DIAGNOSTIC ADJUNCTS DURING PRIMARY SURVEY brought to the OR – that is part of

resuscitation.
Wallace Medina, MD
The primary focus of ATLS is on the FIRST hour of trauma management -
rapid assessment and resuscitation

DEFINITION AND OBJECTIVES THE GOLDEN HOUR

ADJUNCT - a thing added to something else as a supplementary Assessment and resuscitation is done simultaneously
Objectives: ** You cannot do this by yourself. It is a mortal sin if you have a poly trauma
• Aims to review the FRAMEWORK (ATLS), PRINCIPLES of and managed individually. The outcome is chaotic and catastrophic.
assessment and resuscitation of an acutely injured person
• Know the different adjuncts during primary survey and its clinical
IN RAPID ASSESSMENT:
application
AIR
Assess, Intervene, Reassess
Notes:
• An adjunct is something that would be of help to you during your
rapid assessment.
• FRAMEWORK – this is very important because you have to follow OVERVIEW OF TRAUMA MANAGEMENT (ATLS)
a system. You cannot be guided without following a system –
ATLS. • Preparation
• Assessing what? Life threatening. I am assessing conditions that • Triage
would kill my patient or make my patient die in front of me. • Primary survey
• ONE QUESTION – Is it life threatening or not? • Resuscitation
o IF YES – you RESUSCITATE. You have to intervene. • Adjuncts to primary survey
o IF NO – further assess. • Secondary survey
• Adjuncts to secondary survey
Organized consistent approach to an acutely injured patient • Tertiary survey
→ optimal outcome • Definitive care

** I have mentioned about the FRAMEWORK which is ATLS. This is aimed ** That is from pre-hospital – this is the field experience. Triage – you
to come up with an OPTIMAL OUTCOME – the BEST OUTCOME. That is why prioritize, you sort out who needs medical attention first. Primary survey –
it has to be ORGANIZED and CONSISTENT. You have no right to panic, AIR. You have the adjuncts to primary survey. And if the patient is stable –
otherwise it will create a domino effect – you panic, everybody will panic, if there is already a secondary survey, you assume the patient is already
your patient may die. stable or has been resuscitated well or is a responder. There is adjuncts to
secondary survey. And you continue your assessment – tertiary survey, so
you would not be missing any injury. And of course, you decide whether
PRINCIPLES OF TRAUMA MANAGEMENT you discharge the patient or maybe do an elective procedure to correct the
problem.
• First do no harm
• Prioritize - treat the greatest threat to life first
PREPARATION
• Definitive diagnosis is NOT immediately important
• Golden hour - time matters, urgency
1. Pre-arrival phase
• Assess, Intervene, Reassess - check reversal to normal
(responders vs non responders) • Notify receiving hospital (EMS), Role of team leader,
vital information (age, sex, MOI, V/S, injuries).
• Team approach
2. In-hospital phase
Notes: • Universal precautions of trauma team (PPE), experts,
test 24 hrs available, OR- RTX – ICU.
• DO NO HARM.
o If a patient comes in with profuse bleeding on the
**
head → check the bleeding and apply direct pressure
→ Assessment (ABCDE). • Pre-hospital – you have your EMS (Emergency Medical Service)
o If a patient is having difficulty of breathing → give responsible for initially assessing the patient, doing some triage.
oxygen before assessment. The team leader of the EMS must notify the receiving hospital.
The information needed to be conveyed – age, sex, mechanism
• PRIORITIZE. Do ABCDE in order of priority.
of injury (so that the hospital may have an idea of the potential
• TIME MATTERS. Your patient can die if you do it one at a time.
organs at risk for injury), vital signs – stable or not, and of course
Do it simultaneously because it is a team approach.
the possible injuries.
• A-ssess, I-ntervene, R-easses (A.I.R.)
• In-hospital – everybody is ready, everybody is wearing PPE,
o Assess – life threatening conditions
experts are available, make sure the three important areas are
o Intervene – someone else intervenes
open and ready to give service – operating room, radiology
o Reassess – someone else does the reassessment
department, and ICU.
▪ Is my patient stable or responding? Or
unstable, non-responding?
▪ Patient is Unstable? You do not need to
TRIAGE
continue resuscitating with fluids – patient
will eventually die. Patient needs to be
1. Multiple injuries

