Outline
- reception
- primary survey
- secondary survey
- radiology
- procedures
- limb injuries
- spinal injuries
Overview
A clear, simple, and organized approach is needed when managing a severely injured patient. The primary survey promulgated in Advanced Trauma Life Support (ATLS) provides such an approach. The primary survey is organized according to the injuries that pose the most immediate threats to life and is performed in the order described below. In settings with limited resources, the primary survey simplifies priorities and any problems identified should be managed immediately before moving on to the next step of the survey. However, at major trauma centers, many capable clinicians may be present, allowing the team to address multiple problems simultaneously.The primary survey consists of the following steps:
- Airway assessment and protection → maintain cervical spine stabilization when appropriate
- Breathing and ventilation assessment → maintain adequate oxygenation
- Circulation assessment → control hemorrhage and maintain adequate end-organ perfusion
- Disability assessment → perform basic neurologic evaluation
- Exposure, with environmental control → undress patient and search everywhere for possible injury, while preventing hypothermia
Keep the following points in mind while performing the primary survey:
- Airway obstruction is a major cause of death immediately following trauma. The airway may be obstructed by the tongue, a foreign body, aspirated material, tissue edema, or expanding hematoma.
- Definitive guidelines for tracheal intubation in trauma do not exist. It is generally best to intubate early if the patient has sustained significant injuries to the face or neck that may lead to swelling and distortion of the airway.
- In cases of hemodynamic instability, it may be best to delay intubation until adequate physiologic optimization has been achieved, as the medications used for rapid sequence intubation can exacerbate hypotension
- Once an airway has been established, it is important to secure it well and to ensure it is not dislodged any time the patient is moved. Unintended extubation is the most common preventable cause of morbidity in trauma patients.
- Unconscious patients with small pneumothoraces that are not visible or are missed on the initial chest radiograph may develop tension physiology after tracheal intubation from positive pressure ventilation. It is important to re-auscultate the lungs of trauma patients who develop hemodynamic instability after being intubated and to be attentive to ventilator pressure alarms.
- Hemorrhage is the most common preventable cause of mortality in patients with trauma. Be alert for subtle signs of hemorrhagic shock, particularly in the elderly, who may be on cardiovascular medications that blunt such signs, and in young, healthy adults who may not present with obvious manifestations. Hypotension generally does not manifest until at least 30% of the patient’s blood volume has been lost. Such patients are at high risk of death. Elderly patients may be hypotensive relative to their baseline blood pressure but still have blood pressure measurements in the “normal” range. A single episode of hypotension substantially increases the likelihood that a serious injury has occurred.
- Brain injuries are common in patients who have sustained severe blunt trauma and even a single episode of hypotension increases their risk of death.
Reception
- Prehospital Information
- Nature of Incident
- Number, age & sex of casualties
- ABCD
- Management & Effect
- ETA
Airway & Cervical Spine control
- Assess: Ask name, facial/neck injuries, vomit
- Clear Airway: with sucker or Magill forceps
- Chin Lift – one hand on chin, thumb in mouth, pull forward
- Jaw Thrust
- Orotracheal intubation with in-line neck stabilisation: absent gag & poor ventilation, head injury
- 100% oxygen at flow rate 15 l/min
- Full cervical spine immobilisation – hard collar & lateral supports with straps across forehead & chin
Breathing
- Inspect neck & thorax – NB trachea, neck veins
- Respiratory Rate
- Auscultate
Life Threatening thoracic conditions:
- Trauma Clinicians Often Miss Fractures
- Tension pneumothorax
- Cardiac tamponade
- Open chest wound
- Massive haemothorax
- Flail chest
Circulation
- Shock assessment: skin colour, capillary refill, mental state, pulse, blood pressure
- control haemorrhage
- 2 large(14g) cannulas peripherally
- Withdraw 20ml blood for FBC, U&E, Gluc., X-match
- warmed crystalloids
- Blood:
- full x-match
- type specific
- O Neg
Dysfunction
pupils – size, equal, response to light.
conscious level
- Alert
- Verbal stimuli
- Pain stimuli
- Unresponsive
Exposure
clothing – remove all
cold – be aware of Hypothermia, keep warm (warmed blankets)
Secondary survey
- head-to-toe
- log-roll
- PR (& PV)
- tubes – 2 large peripheral IV; urinary catheter, NGT, (chest drain, DPL, central line, arterial line)
- analgesia, anti-tetanus, antibiotics
X-Rays: (done after Primary Survey)
- lateral cervical spine (followed by AP & peg view in X-Ray dept. when patient stable- do not remove collar until all 3 films cleared)
- chest
- pelvis
ATLS- C-spine, pelvis, chest AP
- A- adequacy & alignment
- B- bones – margins & architecture – follow bone margins & comment on general density & architecture
- C- cartilage/joints – joint spaces, surfaces
- S- soft tissues – swelling, air in tissues (open wound/ open fracture)
history (AMPLE)
- Allergies
- Medications
- Past medical history
- Last meal
- Events of injury
cricothyroidotomy
- •last resort for airway control
- •Y connector with O2at 15 l/min
- •Intermittent jet insufflation- sedate & paralyze, only for 30-45min., caution for FB
intercostal drain
- 4th or 5th intercostal space, mid-axillary line
- local anaesthetic down to pleura
- ‘above the rib below’
- blunt dissection. finger exploration
- pass large drain on forceps superior & posterior
- underwater drain
- pursestring suture
pericardiocentesis
- Beck’s Triad- shock,distended neck veins, muffled heart souns
- ECG monitor
- wide bore long sheathed needle
- enter 2cm below left xiphochondral junction, aiming 45° posterior towards tip of left scapula
- positive -> urgent thoracotomy
Limb injuries
Primary survey
Secondary survey
Immobilisation & reduction
Pain control
Wound Care
- Antibiotic prophylaxis
- Tetanus cover
- Photograph
- Betadine dressing
- Culture swab
- Debridement (generous)
- Irrigation
- Fracture stabilisation
- LEAVE WOUND OPEN
spinal injuries
primary suvey
- A: cervical spine control, intubation(blind tracheal, fibre-optic laryngoscope, naso-tracheal), nasogastric tube (ileus)
- B: intercostal paralysis
immobilisation – scoop, spinal board
secondary survey
- Log Roll -swelling, tenderness, steps, gaps
- Neurological exam. – NB. bulbocavernosus reflex
Neurogenic shock: – hypotension, bradycardia [be aware of Patient.s on B-blockers], warm periphery
Spinal Shock: flaccid limbs, reduced reflexes, reduced sensation, Urinary retention, paralytic ileus. [return of bulbocavernosus reflex indicates end of Spinal Shock]