Initial Assessment and

Management

Initial Assessment and

Management
When I can provide
better care in the field
with limited resources
than what my children
and I received at the
primary care facility --there is something
wrong with the system
and the system has to
be changed.

Initial Assessment and

Management
The Concept
Treat the greatest threat
to life first
Lack of a definitive
diagnosis should never
impede treatment
A detailed history was
not an essential
prerequisite to begin the
evaluation of an acutely
injured patient

Initial Assessment and

Management
The Result
A Airway with cervical spine control
B Breathing
C Circulation
D Disability or neurologic status
E Exposure (undress) with
temperature control

Initial Assessment and

Management
INITIAL ASSESSMENT (A systematic
approach that can be reviewed and practiced)
1. Preparation
2. Triage
3. Primary Survey (ABCs)
4. Resuscitation
5. Secondary Survey (head-to-toe)
6. Continued post-resuscitation monitoring and reevaluation
7. Definitive care

Primary Survey
A - Airway maintenance with cervical spine control
B - Breathing and Ventilation
C - Circulation with hemorrhage control
D - Disability ; Neurologic status
E - Exposure / Environmental Control; Completely undress the
patient, but prevent hypothermia

Life threatening conditions are identified and

management is begun simultaneously
Priorities for the care of the pediatric patient
are basically the same as for adults

Primary Survey
Airway with Cervical Spine Control
Ascertain patency
foreign bodies
facial, mandibular, tracheal or laryngeal fractures

Chin-lift or jaw-thrust maneuver

Cervical spine immobilization
C-7 to T-1 cross-table lateral cervical spine x-ray
Multi-system trauma, altered level of consciousness, or
a blunt injury above the clavicle

Primary Survey
Breathing
Assure adequate ventilation
Function of the lungs, chest wall, and diaphragm

Injuries that acutely impair ventilation

Tension pneumothorax
Flail chest with pulmonary contusion
Open pneumothorax

Injuries that compromise ventilation to a

lesser degree
Hemothorax, simple pneumothorax, fractured ribs, and
pulmonary contusion

Primary Survey
Circulation with Hemorrhage Control
Blood volume and cardiac output
Level of consciousness
Skin color
Pulse

Bleeding
External, severe hemorrhage is identified and controlled
in the primary survey
External blood loss is managed by direct manual
pressure
Hemorrhage into the thoracic or abdominal cavities, into
muscles surrounding a fracture, or as a result of
penetrating injury can account for major blood loss

Primary Survey
Disability (Neurologic Evaluation)
Level of consciousness and pupillary size
and reaction
A Alert
V Responds to Vocal stimuli
P Responds to Painful stimuli
U Unresponsive
Decreased level of consciousness
Decreased cerebral oxygenation and/or perfusion
Alcohol and drugs

Primary Survey
Exposure / Environmental Control
Patient should be completely
undressed
Cover and protect from hypothermia
Warm blankets
Intravenous fluids should be warmed
Maintain warm environment

Resuscitation
Airway
Jaw-thrust or chin-lift maneuver
Nasopharyngeal airway
Oropharyngeal airway

Breathing / Ventilation / Oxygenation

Endotracheal intubation
Surgical airway
Chest decompression
Supplemental oxygen therapy

Resuscitation
Circulation

Two large-caliber IV catheters

Blood type, crossmatch, pregnancy test
Balanced salt solution
Blood transfusion
Type-specific blood, O-negative blood, unmatched type
specific blood

Hypovolemic shock should NOT be treated by:

vasopressors, steroids, or sodium bicarbonate

Hypothermia
ECG monitoring

Resuscitation
Urinary and Gastric Catheters
Routine urine analysis
Urethral injury is suspected if there is:
Blood at the penile meatus
Blood in the scrotum
Prostate is high-riding or can not be palpated

Blood in the gastric aspirate may represent:

Swallowed blood
Traumatic insertion
Actual injury to the stomach

If the cribriform plate is fractured or fracture is

suspected, NGT should be inserted orally

Resuscitation
Monitoring
Ventilatory rate and arterial blood gases
End-tidal carbon dioxide monitoring

