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Initial Assessment

and
Management

© ACS
Objectives

 Indentify Management Priorities.


 Apply principles of primary and secondary
survey.
 Institute appropriate resuscitation and
monitoring.
 Recognize value of patient’s history and
biomechanics of injury.
 Anticipate pitfalls.

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Concepts of Initial Assessment
 Rapid Primary survey
 Resuscitation
 Adjuncts to primary survey /resuscitation
 Detailed secondary survey
 Adjuncts to secondary survey
 Reevaluation
 Definitive care

© ACS
© ACS

Initial Assessment

Primary survey and


resuscitation of vital
functions are done
simultaneously –
a team approach
Preparation

Prehospital System
 Transport guidelines /protocols
 On-line medical direction
 Mobilization of resources
 Periodic review of care
 Closest appropriate facility

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Preparation

Inhospital
 Preplanning essential
 Equipment, personnel, services
 Standard precautions
 Transfer agreement

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Standard Precautions

• Cap
• Gown
• Gloves
• Mask
• Shoe covers
• Goggles/face
• Shields

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Triage
 Sorting of patients according to :
• ABCDEs
• Available resources
 Multiple casualties

 Mass casualties

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Primary Survey
 Adult, children, pregnant women –
Priorities are the same !
A Airway with c-spine protection
B Breathing
C Circulation with hemorrhage control
D Disability
E Exposure/Environment

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Special Considerations

Trauma in the Elderly


 5
th leading cause of death

 ↓Physiologic reserve

 Comorbidities : Diseases/medications

 Outcome depends on early, aggressive

care

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Primary Survey
Establish Patent Airway
 C-spine injury
 Pitfalls
• Equipment failure
Caution • Inability to intubate
• Occult airway injury
• Progressive loss of airway

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Primary Survey

Suspect C-Spine Injury


 Spinal protection

 C-spine X-ray when appropriate

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Primary Survey
Breathing
 Assess

 Oxygenate

 Ventilate

Pitfalls
• Airway vs ventilation problem ?
• Latrogenic pneumothorax /tension
pneumothorax

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Primary Survey
Assessment of Organ Perfusion
 Level of consciousness

 Skin color and temperature

 Pulse rate and character

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Primary Survey
Circulatory Management
 Control hemorrhage

 Restore volume

 Reassess

Pitfalls
Elderly Children
Caution Athletes Medication

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Primary Survey
Disability
 Baseline neurologic evaluation

• GCS scoring
• Pupillary response

Observe for neurologic


Caution deterioration

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Primary Survey
Exposure / Environment
• Completely undress the patient

Prevent hypothermia
Caution

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Resuscitation
 Protect and secure airway
 Ventilate and oxygenate

 Stop the bleeding

 Vigorous shock therapy

 Protect from hypothermia

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Adjuncts to Primary Survey
Vital sign

ECG ABGs

Urinary Adjuncts Pulse


Output oximeter
and CO₂

Urinary/gastric catheters
unless contraindicated

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Adjuncts to Primary Survey
Diagnostic Tools
• Chest and pelvic
x-ray
• DPL
• Ultrasound

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Adjuncts to Primary Survey

Consider Early Transfer


 Do not delay transfer for diagnostic tests

 Use time before transfer for

resuscitation

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Reevaluate
Proceed to Secondary Survey After :
 Primary survey completed
 ABCD Es are reassessed

 Vital functions are returning to

normal

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Secondary Survey

The complete

history and
physical

examination

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Secondary Survey
Key Components
 History

 Physical examination : Head-to-toe

 “Tubes and finger in every orifice”

 Complete neuro exam

 Special diagnostic tests

 Reevaluation

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Secondary Survey
History
A Allergies
M Medications
P Past Illnesses
L Last meal
E Events/Environment

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Secondary Survey
Mechanisms of Injury

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Secondary Survey
Head
 Complete neurologic examination

 GCS score determination

 Comprehensive eye/ear exam

Pitfalls
 Unconscious patient

 Periorbital edema

 Occluded auditory canal

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Secondary Survey

Maxillofacial
 Bony crepitus/stability

 Palpable deformity

Pitfalls
• Potential airway obstruction
• Cribriform plate fracture
• Frequently missed injury
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Secondary Survey
Cervical Spine
 Palpate for  Pitfalls
tenderness • Altered LOC for
 Complete motor/ any reason
sensory exams • Other severe ,
 Reflexes painful injury
 C-spine imaging

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Secondary Survey
Neck (soft tissues)
 Mechanism : Blunt  Pitfalls
vs penetrating
• Delayed symptoms
 Symptoms : Airway

obstruction , and signs


hoarseness • Progressive airway
 Findings :Crepitus obstruction
hematoma ,stridor
• Occult injuries
bruit

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Secondary Survey
Chest
 Pitfalls
 Inspect
• Elderly
 Palpate
• Children
 Percuss

 Auscultate

 X-ray

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Secondary Survey
Abdominal Evaluation

Blunt trauma Penetrating trauma

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Secondary Survey
Abdomen
 Inspect, auscultate, palpate, and percuss

 Reevaluate frequently

 Special studies

 Pitfalls

• Hollow viscus and retroperitoneal injuries


• Excessive pelvic manipulation

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Secondary Survey
Perineum Contusions, hematomas,
lacerations, urethral blood

Sphincter tone , high –riding


Rectum
prostate pelvic fracture,
rectal wall integrity, blood

Blood lacerations
Vagina
Urethral injury in women,
pregnancy
Pitfalls

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Secondary Survey
Musculoskeletal : Extreminities
 Contusion , deformity

 Pain

 Perfusion

 Peripheral neurovascular status

 X- rays as needed

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Secondary Survey
Musculoskeletal : Pelvis
 Pain on palpation

 Symphysis width ↑

 Leg length unequal

 Instability

 X-rays as needed

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Secondary Survey
Musculoskeletal
 Pitfalls

• Potential blood loos


• Missed fractures
• Soft-tissue or ligamentous injury
• Occult compartement syndrome (especially
with altered LOC / hypotension)

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Secondary Survey
Neurologic
Spine / Cord CNS
 Complete motor  Frequent reevaluation

and sensory exams  Prefent secondary brain

 Imaging as injury
indicated
 Reflexes

Early neurosurgical consultation


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Adjuncts to Secondary Survey
 Special diagnostic test as indicated
 Pitfalls
• Patient deterioration
• Delay of transfer

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Secondary Survey
Neurologic
 Pitfalls

• Incomplete immobilization
• Suble ↑ in ICP with manipulation
• Rapid deterioration

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Reevaluation

Minimizing Missed Injuries


 High index of suspicion

 Frequent reeveluation and monitoring

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Reevaluation
Pain Management
 Relief of pain /anxiety as appropriate

 Administer intravenously

 Careful monitoring is essential

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Definitive Care

Local Facility

??
Transfer agreements
?? Local resources ??
??

Trauma Specialty
Center Facility
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Record , Legal Considerations
 Concise, chronologic documentation
 Consent for treatment

 Forensic evidence

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Summary
 Primary Survey
 Resuscitation

Adjuncts
• Secondary Survey
Adjuncts
• Definitive care

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