WHISKY DIAGNOSTIC ADJUNCTS DURING PRIMARY SURVEY SURGERY ROTATION 1 | 7

 2. Mass casualties • Good sensorium

** Prioritized in the triage. ** In ALL trauma patients, you perform primary survey, whether the
INITIAL ASSESSMENT patient is walking or stretcher-born. Start with A-airway.
• The easiest way is to communicate – ask what happened. If the
• Primary survey - evaluates physiology patient favorably responds, you can confirm the following.
• Secondary survey - evaluates anatomy • When you are in the airway aspect of assessment, you are
assessing the tubes, the structures or the conduit of air – from
the nose or mouth until it reaches the terminal respiratory unit.
PRIMARY SURVEY • Is it unobstructed? Are the tubes unobstructed? Is there an
upper airway obstruction? Is there a lower airway obstruction?
PRIMARY SURVEY • When the patient starts narrating what happened, then there is
• ASSESS no block, patent airway, sufficient air reserve, adequate
• RESUSCITATE perfusion, and good sensorium.
• TREAT
QUESTION: What will you do in a patient who is restless (combative) and
primary survey is not possible?
QUESTION: Can you name at least 2 life threatening conditions during
primary survey? • SEDATE – your anesthesia colleague will be of great help
• RESTRAIN – not a good idea, because some patients, the more
you restrain them, the more they become combative.

QUESTION: How will you assess the airway of a sedated patient?

• PULSE OXIMETER (adjunct): when we talk of airway, we talk of
oxygenation

BREATHING AND VENTILATION (Look and Listen)

• Jugular venous distention

• Position of trachea
• Respiratory rate
• Percussion and palpation of the chest
• Air entry (auscultation)
• Oxygen saturation

** Breathing can be evaluated by inspection and auscultation.

• Look at the jugular veins

o Hypovolemic – flat, undistended
o Cardiogenic shock secondary to tension
pneumothorax and pericardial tamponade –
distended
• Position of trachea
o Those with tension in the chest could displace the
trachea from the midline
• Respiratory rate
o Important in telling if the patient is in distress or not.
o Normal RR: 12-20 bpm
• Start palpating areas of injury
o Look for crepitations – meaning there is air that has
Areas of FOCUS in PRIMARY SURVEY: (ABCDE)
escaped from the pleural cavity
• Auscultate
• Airway o Most important
• Breathing o A lot of times, especially when you are entertaining a
• Circulation life-threatening condition, you don’t need an x-ray
• Disability o But, after auscultation, and your patient seems to be
• Exposure stable – request CXR or eFAST
• FAST and eFAST – adjuncts • Oxygen saturation
o Pulse oximeter
▪ assesses two physiologic core –
AIRWAY oxygenation and ventilation
o Capnometer (capnography)
Airway: Ask what happened? Appropriate response confirms: ▪ measures CO2 of end tidal readings. This is
• Patent airway an even more important way of
• Sufficient air reserve to permit speech prognosticating whether your patient will
• Adequate perfusion have a negative outcome because of

WHISKY DIAGNOSTIC ADJUNCTS DURING PRIMARY SURVEY SURGERY ROTATION 2 | 7

 persistence in the abnormal value of
capnography.
▪ CO2 normal: 35-45 mmHg Stethoscope is an adjunct.
▪ Measures ventilation and perfusion Sphygmomanometer is an adjunct.

CIRCULATION with hemorrhage control DISABILITY (neurological status)

• External bleeding • Level of consciousness (Glasgow Coma Score)

• Level of consciousness- AVPU • Pupillary size and reaction
• Skin color and temperature • Lateralizing signs
• Pulse rate, character and site
• CRT

**
External bleeding:
• This is one of the exceptions, remember what I mentioned – a
patient comes in, holding the head with profuse bleeding. Will
you start airway and breathing? This is an exception – FIRST DO
NO HARM! Attend to the profuse bleeding first – apply direct
pressure, then proceed with ABC.

