Initial Management And Assessment Flashcards
Order of treatment
Preparation, Triage, Primary survey (+/- immediate resuscitation), Adjuncts to the primary survey and resuscitation, Consideration of the need for patient transfer, Secondary survey, Adjuncts to secondary survey, Continued post resuscitation monitoring and reevaluation, Definitive care
Prehospital phase
Airway, control of bleeding and shock, immobilisation and immediate transport
Hospital preparation
Resus area, airway equipment, warmed crystalloid, monitoring devices, protocol to summon additional assistance, transfer agreements in place
Triage
ABC
Severity of injury
Ability to survive
Availability of resources
Multiple casualties - life threatening and multiple system injuries are treated first
Mass casualties - Greatest chance of survival and requiring least expenditure of time, equipment, supplies and personnel treated first
Primary Survey
Airway + cervical spine Breathing and ventilation Circulation with haemorrhage control Disability (neurologic) Exposure/Environmental control
Prioritised based on greatest risk to life
Airway with restriction of cervical spine
Identify foreign bodies
Identify facial fractures
Identify injuries that can result in airway obstruction
Suction anything accumulated in airways
Based on mechanism of trauma assume that a spinal injury exists
Manual restriction of cervical spine when cervical collar is opened up
Frequent reevaluation is needed
Establish surgically if intubation is contraindicated or cannot be accomplished
Breathing and ventilation
Adequate function of lungs, chest wall and diaphragm
Adequately assess JVP, position of trachea, chest wall excursion, expose the patient’s neck and chest
Auscultation, visual inspection and palpation can detect injuries to the chest wall, percussion of thorax can identify abnormalities
Things to watch out for - pneumothorax, haemothorax (>1500), tracheal or bronchial injuries
As soon as a pneumothorax is noticed - it must be treated before moving on
Every injured patient should receive oxygen
Circulation with haemorrhage control
Blood volume, cardiac output and bleeding are major circulatory issues to consider
Once tension pneumothorax has been excluded as a cause of shock –> consider that hypotension is due to blood loss until proven otherwise
3 key things - level of consciousness, skin perfusion, pulse
Bleeding - external vs internal
- External by manual pressure on the wound (tourniquet - only when direct pressure not effective and life is threatened)
- Internal - identified by imaging –> chest decompression, application of pelvic stabilising splint, extremity splint –> surgical or interventional radiological management
Control of bleeding requires appropriate replacement of intravascular volume
Two large bore IVC - take bloods and don’t forget blood gas, beta HCG, blood type / cross match
- need to put in IO, CVC or venous cutdown
If patient unresponsive to initial crystalloid therapy –> need blood transfusion
Activate MTP if necessary to avoid coagulopathy resuscitation ongoing cycle
May need to administer tranexamic acid - follow up infusion given over 8 hours in hospital when bolus is given pre-hospital
Disability
Level of consciousness and pupillary size
Hypoglycaemia, alcohol, narcotics and other drugs may alter consciousness
Exposure and environmental control
Completely undress
Cover with warm blankets
Warm IV fluids
Adjuncts to the primary survey
Continuous ECG Pulse oximetry - does not give partial pressure Co2 monitoring Ventilatory rate ABG Urinary catheters Gastric catheter - may need to be orally if cribriform plate injury suspected - checks for GIT trauma, decompresses and also decreases risk of aspiration Blood lactate, X-ray, FAST, eFAST, DPL
Secondary survey
History - AMPLE
Head - visual acuity, pupillary size, haemorrhage of fundi/conjunctiva, penetrating injury, contact lenses, dislocation of the lens, ocular entrapment
Maxillofacial structures - automatically presume C spine injury,
Neck - auscultation, palpation, inspection - C spine tenderness, subcutaneous emphysema, tracheal deviation and laryngeal fracture, carotid bruits
- Active bleeding, bruit, airway compromise –> surgery
Chest - Anterior and posterior, palpation of all bones, CXR
- Decreased pulse pressure - tamponade
- Widened mediastinum - aortic rupture
Abdomen and Pelvis - Examination can change as time goes on, need to re-examine
- Pelvic fractures - ecchymosis, pain on palpation pelvic ring
- DPL, USS, CT (if haemodynamically stable) - unexplained hypotension, neurologic injury, impaired sensorium secondary to alcohol, equivocal abdominal findings
MSK - Dont forget back
Neurological system - GCS, pupils, spine, full neuro exam
Compartment syndrome - long bone fractures, crush injuries, prolonged ischaemia, circumferential thermal
Mechanisms of Injury
Frontal impact - Cervical spine, anterior flail chest, myocardial contusion, pneumothorax, aortic disruption, spleen or liver, posterior fracture, head injury, facial fractures
Side impact - contralateral neck sprain, head injury, cervical spine, lateral flail chest, pneumothorax, aortic disruption, diaphragmatic rupture, fractured spleen, fractured pelvis
Rear impact - Cervical spine, head injury, soft tissue injury
Ejection - Not able to predict
Pedestrian - head injury, aortic disruption, abdominal visceral injuries, fractured lower extremities
Fall from height - head injury, axial spine injury, abdominal visceral injuries, fractured pelvis or acetabulum, bilateral lower extremity fractures (including calcaneal)
Penetrating
Stab
Anterior chest - cardiac tamponade, haemothorax, pneumothorax, hemopneumothorax
Left thoraco-abdominal - left diaphragm injury/spleen injury/haemopneumothorax
Abdomen - abdominal visceral injury - peritoneal penetration
Gun-shot wounds
Truncal - high likelihood of injury, trajectory is highly important
Extremity - neuromuscular injury, fractures, compartment syndrome
Thermal injury
Electrical - arrhythmias, myonecrosis/compartment
Inhalational - carbon monoxide poisoning, upper airway swelling, pulmonary oedema
Thermal - eschar
