Initial Assessment and

Management

(Primary Survey assessment)

Departemen Anestesiologi dan Reanimasi

FK-USU/RSUP Haji Adam Malik, Medan

Objectives

� Indentify Management Priorities.

� Apply principles of primary and secondary survey.

� Institute appropriate resuscitation and � Institute appropriate resuscitation and monitoring.

� Recognize value of patient’s history and biomechanics of injury.

� Anticipate pitfalls.

Concepts of Initial Assessment

� Rapid Primary Survey

� Resuscitation

� Adjuncts to primary survey /resuscitation

Detailed secondary survey � Detailed secondary survey

� Adjuncts to secondary survey

� Reevaluation

� Definitive care

Initial Assessment

Primary survey and

resuscitation of vital

functions are done

simultaneously –

a team approach

Preparation

Prehospital System

� Transport guidelines /protocols

� On-line medical direction � On-line medical direction

� Mobilization of resources

� Periodic review of care

� Closest appropriate facility

Preparation

Inhospital

� Preplanning essential

� Equipment, personnel, services� Equipment, personnel, services

� Standard precautions

� Transfer agreement

Standard Precautions

• Cap

• Gown

• Gloves

• Mask

• Shoe covers

• Goggles/face

• Shields

Triage

� Sorting of patients according to :

• ABCDEs

• Available resources • Available resources

� Multiple casualties

� Mass casualties

Primary Survey

� Adult, children, pregnant women –

Priorities are the same !

A Airway with c-spine protection

B Breathing

C Circulation with hemorrhage control

D Disability

E Exposure/Environment

Special Considerations

Trauma in the Elderly

� 5th leading cause of death

↓Physiologic reserve � ↓Physiologic reserve

� Comorbidities : Diseases/medications

� Outcome depends on early, aggressive

care

Primary Survey

� C-spine injury

� Pitfalls

Establish Patent Airway

• Equipment failure

• Inability to intubate

• Occult airway injury

• Progressive loss of airway

Caution

Primary Survey

Suspect C-Spine Injury

�Spinal protection

�C-spine X-ray when appropriate�C-spine X-ray when appropriate

Primary Survey

Breathing

� Assess

� Oxygenate

� Ventilate

Pitfalls

• Airway vs ventilation problem ?

• Latrogenic pneumothorax

/tension pneumothorax

Primary Survey

Assessment of Organ Perfusion

� Level of consciousness

� Skin color and temperature� Skin color and temperature

� Pulse rate and character

Primary Survey

Circulatory Management

� Control hemorrhage

� Restore volume

� Reassess

Pitfalls

Elderly Children

Athletes MedicationCaution

Primary Survey

Disability

� Baseline neurologic evaluation

• GCS scoring • GCS scoring

• Pupillary response

Observe for neurologic

deterioration Caution

Primary Survey

Exposure / Environment

• Completely undress the patient

Prevent hypothermiaCaution

Resuscitation

� Protect and secure airway

� Ventilate and oxygenate

� Stop the bleeding� Stop the bleeding

� Vigorous shock therapy

� Protect from hypothermia

Adjuncts to Primary Survey

Vital sign

ECG ABGs

Urinary Adjuncts Pulse

₂

Urinary Adjuncts Pulse

Output oximeter

and CO₂

Urinary/gastric catheters

unless contraindicated

Adjuncts to Primary Survey

Diagnostic Tools

• Chest and pelvic x-ray

• DPL

• Ultrasound• Ultrasound

Adjuncts to Primary Survey

Consider Early Transfer

� Do not delay transfer for diagnostic tests

� Use time before transfer for resuscitation

Reevaluate

Proceed to Secondary Survey After :

� Primary survey completed

� ABCD Es are reassessed

Vital functions are returning to � Vital functions are returning to

normal

Secondary Survey

The complete

history and history and

physical

examination

Secondary Survey

Key Components

� History

� Physical examination : Head-to-toe

� “Tubes and finger in every orifice”� “Tubes and finger in every orifice”

