The Initial Assessment
OF THE MULTIPLY INJURED PATIENT
Epidemiology
Trauma is a disease.
Trauma is predictable, preventable, and treatable.
Trauma is the 4th leading cause of death in the US.
Trauma is the leading cause of death in people
below the age of 45 in the US.
3.8 M deaths/ year/ worldwide
312 M injured
Epidemiology
•Trimodal distribution
of mortality
•Prehospital (Major
head injuries, rapid
exsanguination)
•Early Hospital
(Head, chest,
abdominal trauma)
•ICU (End result of
prolonged
hypoperfusion)
History of Trauma Systems
The American College of Surgeons has developed
requirements for trauma center certification of commitment
of personnel and resources needed to maintain a state of
readiness to receive critically injured patients.
Importance of The Golden Hour
Objectives
1. Identify the correct sequence of priorities in the
assessment of an injured patient
2. Outline the components of the primary and secondary
surveys
3. Explain the techniques used in the initial resuscitation
phase.
Initial Approach
initial primary assessment,
rapid resuscitation
Thorough secondary survey followed by
diagnostic tests and ultimate disposition.
Subsequent mortality and morbidity tied
directly to the initial assessment and
resuscitation.
Introduction
The initial assessment aims:
Rapid assessment
Rapid life preserving therapy
Prevents further damage to the patient.
It consists of:
Preparation
Triage
Primary survey
Resuscitation
Secondary survey
Continued resuscitation
Definitive care
Preparation and Triage
Preparation
A. Pre-hospital Phase
Hospital notification
Airway maintenance, control external bleeding, immobilization and
transportation.
B. In-hospital phase
Fluids and equipment
Adequate and appropriate personnel
Universal precaution
Triage
Sorting patients based on the need for treatment and the available
facilities.
Primary Survey
A Airway with Cervical Spine Control
B Breathing and ventilation
C Circulation
D Disability: neurological status
E Exposure/ Environmental control
A Airway with cervical spine control
Assume C-spine injury in all patients
DO NOT MOVE THE NECK
Assess airway compromise
Is the patient talking or Apnoeic
Look for signs of:
Agitation and aggression
Foreign bodies, dislodged teeth
Facial fractures and injuries to the neck (trachea and Larynx).
Listen for abnormal breathing sounds, stridor or hoarseness.
Feel for the movement of air.
A Airway with cervical spine control
Management:
1. In-line immobilization of the neck
2. Remove foreign body and suction
3. Administer oxygen 100%
4. Chin lift and jaw thrust manoeuvres
5. Oro-pharyngeal air way
Primary Survey - Airway
Jaw thrust instead of head tilt chin lift
Endotracheal intubation for airway protection or
expected clinical course (ie,obstruction from blood or
vomitus, neck hematoma, facial burns or trauma, GCS 8 or
less, combative patient, potential for airway compromise
while out of department.)
Primary Survey - Breathing
Auscultation for bilateral breath sounds
Palpation for subcutaneous emphysema
-needle decompression followed by chest tube for pneumothorax
Inspection for flail chest
Observation of respiratory rate, oxygen
saturation, and overall work of breathing
-mechanical ventilation for inadequate ventilation or to decrease work of
breathing
B Breathing
1. Determine centrality of the trachea and apex beat
2. Look for symmetrical expansion and respiratory rate.
3. Look for obvious contusion, laceration or flail segments.
4. Listen for movements of air: normal, absent or decreased
5. Listen for heart sounds: normal or muffled
6. Recognise specific life-threatening conditions:
1. Tension pneumothorax
2. Flial chest with pulmonary contusions
3. Open pneumothorax
4. Massive hemothorax
.
Primary Survey - Circulation
Check peripheral pulses, heart rate, BP, pulse
pressure, capillary refill, cyanosis
All hypotensive trauma patients are assumed to
be in hemorrhagic shock
2 large bore peripheral IV’s (at least 18 gauge)
Control external bleedingDraw blood for cross-
match and base line lab investigations and
pregnancy te
Primary Survey - Circulation
Table 251-4 Estimated Fluid and Blood Losses Based on Patient's Initial
Presentation
Class I Class Class Class
II III IV
Blood loss (mL)* Up to 750 750–1500 1500–2000 >2000
Blood loss (percent blood Up to 15 15–30 30–40 40
volume)
Pulse rate <100 100–120 120–140 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure (mm Hg) Normal or Decreased Decreased Decreased
increased
*Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.
Primary Survey - Circulation
Begin volume resuscitation with liter boluses of
crystalloid for class I or II hemorrhage.
Begin crystalloid and blood for class III or IV
hemorrhage.
O- blood until type specific is available
Constant reevaluation is paramount
If class I or II is patient still showing signs of shock after
3L of crystalloid, begin blood
“3:1 rule” 3cc crystalloid for every 1cc of blood loss
Primary Survey - Circulation
5 Places life threatening hemorrhage can occur
-Chest
-Abdomen
-Pelvis
-Thighs
-Externally
Primary Survey - Circulation
Cardiac Tamponade can cause hypotension
with little blood loss.
Becks triad: hypotension, distended neck veins,
muffled heart sounds
Easily confirmed with ultrasound
Pericardiocentesis
D Disability
A Alert
V Responsive to verbal stimuli
P Responsive only to painful stimuli
U Unresponsive
Altered level of consciousness may indicate:
a. Head injury
b. Shock
c. Hypoxia
d. Drug/ Alcohol
At the End of the Primary Survey
1. Assessment and management of:A,B,C,D is
completed.
2. ABG
3. ECG, pulse oximeter, BP Cuff placed
4. Urinary catheter and Naso-gastric tube inserted
5. X rays requested:
1. AP chest
2. AP pelvis
3. Lateral C-spine
6. Consider system involvement and surgical
specialities required.
7. Consider need for patient transfer
AMPLE Key terminology
A Allergies
M Medication
P Past illnesses
L Last Meal
E Ethanol/ Drug abuse
Mechanism of Injury
Vehicle: Stationary / Slow or High Speed
Pedestrian / Passenger (front or back) / Driver
Head-on / Side impact / Rear impact collision
Restrained / Unrestrained
Helmets
Role over accident
Thrown out of the car.
Primary Survey - Disability
Quick assessment of ability to move all extremities
Glascow Coma Scale
Primary Survey – Exposure
Completely undress the patient and inspect the
entire patient from head to toe both front and back.
Maintain spinal precautions during logrolling
Inspect both axillae and peritoneum
Warm blankets!!!
