Chapter 1 Initial Assessment and management

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Chapter 1Initial Assessment and management
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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

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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

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• Repeat primary and secondary survey when finding
  any deterioration in the patients status
• Primary survey and resuscitation are done
  simultaneously

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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

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TRIAGE

• Sorting of patients according to ABCs and
  available resources
• Triages is the responsibility of prehospital
  personnel

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• Not exceed the ability of the facility gt treat
  life -- threatening patient first
• Exceed the capacity of the facility ( mass
  casualties ) gt Treat the greatest chance of
  survival, with the less time, less equipment
  less personnel

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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

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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

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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

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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

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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

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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)

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RESUSCITATION

• Protect/Secure airway protect C-spine
• Breathing/Ventilation/Oxygenation
• Vigorous shock therapy
• At last two large - caliber IV line
• Crystalloid solution ( Ringers lactate 23
  litter)
• Type-specific blood
• surgical intervention
• Protect from Hypothermia 39oC warm IV fluid
• Urinary/gastric catheters unless contraindication

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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

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X-RAY AND DIAGNOSTIC STUDIES

• Cant 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 cant
  exclude cervical spinal injury
• Sonography / DPL
• Pitfalls obesity ( Sonography and DPL are
  difficult )

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CONSIDER NEED FOR PATIENT TRANSFER

• Referring doctor -to -receiving doctor
  communication
• Closest appropriate hospital

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BEFORE SECONDARY SURVEY

• Complete primary survey
• Establish resuscitation
• Normalization of vital functions

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SECONDARY SURVEY

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

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SECONDARY SURVEY

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

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HISTORYMechanisms 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

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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 pt
  still need eye exam.

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SECONDARY SURVEY

• Physical Examination
• Maxillofacial
• No airway obstruction or massive bleeding gt
  treat later
• Midfacial fracture gt R/O cribriform plate
  fracture
• Pitfalls
• Some facial bone fracture is difficulty
  identified early gt reassessment is crucial

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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 gt decubitus ulcer

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SECONDARY SURVEY

• Physical Examination
• Chest
• Pitfalls
• Poor tolerance to minor pulmonary trauma in
  elderly patients
• A normal CXR cant role out chest injury in
  children

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SECONDARY SURVEY

• Physical Examination
• Abdomen
• Identify a surgical abdomen is more important
  than doing a specific diagnosis gt early consult
  surgeon
• Close observation frequent reevaluation of the
  abdomen
• DPL, sonography, abdomen CT
• Pitfalls
• Excessive manipulation of the pelvis should be
  avoid gt just do pelvic x-ray
• Retroperitoneal organs ( pancreatic hollow
  organ ) are very difficult to identify

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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

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SECONDARY SURVEY

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

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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 )

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REEVALUATION

• New findings / deterioration / improvement
• High index of suspicion gt early diagnosis
  management
• Continuous monitoring
• Pain relief

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DEFINITIVE CARE

• Trauma center
• Closest appropriate hospital

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RECORDS AND LEGAL CONSIDERATIONAS

• Records Concise, chronologic documentation
• Consent for treatment
• Forensic Evidence preserve the evidence

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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 )