Level of consciousness: You could use the acronym AVPU

• A – Alert
• V – response to verbal stimuli (ask to raise hand or something)
• P – response to painful stimuli (pinch)
• U – unresponsive (needs to be intubated, IV fluids, and
resuscitating)
Skin color and temperature
• Cold, clammy – signs of shock
• In 30% of the time, patients die of hemorrhage
• In 50% of the time in trauma, patients die of traumatic brain
injury.
** Have your own copy of GCS to look at in ER – so you can easily refer to
it, you cannot memorize this, have a quick reference so you could easily tell
whether you have a normal score or not.
• A score of 8 or less MANDATES intubation.
Always bring your penlight, especially when dealing with traumatic brain
injury. Assess the response, size – symmetrical or anisocoric. This might
mean there is impending herniation – if there is unequal pupil. Penlight is
an adjunct.

Label whether the patient is decorticate or decerebrate.

Which one carries a poorer prognosis? Decerebrate posture.

EXPOSURE (with environmental control)

• Completely undressed
• External Wounds - number matters, trajectories, anatomic zones
• Prevent hypothermia
Pulse rate, character, and site
• Cover with warm blanket
• 3 areas: radial, femoral, and carotid.
• Normal: 60-100 bpm
** The most common mistake in clinical practice is this aspect. Most are
after the wound. What we often neglect is the presence of hypothermia.
CRT
• Circulation of the periphery
The TRIAD OF DOOM:
• Normal: <2sec
• Coagulopathy
• Acidosis
QUESTION: Name an adjunct to assess circulation (aside from PR, CRT).
• Hypothermia
• Vital signs: very important and one way of directly assessing
your circulatory phase
Metabolic Failure
• Urine output: ensure a foley catheter is inserted, it is a
• Hypothermia exacerbates coagulopathy and interferes with the
diagnostic adjunct – a measure of adequacy of your
blood homeostatic mechanism
resuscitation, a measurement of the fluid status of patient.
• Acidosis – uncorrected shock leads to inadequate cellular
• Central Venous Pressure (CVP): its role is during resuscitation,
perfusion, anaerobic metabolism and lactic production
when there is no organ dysfunction yet. Its role becomes
• Coagulopathy – hypothermia, acidosis and massive blood
obsolete when dealing with organ dysfunction – kidney failure.
transfusion
That’s where you use the fluid dynamic response. But when
you’re talking of circulatory phase, we’re talking of resuscitation
These three are the ABSOLUTE INDICATIONS to perform DAMAGE
– it has a use.
CONTROL SURGERY (DCS). Your primary aim is to control bleeding intra-
o Normal CVP: 8-12 cmH20; below 8 – dehydrated.
operatively. If the patient is not doing well – bring the patient to the ICU
o Most of the time, the reason behind hypotension is
and correct the acidosis, correct the hypothermia, correct the
almost always bleeding

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coagulopathy. Once the patient is optimized, bring the patient back. When o Pelvic
you do damage control, you should only do this for ONE HOUR. • Two conditions evaluated by eFAST
o Apical part: pneumothorax
Do not forget to cover the patient after undressing to prevent o Basal part: hemothorax
hypothermia.
** Aside from covering the patient, when you start operating the patient ADJUNCTS: FAST and Extended FAST (eFAST)
in our institution, seldom do they close or turn off the aircondition. They
are after their own convenience knowing that the killer of trauma is • Unstable patient, 4Ps, reader dependent
hypothermia. You have a patient, all naked – just drapes on top of the body. • FAST superior than X-ray in detecting thoracic injuries (pneu-
You are trying to wash the entire peritoneum because of some hemothorax)
contamination. With the presence of a cool airconditioning system – • 67%-70% (ER physician); 92% sensitive & 100% specific
everything will be cold, and this will lead to hypothermia. Hypothermia will (prospective study)
lead to coagulopathy. Patient will bleed more. • Detection of blood 20 cc, 100% if effusion is 100cc
• Quantification of effusion volume

ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION

ADJUNCTS: TUBES: NGT

X-RAYS AND DIAGNOSTIC STUDIES • Primary survey: Decompression - decrease the intra thoracic
• Chest pressure, removes gastric content
• Pelvis • Detection of Upper GI bleeding - Inconclusive
• C-spine • Intraopratively – NGT assist in handling of stomach
• FAST • Post operatively – decrease ileus formation
** Skeletal series – referring to cervical spine, chest, and pelvic x-ray.
**
TUBES • Myth: NGT will be able to detect upper GI bleeding
• IFC o Many studies did not concur with this
• NGT • It decompresses two regions
o Because it decompresses the stomach, it indirectly
MONITORING DEVICES decreases the intrathoracic pressure, improving the
• ABG ventilatory phase (breathing)
• End tidal CO2 o It decompress the gastric contents, maybe lessening
• EKG the incidence of aspiration.
• Pulse Oximetry
• Blood Pressure
ADJUNCTS: TUBES: IFC (Indwelling Foley Catheter)

ADJUNCTS: Chest X-ray • Measure of adequacy of resuscitation (0.5-1cc/kg/hr)

• Chest X-ray - initial tool for screening for thoracic injuries
(Pneumothorax and hemothorax)
• 54% Accuracy (systematic review)
• Detects blood Amounting to 175 cc
• Rib fractures (flail chest, contusion)
• cardiac injuries (widening of cardiac shadow),
• intraabdominal injuries (elevation of diaphragm, perforation)
** In government institutions, this is the first thing to do. Most of the
radiology department are near the ER or if not, they have a portable X-ray.
X-ray if you are entertaining thoracic injuries. However, only 54% accuracy.
And an amount of at least 175 cc of blood is needed to detect hemothorax.
ADJUNCTS: MONITORING
QUESTION: Which of the following areas is being evaluated by eFAST?
A. Pericardiac
B. Basal Lung portion
C. Diaphragm
D. Morrison’s pouch
Answer: B. Basal lung portion
• What’s the other name for Morrison’s Pouch? Hepatorenal
recess or right subhepatic space or perihepatic area.
• eFAST means EXTENDED Focused assessment with sonography
for trauma – meaning outside the primary areas you do FAST.
• Primary areas of FAST:
o Perihepatic
o Pericardial
o Perisplenic
• Normal urine output: rate per kg per hour
• Part of circulatory phase
• Primarily used for monitoring. You do not monitor if
there is blood, you monitor the volume primarily.
• Detecting genitourinary tract - misleading results
• Checked regularly - kinked leads to erroneous reporting
• Eg. If the UO is very low, meaning the patient’s
intravascular volume is compromised – you are going
to pump in a lot of fluid. Remember, you’re giving
crystalloids, and it’s not only concentrated in the
plasma or intravascular but also in the interstitial.
There will be a risk of volume overload.
• ABG and serum lactate
o indicators of adequate fluid resuscitation
o limited role in detecting occult organ injury in blunt
abdominal trauma (added cost)
▪ inconsistent result, therefore they omitted
this because it is just an added expense
• EKG
o abnormal findings suggest cardiac injury but low
sensitivity.
o But addition of cardiac enzymes,
▪ Troponin I (>90% sensitive & specific).
o for BCI (blunt cardiac injury).
▪ Sensitivity (54%), Specificity (74%),

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 ▪ NPV (83%), PPV (41%) Chest/Lungs: Symmetrical Chest Expansion, clear breath sounds (L), (-)
• End tidal CO2 - predictor of mortality, 18mmhg (35-45mmhg) crackles and wheezes
• Pulse oximetry - 94-98% Abdomen: Unremarkable
• Blood pressure - measures of perfusion, late shock Extremities: Grossly Normal Extremities, CRT <25
GUT: Unremarkable
CASE SCENARIO
Subjective Objective
M.L., 52-year-old, male stabbed by BP: 80/60
unknown assailant at the Left Anterior 10:00 AM HR: 110
Chest. RR: 23
• MOI: Stabbing (unknown (+) difficulty breathing GCS: 15
weapon) (+) chest pain
Decreased breath sounds the (L) chest
• DOI: 3/27/2020
• POI: Pasay City
(+) minimal flow of blood on the stab area
• TOI: 6am
• Vital Signs:
o BP 130/70 mmHg,
QUESTION: WHAT is the MOST appropriate management for the patient?
o HR 85/min,
A. Repeat CXR
o RR 20/min,
B. eFAST
o T 36.7C,
C. CTT
o wt-60kg
D. Fluid resuscitation
** Single stab site. They don’t know where is the trajectory, but you can
Answer: C. CTT
see the imaginary box (cardiac box) – bounded superiorly by the clavicle,
• Because of the hypotension and decreased breath sounds, one
laterally by the nipple (female – inferior mammary line), and inferiorly by
of the things they are thinking of is a tension pneumothorax or a
the xiphoid process and some costal margin.
massive hemothorax. You need to IMMEDIATELY DECOMPRESS
because of the mediastinal shift created from the tension on the
QUESTION: How will you manage the case?
left side. So, they did chest tube thoracostomy.
• Primary Survey

