1 - INITIAL A SSESSMENT + M ANAGEMENT 1. What are the two phases of preparation? 1. Prehospital - coordination with receiving hospital 2. Hospital - preparations made to facilitate patient's resuscitation 2. Key points of prehospital phase of preparation. 1. notification of receiving hospital before personnel transport the patient from scene 2. emphasis placed on; a. airway maintenance b. control of external bleeding and shock c.
immobilization
d. immediate transport to the closest appropriate facility 3. effort made to minimize time spent on scene and en route 3. Key points of hospital phase of preparation. Preparing area: 1. ideally resuscitation bay Preparing equipment: 1.
airway equipment - organized, tested, available
2.
warmed fluids
Preparing staff: 1.
accessory medical staff summoned
2.
radiolographers + laboratory informed
Staff to be wearing appropriate PPE: 1.
face mask
2.
eye protection
3.
apron
4.
gloves
4. Outline the primary survey. The primary survey identifies immediately life-threatening conditions in a logical and sequential manner (though often performed simultaneously in practice). Airway maintenance with cervical spine protection Breathing and ventilation Circulation with hemorrhage control Disability: Neurological status Exposure/Environmental control: undress the patient, but prevent hypothermia
5. Primary survey priorities for pediatric patients. Identical assessment and management priorities. Different parameters for injury pattern, heat loss, fluid/medications, etc. 6. Primary survey priorities for pregnant females. Same priorities as for non-pregnant females, but with knowledge that anatomical and physiological changes modify the response to injury. Important to recognize pregnancy e arly (palpation of gravid uterus, BhCG) and perform fetal assessment.
7. Primary survey priorities for elderly patients. Same priorities. 8. Summarize airway assessment. foreign bodies facial/mandibular/tracheal/laryngeal fractures GCS < 9 indicates need for definitive airway repeated assessment is required to ensure c ontinued patency 9. Summaries C-spine protection. prevent excessive movement of the ce rvical spine use immobilization devices if collar is removed, inline stabilization assume a cervical spine injury in any patient with multisystem trauma, especially those with an altered level of consciousness or a blunt injury above the clavicle 10. Outline pitfalls in airway and C-spine management. equipment failure 11. Summaries assessment of breathing and ventilation. chest wall movement auscultate lungs for adequate gas flow visual inspection and palpation for chest wall injuries 12. What injuries should be specifically assessed for in i nitial assessment of breathing? tension pneumothorax flail chest massive haemothorax open pneumothorax 13. What is a major pitfall in assessment of breathing? Differentiation between airway compromise and breathing difficulty. Management: more important to suspect and treat airway com promise, but do not relax once airway is secure re-examination of chest + urgent CXR once patient is intubated while show up breathing issues 14. Outline assessment of circulation. Hemodynamics: observations level of consciousness skin color pulses (peripheral + central) External hemorrhage - identify + control during primary survey. 15. How is disability/neuro disability/neurology logy assessed? level of consciousness (GCS) pupillary size + reaction lateralizing signs spinal cord injury level 16. What is involved in exposure/envi exposure/environmental ronmental control? patient completely undressed once assessment completed, cover patient with warm blankets or an external warming device to prevent hypothermia IV fluids should be warmed before infusion warm environment should be maintained if possible
17. Outline airway resuscitation. To achieve patency: chin-lift or jaw-thrust maneuvers oral or nasopharyngeal airways if required/tolerated intubation surgical airway 18. Outline breathing resuscitation. decompression of tension pneumothorax supplementary oxygen for all patients 19. Outline circulatory resuscitation. Essentially 2 factors: 1. definitive bleeding control - o peration, angioembolisation, pelvic stabilization IV volume resuscitation - 2 x large bore cannula, warmed IV fluids 20. What are adjuncts to primary survey and resuscitation? ECG monitoring urinary and gastric catheters other monitoring (ventilatory rate, ABG, pulse oximetry, blood pressure) X-rays and diagnostic studies 21. What is the importance of ECG monitoring? arrhythmias - blunt cardiac injury PEA - tamponade, te nsion PTX, profound hypervolemia bradycardia - hypoxia, hypoperfusion, hypothermia 22. What is the importance of urinary catheters? urine output is a sensitive indicator of volume status + renal perfusion best measured through indwelling urinary catheter 23. What is a contraindication to transurethral catheterization?
