Chapter 3 - Initial assessment Flashcards
Steps for initial assessment
- preparation and triage
- Primary survey + corresponding interventions
- re-evaluation (including TRANSFER / HIGHER LEVEL CARE)
- Secondary survey + corresponding interventions
- Re-evaluation and post reusustiation care
- Definantive care of the transfer to an appropriate traume ceter
Considerations of a patient when first entering a trauma bay
- Universal precautions
- PPE
- Hazardous exposure
Across the room observation
evaluation can allow for rapid determination of a patients overall physiologic stability
Uncontrolled hemorrhage
- IF noted during across-the-room observations would go (<C> ABC)</C>
- leading cause in combat casulty death
MARCH Mnemonic (Battlefeilds)
Haemorrhage
<M>assive hemorrhage - control with the use of tourniquets - REPLACE Blood loss @ ratios of 1:1:1 (Platelets, red blood cells and plasma)
<a>irway - establish and maintain
<R>espiration - decompress suspected tension pneumothorax and support vent. oxygen required
<C>irculation - IO / IV
<H>ead injury / hypothermia - PREVENT and treat
</H></C></R></a></M>
Airway +
Alertness, Airway and CSpine
C spine
C-spine
- considered in all multi-trauma patients
- Need CT or radiography
- Older adult with blunt trauma
HOW?
1. Manual stabilisation - two hands holding the patient’s head and neck in alignment
2. Spinal motion restriction: semi rigid cervical collar
**minimum of 2 people for inline stabilisation to remove helemt
Alertness assessment
Alert - maintain an airway and talk to you
Verbal - responds to verbal stimuli; may need an adjunct to protect the tongue from obstructing the airway
Pain - may not be able to maintain airway ; may need adjunct or may need a definitive airway
Unresponsive - airway needed. pulse vs no pulse
Assessment of the airway
Open mouth
- assessment of obstructions or potential
- jaw thrust if any issues
*if Cpsine > 2 people to complete, one for manual stabilisation and second to do the jaw thrust
INSPECT: anything loses, foreign
LISTEN: any airway sounds (indicate partial obstruction)
PALPATINE: possible bone deformity / subcutaneous emphysema
DEFINITIVE AIRWAY :
1. C02 after 5-6 breaths assess for exhaled co2
2. Observe rise and fall
3. Auscultate for the absence of gruelling and presence of bilateral breathe sounds
What situations need a definitive airway ?
- GCS >8
- serve maxilllofacial fractures
- Apena
- facial burns
- largenal , neck or tracheal hematomia
- high risk aspertation
- high risk of detertaion of neurological satus
Can’t intubate?
Do 10-15L / minute NRB
Breathing / Ventilation - INSPECT
INSPECT Spontaneous, symmetrical, A+E (looking), skin colour. looking for any continuous, abrasions or deformities that may be a sign of underlying injury.
*open pneumo - sucking chest wound
- JVD + deviation of the tracea are late signs of a tension pneumo.
Breathing / Vent: Auscultate
resp. assessment
Breathing/vent - palpate
- the integrity of boney structures
- subcutaneous emphysema (sign of a pnenumo)
- soft tissue injury
What would happen if a patient couldn’t oxygenate their body?
Hypoxemia , resulting in anerobic metabilism and acidosis.
ETCO2 - what is good and what is bad?
IDEAL 35-45 mmHg
>50 mmHg = depressed ventiltaion
Ideal ventilation
10-12 breaths per minute, (one every 5 to 6 seconds).
What is the number one priority when “looking across the room”
<C> replaces A in ABC if massive hemorrhage
</C>
What would muffled heart sounds indicate?
pericardial tamponade
Number 1 sign of pericardial tamponade
muffled heart sounds
Causes (possible) of PEA
- a penetrating wound to the heart
- pericardial tamponade
- rupture of great vessels
- intra abdominal hemorrhage
What would a rapid and thready pulse indicate? in a hemorrhage
hypovolemia
What would an irregular pulse indicate in a hemorrhage?
potential cardiac dysfunction
Volume resuscitation
Traditionally, it isotonic crystalloid.
However, raising BP in this manner can dislodge clots the body has formed and promote further bleeding. it can also lead to dilutional coagulopathy.
NOW = red blood, platelets and plasma.
- this helps to optimise delivery of oxygen, acidosis is corrected and coagulopathy is prevented.
Disability
CT
ABC
BGL
Toxicology
Exposure
cut the clothes
- hypothermia, hypotension and acidosis are a potentially lethal combination in the injured patient.
- need to prevent heat loss
F - full set of vital signs and family presence
monitor effectiveness of resussitation
Primary assessment (A-G)
Airway, alertness and Cspine
Breathing & Ventillation
Circulation control or hemorrhage
Disability (Neurological status)
Exposure and environmental control
Full set of vital signs and family presence
Get the monitoring devices and give comfort <LMNOP></LMNOP>
G - Get monitoring devices and give comfort
LMNOP
L - lab studies ;
*lactic acid is a KEY indicator of tissue perfusion. High levels = hypoperfusion. >2 to 4 mmol/L are associated with poor outcomes
*An Abnormal base deficit may indicate poor perfusion and tissue hypoxia, which generates hydrogen ions and metabolic acidosis… Base deficit >6 = poor outcomes
M - monitor cardiac rate and rthym
N - Nasogestic + Orogstic considtation. Can help to optomise infataion of the lungs
P - pain assessment and management
Re-evaluation considerations
- portable radiography
- consider need for patient transfer - definitive / specalised
Secondary survey steps (H-J)
Head to toe
Inspect posterior surface
Just keep reevaluating
History - MIST
Mechanism of injury
injuries
signs and symptoms
treatment
History - SAMPLE
symptoms
allergies
medications
past medical hx
last oral intake. output. period
event and environmental factors
Others factors with history
Age
Burns
Preg.
Disabilities
Head to toe
Use of eFAST (resus)
Head to toe - “LACE” for each section
LACE
Lacertaions
Abratuions / avulsios
cotutaions
Edema, Ecchmosis
Head to toe
- general appearance
- eyes; diplopia can mean entrapment of cranial nerves 3, 4 and 6. REMOVE contacts
- Ears; Do NOT pack ear (in case of CSF leak). check for glucose *approx 2/3 of the BGL. test for B2 -transferrin.
- neck and spine
- chest
- abdomen. flanks
- pelvis/perineum
- extremities
URINE OUTPUT? WHY
reflects end-organ perfusion and is considered a sensitive indicator of the patient’s volume status
IDC
Secondary survey - rectal tone
Rectal tone can indicate spinal cord injury. A DRE is performed by a physician
- the presence of rectal tone or the absence
- the presence of a high-riding prostate
Secondary survey - Just keep reevaluating
Major componenets (VIPP)
-Vital signs
-Injuries sustained and interventions performed
- Primary survey
- Level of pain
Secondary survey - what to consider for other tests/treatments
CT
Wound care
Splints
Traction
TETANUS
ABs
