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Primary and

secondary assessment
in trauma
Jim Holliman, M.D., F.A.C.E.P.
Profesor Asociat de Chirurgie şi Medicină de
Urgenţă
Director al Centrului Internaţional de Medicină de
Urgenţă
M.S. Hershey Medical Center
Penn State University
Hershey, Pennsylvania, USA
SEQUENCE OF BASIC TREATMENT
IN TRAUMA

 Early primary examination


 Start resuscitation maneuvers
 Consideration of full secondary
examination
 It will assess whether the patient
requires emergency surgery or
transfer to another medical unit
 Definitive treatment
 Rehabilitation
Specific maneuvers in trauma

 Primary and secondary evaluation


 Opening the airway and ventilation
 Orotracheal intubation and nasotracheal
intubation
 Installing intravenous lines
 Techniques for immobilization of limbs and spine
 Installing intraosseous line
 Identify radiological lesions
 Surgical Procedures: cricothyrotomy, vein
denudation , pericardiocentesis, toracocentesis,
chest drainage, perithoneal lavage, local
anesthesia, suture of wounds
Deaths occur in three important moments
AFTER TRAUMA INJURIES

 The first moment - from several seconds to


minutes after injury:
 - Produced by :
 brain tissue laceration or the upper level of
the spinal cord
 heart and large vessels laceration
 - Few traumatized with such lesions can be
saved
 - The best treatment is prevention''''
 The second important moment - from
several minutes to several hours after
injury
 - Produced by:
 subdural or epidural haematoma
 haemo-and pneumotorax
 rupture of the spleen or liver
 pelvic fracture
 massive loss of blood due to multiple
fractures
 These patients can often save with
coordinated emergency response
 The third moment - from several
days to several weeks
 - Produced by:
 Craniocerebral severe trauma
 Sepsis
 Multiple System and Organ Failure
 An appropriate emergency
treatment can prevent some deaths
in this range
HEALTH CARE THAT GIVES TO MAJOR TRAUMA is
different from those which give patients medically stable

 For stable patients medical standard sequence is:


 history, medical history
 physical examination from head to toe
 differential diagnosis
 Laboratory examinations (lab, radiological, etc.).
 Final diagnosis
 This process is fully amended in front of a
traumatized patient to prevent any issue which
may cause his death
THREE PRINCIPLES OF THE
EMERGENCY MEDICAL ASSISTANCE
IN TRAUMA

 If the patient has multiple problems or injuries


, will be treated in the first one that could
immediately threatening life of the patient
 Appropriate treatment should not be delayed
just because the diagnosis is uncertain
 It is necessary to begin a detailed history of a
patient assessment and treatment of
traumatized
IDENTIFICATION of life-threatening injuries
IN TRAUMA

 Life-threatening injuries in trauma are


(arranged in descending order of severity):
 Airway obstruction - kills the fastest
 Position of the head, blood, vomiting, foreign
body, external compression
 Absence of breath - almost immediately kill
 Pneumotorax, haemotorax, lung damage
 Absence of circulation
 Bleeding (internal or external), heart damage,
arrhythmias
 Intracranial expansive processes
''ABCDE" IN TRAUMA

 Always follow the following sequence


 A - airway release (pay attention on the
cervical region )
 B - breathing
 C - circulation (attention to the cervical
column)
 D - neurological status
 E - exposure to environmental factors
 It will follow by completely undress the patient
to be examined, but take all necessary steps
to not induce hypothermia
INITIAL ASSESSMENT

 Objectives
 Identification and immediate
treatment of injuries respecting
priorities
 Establish the necessity of carrying
out maneuvers of resuscitation after
that will be follow by secondary
assessment
 Appropriate triage in cases with
multiple victims
 Corect steps in trauma :
 Initial Assessment – Early Primary
examination
 The start of resuscitation maneuvers
 Consideration of detailed secondary
examination
 Laboratory tests for diagnosis
 frequent reassessment of the patient
 Definitive care measures
Basic principles of initial assessment

 Corrections of situations posing an


immediate danger to life
(reanimation) should be done
simultaneously with primary
examination
 Start treatment before establish
definitive diagnosis
COMMUNICATION BETWEEN THE
DEPARTMENT OF EMERGENCY AND
MEDICAL TEAM IN PREHOSPITAL

