Trauma Primary and Secondary Survey

Sarah Pearson Emergency Department Consultant Queens Hospital, Burton

Trauma Resuscitation
Aim


Structured approach to the assessment of severely injured patient and institution of lifelifepreserving therapy

Trauma


Structured Approach

rapid primary evaluation ABC . resuscitation of vital function more detailed secondary assessment emergency treatment initiation of definitive care

Trauma Assessment & Resuscitation

  

Technically longitudinal progression of events In reality often parallel or simultaneous

Treat problems as they are found

Trauma Assessment
Primary Survey

A B C D E

airway & cervical spine control breathing & oxygen therapy circulation & haemorrhage control disability & neurological status exposure & environment

DEFG

don t ever forget glucose

Trauma Assessment


A - airway and C-spine control C   

direct clearance / gentle suction position to establish patent airway check adjuncts and definitive airway if used C - spine immobilisation

Pitfalls  Beware of struggling patient  paralysed patient  unknown laryngeal # or airway transection  Finger sweep

Trauma Resuscitation


Airway Manoeuvres
  

Definitive airway


jaw thrust chin lift head tilt

ETT (oral or nasal)

Surgical airway
needle cricothyroidotomy (jet insufflation )  surgical cricothyroidotomy (mini(mini-tracheostomy)  tracheostomy


Adjunts
 

OroOro-pharyngeal airway NasoNaso-pharyngeal airway

Trauma Assessment


B- Breathing with oxygen therapy

   

chest wall and abdominal inspection check for air shift palpation, percussion and auscultation high flow oxygen

Pitfalls
 

airway compromise equipment failure

Trauma Resuscitation


Breathing with oxygen therapy



  

patent airway established with continuous CCspine protection supplemental oxygen given - mask or catheter assist breathing if necessary bag & mask chest decompression if tension pneumothorax is suspected attach monitors pulse oximeter

Most fatal chest injuries

     

A T O M F C

Airway transection/rupture Tension pneumothorax Open pneumothorax Massive haemothorax Flail segment Cardiac tamponade

Trauma Resuscitation


Indications for intubation and ventilation

   

Impending airway compromise Inadequate support from bag & mask Prolonged ventilation needed controlled ventilation needed

Trauma Assessment


C - circulation and haemorrhage control

   

level of consciousness colour, pulse,capillary refill , B.p look for obvious bleeding ensure patent intravenous(IV) access possible

largest

Pitfalls
  

poor correlation of b.p with cardiac output tachycardia in athletes occult bleeding

Trauma Resuscitation


Circulation


    

control bleeding by direct pressure or operative intervention two good IV accesses + fluid therapy Consider inter-osseous needles if IV is difficult intercutcut-downs may be necessary take blood for baseline tests, GXM and BM monitor urinary output

Trauma Assessment


disability
A - Alert V - responds to Voice P - responds to Pain U - Unresponsive GCS may be used Pupils Posture haemorrhage or drugs lucid interval

  

Pitfalls
 

Trauma Assessment


E - Exposure and Environmental control

 

completely undress with minimal movement keep patient warm and decent

Pitfalls


massive infusion of cold fluids may worsen already existing hypothermia

Trauma Resuscitation


Adjuncts to Primary survey & Resuscitation



Monitoring
vital signs  arterial gases  urinary output


X-rays (trauma series)

CXR  Lateral C-spine C Pelvis


Trauma Resuscitation


More Adjunts


Other diagnostic studies

Focused assessment sonography in trauma(FAST)  Computerised tomography(CT)  Diagnostic peritoneal lavage(DPL)


 

Gastric tube (nasal or oral) Urinary catheter

Trauma
Secondary Survey
 

head to toe assessment with due consideration to the already identified injuries But
  

primary survey must be completed resuscitative efforts must be well established and continued patient should be demonstrating normalisation of vital functions review ABC if any deterioration is noted during secondary survey

Trauma
Secondary Survey


History -AMPLE  A - allergies  M - medications  P - past medical history  L - last meal  E - events/environment relating to injury

Trauma


History


Details about events and environment

Source
  

Vehicular accident Fall from height Assault including suicide(think NAI) Blunt Penetrating burns and cold

Type
  

other hazardous environment

Trauma
Secondary Survey


Examination
       

head and face Neck chest abdomen Perineum Back log roll Limbs Neurology

*Use as framework for recording notes

Trauma
Secondary Survey


Log roll
  

5 people must be a clear leader must give clear instructions

Note: May be done earlier to relieve pressure from spinal board

Trauma
Definitive care
 

Referral Safe transfer or retrieval

Trauma Resuscitation

Trauma Resuscitation
Summary
   

Simple concept of trauma management Sequence of assessment and resuscitation Essential initial imaging in trauma System of recording notes in trauma