Pulse Oximetry
Appropriate oxygenation is a reflection of
proper airway, breathing and circulatory status

Blood pressure
ECG monitoring

Resuscitation
Consider the need for patient transfer
Remember:
Life-saving measures are initiated when the
problem is identified, rather than after the primary
survey
During the primary survey and the resuscitation
phase, the evaluating physician frequently has
enough information to indicate the need for
transfer of the patient to another facility
Referring physician to receiving physician
communication is essential

Resuscitation
Roentgenograms
Should be used judiciously and NOT delay patient
resuscitation
In blunt trauma, x-rays to be obtained:
Cervical spine
Chest (AP)
Pelvis (AP)

After all life-threatening injuries are identified:

Complete cervical, thoracic and lumbar spine

In penetrating injuries, x-rays are:

Chest (AP)
Films pertinent to the site of wounding

Secondary Survey
Tubes and fingers in every orifice
The secondary survey does not begin until
the primary survey (ABCs) is completed,
resuscitation is initiated, and the patients
ABCs are reassessed
Head-to-toe evaluation
Complete neurologic examination (GCS)
Special procedures
Peritoneal lavage, radiologic evaluation, and
laboratory studies

Secondary Survey
History

A
M
P
L
E

Allergies
Medication currently taken
Past illnesses
Last meal
Events / environment related to
the injury
Blunt trauma
Penetrating trauma
Burns
Hazardous environment

Secondary Survey
Physical Examination
Head
Scalp and skull examination
Eye and ear examination

Maxillofacial
Cribriform plate fracture - orogastric intubation

Cervical spine and Neck

presume injury in patients with maxillofacial or
head trauma
Extreme care must be taken when removing
helmet

Secondary Survey
Physical Examination
Chest
Visual evaluation
Open pneumothorax, flail chest
Palpation
Fractures
Auscultation
Cardiac tamponade - distant heart sounds and
narrow pulse pressure, distended neck veins
Tension pneumothorax - decreased breath sounds,
shock, distended neck veins
Chest X-ray
Widened mediastinum, pneumohemothorax,
fractures

Secondary Survey
Physical Examination
Abdomen
A normal initial examination of the abdomen
DOES NOT exclude intra-abdominal injury
Candidates for peritoneal lavage
Unexplained hypotension
Neurologic injury
Impaired sensorium secondary to alcohol or drugs

Fractures of the pelvis or lower rib cage may

hinder adequate abdominal examination

Secondary Survey
Physical Examination
Perineum / Rectum / Vagina
Rectal Examination

Presence of blood within the bowel lumen

High-riding prostate
Pelvic fractures
Integrity of the rectal wall
Quality of the sphincter tone

Vaginal Examination
Blood in the vaginal vault
Vaginal lacerations
Pregnancy test

Secondary Survey
Physical Examination
Musculoskeletal
Extremities
Deformity, abnormal movement, tenderness,
crepitation

Pelvis
Pressure over anterior iliac spine and symphisis
pubis
Assessment of peripheral pulses

Ligament rupture, muscle-tendon injury, nerve

injury or ischemia

Secondary Survey
Physical Examination
Neurologic
Motor, sensory, level of consciousness,
pupillary reaction
Immobilization of the entire patient
Cervical collar
If there is neurologic deterioration,
ABCs must be reassessed

Re-Evaluation

New findings are not overlooked

Discover deterioration
Underlying medical problems
Effective analgesia
Monitoring
Vital signs
Urinary output
Arterial blood gas
Cardiac monitoring devices

Definitive Care
The CLOSEST APPROPRIATE
hospital should be chosen based on
its overall capabilities to care for the
injured patient

Roentgenogram

Cervical Spine X-ray

Cross-table lateral
C-1 to C-7

Airway
Chin-lift maneuver

Airway
Nasopharyngeal airway

Airway
Endotracheal Intubation

Surgical Airway
Cricothyroidotomy

Roentgenogram

Chest X-ray (AP)

Pneumothorax

Roentgenogram

Pelvic fracture