- 1 Initial assessment and management

- I: the primary survey and resuscitation

Peter Driscoll, David Skinner

More than 90% of the injured patients seen in British emer- "',""
gency departments have been subjected to blunt trauma.
These patients are often difficult to assess because many of
their injuries are hidden. They should be managed using a
team approach and a predetermined plan for the initial
assessment and urgent resuscitation. All members of the
team must be familiar with their own roles and those of
their colleagues. These two essential elements will enable the
members of the team to carry out their individual tasks
simultaneously. "

The tra1Ulla teaDl f
Personnel-The trauma team should initially comprise four ,~
doctors, five nurses, ~nd a radiographer. The medical team Trauma team in action.
consists of a team leader, an "airway" doctor and two
"circulation" doctors. The nursing team comprises a team
leader, an "airway" nurse, two "circulation" nurses and a
"relatives" nurse.
Teammembers'roles-Examples of paired roles and tasks are
given on page 2,. but assignments may vary among units
depending on the resources available. To avoid chaos and
disorganisation, no more than six people should be touching Objectives of the tra1Ulla teaDl
the patient. The other team members must keep well back. . IdentifYand correct life threatep,ing injuries
. Resuscitate the patieht ancfstabilise the vital

Before the patient arrives . SIgnS
Determine the nature and extent of other

..
Many emergency departments are warned by the ambulance lllJunes
service of the impending arrival of a seriously injured patient. Categomse the'injuii'es in order of priority
This communication system can also provide the trauma team Prepare and transport the patient to a place
with helpful information about the patient's condition and the of defmitive care
paramedics' prehospital interventions.
. After the warning, the team should assemble in the
resuscitation room and put on protective clothing. The
absolute minimum is rubber latex gloves, plastic aprons and
eye protection because all blood and body fluids should be
assumed to carry HIV and hepatitis viruses. Ideally, full
protective clothing should be worn by each member of the
t,eam, and all must have been immunised against tetanus and
the hepatitis B virus. Trauma patients often have sharp objects ,..':
such as glass and other debris in their clothing, hair and on
their skin. Ordinary surgical gloves give no protection against 1
this, so the staff who undress the patient should initially wear
more robust gloves.
While protective clothing is being put on, the team leaders
need to brief the team, ensuring that each member knows the
task for which he or she is responsible. A final check of the
equipment by the appropriate team members can then be
made. As the resuscitation room must be kept fully stocked and
ready for use at any time, only minimum preparation should
be necessary. The resuscitation room: preparing for the patient's arrival.

,

shou' ute. manu patier . of thi vomit turn t has h prope body shoul with. rather than reacted . If the patient deteriorates at any stage. they do not become disconnected or snagged. intu Orot recOI proV( C . and the appropriate tasks performed bec3 automatically and simultaneously by the team. devic vom . . with resp 2 L I . cone thq l exacerbation of pre-existing injuries (see chapter 8). Provided there is no urgent airway problem requiring immediate intervention. the . Once the patient arrives in the Bre: Liste resuscitation room. . beca cont the Primary survey and resuscitation exan wou The objectives of this phase are to identify and treat any imme. ation . proVl If . beginning again with the airway. patient can be moved. can] intra. seen problems are anticipated and prepared for.or \ to. The transfer of the patient from stretcher to trolley must be coordinated to avoid rotation of the spinal column or . exc If the ambulance bay is a long way from the resuscitation spm . the medical team leader must reassess the patient. allo\ room. Team cov members should also check that lines and leads are free so that resp . . posit crep! cal sI head Reception and transfer and . C the p uncol their . Each patient should be pent assessed in the same way. . stop clock so that accurate times can be recorded. sensil: perfw . the p objeCl T . tam] diately life threatening condition. . . It is vital that . ABC of Major Trauma Airw It is dama Medical and other staff there with t . the staff in charge of the airway should assess the patient in the back of the ambulance. . the nursing team leader should start the .

Chin lift or jaw thrust manoeuvres can be used to correct befed the position of the tongue. . Here the cervical spine can be damaged by immobilising the h~ad and neck while allowing the rest of the body to move.pneufiJ.leak between the face: aI1d !TIask Unilateral -intubation Qf the right main bronchus penetrating injury. the patient's mouth should be opened and any solid foreign objects removed with Magill forceps and fluid sucked out. Common causes Bilateral of inadequate ventilation J:. protecting the cervical spine It is important to assume that the cervical spine has been damaged if there is suspicion of injury above the clavicles or if there is a history of a high speed impact. no attempt should be made to turn the patient's head to one side unless a cervical spine injury has been ruled out radiologic ally and clinically. Once the airway has been cleared and secured. . and treated.haemothorax seen with a flail chest only if the segment is large. effort and symmetry should then be recorded -because these are sensitive indicators of underlying pulmonary contusion. and gives logical answers to nous sensible questions.is therefore accepted.or when the patient's muscles become fatigued. If the patient vomits. 3 . This is done with a semirigid collar. a nasopharyngeal airway is preferred ill Nasopharyngeal airway. and evidence of penetrating tamponade trauma. . In the absence of a spinal board the trolley ICal should be tipped head down by 200 and the vomit sucked away with a rigid sucker as it appears in the mouth. The respiratory rate. At .us patients. Initial assessment and management Airway management. Cardiac tamponade Open chest wound Massive haemothorax conditions that must be urgently identified. all the clothes covering the front and sides of the chest must be removed. Cardiac after trauma is usually associated with a . The' only exception is the resdess and thrashing patient. and tape. The complications of alcohol ingestion and possible injuries of the chest and abdomen increase the chance of the patient Guedal airway. shallow. If the patient replies in a normal voice. or a commercially available spine support. and a rise in intracranial pressure.~$piratorytract the same time. tracheal ft position.. every patient / should receive 100% oxygen at a flow rate of 15 litres per min- ute. If the patient is properly secured to a spinal (back) board. body in a main bronchus with a flail chest usually has a rapid. ventilation with a bag-valve-mask rtion device may lead to gastric distension with air and can induce vomiting. provided that there is no evidence of a base of skull fracture. The doctor dealing withthe airway should talk to the patient while the neck is kept manually in a neutral position by the airway nurse. If this proves impossible then a surgical airway must be provided. pneumothorax and fractured ribs. Consideration can now be given to securing the cervi- cal spine so that the airway nurse can safely release the patient's head and neck. surgical emphysema and laryngeal crepitus. Therefore patients without a gag reflex should be the intubated so that ventilation can be carried out safely. venous distension. As the use of Guedel airways in these patients can precipitate vomiting. however. paradoxical breathing is i. or central.. To see if any of these conditions is present. Orotracheal intubation with in-line stabilisation of the neck is recommended. cervical movement. open wounds. the whole body can be turned. haemothorax. The patient -foreign. Suboptimal immobilis- ation with just a semirigid collar . which often obstructs the airway in unconscio. . -significant lung contusion respiratory pattern initially. during . Breathing Listed in the box are five immediately life threatening thoracic . Those with a gag reflex can maintain their own airway. If there is no reply. sand bags Patient with rigid collar in place. The team leader should also remember that ~pneumothorilX because of intercostal muscle spasm. ce If the patient is apnoeic. the airway is patent and the brain is being d perfused adequately with oxygenated blood. vomiting. symmetrical. Immediately life threateniJ).Flail the primary survey and resuscitation phase (see chapter 4). the medical team leader should visually examine both sides of the chest for bruising.g Tensi()iJ.()thor~ thoracic conditions . The neck must then be examined for wounds. rather than nasotracheal intubation. abrasions. .