Urethral transection/injury. Should be suspected if: blood at meatus perineal ecchymosis blood in scrotum high-riding or nonpalpable prostate pelvic fracture 24. What is the importance of gastric catheters? stomach decompression reduces the risk of aspiration blood in gastric aspirate indicates oropharyngeal blood, traumatic insertion, or injury to upper gastric tract 25. What is the importance of ventilatory rate monitoring and ABG? For monitoring of the adequacy of respiration. Capnography is also useful. 26. What is the importance of pulse oximetry?
Monitoring oxygenation is important in injured patients. Remember that it does not measure PaO2 or PaCO2. 27. What imaging should be done as an adjunct to primary survey and resuscitation? X-ray:
chest pelvis
C-spine
In obtunded patients, CT brain. FAST and/or DPL. 28. What is the secondary survey and when does it start? Head-to-toe evaluation of the patient, including complete history and physical examination, and reassessment of all vital signs. It does not begin until the primary survey is completed, resuscitation is underway, and normalization of vital functions has been demonstrated. 29. What is an AMPLE history? A - allergies M - medications P - past medical history/pregnancy L - last meal E - Events/environment related to the injury 30. What is important information to gain about the mechanism of injury and environment? Type of trauma: blunt penetrating thermal Hazardous environment: chemicals toxins radiation 31. What is the sequence of examination during the secondary survey? head maxillofacial structures cervical spine + neck chest abdomen perineum/rectum/vagina musculoskeletal system neurological system 32. Outline secondary survey examination of the head. Entire scalp and head examined for: lacerations contusions evidence of fractures
Eye examination. 33. What is involved in examination of the eyes?
visual acuity pupillary size conjunctival/fundal hemorrhage penetrating injury contact lenses (remove ASAP) lens dislocation ocular entrapment
34. Outline maxillofacial examination. identify any fractures of the facial bones clinically if they are not associated with airway compromise, definitive management may be safely delayed avoid passing any tubes nasally in the presence of midface fractures 35. Outline examination of cervical spine + neck. Inspection: lacerations bruising deformities Palpation: C-spine tenderness subcutaneous emphysema tracheal deviation laryngeal fracture carotid arteries Auscultation: carotid bruits 36. Important points regarding penetrating neck injuries. Wounds that extend through the platysma should not be explored manually, probed with instruments, or treated in ED. 37. Outline secondary survey examination of the chest. visual examination (anterior + posterior) - flail segments, open PTX, contusions, hematomas palpation of entire chest cage (ribs, c lavicles, sternum) - tender areas, sternal pressure tenderness auscultation of chest and heart CXR examination 38. Outline secondary survey examination of the abdomen. identification of abdominal injury is important close observation and frequent re evaluation is important Consider peritoneal lavage, FAST or CT in patients with: unexplained hypotension neurological injury altered sensorium (drugs/alcohol) equivocal abdominal findings 39. Outline secondary survey examination of the perineum/rectum perineum/rectum/vagina. /vagina. Perineum: contusions hematomas lacerations urethral bleeding Rectum: presence of blood in bowel lumen high-riding prostate pelvic fractures integrity of rectal wall sphincter tone
Vagina: blood in vaginal vault vaginal lacerations 40. Outline secondary survey examination of the musculoskeletal system. extremities - contusions, deformities, focal tenderness over long bones, abnormal movement pelvis - ecchymosis, pain on palpation of pelvic ring, mobility of the pelvis on AP pressure, assessment of peripheral pulses spine - palpation for thoracolumbar spinal fractures 41. Outline secondary survey examination of the neurological system. level of consciousness pupillary size and response motor and sensory evaluation of the extremities Frequent re-assessment for deterioration is important.
