16. Assesment of a trauma patient in emergencyppt

16. Assesment of a trauma patient in emergency

1. INITIAL ASSESSMENT OF A
TRAUMA PATIENT
Sante Medical Collage
Dr. Ruth H.
July 2023

2. Initial Assessment and Management
Committee on Trauma Presents
Initial
Assessment
and
Management

3. TRAUMA IN DEVELOPING WORLD
•Limited resources
•Limited facilities
•Limited communication
•Evidence that trauma management
systems work
•PTC considers these limitations

4. PTC SYSTEM
TRIAGE
PRIMARY SURVEY
SECONDARY SURVEY
STABILISATION
TRANSFER
DEFINITIVE CARE

5. Case Scenario
●44-year-old male driver who crashed
head-on into a wall
●Patient found unresponsive at the scene
●Arrives at hospital via basic life support
with c-collar in place and strapped to a
backboard; technicians assisting
ventilations with bag-mask
What is the sequence of priorities
in assessing this patient?

6. Objectives
●Apply principles of primary and
secondary surveys
●Identify management priorities
●Institute appropriate resuscitation
and monitoring procedures
●Recognize the value of the patient
history and biomechanics of injury
●Anticipate and manage pitfalls

7. Standard Precautions
●Cap
●Gown
●Gloves
●Mask
●Shoe covers
●Goggles / face shield

8. Initial Assessment
Primary survey and
resuscitation of vital
functions are done
simultaneously
using a team
approach.

9. Concepts of Initial Assessment
Definitive Care
Reevaluation
Adjuncts
Adjuncts
Primary Survey
Resuscitation
Reevaluation
Detailed
Secondary Survey

10. What is a quick, simple way
to assess a patient in 10 seconds?
●Identify yourself
●Ask the patient his or her name
●Ask the patient what happened
Quick Assessment

11. Appropriate Response Confirms
A Patent airway
B Sufficient air reserve to permit speech
C Sufficient perfusion to permit
cerebration
D Clear sensorium

12. PRIMARY SURVEY
•A RAPID SEQUENTIAL LOOK
• 2 MINUTES
• TREAT AS YOU FIND

13. PRIMARY SURVEY
Airway
Breathing
Circulation
Disability
Exposure

14. SECONDARY SURVEY
•Follows primary survey
•Only when ABCs are stable
•Thorough head to toe examination
•Return to primary survey if patient
unstable

15. STABILISATION AND TRANSFER

16. DEFINITIVE CARE PHASE

17. Primary Survey
Airway with c-spine protection
Breathing with adequate oxygenation
Circulation with hemorrhage control
Disability
Exposure / Environment

18. Primary Survey
The priorities are
the
same for all
patients.

19. Special Considerations
●Trauma in the elderly
●Pediatric trauma
●Trauma in pregnancy

20. AIRWAY
ASSESSMENT
•Colour
•Conscious state
•Chest excursion
•Accessory muscle use

21. Primary Survey
Establish patent airway and
protect c-spine

Occult airway injury
Progressive loss of
airway
Equipment failure
Inability to intubate
Pitfalls
Airway

22. AIRWAY
MANAGEMENT
•Clear mouth
•Chin lift/jaw thrust
•Guedel / Nasopharyngeal
airway
•Intubation
•Cervical spine care

23. Primary Survey
Assess and ensure adequate
oxygenation and ventilation
● Respiratory rate
● Chest movement
● Air entry
● Oxygen saturation
Breathing

24. BREATHING
BEWARE
•Tension pneumothorax
•Massive haemothorax
•Open pneumothorax
•Flail(Hit) chest
•Lung contusion (bruise)

25. BREATHING
MANAGEMENT
•Oxygen (if available)
•Artificial ventilation
•Decompress pneumothorax
•Drain haemothorax

26. Primary Survey
● Level of consciousness
● Skin color and temperature
● Pulse rate and character
Assess for organ perfusion
Circulation

27. CIRCULATION
ASSESSMENT
•Cardiac output
•Blood volume
•External haemorrhage

28. Primary Survey
●Control hemorrhage
●Restore volume
●Reassess patient
Elderly
Children
Athletes
Medications
Circulatory Management
Pitfalls

29. CIRCULATION
BEWARE
•Intra-abdominal injury
•Intra-thoracic injury
•Long bone fracture
•Pelvic fracture
•Penetrating injury
•Scalp wounds

30. CIRCULATION
MANAGEMENT
•Stop bleeding
•Large bore intravenous access x
2
•Blood for crossmatch and Hb
•Administer IV fluid

31. Disability
● Baseline neurologic
evaluation
●
Glasgow Coma Scale score
●
Pupillary response
Observe for
neurologic
deterioration
Primary Survey
Caution

32. DISABILITY
•Pupils
•Check awareness
–A Awake
–V Responds to verbal
command
–P Responds to pain
–U Unresponsive

33. Prevent
hypothermia
Exposure / Environment
Completely undress the patient
Missed
injuries
Primary Survey
Pitfalls
Caution

34. Resuscitation
● Protect and secure
airway
● Ventilate and oxygenate
● Stop the bleeding!
● Vigorous shock therapy
● Protect from
hypothermia

35. REASSESSMENT OF ABCDE
If patient is, or becomes,
unstable

36. Adjuncts to Primary Survey
PRIMARY SURVEY
Vital signs
ABGs
Pulse
oximeter
and CO
2
Urinary / gastric catheters
unless contraindicated
Urinary
output
ECG

