Trauma Trauma assessment and assessment and

managementmanagement

AFAF

Primary surveyPrimary survey ABC’sABC’s - Identified and - Identified and simultaneoussimultaneous

managementmanagement of the life-threatening of the life-threatening conditionsconditions

• A – Airway management with C-spine controlA – Airway management with C-spine control• B – BreathingB – Breathing• C – Circulation & hemorrhage controlC – Circulation & hemorrhage control• D – Disability: neurologic statusD – Disability: neurologic status• E – Exposure: completely undress the patientE – Exposure: completely undress the patient

Initial trauma managementInitial trauma management

Airway obstructionAirway obstruction

AwarenessAwareness• Altered level of consciousness Altered level of consciousness

TT –trauma –trauma AA – alcohol – alcoholII – infection – infection EE - epilepsy - epilepsyPP – psych – psych II - insulin - insulinPP – poison – poison OO - opiates - opiatesS S – shock – shock UU – urea/metabolic – urea/metabolic

• Head, neck, facial traumaHead, neck, facial trauma

Initial trauma management

Airway obstructionAirway obstructionRecognitionRecognition• LookLook

– Agitation – hypoxiaAgitation – hypoxia– Obtundation – hypercarbiaObtundation – hypercarbia– Facial, mandibular, tracheal/laryngeal fracturesFacial, mandibular, tracheal/laryngeal fractures

• ListenListen– Snoring gurgling sounds – pharynx occlusionSnoring gurgling sounds – pharynx occlusion– Hoarseness – laryngeal obstruction / traumaHoarseness – laryngeal obstruction / trauma

• FeelFeel– Air movementAir movement

Initial trauma management

Airway obstructionAirway obstruction

Management Management The purpose:The purpose:• Maintain an intact airwayMaintain an intact airway• Protect the airway in jeopardyProtect the airway in jeopardy• Provide the airway when not Provide the airway when not

availableavailable

Initial trauma management

Airway managementAirway management

• Chin lift or jaw thrust maneuversChin lift or jaw thrust maneuvers• Inspection for foreign bodies Inspection for foreign bodies • Suction – remove blood & secretionsSuction – remove blood & secretions• Nasopharyngeal airwayNasopharyngeal airway• AMBU ventilationAMBU ventilation• Endotracheal intubation (oral / Endotracheal intubation (oral /

nasal)nasal)

Initial trauma management

Surgical airwaysSurgical airways IndicationsIndicationsInability to intubate the tracheaInability to intubate the tracheaContraindicationsContraindications• Severe maxillo-facial injuriesSevere maxillo-facial injuries• Larynx fractureLarynx fractureNeedle Needle cricothyroidotomy for children cricothyroidotomy for children

under 12y for 30-45 minunder 12y for 30-45 minSurgical cSurgical cricothyroidotomyricothyroidotomy

Initial trauma management

C-spine protectionC-spine protection

• Prevention of excessive Prevention of excessive movementmovement

• HyperflexionHyperflexion• HyperextensionHyperextension• RotationRotation

Initial trauma management

C-spine protectionC-spine protection

• Suspicion of C-spine injury Suspicion of C-spine injury • Trauma historyTrauma history• Severe face & head traumaSevere face & head trauma• Injuries above the clavicleInjuries above the clavicle

➣➣ Neurologic examination does not Neurologic examination does not rule outrule out

C-spine injuryC-spine injury

Initial trauma management

C-spine X-RayC-spine X-Ray

• C1 – C7 – D1C1 – C7 – D1• Lateral c-spine film does not exclude Lateral c-spine film does not exclude

all c-spine injuriesall c-spine injuries• Flexion & extension with orthopedist Flexion & extension with orthopedist

presencepresence

Initial trauma management

C-spine immobilizationC-spine immobilization

TemporarilyTemporarily• Philadelphia collarPhiladelphia collar• Tora bookTora book• Manual in-lineManual in-line

Initial trauma management

B – BreathingB – Breathing • Adequate gases exchange: O2 Adequate gases exchange: O2

transfer & CO2 eliminationtransfer & CO2 elimination• Involves adequate function of the Involves adequate function of the

lungs, chest wall and diaphragmlungs, chest wall and diaphragm• Expose the patient chest Expose the patient chest • AuscultationAuscultation• PercussionPercussion• Visual inspection & palpationVisual inspection & palpation