 Support of patient is much improved


when there is proper communication
between hospital and prehospital
 Telephone or radio report regarding
traumatized patient should be short
(under 45 seconds) and should be
given as early as possible before
arrival at hospital
What information must contain
PREHOSPITAL REPORT ?
 The number of victims, their age and sex
 The mechanism of injury
 Lesions suspected
 Vital signs
 Treatment maneuvers performed so far
 Approximate time to arrival at hospital
 Special precautions needed to take
account of hospital staff:
 contamination with hazardous materials
 patient or belong to violent
PREPARATIONS TO BE MADE IN
EMERGENCY DEPARTMENT BEFORE
ARRIVAL OF VICTIMS WITH MAJOR TRAUMA
 Alerting trained staff
 Issue of a hospital bed for the victim
 Arrange:
 equipment to support airway, IV lines and
infusion solutions, bandages, catheters of
pleurostoma and collection containers,type 0
negative blood
 Alerting staff to:
 radiology, laboratory, clinic ATI , special nursing
units and guard
PRIMARY EXAMINATION

A - airway release (emphasis on the


cervical column)
 B - breathing
 C - circulation (control bleeding)
 D - neurological status ( neurological
"mini-exam" )
 E - exposure to environmental
factors
 (D and E are greater in secondary
examination)
HOW IS MADE THE PRIMARY
EXAMINATION?
 The patient will be examined visually
immediately
 breath?
 speaks?
 what is color skin?
 bleeding?
 is properly restrained?
 It will get a brief history:
– mechanism of injury
– when the incident occurred
 Issue airway if necessary (attention to the
cervical column)
 introduce an oropharyngeal route if the
patient is unconscious
 assist breathing:
 listen with stethoscope the chest
 pulsoximetry
 assisted ventilation if necessary
 increased flow oxygen on masks to all
patients
 Early protection of cervical spine:
 immobilize all suspected neck injury with
rigid cervical collar
Patients that necessitate EARLY
IMMOBILISATION OF CERVICAL SPINE
 Setting lesion mechanism :
 by drop
 car crash
 blow with a hard object in the head or neck
 Unconscious
 Neck pain
 Crepitation or deformed in the rear part of the
neck
 Altered state of consciousness (alcohol, drugs ,
etc..)
 CIRCULATION :
 check pulse, blood pressure,
breath frequency
 temperature, if possible as
quickly
 check if the patient has external
bleeding and hemostasis by local
compression
 monitor the patient and
determining the heart rate
 Airways:
 maneuver to open airway
 if unconscious - oropharyngeal way
 Breathing:
 ventilation on mask and balloon
 if necessary, Heimlich maneuver
 OTI if the mask and ballon ventilation
is ineffective
 OTIperformed with the patient's head
supported by a nurse and neck in the
shaft is the most appropriate
 May be Nasopharyngeal-tracheal
intubation if:
– excluding nasal and facial fractures
– excluded coagulopathy
 Cricothyroidotomy if you can not
make OTI
RESUSCITATION MEASURES TO BE
CARRIED OUT DURING THE PRIMARY
EXAMINATION
 The circulatory disorders or suspected massive blood loss:
 will mount at least one line i.v. Using a cannula plate
(at least 18G, prefers 16-14G)
 preference is to given Ringer Lactate or normal saline
 solutions will be administered slowly if the patient
presents TCC(cranio-cerebral trauma) isolated,
closed
 solutions will be administered very quickly if the
patient is hypotensive
 rapid blood transfusion with Type O negative (two or
more units if there is an obvious massive blood loss
or severe hypotension)
RESUSCITATION MEASURES TO BE
CARRIED OUT DURING THE PRIMARY
EXAMINATION

 If there is a massive external bleeding:


 direct pressure on the wound with a
bandage
 rarely need direct clipping of the visible
injured arteries
 sterile dressings that cover any open
fracture or exposed visceral
 tourniquet is almost never indicated
RESUSCITATION MEASURES TO BE
CARRIED OUT DURING THE PRIMARY
EXAMINATION
 After examining the thorax: look for rapidly fatal Injury
 whether suspected masive hemotorax or suffocating
pneumotorax - toracostomy immediate followed by
chest drainage
 in case of coastal shutter - stabilization using a wide
adhesive
 valve penumotorax - the valve will close with
dressing and drainage will be spinning
 suspicion of cardiac tamponade with imminent
cardiac arrest - pericardiocentesis
COMPLETING PRIMARY
EXAMINATION

