Initial Assessment

and
management
 OBJECTIVES

• Identify the correct sequence of priorities in assessing the

multiply injured patient
• Apply the primary and secondary evaluation surveys to
assessment of the multiply injured patient
• Apply guidelines and techniques in the initial resuscitative
and definitive--case phase
• Anticipate the pitfalls associated with the initial assessment
and management ( minimize their impact )
• Conduct an initial assessment survey on a simulated
multiply injured patient
CONCEPTS OF INITIAL ASSESSMENT

• Preparation
• Triage
• Primary survey ( ABCDEs )
• Resuscitation
• Adjuncts to primary survey and resuscitation
• Secondary survey ( head-to-toe evaluation and history )
• Adjuncts to the secondary survey
• Continued postresuscitation monitoring and reevaluation
• Definitive care
• Repeat primary and secondary survey when finding
any deterioration in the patient’s status

• Primary survey and resuscitation are done

simultaneously
 PREPARATION

• Prehospital
– Airway maintenance
– Control of external bleeding & shock
– Immobilization of the patient
– Communication with receiving hospital & immediate
transport to the closest, appropriate facility
– History taking ( include events )
• Inhospital
– Advanced planning ( especially massive casualty )
– Equipment & personnel
– Communicable disease protection
– Transfer agreements
 TRIAGE

• Sorting of patients according to ABCs and available

resources

• Triages is the responsibility of prehospital personnel

• Not exceed the ability of the facility ==> treat life -- threatening
patient first

• Exceed the capacity of the facility ( mass casualties ) ==> Treat

the greatest chance of survival, with the less time, less
equipment & less personnel
 PRIMARY SURVEY

• Adult / Pediatric priorities same

• Identified the life-threatening conditions and simultaneously
managed
– A: Airway maintenance with cervical spine protection
– B: Breathing and ventilation
– C: Circulation with hemorrhage control
– D: Disability ( Neurologic status )
– E: Exposure / Environmental control: Undress the patient &
prevent hypothermia
 PRIMARY SURVEY

• Airway Maintenance with Cervical Spine Protection

– Oral foreign bodies, facial, mandibular, or tracheal / laryngeal
fractures may result in airway obstruction
– Assume C-spine injury
• Multisystem trauma
• Altered level of consciousness
• Blunt injury above clavicle
– Pitfalls:
• Difficult airway
• Obesity: surgical airway cannot be performed smoothly
• laryngeal fracture or incomplete upper airway transection
 PRIMARY SURVEY

• Breathing and Ventilation

– Airway patency  adequate breathing & ventilation
– injury that may acutely impair ventilation
• 1. Tension pneumothorax
• 2. Flail chest with pulmonary contusion
• 3. Massive hemothorax
• 4. Open pneumothorax
above problems need to be identified in the primary survey and
managed
– Pitfall: Differentiation of ventilation problems from airway
compromise may be difficult
 PRIMARY SURVEY

• Circulation with Hemorrhage Control

– Assess blood volume and cardiac output
• level of consciousness
• skin color
• pulse
– Bleeding control: direct manual pressure on the wound
– Pitfall:
• The response of elderly, children, athletes and others with
chronic medical conditions to hypovolemia is different
from normal people
 PRIMARY SURVEY

• Disability ( Neurologic Evaluation )

– Level of consciousness
• A. Alert
• V. Response to voice
• P. Response to pain
• U. Unresponsive
– Pupils
– Pitfall:
• Lucid interval ( talk and die ) : EDH, frequent neurologic
reevaluation can minimize this problem
 PRIMARY SURVEY

• Exposure/Environmental Control
– Undress patient completely
– Protect from hypothermia

– Pitfall:
• early control of the hemorrhage is the best method to
keep body temperature( early surgical intervention)
 RESUSCITATION

• Protect/Secure airway & protect C-spine

• Breathing/Ventilation/Oxygenation
• Vigorous shock therapy
– At last two large - caliber IV line
– Crystalloid solution ( Ringer’s lactate 2~3 litter)
– Type-specific blood
– surgical intervention
• Protect from Hypothermia : 39oC warm IV fluid
• Urinary/gastric catheters unless contraindication
ADJUNCTS TO PRIMARY SURVEY AND
RESUSCITATION

• Monitor:
– Ventilatory rate and ABGs/ end-tidal CO2
Pitfalls: Combative patients often extubate or bite
endotracheal tube
– Pulse oximetry
– ECG & BP monitor
– Temperature
– urine output
X-RAY AND DIAGNOSTIC STUDIES

