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