TRAUMA
Published on Dec 03, 2016
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PRESENTATION OUTLINE
TRAUMA
Primary & Secondary Survey
The following presentation focuses on the initial steps in patient assessment and management following an acute trauma.
2 Types Trauma
- Blunt
- Penetrating
- **Tx’d same way: primary survey -> secondary survey (w/ continued reassessment)
Trauma is broken down into two main categories - blunt and penetrating.
The important point is that all trauma follows the same universal workup using a primary and secondary survey.
The important point is that all trauma follows the same universal workup using a primary and secondary survey.
PRIMARY SURVEY
Initial assessment for identification of life-threatening injuries
Photo by horizontal.integration
“ABCDE”
Airway, Breathing, Circulation, Disability, Exposure
Primary survey consists of 5 major components followed in a step-wise fashion.
They can be remembered with the mnemonic "ABCDE" - Airway, Breathing, Circulation, Disability, Exposure.
They can be remembered with the mnemonic "ABCDE" - Airway, Breathing, Circulation, Disability, Exposure.
AIRWAY
- Steps - identify airway patency
- Concerning - blood/vomit, c-collar, teeth
- Serious - fractures, airway obstruction
- To do - poor breathing or GCS
Initial assessment is all about assessing airway patency. The simplest way to do this is to ask the patient a question. If they are answering in clear, full sentences then you know the airway is patent.
Concerning findings include a patient with blood or vomit in or around their mouth, missing or loose teeth, inability to visualize airway, maxillofacial fractures, presence of a restricting c-collar.
If patient is not breathing, has seriously concerning presentation, or GCS
Concerning findings include a patient with blood or vomit in or around their mouth, missing or loose teeth, inability to visualize airway, maxillofacial fractures, presence of a restricting c-collar.
If patient is not breathing, has seriously concerning presentation, or GCS
Photo by CarbonNYC [in SF!]
BREATHING
- Steps - Expose, Inspect, auscultate, percuss, palpate, pulse oximetry, respiratory rate
- Concerning - decreased BS, crepitus, chest assymmetry, tracheal shift, rib fractures, oral cyanosis
- Serious - t.pneumo, pulm contusion, c.tamponade, flail chest
- To do - needle decompress + chest tube thoracostomy, pericardiocentesis, CXR
In assessing a patient's breathing it is important too fully expose and inspect the patients chest. You must auscultate, percuss, palpate BOTH sides of lung listening for abnormalities. Pulse oximetry and respiratory rate must also be measured.
Major concerns are decreased breath sounds or respiratory rate, crepitus on palpation, tracheal shift, rib fractures or oral cyanosis.
This concerning findings could suggest a punctured lung/ tension pneumothorax, cardiac tamponade (muffled heart sounds), or a flail chest each requiring immediate intervention.
If you suspect tension pneumothorax you want to do a needle decompression @ midclavicular line followed by a tube thoracostomy in 4th I/C space @ midaxillary line.
If you suspect cardiac tamponade, patient may require a pericardiocentesis to relieve fluid around heart.
Major concerns are decreased breath sounds or respiratory rate, crepitus on palpation, tracheal shift, rib fractures or oral cyanosis.
This concerning findings could suggest a punctured lung/ tension pneumothorax, cardiac tamponade (muffled heart sounds), or a flail chest each requiring immediate intervention.
If you suspect tension pneumothorax you want to do a needle decompression @ midclavicular line followed by a tube thoracostomy in 4th I/C space @ midaxillary line.
If you suspect cardiac tamponade, patient may require a pericardiocentesis to relieve fluid around heart.
Photo by Luu Cruz
CIRCULATION
- Steps - Assess blood flow - Check BP, HR, peripheral pulses, skin temp/color
- Concerning - hypotension, tachycardia, cold extremities, absence of peripheral pulses
- Serious - Hemorrhage, blood loss
- To do - IV access (2 x large bore 18G), give fluids (2L NS), compress visible bleeds, tourniquet, CBC/Lactate/type and screen
Circulation is all about assessing blood flow. This involves checking blood pressure on both right and left side, checking HR, and assessing peripheral pulses bilaterally, in both upper and lower limbs. You must also feel the skin for coolness that may indicate decreased flow to periphery.
Concerning findings include hypotension, tachycardia, cold/clammy extremities, absence of peripheral pulses.
Major cause of these findings include hemorrhage/blood loss in the body or in the field (see next slide).
Major steps involve obtain IV access in both arms using 2 large-bore IV needles.
Concerning findings include hypotension, tachycardia, cold/clammy extremities, absence of peripheral pulses.
Major cause of these findings include hemorrhage/blood loss in the body or in the field (see next slide).
Major steps involve obtain IV access in both arms using 2 large-bore IV needles.
Photo by árticotropical
5 locations of MAJOR BLOOD LOSS
- Chest
- Abdomen
- Pelvis
- Thigh
- **Street
In patients experience signs of major blood loss (eg, hypotension), there are 5 areas that must always be considered: chest, abdomen, pelvis, thigh, street (lost in the field). Further assessment and management is warranted.
Photo by Csutkaa
DISABILITY
- Steps - Assess neurologic status using Glasgow Coma Scale (1 -> 15), check pupils, extremity sensory and motor function
- GCS = "Extra Value Meal = $4.56"
- Eyes (1->4), Verbal (1->5), Motor (1->6)
Disability is about assessing neurological status. The most common way to do this in a trauma setting primary survey is to check pupils and glasgow coma scale (GCS).
GCS can be remembered using the mnemonic "Extra Value Meal = $4.56".
