Primary survey in traumatic patients .pptx

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1. PRIMARY SURVEY

2. Precepts of Trauma Evaluation Treat the greatest threat to life first Lack of a definitive diagnosis should never impede the indicated treatment, a detailed history is not essential to begin with .... Physiologic approach Time is of the essence Do no further harm

3. Goals Rapid, accurate, and physiologic assessment of patient’s condition Resuscitation, stabilization, and monitoring of patient, according to prioritize Preparation for patient’s interhospital transfer, if patient’s needs exceed facility’s capabilities

4. Road Traffic Accident Statistics Road traffic accidents are a leading cause of trauma worldwide. In 2021, an estimated 1.3 million people died due to road traffic accidents globally (World Health Organization). 90% of road traffic fatalities occur in low- and middle-income countries. Young adults aged 15-29 are disproportionately affected by road traffic injuries. Efforts to improve road safety and trauma care systems can significantly reduce mortality

5. Systematic approach: The Initial Assessment Preparation Triage Primary survey(ABCDEs)with immediate resuscitation of patients with life-threatening injuries Adjuncts to primary survey and resuscitation Consideration of the need for patient transfer Secondary survey (head-to-toe evaluation and patient history) Adjuncts to the secondary survey Continued postresuscitation monitoring and reevaluation Definitive care

6. Introduction to the Primary Survey The primary survey is a systematic approach to identify and treat life-threatening injuries. It focuses on key areas that can cause immediate death: airway, breathing, circulation, disability, and exposure. Utilizes the ABCDE mnemonic to guide clinicians. Designed to be completed rapidly upon patient arrival. Initiates immediate interventions for life-threatening conditions like airway obstruction and shock.

7. Indications for Primary Survey Performed on all trauma patients, regardless of their apparent stability. Identifies injuries that may not be obvious but are life-threatening. Initiates resuscitation to ensure vital functions are maintained. No contraindications; even seemingly minor injuries can mask serious conditions. Special considerations for intoxicated, uncooperative, or severely injured patients.

8. ABCDE Overview A irway with cervical spine precautions. B reathing and ventilation. C irculation with hemorrhage control. D isability/neurological assessment. E xposure and environmental control. Each step requires careful attention, with immediate interventions as needed.

9. Primary survey with simultaneous resuscitation: identify and treat what is killing the patient Secondary survey: proceed to identify all other injuries Definitive care: develop a definitive management plan

10. Airway (A): Overview Airway patency is the highest priority as obstruction can rapidly cause death. Ask simple questions to assess airway patency: Can the patient speak clearly? Look for signs of airway obstruction: snoring, stridor, gurgling, or cyanosis. Maintain cervical spine immobilization if trauma is suspected. Techniques to open the airway include the chin lift and jaw thrust maneuver .

11. Airway (A): Techniques Chin lift : Thumb under the chin lifts the mandible forward. Jaw thrust : Long fingers placed behind the mandible to push anteriorly. Intubation should be performed if airway patency cannot be maintained. Be cautious of potential facial fractures, which complicate airway management. Surgical airway (cricothyroidotomy) may be required for severe obstructions.

12. Airway and Cervical Spine Protection Always assume a cervical spine injury in trauma until proven otherwise. Cervical spine immobilization should be performed manually during airway management. Use a cervical collar once airway and spine are stabilized. Two-person technique: one person stabilizes the spine while the other manages the airway. Avoid unnecessary neck movements that could worsen spinal injuries.

13. Breathing (B): Overview After ensuring airway patency, assess the patient’s ability to breathe. Check for symmetrical chest rise and fall. Auscultate lung fields for breath sounds: diminished or absent sounds may indicate pneumothorax or hemothorax . Inspect for signs of chest trauma: flail chest, penetrating wounds, or tracheal deviation. Provide oxygen immediately to all trauma patients.

14. Breathing (B): Interventions If a pneumothorax is suspected, perform a needle decompression. For open chest wounds, apply a three-sided occlusive dressing to prevent air entry. For flail chest and respiratory distress, initiate positive pressure ventilation. Administer high-flow oxygen via mask or ventilator. Rapid intubation may be needed for severe respiratory compromise.

15. Circulation (C): Overview Hemorrhage is the leading cause of preventable death in trauma. Assess skin color , pulse rate and quality, and level of responsiveness. Look for signs of shock: pale, cool skin, weak pulses, or altered consciousness. Control visible bleeding with direct pressure or tourniquets. Initiate intravenous access with large-bore IVs for fluid resuscitation.

16. Circulation (C): Shock Management Shock can result from blood loss (hypovolemic shock) or internal bleeding. Administer isotonic fluids (normal saline or lactated Ringer’s) rapidly. After 1-2 liters of fluid, administer blood products if bleeding is uncontrolled. Check capillary refill time (normal is under 2 seconds). Suspect pericardial tamponade if the patient has shock without external hemorrhage .

17. Haemorrhage Control Control external bleeding with direct pressure, gauze, and tourniquets. Tourniquets should only be used for limb hemorrhage and tightened until bleeding stops. Monitor for signs of internal bleeding using FAST ultrasound. Uncontrolled hemorrhage requires urgent surgical intervention. Shock can occur even if blood pressure is normal; compensate based on clinical signs

18. Disability (D): Neurological Assessment Assess the patient’s level of consciousness using the AVPU scale: Alert, responds to Voice, responds to Pain, Unresponsive. Perform a quick Glasgow Coma Scale (GCS) to assess brain injury. Check pupil size and response to light. Monitor for lateralizing signs, such as weakness or paralysis on one side of the body. A GCS score of 8 or less indicates the need for airway protection (intubation).