37. PRIMARY SURVEY
X-RAYS ( if available)
Cervical spine (lateral)
Chest
Pelvis

38. Adjuncts to Primary Survey
Diagnostic Tools

39. Adjuncts to Primary
Survey
Diagnostic Tools
● FAST
● DPL

40. ●Use time before
transfer for
resuscitation
●Do not delay
transfer for
diagnostic tests
Consider Early Transfer
Adjuncts to Primary
Survey

41. What is the secondary survey?
The complete
history and
physical
examination

42. When do I start the secondary survey?
After
● Primary survey is completed
● ABCDEs are reassessed
● Vital functions are returning to
normal
Secondary Survey

43. SECONDARY SURVEY
•On completion of primary survey
•When ABC’s are stable
•Aim to find any injury that may threaten
life or limb
•It is a thorough head to toe examination
•Immediately return to ABC’s if any
deterioration

44. Secondary Survey
● History
● Physical exam: Head to toe
● Complete neurologic exam
● Special diagnostic tests
● Reevaluation
What are the components of the secondary survey?

45. Secondary Survey
History
Allergies
Medications
Past illnesses
Last meal
Events / Environment /
Mechanism

46. Secondary Survey
Mechanisms of Injury

47. SECONDARY SURVEY
HEAD EXAMINATION
•Scalp (bruising, lacerations)
•Skull (tenderness, depression)
•Eyes (pupils, fundi, lens, conjunctva)
•CSF or blood from ear, nose, mouth

48. Secondary Survey
● Bony crepitus
● Deformity
● Malocclusion
Maxillofacial
Potential airway obstruction
Cribriform plate fracture
Frequently missed
Pitfalls

49. Secondary Survey
Mechanism: Blunt vs penetrating
Symptoms: Airway obstruction, hoarseness
Findings: Crepitus, hematoma, stridor, bruit
Neck (Soft Tissues)
Delayed symptoms and signs
Progressive airway
obstruction
Occult injuries
Pitfalls

50. Secondary Survey
● Inspect
● Palpate
● Percuss
● Auscultate
● X-rays
Chest

51. Secondary Survey
● Inspect /
Auscultate
● Palpate / Percuss
● Reevaluate
● Special studies
Abdomen
Hollow viscous injury
Retroperitoneal injury
Pitfalls

52. Perineum
Contusions, hematomas, lacerations, urethral blood
Rectum
Sphincter tone, high-riding prostate, pelvic fracture,
rectal wall integrity, blood
Vagina
Blood, lacerations
Urethral injury
Pregnancy
Secondary Survey
Pitfalls

53. ●Pain on palpation
●Leg length unequal
●Instability
●X-rays as needed
Secondary Survey
Pelvis
Excessive pelvic manipulation
Underestimating pelvic blood
loss
Pitfalls

54. ●Contusion, deformity
●Pain
●Perfusion
●Peripheral
neurovascular status
●X-rays as needed
Secondary Survey
Extremities

55. Potential blood loss
Missed fractures
Soft tissue or ligamentous injury
Compartment syndrome (especially with
altered sensorium / hypotension)
Secondary Survey
Musculoskeletal
Pitfalls

56. Secondary Survey
●GCS
●Pupil size and reaction
●Lateralizing signs
●Frequent reevaluation
●Prevent secondary
brain injury
Early
neurosurgical
consult
Neurologic: Brain

57. Altered sensorium
Inability to cooperate with
clinical exam
●Whole spine
●Tenderness and swelling
●Complete motor and sensory exams
●Reflexes
●Imaging studies
Secondary Survey
Neurologic: Spinal Assessment
Pitfalls

58. Secondary Survey
Early
neurosurgical /
orthopedic consult
Neurologic: Spine and Cord
Conduct an in-depth evaluation of the
patient’s spine and spinal cord

59. Incomplete immobilization
Neurologic deterioration
Secondary
Survey
Neurologic
Pitfalls

60. SECONDARY SURVEY
DON’T FORGET THE BACK!

61. SECONDARY SURVEY
LOG ROLL
•Adequate number of personnel ( 4 )
•One giving commands - usually
airway/neck controller
•Clear timing and instructions
•Look for wounds, bruising,
tenderness, deformity of spine,
sensation

62. Adjuncts to Secondary Survey
Special Diagnostic Tests as Indicated
Patient
deterioration
Delay of transfer
Deterioration
during transfer
Poor
communication
Pitfalls

63. SECONDARY SURVEY
X-RAYS
•In secondary survey if not already done
•Chest
•Cervical spine - all 7 vertebrae
•Pelvis
•Others as indicated by examination

64. Pain Management
●Relief of pain / anxiety
as appropriate
●Administer
intravenously
●Careful monitoring is
essential

65. Transfer
Those whose injuries exceed institutional
capabilities:
● Multisystem or complex injuries
● Patients with comorbidity or age extremes
Which patients do I transfer to
a higher level of care?

66. When should the transfer occur?
As soon as possible after stabilizing
measures are completed:
● Airway and ventilatory control
● Hemorrhage control (operation)
Transfer

67. Transfer to Definitive Care
Transfer agreements
Local resources
Trauma
center
Specialty
facility
Local facility

68. Summary
Definitive Care
Reevaluation
Adjuncts
Adjuncts
Primary Survey
Resuscitation
Reevaluation
Detailed
Secondary Survey