Initial assessment and management Flashcards
Components of the initial assessment
Preparation
Triage
Primary survey + Simultaneous resuscitation
Adjuncts
Consider transfer
Re-evaluation
Secondary survey
Re-evaluation
Definitive care
Priorities in the prehospital phase
Airway maintenance
Breathing support
Control of bleeding and shock
Immobilisation
Immediate transfer to closest appropriate facility
ATMIST handover
Age
Time of event
Mechanism of injury
Injuries head to toe
(Vital) Signs and symptoms
Treatments given / Time of arrival
Hospital phase
Resuscitation area
Airway equipment (organised, tested, accessible)
Warmed IV crystalloids (via Belmont)
Monitoring devices
Protocol for requesting additional assistance
Transfer agreements
PPE required for major trauma
Face mask
Eye protection / visor
Water resistant gown
Gloves
Primary survey
Airway and C spine immobilisation
Breathing
Circulation
Disability
Exposure / Environment
Goal of primary survey
Identify and treat life threatening injuries in a prioritised manner
10 second assessment
Introduce yourself
Ask their name
Ask them what happened
Airway management
Clearing the airway
Suction
Oxygen
Securing airway
Maintain C spine
If in doubt regarding patient airway - intubate
Requirements for adequate breathing
Adequate function of:
- Lungs
- Chest wall
- Diaphragm
Breathing management
JVP
Trachea position
Chest wall movement
RR
Air entry
O2 saturation
Considerations for circulation / perfusion assessment
Blood volume
Cardiac output
Bleeding
Signs of reduced perfusion
Reduced GCS
Skin colour / temp
Pulse rate and character
Disability assessment
GCS
Pupil size and reactivity
Lateralising signs
Spinal cord injury
Causes of reduced / reducing GCS
Cerebral injury
Reduced cerebral perfusion
If change in GCS - re-assess from ABCDE
Exposure assessment
Expose patient fully and keep warm with blankets
Temperature
Management of hypothermia
Warm blankets
Warm fluids
Control haemorrhage
Adjuncts to primary survey
ECG
Obs
ABG
Urine output
Imaging
Imaging adjuncts to primary survey
XR - chest or pelvis only
CT
FAST
eFAST
Diagnostic peritoneal lavage
When to consider need to transfer patient
Early
When pt needs exceed facility capabilities
Don’t delay transfer for diagnostic tests or secondary survey
When to complete secondary survey
After primary survey complete and patient resuscitation efforts are normalising the patient
Secondary survey
History
Head to toe examination
Complete neuro exam
Diagnostic tests including imaging
Re-evaluation
AMPLE history
Allergies
Medications
PMH / Pregnancy test
Last meal
Events
Categories of Mechanism of Injury
Blunt trauma
Penetrating trauma
Thermal injuries
Injuries from hazardous environments
Suspected injury patterns from RTC frontal impact
C spine fracture
Flail chest
Myocardial contusion
Pneumothorax
Traumatic aortic disruption
Spleen / liver injury
Suspected injury patterns from RTC side impact
Head injury
C spine fracture
Flail chest
Pneumothorax
Traumatic aortic disruption
Spleen / liver / kidney injury depending on side
Suspected injury patterns from RTC rear impact
C spine injury
HI
Soft tissue neck injury
Suspected injury patterns from RTC ejection from vehicle
Greater risk for all injury mechanisms
No specific injury patterns
Suspected injury patterns from car vs pedestrian
HI
Traumatic aortic disruption
Abdo visceral injuries
Fractured lower extremities / pelvis
Suspected injury patterns from fall from height
HI
Axial spine injury
Abdo visceral injuries
Fractured pelvis / acetabulum
B/L lower extremity fractures inc calcaneal fractures
Suspected injury patterns from anterior chest stab wounds
Cardiac tamponade if within “box”
Haemo/pneumo -thorax
Suspected injury patterns from left / right thoraco-abdominal stab wounds
Diaphragm injury
Spleen / liver injury
Haemopneumothorax
Suspected injury patterns from truncal gunshot wounds (GSW)
High likelihood of injury
Trajectory / retained projectiles help predict injury
Suspected injury patterns from extremity gunshot wounds (GSW)
Neurovascular injury
Fractures
Compartment syndrome
Suspected injury patterns from thermal burns
Circumferential eschar on extremity or chest
Eschar definition
(Pronounced es-car)
Dead tissue that sheds or falls off the skin
Suspected injury patterns from electrical burns
Arrhythmias
Myonecrosis / compartment syndrome
Suspected injury patterns from inhalation burns
CO poisoning
Upper airway swelling
Pulmonary oedema
Secondary survey examination
Head / scalp
Eye / ear
Maxillofacial structures
Neck
Chest
Abdo / Pelvis
Perineum +/- Rectum / Vagina
MSK system / extremities
Log roll + spinal examination
Neurological system
Specialised tests
Contraindication to NG tube insertion
Fracture of cribriform plate
Examination of maxillofacial structures
Facial bones
Dental occlusion
Intra-oral examination
Look for potential airway obstruction and CIs to NG tube placement
Examination of neck
Inspect
Palpate (inc carotid arteries)
Auscultate
In head or maxillofacial trauma assume unstable C spine injury until all studies completed
Findings on examination of neck
Crepitus
Haematoma
Stridor
Bruits
Examination of perineum
Contusions
Haematomas
Lacerations
Urethral blood
Examination of rectum
Sphincter tone
Pelvic fracture
Rectal wall integrity
Blood
Examination of vagina
Blood
Lacerations
Contraindication to catheter insertion
High suspicion of urethral injury
Injuries with high risk of developing compartment syndrome
Long bone fractures
Crush injuries
Prolonged ischaemia
Circumferential thermal injuries
How to minimise blood loss from pelvic fracutes
Pelvic binder or sheet
Do not repeatedly / vigorously manipulate the pelvis in patients with fractures as can dislodge clots
Examination of neurological system
GCS
Pupil size and reactivity
Lateralising signs
Motor / sensory of extremities
Frequent re-evaluation
How to minimise secondary brain injury
Optimising oxygenation / perfusion
Specialised diagnostic tests
XRs of extremities
CT trauma series
Contrast urography / angiography
TOE
Bronchoscopy
OGD
Multiple casualties definition
Number or patients and their injury severity does NOT exceed capabilities of the facility
Mass casualties definition
Number or patients and their injury severity DOES exceed capabilities of the facility