� Complete neuro exam

� Special diagnostic tests

� Reevaluation

Secondary Survey

History

A Allergies

M MedicationsM Medications

P Past Illnesses

L Last meal

E Events/Environment

Secondary Survey

Mechanisms of Injury

Secondary Survey

Head

� Complete neurologic examination

� GCS score determination

� Comprehensive eye/ear exam

Pitfalls

� Unconscious patient

� Periorbital edema

� Occluded auditory canal

Secondary Survey

Maxillofacial

� Bony crepitus/stability

� Palpable deformity� Palpable deformity

Pitfalls

• Potential airway obstruction

• Cribriform plate fracture

• Frequently missed injury

Secondary Survey

Cervical Spine

� Palpate for

tenderness

� Pitfalls

• Altered LOC for

� Complete motor/

sensory exams

� Reflexes

� C-spine imaging

any reason

• Other severe ,

painful injury

Secondary Survey

Neck (soft tissues)

� Mechanism : Blunt

vs penetrating

� Symptoms : Airway

� Pitfalls

• Delayed symptoms� Symptoms : Airway

obstruction ,

hoarseness

� Findings :Crepitus hematoma ,stridor

bruit

and signs

• Progressive airway

obstruction

• Occult injuries

Secondary Survey

Chest

� Inspect

� Palpate� Pitfalls

• Elderly Palpate

� Percuss

� Auscultate

� X-ray

• Elderly

• Children

Secondary Survey

Abdominal Evaluation

Blunt trauma Penetrating trauma

Secondary Survey

Abdomen

� Inspect, auscultate, palpate, and percuss

� Reevaluate frequently

� Special studies

� Pitfalls

• Hollow viscus and retroperitoneal injuries

• Excessive pelvic manipulation

Secondary Survey

Perineum

Rectum

Contusions, hematomas,

lacerations, urethral blood

Sphincter tone , high –riding

prostate pelvic fracture,

rectal wall integrity, blood

Vagina

Pitfalls

rectal wall integrity, blood

Blood lacerations

Urethral injury in women,

pregnancy

Secondary Survey

Musculoskeletal : Extreminities

� Contusion , deformity

� Pain Pain

� Perfusion

� Peripheral neurovascular status

� X- rays as needed

Secondary Survey

Musculoskeletal : Pelvis

� Pain on palpation

� Symphysis width ↑� Symphysis width ↑

� Leg length unequal

� Instability

� X-rays as needed

Secondary Survey

Musculoskeletal

� Pitfalls

• Potential blood loos

• Missed fractures

• Soft-tissue or ligamentous injury

• Occult compartement syndrome (especially

with altered LOC / hypotension)

Secondary Survey

Neurologic

Spine / Cord

� Complete motor

CNS

� Frequent reevaluation� Complete motor

and sensory exams

� Imaging as

indicated

� Reflexes

Early neurosurgical consultation

� Frequent reevaluation

� Prefent secondary

brain injury

Adjuncts to Secondary Survey

� Special diagnostic test as indicated

� Pitfalls

• Patient deterioration • Patient deterioration

• Delay of transfer

Secondary Survey

Neurologic

� Pitfalls

• Incomplete immobilization• Incomplete immobilization

• Suble ↑ in ICP with manipulation

• Rapid deterioration

Reevaluation

Minimizing Missed Injuries

� High index of suspicion

� Frequent reeveluation and monitoring

Reevaluation

Pain Management

� Relief of pain /anxiety as appropriate

Administer intravenously� Administer intravenously

� Careful monitoring is essential

Definitive Care

Local Facility

??

Transfer agreementsTransfer agreements

?? Local resources ??

??

Trauma Specialty

Center Facility

Record , Legal Considerations

� Concise, chronologic documentation

� Consent for treatment

Forensic evidence� Forensic evidence

Questions

Summary

� Primary Survey

� Resuscitation

AdjunctsAdjuncts

• Secondary Survey

Adjuncts

• Definitive care