1 Initial Assessment and Management Tenth Edition

1 Initial Assessment and Management

The primary survey (ABCD) is the cornerstone of the initial

assessment of the trauma patient. Repeat the primary survey
frequently to identify any deterioration in the patient’s
status that indicates the need for additional intervention.

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1 Initial Assessment and Management

Objectives
By the end of this interactive discussion, you will be able to:
1. Explain the importance of preparation prior to trauma patient arrival.
2. Evaluate the mechanism of injury to determine the patient’s potential
injuries.
3. Identify the correct sequence of priorities for the assessment of a multiply
injured patient.
4. Apply the principles of the primary and secondary surveys to the assessment
of a multiply injured patient.
5. Discuss the importance of reevaluating a patient who is not responding
appropriately to initial resuscitation and management.
6. Recognize patients who require transfer to another facility for definitive
management.
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1 Initial Assessment and Management

Case Scenario

18-year-old male , unrestrained

M driver in MVC vs. tree
I None reported
S Vitals not reported
Prolonged extrication; transported
T to ED by ambulance; O2 by mask;
fluids via single IV; spinal motion
restricted on long spine board
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1 Initial Assessment and Management

Discussion Questions:
Case Details

1. How would you prepare for the arrival 18-year-old male ,

M unrestrained driver in MVC
of this patient? vs. tree

2. What other information would be I None reported

helpful to know in order to prepare? S Vitals not reported

3. From the history, what are the
potential injuries this patient may have
suffered?
Prolonged extrication;
transported to ED by
T ambulance; O2 by mask;
fluids via single IV; spinal
motion restricted on long
spine board

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1 Initial Assessment and Management

Case Scenario Progression

• EMS report: patient is

lethargic, mumbling
unintelligibly
• Patient has facial injuries
• Vital signs: HR 120; BP 90/40;
RR 24, O2 sat 89%, temp 36°C

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1 Initial Assessment and Management

Discussion Questions:
Case Details

1. Based on this information, what • EMS report: patient

interventions can be done in the is lethargic,
prehospital setting? mumbling
unintelligibly
2. Which patients should be immediately
• Patient has facial
transported to the trauma center injuries
based on their field presentation?
• Vital signs: HR 120;
BP 90/40; RR 24, O2
sat 89%, temp 36°C

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1 Initial Assessment and Management

Case Scenario Progression

• Patient arrives at hospital

• Vital signs: HR 120; BP 90/palp;
RR 20; O2 sat 82%, temp 35.5°C.

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1 Initial Assessment and Management

Discussion Questions:
Case Details

1. What are your clinical concerns? • Patient arrives at

hospital
2. What are your management priorities?
• Vital signs: HR 120;
BP 90/palp; RR 20;
O2 sat 82%, temp
35.5°C.

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1 Initial Assessment and Management

Case Scenario Progression

Primary survey reveals:
A: Obvious facial trauma and mumbling incoherently.
B: Decreased breath sounds, L chest; no visible neck veins
C: Minimal bleeding; open L femur fracture; L chest bruising;
possible pelvic fracture
D: Localizes to pain with upper extremities; moans to painful
stimuli; does not open eyes

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1 Initial Assessment and Management

Discussion Questions:
Case Details
A: Obvious facial trauma and
1. What are your clinical concerns? mumbling incoherently.
B: Decreased breath sounds, L
2. What are your management priorities? chest; no visible neck veins
C: Minimal bleeding; open L
femur fracture; L chest
bruising; possible pelvic
fracture
D: Localizes to pain with upper
extremities; moans to
painful stimuli; does not
open eyes

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1 Initial Assessment and Management

Case Scenario Progression

• Patient intubated
• Femur fracture reduced and immobilized; pelvic stabilizing
device applied
• 500 mL warmed crystalloid and 1 unit unmatched pRBCs IV
• Vital signs: HR 97; BP 110/64; RR 24; O2 sat 96%
• Patient begins to respond to verbal stimuli, opens eyes, and tries
to brush away your hands

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1 Initial Assessment and Management
Discussion Questions:
1. What additional adjuncts and
treatments would you order at this
time?
2. When should the transfer occur and
what tests are necessary before
transferring the patient?
Case Details
• Patient intubated
• Femur fracture reduced and
immobilized; pelvic stabilizing
device applied
• 500 mL warmed crystalloid
and 1 unit unmatched pRBCs
IV
• Vital signs: HR 97; BP 110/64;
RR 24; O2 sat 96%
• Patient begins to respond to
verbal stimuli, opens eyes,
and tries to brush away your
hands
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1 Initial Assessment and Management

Case Scenario Progression

•Patient’s LOC decreases

• Patient opens his eyes to
pressure and moves away from
stimulus (normal flexion)
• Vital signs: HR 100; BP 100/60;
RR 20
• Good breath sounds bilaterally

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1 Initial Assessment and Management

Secondary survey:
• Pupils: 5 mm, minimally reactive, L; 6
mm, reactive, R
• Laceration and soft tissue injury, L
temporal-frontal region; no active
bleeding
• L hemotympanum
• Large ecchymosis, L anterior chest
• Abdomen soft, nondistended

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1 Initial Assessment and Management

Discussion Question:

What is your first step when a patient’s condition changes?

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1 Initial Assessment and Management

Discussion Question:

When does the secondary survey occur, and how is it conducted?

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1 Initial Assessment and Management

Case Scenario Progression

• No neurosurgery on site
• Decision: transfer patient to
another facility for definitive care
• Contact the family to give update
and obtain consent for transfer

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1 Initial Assessment and Management
Discussion Questions:
1. The family insists on obtaining a CT of
the head, even though this will
significantly delay transport (the team
is ready). Do you agree and why?
2. What information should you provide to
the receiving facility?
Case Details
• Patient intubated
• Femur fracture reduced
and immobilized; pelvic
stabilizing device applied
• 500 mL warmed crystalloid
and 1 unit unmatched
pRBCs IV
• Vital signs: HR 97; BP
110/64; RR 24; O2 sat 96%
• Patient begins to respond
to verbal stimuli, opens
eyes, and tries to brush
away your hands
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1 Initial Assessment and Management

Case Scenario Conclusion

The patient is transferred to a

trauma center via air, and goes to
surgery for evacuation of an
intracranial hematoma.

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1 Initial Assessment and Management

Any Questions?

?
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1 Initial Assessment and Management

Review Objectives
By the end of this interactive discussion, you will be able to:
1. Explain the importance of preparation prior to trauma patient arrival.
2. Evaluate the mechanism of injury to determine the patient’s potential
injuries.
3. Identify the correct sequence of priorities for the assessment of a multiply
injured patient.
4. Apply the principles of the primary and secondary surveys to the assessment
of a multiply injured patient.
5. Discuss the importance of reevaluating a patient who is not responding
appropriately to initial resuscitation and management.
6. Recognize patients who require transfer to another facility for definitive
management.
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1 Initial Assessment and Management

Key Learning Points

1. The initial management of the injured patient requires:

• coordination with prehospital providers
• preparation for receiving the patient
• anticipation of injuries based on the mechanism of injury
2. The evaluation of all trauma patients follows a precise algorithm.
3. Patients who exceed the capability of the institution should be
identified rapidly and process for transfer begun.
4. Evaluate the patient according to priority using the ABCDEs.

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