Primary and secondary survey379487438.ppt

Mmm

1. Initial Assessment
and
management

2. 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

3. 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

4. •Repeat primary and secondary survey when finding
any deterioration in the patient’s status
•Primary survey and resuscitation are done
simultaneously

5. 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

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

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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)

14. RESUSCITATION
•Protect/Secure airway & protect C-spine
•Breathing/Ventilation/Oxygenation
•Vigorous shock therapy
–At last two large -caliber IV line
–Crystalloid solution ( Ringer’s lactate 2~3litter)
–Type-specific blood
–surgical intervention
•Protect from Hypothermia : 39
o
C warm IV fluid
•Urinary/gastric catheters unless contraindication

15. ADJUNCTS TO PRIMARY SURVEY AND
RESUSCITATION
•Monitor:
–Ventilatory rate and ABGs/ end-tidal CO
2
Pitfalls: Combative patients often extubate or bite
endotracheal tube
–Pulse oximetry
–ECG & BP monitor
–Temperature
–urine output

16. X-RAY AND DIAGNOSTIC STUDIES
•Can’t 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 can’t exclude cervical
spinal injury
•Sonography / DPL
Pitfalls: obesity ( Sonography and DPL are difficult )

17. CONSIDER NEED FOR PATIENT TRANSFER
Referring doctor -to -receiving doctor communication
Closest appropriate hospital

18. BEFORE SECONDARY SURVEY
•Complete primary survey
•Establish resuscitation
•Normalization of vital functions

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

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

21. HISTORY
Mechanisms 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

22. 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 p’t still
need eye exam.

23. SECONDARY SURVEY
•Physical Examination
–Maxillofacial
•No airway obstruction or massive bleeding ==> treat later
•Midfacial fracture ==> R/O cribriform plate fracture
Pitfalls:
Some facial bone fracture is difficulty identified early ==>
reassessment is crucial

24. 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 ==> decubitus ulcer

25. SECONDARY SURVEY
•Physical Examination
–Chest
•Pitfalls:
–Poor tolerance to minor pulmonary trauma in
elderly patients
–A normal CXR can’t role out chest injury in
children

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

27. 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

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

29. 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 )

30. REEVALUATION
•New findings / deterioration / improvement
•High index of suspicion ==> early diagnosis &
management
•Continuous monitoring
•Pain relief

31. DEFINITIVE CARE
•Trauma center
•Closest appropriate hospital

32. RECORDS AND LEGAL CONSIDERATIONAS
•Records: Concise, chronologic documentation
•Consent for treatment
•Forensic Evidence: preserve the evidence

33. 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 )

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You