Chapter 1
Initial Assessment
and
management
OBJECTIVES
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Identify the correct sequence of priorities in assessing the
multiply injured patient
Apply the primary and secondary evaluation surveys to
assessment of the multiply injured patient
Apply guidelines and techniques in the initial resuscitative
and definitive--case phase
Anticipate the pitfalls associated with the initial assessment
and management ( minimize their impact )
Conduct an initial assessment survey on a simulated
multiply injured patient
CONCEPTS OF INITIAL
ASSESSMENT
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Preparation
Triage
Primary survey ( ABCDEs )
Resuscitation
Adjuncts to primary survey and resuscitation
Secondary survey ( head-to-toe evaluation and history )
Adjuncts to the secondary survey
Continued postresuscitation monitoring and reevaluation
Definitive care
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Repeat primary and secondary survey when finding
any deterioration in the patient’s status
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Primary survey and resuscitation are done
simultaneously
PREPARATION
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Prehospital
– Airway maintenance
– Control of external bleeding & shock
– Immobilization of the patient
– Communication with receiving hospital & immediate
transport to the closest, appropriate facility
– History taking ( include events )
Inhospital
– Advanced planning ( especially massive casualty )
– Equipment & personnel
– Communicable disease protection
– Transfer agreements
TRIAGE
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Sorting of patients according to ABCs and available
resources
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Triages is the responsibility of prehospital
personnel
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Not exceed the ability of the facility ==> treat life -threatening patient first
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Exceed the capacity of the facility ( mass casualties )
==> Treat the greatest chance of survival, with the less
time, less equipment & less personnel
PRIMARY SURVEY
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Adult / Pediatric priorities same
Identified the life-threatening conditions and simultaneously
managed
– A: Airway maintenance with cervical spine protection
– B: Breathing and ventilation
– C: Circulation with hemorrhage control
– D: Disability ( Neurologic status )
– E: Exposure / Environmental control: Undress the patient &
prevent hypothermia
PRIMARY SURVEY
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Airway Maintenance with Cervical Spine Protection
– Oral foreign bodies, facial, mandibular, or tracheal / laryngeal
fractures may result in airway obstruction
– Assume C-spine injury
 Multisystem trauma
 Altered level of consciousness
 Blunt injury above clavicle
– Pitfalls:
 Difficult airway
 Obesity: surgical airway cannot be performed smoothly
 laryngeal fracture or incomplete upper airway transection
PRIMARY SURVEY
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Breathing and Ventilation
– Airway patency  adequate breathing & ventilation
– injury that may acutely impair ventilation
 1. Tension pneumothorax
 2. Flail chest with pulmonary contusion
 3. Massive hemothorax
 4. Open pneumothorax
above problems need to be identified in the primary survey
and managed
– Pitfall: Differentiation of ventilation problems from airway
compromise may be difficult
PRIMARY SURVEY
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Circulation with Hemorrhage Control
– Assess blood volume and cardiac output
 level of consciousness
 skin color
 pulse
– Bleeding control: direct manual pressure on the wound
– Pitfall:
 The response of elderly, children, athletes and others with
chronic medical conditions to hypovolemia is different
from normal people
PRIMARY SURVEY
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Disability ( Neurologic Evaluation )
– Level of consciousness
 A. Alert
 V. Response to voice
 P. Response to pain
 U. Unresponsive
– Pupils
– Pitfall:
 Lucid interval ( talk and die ) : EDH, frequent neurologic
reevaluation can minimize this problem
PRIMARY SURVEY
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Exposure/Environmental Control
– Undress patient completely
– Protect from hypothermia
– Pitfall:
 early control of the hemorrhage is the best method to
keep body temperature( early surgical intervention)
RESUSCITATION
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Protect/Secure airway & protect C-spine
Breathing/Ventilation/Oxygenation
Vigorous shock therapy
– At last two large - caliber IV line
– Crystalloid solution ( Ringer’s lactate 2~3 litter)
– Type-specific blood
– surgical intervention
Protect from Hypothermia : 39oC warm IV fluid
Urinary/gastric catheters unless contraindication
ADJUNCTS TO PRIMARY SURVEY AND
RESUSCITATION
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Monitor:
– Ventilatory rate and ABGs/ end-tidal CO2
Pitfalls: Combative patients often extubate or bite
endotracheal tube
– Pulse oximetry
– ECG & BP monitor
– Temperature
– urine output
X-RAY AND DIAGNOSTIC STUDIES
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Can’t delay or interrupt the primary survey and resuscitation
Trauma series ( portable X-ray ): CXR, C-spine/ lateral view,
pelvic AP view
A negative or inadequate c-spine x-ray can’t exclude cervical
spinal injury
Sonography / DPL
Pitfalls: obesity ( Sonography and DPL are difficult )
CONSIDER NEED FOR PATIENT
TRANSFER
Referring doctor -to -receiving doctor communication
Closest appropriate hospital
BEFORE SECONDARY SURVEY
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Complete primary survey
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Establish resuscitation
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Normalization of vital functions
SECONDARY SURVEY
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History taking
Complete neurologic exam.
Head-to-toe evaluation
Roentgenograms
Special procedure
Tubes and fingers in every orifice
Re-evaluation
SECONDARY SURVEY
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History
– A. Allergies
– M. Medications currently used
– P. Past illness / pregnancy
– L. Last meal
– E. Events / Environment related to injury
HISTORY
Mechanisms of injury
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Blunt
– Automobile collisions
 Seat belt usage
 Steering wheel deformation
 Direction of impact
 Ejection of passenger form the vehicle
Burns and Cold injury
– Inhalation injury and CO. intoxication in fire field
Hazardous environment
Penetrate
– Anatomy factors
– Energy transfer factor
 Velocity and caliber of bullet
 Trajectory
 Distance
SECONDARY SURVEY
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Physical Examination
– Head
– entire scalp and head
– eye:
 pupil
 visual acuity
 EOM
 foreign body ( soft contact lens….)
– Pitfalls:
Severe facial swelling or unconsciousness p’t still
need eye exam.
SECONDARY SURVEY
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Physical Examination
– Maxillofacial
 No airway obstruction or massive bleeding ==> treat later
 Midfacial fracture ==> R/O cribriform plate fracture
Pitfalls:
Some facial bone fracture is difficulty identified early ==>
reassessment is crucial
SECONDARY SURVEY
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Physical Examination
– C-spine and Neck
 Maintain immobilization
 Complete evaluation
 Complete radiology study
 Cautions helmet removed
 Penetrating injury: Not be explored in the emergency
department; explored & treat in the operative room
Pitfalls:
Blunt injury to Neck: Carotid artery intima injury or
dissection ( delay onset )
Immobilization ==> decubitus ulcer
SECONDARY SURVEY
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Physical Examination
– Chest
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Pitfalls:
– Poor tolerance to minor pulmonary trauma in
elderly patients
– A normal CXR can’t role out chest injury in
children
SECONDARY SURVEY
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Physical Examination
– Abdomen
 Identify a surgical abdomen is more important than doing a
specific diagnosis ==> early consult surgeon
 Close observation & frequent reevaluation of the abdomen
 DPL, sonography, abdomen CT
Pitfalls:
– Excessive manipulation of the pelvis should be avoid
==> just do pelvic x-ray
– Retroperitoneal organs ( pancreatic & hollow organ )
are very difficult to identify
SECONDARY SURVEY
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Physical Examination
– Perineum / rectum / vagina
 Perineum:
Contusions, hematomas, urethral
bleeding…….
 Rectum:
Sphincter tone, high riding prostate,
blood…..
 Vagina:
Blood, laceration
Pitfalls:
Female urethral injury is difficult to detect
SECONDARY SURVEY
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Physical Examination
– Musculoskeletal
 Extremities / pelvis: Contusion, deformity, pain
crepitation, abnormal
movement
 Vascular: Assess all peripheral pulses
 Spine: Physical findings, mechanism of injury
SECONDARY SURVEY
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Physical Examination
– Neurologic
 Determine GCS score
 Re-evaluate pupils
 Sensory / motor evaluation
 Maintain immobilization
 Prevent secondary CNS injury ( keep stable vital signs,
avoid increased ICP and treat IICP )
 Early neurosurgical consultation
Pitfalls:
Intubation should be done expeditiously and as smoothly
as possible ( Intubation will increase ICP )
REEVALUATION
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New findings / deterioration / improvement
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High index of suspicion ==> early diagnosis &
management
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Continuous monitoring
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Pain relief
DEFINITIVE CARE
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Trauma center
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Closest appropriate hospital
RECORDS AND LEGAL
CONSIDERATIONAS
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Records: Concise, chronologic documentation
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Consent for treatment
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Forensic Evidence: preserve the evidence
SUMMARY
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Initial assessment & management of multiply injured
patient
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Primary survey ( ABCDEs )
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Resuscitation & monitor ( life-threatening problems )
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Secondary survey ( head-to-toe, history )
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Definitive care ( early consultation, surgical intervention
or transport )