Closed tube placed midaxillary line,

PRIMARY SURVEY
usually at the level of the 5th intercostal
(nipple line for male)
Airway: Patient is able to communicate
Breathing: No dyspnea, No tachypnea, Clear breath sounds Midaxillary: to avoid injury to the
Circulation: Stable BP (slightly hypertensive), normal HR intraabdominal organs, particularly the
Disability: Awake, coherent, GCS 15 (E4V5M6) spleen and the liver. The site is thine so
Exposure: No other injuries noted there is easy access. You could place
the stethoscope here to hear the
QUESTION: What diagnostic adjunct would be most useful at this time? breath sounds.

• CXR: initial test for thoracic injury

• FAST: potential injury to a particular organ – the heart, because CHEST XRAY POST CTT INSERTION
it is in the cardiac box. One of the areas evaluated by FAST is the (03/27/2020)
pericardiac – to know if there is tamponade VS post CTT insertion
• eFAST: to know if there is hemothorax, but the CXR can already
view the widening of the mediastinum (though the heart is not BP 100/70 mmHg
yet involved) HR 96/min
RR 22/min
CHEST XRAY RESULT: T 36.5C

Stab wound at the level of the 5th rib – CTT output: 500cc (bloody) initial
nipple area. More of the medial side.
The heart is not involved at the time the ** after the insertion and resuscitation, they were able to revert to normal
CXR is taken. the vital signs. There was an initial 500cc of blood that was evacuated thru
The trachea is in the midline. the CTT.
The cardiophrenic angle is still visible
The costophrenic angle is also seen.