 After the primary examination (ABC and


resuscitation measures) was completed we
will begin secondary examination
PRIORITIES OF SECONDARY
EXAMINATION
 Undress patient fully to allow detailed
examination - this may involve cutting clothes
if movements are painful or life threatening
for the patient
 It will use heat sources (heaters, blankets) to
protect the patient from hypothermia
 It is reassessing vital signs - temperature
should be measured
PRIORITIES OF SECONDARY
EXAMINATION
 Full review "from head to toe"
 Nasogastric tube and / or bladder (if
there are contraindications)
 X-rays - the common are X-rays of
thorax, lateral cervical column , pelvis
 It will assess the need for other
laboratory tests
SECONDARY EXAMINATION
 First is established trauma history
 Comprehensive medical history:
 allergies
 medication
 pathological history
 last meal (at what time)
 events preceding the trauma
 Injury mechanism is established
 Assessing the presence of other harmful factors
 hypoglycemia, exposure to toxins , CO
•Full review "from head to toe"

 It assesses the state of consciousness - GCS


 The scalp
 Examine the eardrum
 Examine the nose and mouth
 The face and mandible
 Check pupillary response and eye movements
It immobilizes the head and neck:
cervical collar is removed, examine the front
of the neck and check the position of trachea
look and papation the back of the neck
further application of cervical collar
Examine the chest wall and clavicula by
percussion and palpation
Hear lung and heart
Palpation of the upper portion of the back
Potentially fatal chest injuries
 break tracheae
 pulmonary contusion
 myocardial contusion
 aneurysm of aorta
 rupture of diaphragm
 rupture of the esophagus
Currently non-lethal injuries

 rib fractures, the clavicle, the sternum
 strain sternoclaviculara
 scapula fracture
 traumathic asphyxia
 simple chest contusion
•Full review "from head to toe"
 Listening, palpating and percussion
 The abdomen
 The back
 The pelvis
 The patient lie flat back side maintaining the shaft spine
 The genitals
 It is necessary a vaginal and rectal examination:
 will assess any damage to the prostate
 Analysis stool with tincture of guaiac
•Full review "from head to toe"

 Palpating the limbs


 Assessing articulations
 Palpating peripheral pulse and measure
capillary refill
 Tendon function is evaluated
•Full review "from head to toe"

 Assessing neurological status - GCS


 Mental status / orientation (recognition of
individuals, orientation in space and time)
 Examination of cranial nerves II-XII
 Examination of motor, sensory and reflexes of
all four limbs
 Coordination of movements
Secondary Examination
 Immobilization and dressing wounds
 Pruning wounds for a better appreciation of
the depth
 Deep penetrating bodies are not extracted ,
do this only in the operating room
(premature removal can give
exsanguination, if penetrating body
tamponing one major blood vessel)
Secondary Examination - Final
 Should be considered an ECG carried out on 12 derivation (in case
of hypotension, major chest trauma, chest pain)
 Radiographs minimum required (for a major injury of the torso)
are lateral cervical column, skull, pelvis (is required to make
secondary examination)
 Radiographs of all parties suspected of fracture
 Additional tests if needed: peritoneal lavage, CT, angiography,
ECO
 Nasogastric tube and bladder, if not contraindication is present
CONTRAINDICATIONS
nasogastric and urinary tube
 Nasogastric probe :
 nasal fractures, mediofaciale, severe
coagulopathies
 in such cases the probe is inserted
orogastric
 Urinary probe
 urethral lesions suspected - blood in urine
meat , impalpable prostate, perineal
haematoma
SUMMARY OF INITIAL
EXAMINATION
I. Primary assessment / resuscitation
A, B, C, D, E
II. Secondary assessment
X-ray, laboratory, nasogastric tube and urinary
III.Reevaluations
Final diagnosis
options: letting the patient home, admission to a ward,
admission to ATI, the entry in the operating room,
another clinical trasnfer