direct pressure.
2.
IV Fluids
3.
Surgery
 

Yes
No
Tension Pneumothorax Pericardial Tamponade

1. Big Needle (Thoracentesis)
 OR
2. IV Cartheter into pleural space, High in anterior chest wall

1. Ultrasound
2.
Pericardiocentesis
      PLUS
IV Fluids (must replace fluids to increase HR/CO)

OR

Go straight to Medium-Sternotomy (Surgery)


 

D ISABILITY

Eyes Open Best Verbal Response Best Motor Response
Spontaneously 4 Answers questions appropriately 5 Obeys commands 6
To voice 3 Confused, disoriented 4 Localizes to pain 5
To pain 2 Inappropriate words 3 Withdraws from pain 4
No response 1 Incomprehensible sounds 2 Decorticate (flexion) 3

 

 
No verbal response 1 Decerebrate (extension) 2
 
 

 

 
No response 1

Don't Forget Neuro (Glasgow Coma Scale)

Reason for This

Neuro Exam

  1. Make a rapid neurological assessment (AVPU)
    • If there is no time to do Glasgow Coma Scale (GCS), use the following
      • A: Awake
      • V: Verbal response
      • P: Painful response
      • U: Unresponsive
  2. Head
    • Pupils
    • Level of consciousness
      • Evaluate using GCS 
      • GCS <8:
        • Indication for intubation (controversial)
        • Severe brain injury
    • For altered mental status (AMS)
      • R/O or Tx for
        • Hypoxia
          • Administer 100% O2 via non-nebulizer or intubate
        • Hypoglycemia
          • Administer dextrose (Glucose) IV (50 mL of 20% soln)
        • Opioid intoxication (pin-point pupils, hypoventilation)
          • Administer naloxone IV or ET tube
          • 0.4-2 mg adults or 0.01 mg/kg children
        • Wernicke's encephalopathy
          • Thiamine (100 mg IV) available in Pabrinex 250 mg/ampoule set
    • Cranial nerves
    • Head & face
      • Tympanic membranes
        • Hemotympanum
  3. C-Spine
    • Palpate C-Spine carefully for bony tenderness, step-offs
    • DTRs, motor & sensory (light touch & pinprick)
      • Document focal deficits or lowest remaining functional level
        • Quick exam
    • Assess for sacral & posterior column fxn sparing
      • Indicates incomplete injury & improved prognosis
      • Rectal tone

Start Cerebroprotective Measures (If indicated)
See also ICP Management

  1. Sedate intubated brain-injured pts
    • Midazolam
    • Propofol
  2. Lower ICP if suspect herniation
    • Mild hypervent.
      • PaCO2 35 mmHg
    • Mannitol 1.0 g/kg
    • For pts not in shock


 

E XPOSURE/ENVIRONMENT

 

Diagnostic Testing: