Specialists Without Borders
Seminar in Surgery
Rwanda, September 2010
Early Assessment and
Management of Trauma
Frank Stening
Australia
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
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•
•
•
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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.
2.
3.
4.
5.
6.
7.
Preparation
Triage
Primary survey (ABC’s)
Resuscitation
Secondary survey (Head-to-toe)
Continued post resuscitation monitoring
and re-evaluation
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
B
C
D
E
Airway with c-spine protection
Breathing
Circulation with haemorrhage control
Disability
Exposure / Environment
EMST
Special Groups to Consider
• Children
• Elderly
• Pregnant women
Primary Survey
Establish Patent Airway
 Beware C-spine injury
 Pitfalls
Caution
 Equipment failure
 Inability to intubate
 Occult airway injury
 Progressive loss of airway
Primary Survey
Breathing
• Oxygenate
• Assess
• Ventilate
Caution
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
Primary Survey
Circulatory Management
• Control haemorrhage
• Restore volume
• Reassess
Caution
Pitfalls
 Elderly  Children
 Athletes  Medications
Primary Survey
Disability
• Baseline neurologic evaluation
– GCS scoring
– Pupillary response
Caution
Observe for
neurologic
deterioration
Primary Survey
Exposure / Environment
• Completely undress the patient
Caution
Prevent hypothermia
Adjuncts to Primary Survey
Vital signs
ECG
Urinary
output
ABGs
Adjuncts
Urinary/gastric
catheters unless
contraindicated
Pulse
oximeter
and CO2
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
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History
Physical examination: Head-to-toe
“Tubes and fingers in every orifice”
Complete neuro exam
Special diagnostic tests
Re-evaluation
Secondary Survey
History
A Allergies
M Medications
P Past illnesses
L Last meal
E Events / Environment
Secondary Survey
Mechanisms of Injury
Secondary Survey
Head
Complete 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
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–
Altered LOC for any reason
Other severe, painful injury
Secondary Survey
Neck (Soft tissues)
• Mechanism: Blunt vs Pitfalls
 Delayed
penetrating
symptoms/signs
• Symptoms: Airway
 Progressive
obstruction,
airway
hoarseness
obstruction
• Findings: Crepitus,
 Occult injuries
haematoma, stridor,
bruit
Secondary Survey
Chest
•
•
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•
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Inspect
Palpate
Auscultation
Percussion
X-rays
Pitfalls
 Elderly
 Children
Secondary Survey
Abdomen
• Inspect, auscultate, palpate, and percuss
• Re-evaluate frequently
• Special studies
Pitfalls
– Hollow viscus and retroperitoneal injuries
– Excessive pelvic manipulation
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
Secondary Survey
Musculoskeletal: Extremities
•
•
•
•
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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
Musculoskeletal
Pitfalls
– 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
Secondary Survey
Neurologic
Pitfalls
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–
–
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