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Early Assessment and Management of Trauma
Frank SteningAustralia
Specialists Without BordersSeminar in Surgery
Rwanda, September 2010
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
KEY QUESTION
How do we minimise MISSED injuries ?
How do we improve survival rates ?
( Who needs transfer When do they need transfer )
Concepts of Initial Assessment
• Rapid primary survey• Resuscitation• Adjuncts to primary survey/resuscitation• Detailed secondary survey• Adjuncts to secondary survey• Re-evaluation• Definitive care
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
Initial Assessment
Primary survey and resuscitation of vital functions are done simultaneously = a team approach
Triage
Sorting of patients according to:ABCDEs Available resources
Multiple casualties Mass casualties
A quick, simple way to assess the patient in 10 seconds
Identify yourself Ask the patient his / her name Ask the patient what happened
... an appropriate response suggests:
Patent airway Sufficient air reserve to permit speech Clear sensorium
Now proceed to a rapid primarysurvey
Primary Survey
• Adults, paediatric, pregnant women Priorities are the same!
A Airway with c-spine protectionB BreathingC Circulation with haemorrhage controlD DisabilityE Exposure / Environment
EMST
Special Groups to Consider
• Children• Elderly• Pregnant women
Primary Survey
Establish Patent Airway
Beware C-spine injuryPitfalls
Equipment failure Inability to intubateOccult airway injuryProgressive loss of airway
Caution
Breathing• Oxygenate• Assess• Ventilate
Caution
Primary Survey
Pitfalls Airway vs ventilation
problem? Iatrogenic pneumothorax/
tension pneumothorax
Primary Survey
Assessment of Organ Perfusion
Level of consciousness Skin colour and temperature Pulse rate and character
Circulatory Management• Control haemorrhage• Restore volume• Reassess
Caution
Primary Survey
PitfallsElderlyAthletes
ChildrenMedications
Disability• Baseline neurologic evaluation– GCS scoring– Pupillary response
Caution
Primary Survey
Observe for neurologic
deterioration
Exposure / Environment• Completely undress the patient
Caution
Primary Survey
Prevent hypothermia
Adjuncts to Primary Survey
Vital signs
Adjuncts
ABGs
Pulse oximeterand CO2
Urinary/gastric catheters unless contraindicated
Urinary output
ECG
PRIORITY PLAN
X-RAYS (should be used judiciously and should not delay resuscitation)
Lateral cervical spine AP chest AP pelvis
Adjuncts to Primary Survey
Diagnostic Tools• Chest and pelvic x-rays• DPL• Ultrasound
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
Secondary Survey
Key Components• History• Physical examination: Head-to-toe• “Tubes and fingers in every orifice”• Complete neuro exam• Special diagnostic tests• Re-evaluation
Secondary Survey
HistoryA Allergies
M Medications
P Past illnesses
L Last meal
E Events / Environment
Secondary Survey
Mechanisms of Injury
Secondary Survey
HeadComplete neurologic exam GCS score determination Comprehensive eye exam Pitfalls– Unconscious patient– Periorbitaloedema– Occluded auditory canal
Secondary Survey
Maxillofacial• Bony crepitus/stability• Palpable deformity Pitfalls– Potential airway obstruction– Cribriformplate fracture– Frequently missed injury
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
Secondary Survey
Neck (Soft tissues)• Mechanism: Blunt vs
penetrating• Symptoms: Airway
obstruction, hoarseness• Findings: Crepitus,
haematoma, stridor, bruit
PitfallsDelayed
symptoms/signsProgressive
airway obstruction
Occult injuries
Secondary Survey
Chest• Inspect• Palpate• Auscultation• Percussion• X-rays
PitfallsElderlyChildren
Secondary Survey
Abdomen• Inspect, auscultate, palpate, and percuss• Re-evaluate frequently• Special studiesPitfalls– Hollow viscus and retroperitoneal injuries– Excessive pelvic manipulation
Secondary Survey
PerineumContusions, haematomas, lacerations, urethral bloodRectumSphincter tone, high-riding prostate, pelvic fracture, rectal wall integrity, bloodVaginaBlood, lacerationsPitfallsUrethral injury in women, pregnancy
Secondary Survey
Musculoskeletal: Extremities• Contusion, deformity• Pain• Perfusion• Peripheral neurovascular status• X-rays as needed
Secondary Survey
Musculoskeletal: Pelvis
• Pain on palpation• Symphysiswidth • Leg length uneven• X-rays as needed
Secondary Survey
MusculoskeletalPitfalls– Potential blood loss– Missed fractures– Soft-tissue or ligamentous injury– Occult compartment syndrome (especially with
altered LOC/hypotension)
Secondary Survey
NEUROLOGIC Spine / Cord • Complete motor and sensory exam• Imaging as indicated• Reflexes
CNS
Frequent re-evaluation
Prevent secondarybrain injury
Secondary Survey
Neurologic Pitfalls– Incomplete immobilisation– Subtle in ICP with manipulation– Rapid deterioration
Re-evaluation
Minimising Missed Injuries• High index of suspicion• Frequent re-evaluation and monitoring
Re-evaluation
Pain Management Relief of pain/anxiety as appropriate Administer intravenously Careful monitoring is essential
PRIORITY PLAN
DEFINITIVE CARE
After identifying the patients injuries, managing life threatening problems and obtaining special studies
SUMMARY
1. Primary survey 2. Resuscitation Adjuncts 3. Secondary survey 4. Definitive care