Eyes (1->4), Verbal (1->5), Motor (1->6)
E:
1 - No eye opening
2 - Eye opening in response to pain stimulus
3 - Eye opening to speech.
4 - Eyes opening spontaneously
V:
1 - No verbal response
2 - Incomprehensible sounds.
3 - Inappropriate words
4 - Confused.
5 - Oriented.
M:
1 - No motor response
2 - Decerebrate posturing accentuated by pain
3 - Decorticate posturing accentuated by pain
4 - Withdrawal from pain
5 - Localizes to pain
6 - Obeys commands
Note - Statue of liberty has GCS = 6 (can't be 0!)
GCS can be remembered using the mnemonic "Extra Value Meal = $4.56".
Eyes (1->4), Verbal (1->5), Motor (1->6)
E:
1 - No eye opening
2 - Eye opening in response to pain stimulus
3 - Eye opening to speech.
4 - Eyes opening spontaneously
V:
1 - No verbal response
2 - Incomprehensible sounds.
3 - Inappropriate words
4 - Confused.
5 - Oriented.
M:
1 - No motor response
2 - Decerebrate posturing accentuated by pain
3 - Decorticate posturing accentuated by pain
4 - Withdrawal from pain
5 - Localizes to pain
6 - Obeys commands
Note - Statue of liberty has GCS = 6 (can't be 0!)
Photo by mikecogh
EXPOSURE
E - exposure
EXPOSURE
- Steps - Assess for ANY possible injury- disrobe patient, roll (maintain c-spine precaution), check spinal tenderness, DRE (GI bleed), temp, bruising, lacerations
- Concerning - open wounds, no exit wound (GSW), spine tenderness
- To Do - Log roll -> Palpate spine, check skin folds and axillae, Keep warm! (blankets)
Exposure is a full assessment for any other possible injury other than what patient expresses or what was mentioned by EMT. This includes fully disrobing the patient, checking axillary region, rolling patient (while maintaining c-spine precaution), checking for spinal tenderness by palpating entire spine, conducting a digital rectal exam (GI bleed), and measuring temperature
Concerning signs include any spinal tenderness, open wounds, or bullet wounds with entry but no exit signs.
Above all else, remember to keep patient warm. Exposure is important but it is important in assessment but must be done quickly, followed by warm blankets.
Concerning signs include any spinal tenderness, open wounds, or bullet wounds with entry but no exit signs.
Above all else, remember to keep patient warm. Exposure is important but it is important in assessment but must be done quickly, followed by warm blankets.
SECONDARY SURVEY
Once the primary survey has been conducted and any immediate life threats have been identified and managed, the secondary survey is conducted to identify the presence of other injuries missed in the focused primary survey.
Photo by Leo Reynolds
SECONDARY SURVEY
- “I will get a comprehensive history and physical” (AMPLE) - Complete head-to-toe physical exam
- Frequently Reassess vitals
- Labs
- Imaging
- FAST exam
The secondary survey involved getting a comprehensive history and physical (including "AMPLE"), continuously reassessing vitals, as well as ordering the necessary labs, imaging, and FAST exam as needed*.
*note - labs, imaging, and FAST are often ordered throughout the primary survey and into the secondary survey. There is no universal order to these tests - these should be ordered as the requirement presents.
*note - labs, imaging, and FAST are often ordered throughout the primary survey and into the secondary survey. There is no universal order to these tests - these should be ordered as the requirement presents.
Photo by Leo Reynolds
Complete Hx + "AMPLE"
- Allergies
- Medications
- Past Medical History
- Last meal (surgery?)
- Events surrounding incident
Part of the comprehensive history is the mnemonic "AMPLE", which any patient requiring surgery will need answered. This includes any allergies (meds, food), and medications and when was the last time they were taken, when was the last meal and what did it consist of, and finally any events patients/family/bystanders recall surrounding the incidence of the event.
Photo by Charles Williams
COMPLETE PE
- Every orifice, torso, extremity
- Ears → otorrhea - basilar skull fracture
- Nose - rhinorrhea, hematoma
- Extremities - r/o compartment syndrome, fractures (esp hip dislocation)
- Ribs - assess for breaks
Complete physical exam is head-to-toe, covering every orifice and extremity.
Photo by Tojosan
Labs, Imaging
- CBC, ABG, Lactate, Type and Cross, glucose
- CXR (AP)
- PXR (AP)
- Lateral c-spine
- EKG
Labs, though typically patient dependent, often involve CBC, ABG, Lactate, Type and Cross, glucose.
In addition, further imaging may be warranted including neck, chest, or pelvic xray as well as an EKG if suspected LOC or cardiac involvement.
In addition, further imaging may be warranted including neck, chest, or pelvic xray as well as an EKG if suspected LOC or cardiac involvement.
Photo by Pulmonary Pathology
FAST EXAM
- Focused assessment with sonography for trauma
- Screen for internal bleeding following trauma
FAST exam is a Focused assessment with sonography for trauma. The purpose is to screen for internal bleeding following trauma using a non-invasive, quick technique that is an essential tool to any EM physician.
The details of which are covered in a separate lecture.
The details of which are covered in a separate lecture.
Summary - Trauma
- Primary Survey - ABCDE's
- Secondary Survey - comprehensive H&P (+ "AMPLE"), reassess vitals, labs, imaging, and FAST exam
Trauma is broken down into two main categories - blunt and penetrating.
The important point is that all trauma follows the same universal workup using a primary and secondary survey.
The important point is that all trauma follows the same universal workup using a primary and secondary survey.