• Can’t delay or interrupt the primary survey and resuscitation

• Trauma series ( portable X-ray ): CXR, C-spine/ lateral view,
pelvic AP view
• A negative or inadequate c-spine x-ray can’t exclude cervical
spinal injury
• Sonography / DPL

Pitfalls: obesity ( Sonography and DPL are difficult )

CONSIDER NEED FOR PATIENT TRANSFER

Referring doctor -to -receiving doctor communication

Closest appropriate hospital
BEFORE SECONDARY SURVEY

• Complete primary survey

• Establish resuscitation

• Normalization of vital functions

SECONDARY SURVEY

• History taking
• Complete neurologic exam.
• Head-to-toe evaluation
• Roentgenograms
• Special procedure
• Tubes and fingers in every orifice
• Re-evaluation
SECONDARY SURVEY

• History
– A. Allergies
– M. Medications currently used
– P. Past illness / pregnancy
– L. Last meal
– E. Events / Environment related to injury
 HISTORY
Mechanisms of injury

• Blunt
– Automobile collisions
• Seat belt usage
• Steering wheel deformation
• Direction of impact
• Ejection of passenger form the vehicle
• Burns and Cold injury
– Inhalation injury and CO. intoxication in fire field
• Hazardous environment
• Penetrate
– Anatomy factors
– Energy transfer factor
• Velocity and caliber of bullet
• Trajectory
• Distance
 SECONDARY SURVEY

• Physical Examination
– Head
– entire scalp and head
– eye:
» pupil
» visual acuity
» EOM
» foreign body ( soft contact lens….)
– Pitfalls:
Severe facial swelling or unconsciousness p’t still
need eye exam.
 SECONDARY SURVEY

• Physical Examination
– Maxillofacial
• No airway obstruction or massive bleeding ==> treat later
• Midfacial fracture ==> R/O cribriform plate fracture

Pitfalls:
Some facial bone fracture is difficulty identified early ==>
reassessment is crucial
 SECONDARY SURVEY

• Physical Examination
– C-spine and Neck
• Maintain immobilization
• Complete evaluation
• Complete radiology study
• Cautions helmet removed
• Penetrating injury: Not be explored in the emergency
department; explored & treat in the operative room

Pitfalls:
Blunt injury to Neck: Carotid artery intima injury or
dissection ( delay onset )
Immobilization ==> decubitus ulcer
 SECONDARY SURVEY

• Physical Examination
– Chest

• Pitfalls:
–Poor tolerance to minor pulmonary trauma in
elderly patients
–A normal CXR can’t role out chest injury in
children
 SECONDARY SURVEY

• Physical Examination
– Abdomen
• Identify a surgical abdomen is more important than doing a
specific diagnosis ==> early consult surgeon
• Close observation & frequent reevaluation of the abdomen
• DPL, sonography, abdomen CT

Pitfalls:
– Excessive manipulation of the pelvis should be avoid
==> just do pelvic x-ray
– Retroperitoneal organs ( pancreatic & hollow organ )
are very difficult to identify
 SECONDARY SURVEY

• Physical Examination
– Perineum / rectum / vagina
• Perineum: Contusions, hematomas, urethral
bleeding…….
• Rectum: Sphincter tone, high riding prostate,
blood…..
• Vagina: Blood, laceration

Pitfalls:
Female urethral injury is difficult to detect
 SECONDARY SURVEY

• Physical Examination
– Musculoskeletal
• Extremities / pelvis: Contusion, deformity, pain
crepitation, abnormal
movement
• Vascular: Assess all peripheral pulses
• Spine: Physical findings, mechanism of injury
 SECONDARY SURVEY

• Physical Examination
– Neurologic
• Determine GCS score
• Re-evaluate pupils
• Sensory / motor evaluation
• Maintain immobilization
• Prevent secondary CNS injury ( keep stable vital signs,
avoid increased ICP and treat IICP )
• Early neurosurgical consultation

Pitfalls:
Intubation should be done expeditiously and as smoothly
as possible ( Intubation will increase ICP )
 REEVALUATION

• New findings / deterioration / improvement

• High index of suspicion ==> early diagnosis &

management

• Continuous monitoring

• Pain relief
DEFINITIVE CARE

• Trauma center

• Closest appropriate hospital

RECORDS AND LEGAL CONSIDERATIONAS

• Records: Concise, chronologic documentation

• Consent for treatment

• Forensic Evidence: preserve the evidence

 SUMMARY

• Initial assessment & management of multiply injured

patient

• Primary survey ( ABCDEs )

• Resuscitation & monitor ( life-threatening problems )

• Secondary survey ( head-to-toe, history )

• Definitive care ( early consultation, surgical intervention

or transport )
Thank
You

34