19. Glasgow Coma Scale (GCS) Eye Opening (4 points) : Spontaneous, to voice, to pain, none. Verbal Response (5 points) : Oriented, confused, inappropriate words, incomprehensible sounds, none. Motor Response (6 points) : Follows commands, localizes pain, withdraws from pain, abnormal posturing, none. Total possible score: 3-15. Reassess regularly to monitor for deterioration.

20. Exposure (E): Complete Examination Expose the patient fully to assess for hidden injuries. Look for bruises, lacerations, burns, or deformities. Assess the back by log-rolling the patient while maintaining spinal precautions. Keep the patient warm with blankets or external warming devices to prevent hypothermia. Hypothermia can exacerbate trauma-related bleeding (coagulopathy).

21. Environmental Control Trauma patients are prone to hypothermia, which worsens coagulopathy and shock. Use warming blankets, warm fluids, and maintain a warm environment in the trauma bay. Remove wet clothing and cover the patient appropriately during assessment. Early control of hypothermia is critical for patient survival. Monitor the patient’s core temperature and act quickly if hypothermia is detected.

22. Adjuncts to the Primary Survey ECG : Monitor for dysrhythmias and signs of cardiac ischemia or tamponade. Chest X-ray : Evaluate for pneumothorax, hemothorax , rib fractures, or aortic injury. Pelvic X-ray : Identify pelvic fractures, which can cause massive internal bleeding. FAST Exam : Rapid bedside ultrasound to detect free fluid in the abdomen or pericardium. Urinary catheter and gastric tube insertion may help with fluid status monitoring but are contraindicated in some injuries.

23. Focused Assessment with Sonography in Trauma (FAST) FAST is a rapid ultrasound to check for intra-abdominal bleeding. Scans four areas: pericardial sac, hepatorenal space, splenorenal space, and pelvis. Used to detect hemoperitoneum or pericardial tamponade. Non-invasive, quick, and effective for guiding surgical decisions. FAST is critical when time or patient instability prevents more detailed imaging.

24. Airway Adjuncts and Intubation If the patient cannot maintain their airway, prepare for intubation. Pre-oxygenate before intubation to prevent hypoxia. Use rapid sequence induction (RSI) for sedated intubation. Have backup plans in place, such as a laryngeal mask airway (LMA) or cricothyroidotomy. Monitor oxygen saturation, capnography, and chest rise during intubation.

25. Chest Tube Insertion Chest tubes may be needed for pneumothorax or hemothorax . Insert in the 5th intercostal space, mid-axillary line. A tube is required for large air or blood collections in the pleural space. Monitor drainage and air leaks after placement. Ensure continued lung expansion with post-placement chest X-rays.

26. Urinary and Gastric Catheters Urinary catheters help assess fluid output and monitor renal function. Contraindicated if there is blood at the urethral meatus or suspicion of urethral injury. Gastric catheters decompress the stomach, preventing aspiration. Avoid nasogastric tubes in patients with facial trauma or suspected basilar skull fractures. Gastric decompression can also improve ventilation in intubated patients.

27. Post-Primary Survey Decision Making After the primary survey, determine the next steps for patient care. Options include further imaging, surgery, ICU admission, or monitoring. Ongoing reassessment is essential to detect delayed signs of deterioration. Communicate findings with the trauma team and prepare for transfer if needed. Disposition decisions must balance patient stability and the need for definitive care.

28. Common Pitfalls in Primary Survey Failure to maintain cervical spine protection during airway maneuvers . Inadequate control of bleeding, especially from hidden sources. Underestimating the severity of shock despite normal blood pressure. Incomplete exposure of the patient, leading to missed injuries. Delayed recognition of life-threatening conditions such as tamponade or tension pneumothorax.

29. Team-Based Approach to Primary Survey Trauma care is a team effort, requiring coordination between multiple specialists. The team typically includes emergency physicians, trauma surgeons, anesthesiologists , and nurses. Effective communication and role assignment are critical for efficient trauma management. The team leader should direct the survey and ensure that each step is completed. Regular training in trauma simulations helps teams stay prepared for real-world scenarios.

30. Role of Communication and Documentation Accurate and timely communication between team members improves outcomes. All findings, interventions, and patient responses should be documented in real time. Documentation is crucial for continuity of care as patients move through different departments. Clear communication with receiving teams (e.g., ICU or surgery) ensures smooth transitions. Always document the reassessment of critical findings, especially changes in vital signs.

31. Importance of Reassessment Continuously reassess airway, breathing, and circulation throughout patient care. Deterioration in the patient's condition should prompt immediate reevaluation . Changes in vital signs or mental status may indicate new or worsening injuries. Ongoing reassessment can prevent missed diagnoses and guide treatment modifications. Regular reassessments are critical in the dynamic environment of trauma care.

32. Trauma in Special Populations Pediatrics : Children have different physiological responses to trauma, requiring modified approaches. Elderly : Older adults may present with subtle signs of shock and have higher mortality rates. Pregnant patients : Assessment must account for both maternal and fetal well-being. Consider specific adjustments for patients with pre-existing medical conditions (e.g., heart disease). These populations may require specialized equipment and management strategies.

33. Conclusion The primary survey is the cornerstone of initial trauma care. By following the ABCDE approach, clinicians can rapidly assess and manage life-threatening injuries. Timely interventions save lives and improve long-term outcomes for trauma patients. Regular trauma training, combined with effective teamwork, is essential for maintaining high-quality care. Trauma care is a continuously evolving field, requiring constant updates in protocols and techniques.