** still recommend FAST if someone is available to read it.

SECONDARY SURVEY: evaluates the anatomy

HEENT: Anicteric Sclera, Pink Palpebral conjunctive, (-) lymphadenopathy

Heart: Adynamic precordium, Normal rate, regular rhythm, no murmur

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 You can see the tube thoracostomy
directed down. It doesn’t matter as
long as it’s functioning. How to
know? – There is a level, usually a
fluid, that fluctuates and coincides
with the respiration of the patient. It
tells you that the tube is in proper
placement.
You can see half of the thorax on the
left is compromised. There is still
blood in that area. Trachea is in the
middle. Cannot see the cardiophrenic and barely see the costophrenic of
the left side. Meaning there is blood in there. You just don’t know whether
the blood stopped or there is continuous bleeding.
Subjective Objective
BP: palpatory 60
12:25 PM HR: 107/min
RR: 19/min
(+) dyspnea GCS: 15
(+) chest pain
Decreased breath sounds the (L) chest
CTT output: 300cc (bloody)
UO: No initial output
** after 2 hrs, the same manifestation. But this time, the patient developed
palpatory 60, tachycardic, an addition of 300cc of blood, UO is negative.
QUESTION: What will be the management for this patient?
A. eFAST
B. Insert another CTT with negative pressure
C. Fluid challenge and FWB transfusion
D. Exploratory thoracotomy
Answer: D. Exploratory thoracotomy
WHISKY DIAGNOSTIC ADJUNCTS DURING PRIMARY SURVEY
** At this point, your patient is seemingly not responding. The indication
for emergency thoracotomy in your textbook (above pic) is an American
standard – indication of initial drainage of 1.5 or 1L of blood. but
considering Asians, they are smaller built, an 800cc of blood evacuated is
already an indication – that you need to open the chest and stop the
bleeding. Remember, SURGERY IS PART OF RESUSCITATION, it just so
happens that in here, there was a late occurrence or really a failure to really
monitor the patient.
QUESTION: What fluid would be appropriate in this case?
A. Plain LR
B. Plain NSS
C. D5W
D. Dextran
Answer: B. Plain NSS
** Crystalloids: Plain LR, Plain NSS
D5W: not a crystalloid because it has no electrolyte
Dextran: Colloid
A and B – it goes into your intravascular and interstitial
C – it goes everywhere, it is dangerous, in can enter the intracellular
D – it goes into the intravascular only
The one that will raise this fast is the Dextran, but of course, the fluid of
choice will be either A or B. But the one which is really isotonic is plain NSS.
For resuscitation purposes, you can use plain NSS, but for clinical practice
you can either use plain NSS or plain LR.
There is a danger in your NSS – hyperchloremia, it could lead to metabolic
acidosis.
QUESTION: What are the indications for exploratory thoracotomy
present in this patient?
Answer: Hemodynamic Instability
** The universal indication to do exploratory thoracotomy is hemodynamic
instability. That is secondary to persistent bleeding. Primary objective of
resuscitation is to do control. Open the patient and control the source of
bleeding.
MORTALITIES IN TRAUMA
• Airway obstruction
• Respiratory Failure
• Shock
• Brain injuries
** It is important to know the mortalities in trauma because this is why we
have the order of sequence ABCD – it involves airway, breathing,
circulation, and disability.
MECHANISM OF INJURY (MOI)
BLUNT
• MVC
• FALL
PENETRATING
• STAB
• GUNSHOT
SURGERY ROTATION 6 | 7
** MOI is important for the members of the trauma team. The case is
penetrating injury secondary to stab wound. Below is a table to compare
GSW and SW on why we are more aggressive in GSW than SW.

GSW SW
High velocity energy transfer Low velocity low energy transfer
Unpredictable pattern of injuries More predictable
Increase intrabdominal injuries Low intrabdominal injuries
More tissue damage Less tissue damage
<Conservative > Conservative

** in our patient, a single stab wound but the patient still continuous to
experience hemodynamic instability, so we have to open.

ADJUNCTS THAT CAN BE APPLIED TO THE PATIENT ** Patient was initially stable, if cardiac US or FAST was done and positive;
then the patient is unstable (hemodynamic instability), open the patient
• Chest X-ray with easy access using left anterolateral thoracotomy.
• Pelvic X-ray → ×
• FAST
EXPLORE! – the following are present in the patient
** CXR was done, FAST was not done, but it has to be because it can rule
out presence of penetrating cardiac injury, because we don’t know the ✓ Hypotension (with or without abdominal distention)
trajectory of the stab site. There is also a possible pericardial injury or ✓ Narrow pulse pressure
cardiac tamponade. ✓ Tachycardia
✓ High or low respiratory rate
• ECG
✓ Signs of inadequate end organ perfusion
• Pulse Oximetry
• Peritoneal signs (eg, pain, guarding, rebound tenderness)
• IFC
and/or peritonitis
• NGT → ×
• Diffuse and poorly localized pain that fails to resolve
** ECG should have been done because it’s in the cardiac box. All cardiac
box injury – blunt or penetrating mandates evaluation of the heart – with IN SUMMARY
Troponin I. eFAST – evaluation of the lower lung field. Pulse oximeter was
done, IFC was inserted. No need for NGT. These are the ADJUNCTS TO PRIMARY SURVEY:

• Pericardiocentesis • Vital signs

• Subxiphoid pericardial window • Trauma Series/Skeletal Series
• Digital Examination → × • Pulse Oximeter and CO2
• FAST
** Pericardiocentesis to rule out tamponade. Subxiphoid pericardial • ECG
window to really know for direct visualization if the pericardial sac is empty • Venous blood
of blood. • ABGs
• Urinary output
• Urinary/gastric catheters unless contraindicated - TUBES
EXPLORE

*********END OF LECTURE*********

In trauma it is not speed but TIMING, it is not courage but

KNOWLEDGE, it is not transfusion but CONTROL and it is not
individual's ability but TEAMWORK.
- W.Y.M.

Hardships often prepare ordinary people

for an extraordinary destiny.

Reference: PPT

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