Trauma Management and early assessment in

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1. Early Assessment and
Management of Trauma
Frank Stening
Australia
Specialists Without Borders
Seminar in Surgery
Rwanda, September 2010

2. Objectives
•Identify management priorities
•Understand concept of Primary and
Secondary Survey
•Institute appropriate resuscitation and
monitoring within first 60-120 minutes
•Recognize the value of the patient’s history
and mechanism of injury
•Anticipate pitfalls

3. KEY QUESTION
How do we minimise MISSED injuries ?
How do we improve survival rates ?
( Who needs transfer
When do they need transfer )

4. Concepts of Initial Assessment
•Rapid primary survey
•Resuscitation
•Adjuncts to primary survey/resuscitation
•Detailed secondary survey
•Adjuncts to secondary survey
•Re-evaluation
•Definitive care

5. INITIAL MANAGEMENT AND
ASSESSMENT
1. Preparation
2. Triage
3. Primary survey (ABC’s)
4. Resuscitation
5. Secondary survey (Head-to-toe)
6. Continued post resuscitation monitoring
and re-evaluation
7. Definitive care

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

7. Triage
Sorting of patients according to:
ABCDEs
Available resources
Multiple casualties
Mass casualties

8. A quick, simple way to assess the
patient in 10 seconds
Identify yourself
Ask the patient his / her name
Ask the patient what happened

9. ... an appropriate response
suggests:
Patent airway
Sufficient air reserve to permit speech
Clear sensorium
Now proceed to a rapid primarysurvey

10. Primary Survey
•Adults, paediatric, pregnant women
Priorities are the same!
AAirway with c-spine protection
BBreathing
CCirculation with haemorrhage control
DDisability
EExposure / Environment
EMST

11. Special Groups to Consider
•Children
•Elderly
•Pregnant women

12. Primary Survey
Establish Patent Airway
Beware C-spine injury
Pitfalls
Equipment failure
Inability to intubate
Occult airway injury
Progressive loss of airway
Caution

13. Breathing
•Oxygenate
•Assess
•Ventilate
Caution
Primary Survey
Pitfalls
Airway vs ventilation
problem?
Iatrogenic pneumothorax/
tension pneumothorax

14. Primary Survey
Assessment of Organ Perfusion
Level of consciousness
Skin colour and temperature
Pulse rate and character

15. Circulatory Management
•Control haemorrhage
•Restore volume
•Reassess
Caution
Primary Survey
Pitfalls
Elderly
Athletes
Children
Medications

16. Disability
•Baseline neurologic evaluation
–GCS scoring
–Pupillary response
Caution
Primary Survey
Observe for
neurologic
deterioration

17. Exposure / Environment
•Completely undress the patient
Caution
Primary Survey
Prevent hypothermia

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

19. PRIORITY PLAN
X-RAYS
(should be used judiciously and should
not delay resuscitation)
Lateral cervical spine
AP chest
AP pelvis

20. Adjuncts to Primary Survey
Diagnostic Tools
•Chest and pelvic x-rays
•DPL
•Ultrasound

21. Secondary Survey
What is secondary survey?
–Available history and head-to-toe examination
When do I start?
–After primary survey complete
–After ABCDE’s re-assessed
–Vital functions are returning to normal

22. Secondary Survey
Key Components
•History
•Physical examination: Head-to-toe
•“Tubes and fingers in every orifice”
•Complete neuro exam
•Special diagnostic tests
•Re-evaluation

23. Secondary Survey
History
AAllergies
MMedications
P Past illnesses
LLast meal
EEvents / Environment

24. Secondary Survey
Mechanisms of Injury

25. Secondary Survey
Head
Complete neurologic exam
GCS score determination
Comprehensive eye exam
Pitfalls
– Unconscious patient
–Periorbitaloedema
– Occluded auditory canal

26. Secondary Survey
Maxillofacial
• Bony crepitus/stability
• Palpable deformity
Pitfalls
–Potential airway obstruction
–Cribriformplate fracture
–Frequently missed injury

27. Secondary Survey
Cervical Spine
• Palpate for tenderness
• Complete motor/sensory exams
• Reflexes
• C-spine imaging
Pitfalls
– Altered LOC for any reason
– Other severe, painful injury

28. Secondary Survey
Neck (Soft tissues)
•Mechanism: Blunt vs
penetrating
•Symptoms: Airway
obstruction,
hoarseness
•Findings: Crepitus,
haematoma, stridor,
bruit
Pitfalls
Delayed
symptoms/signs
Progressive
airway
obstruction
Occult injuries

29. Secondary Survey
Chest
•Inspect
•Palpate
•Auscultation
•Percussion
•X-rays
Pitfalls
Elderly
Children

30. Secondary Survey
Abdomen
•Inspect, auscultate, palpate, and percuss
•Re-evaluate frequently
•Special studies
Pitfalls
–Hollow viscus and retroperitoneal injuries
–Excessive pelvic manipulation

31. Secondary Survey
PerineumContusions, haematomas,
lacerations, urethral blood
RectumSphincter tone, high-riding prostate,
pelvic fracture, rectal wall
integrity, blood
VaginaBlood, lacerations
PitfallsUrethral injury in women, pregnancy

32. Secondary Survey
Musculoskeletal: Extremities
•Contusion, deformity
•Pain
•Perfusion
•Peripheral neurovascular status
•X-rays as needed

33. Secondary Survey
Musculoskeletal: Pelvis
• Pain on palpation
•Symphysiswidth
• Leg length uneven
• X-rays as needed

34. Secondary Survey
Musculoskeletal
Pitfalls
–Potential blood loss
–Missed fractures
–Soft-tissue or ligamentous injury
–Occult compartment syndrome (especially with
altered LOC/hypotension)

35. Secondary Survey
NEUROLOGIC
Spine / Cord
• Complete motor and sensory exam
• Imaging as indicated
• Reflexes
C


36. Secondary Survey
Neurologic
Pitfalls
– Incomplete immobilisation
– Subtle in ICP with manipulation
– Rapid deterioration

37. Re-evaluation
Minimising Missed Injuries
• High index of suspicion
• Frequent re-evaluation and monitoring

38. Re-evaluation
Pain Management
Relief of pain/anxiety as appropriate
Administer intravenously
Careful monitoring is essential

39. PRIORITY PLAN
DEFINITIVE CARE
After identifying the patients injuries,
managing life threatening problems and
obtaining special studies

40. SUMMARY
1. Primary survey
2. Resuscitation
Adjuncts
3. Secondary survey
4. Definitive care