Initial trauma management

Ventilation ImpairVentilation Impair•Tension pneumothoraxTension pneumothorax•Open pneumothoraxOpen pneumothorax•Flail chest with pulmonary Flail chest with pulmonary

contusioncontusion• HemothoraxHemothorax• Simple pneumothoraxSimple pneumothorax• Fractured ribsFractured ribs• Pulmonary contusion Pulmonary contusion

Initial trauma management

C – Circulation with C – Circulation with Hemorrhage controlHemorrhage control

Blood volume & Cardiac outputBlood volume & Cardiac output • Level of consciousnessLevel of consciousness• Pulse signs of volemia: rate, quality, Pulse signs of volemia: rate, quality,

regularity regularity •Radial > 80Radial > 80•Femoral > 80 Femoral > 80 •Carotid > 60Carotid > 60

• Skin colorSkin color• Capillary refill > 2 secCapillary refill > 2 sec

Initial trauma management

Bleeding Bleeding External severe hemorrhage identified External severe hemorrhage identified

& controlled in the primary survey& controlled in the primary survey• Direct pressureDirect pressure• Pneumatic splints and MASTPneumatic splints and MAST• Not use by tourniquetsNot use by tourniquets• Operative repair of the major intra-Operative repair of the major intra-

thoracic or intra-abdominal bleedingthoracic or intra-abdominal bleeding• Hypovolemia resulting from # of femur Hypovolemia resulting from # of femur

and / or pelvisand / or pelvis• Penetrating arterial or venous injuries Penetrating arterial or venous injuries

Initial trauma management

D – DisabilityD – DisabilityBriefBrief neurologic examination neurologic examination• AA – Alert – Alert• V V – Responds to Vocal stimuli– Responds to Vocal stimuli• PP – Responds to Painful stimuli – Responds to Painful stimuli• UU – Unresponsive – Unresponsive• Pupillary size & reactionPupillary size & reaction ➣➣ More detailed evaluation - during More detailed evaluation - during

the the secondary surveysecondary survey

Initial trauma management

E – Exposure / E – Exposure / Environmental controlEnvironmental control

• UndressingUndressing• Protection from hypothermiaProtection from hypothermia

Initial trauma management

Secondary surveySecondary survey

• ““Tube and fingers in every orifice”Tube and fingers in every orifice”• Head to toe evaluationHead to toe evaluation• Vital signs assessmentVital signs assessment• Complete neurologic examination Complete neurologic examination

(CGS score)(CGS score)• X-raysX-rays• Laboratory studiesLaboratory studies

Initial trauma management

HistoryHistory• AA Allergies Allergies• MM Medications Medications• P P Past illness Past illness• L L Last meal Last meal• EE Events/ environment related to Events/ environment related to

the injurythe injury

• Mechanism of injuryMechanism of injury• Types of injuryTypes of injury

Initial trauma management

Factors determine severity Factors determine severity of injuryof injury

• Region of the bodyRegion of the body• Organs of the proximityOrgans of the proximity• Velocity of the missileVelocity of the missile• CaliberCaliber• TrajectoryTrajectory• DistanceDistance

Initial trauma management

Physical examinationPhysical examinationHeadHead• Scalp examinationScalp examination• EyesEyes

•Visual acuityVisual acuity•Pupillary sizePupillary size•Hemorrhages to the conjunctiva and Hemorrhages to the conjunctiva and fundifundi

•Penetrating injuryPenetrating injury•Contact lenses - removeContact lenses - remove•Lens dislocationLens dislocation

nInitial trauma management

Re-evaluationRe-evaluation

• New findingsNew findings• Discover deterioration of previous Discover deterioration of previous

signssigns• Relief of pain - opioidsRelief of pain - opioids

•Respiratory depressionRespiratory depression•Mask neurologic signsMask neurologic signs

Initial trauma management

MonitoringMonitoring

• Vital signsVital signs• Urinary outputUrinary output• ABGABG• ECGECG• Pulse oxymetryPulse oxymetry• End tidal CO2End tidal CO2

Initial trauma management

Records Records

• Physician attending & consultingPhysician attending & consulting• NurseNurse• Chronologic reportChronologic report• MedicationsMedications

Initial trauma management