Multitraumer Flashcards
Concepts of Initial Assessment
Preparation
Primary survey
Resuscitation
Adjuncts
Reevaluation
–>
Deailed secondary survey
Resuscitation
Adjuncts
–>
Reevaluation
Definitive care
Initial assessment and management refers to the entire process of evaluating, treating, conducting a detailed head-to-toe evaluation, reevaluating the patient, and transferring that patient, as necessary, to a facility with the resources to provide optimal care.
Primary survey?
ABCD
Airway, C spine Breathing Circulation (hemorrhage) Disability (neuro) Exposure
Primary survey and resuscitation of vital functions are done simultaneously using a team approach.
Hurtig vurdering af ABCD
Ask the patient his or her name
Ask the patient what happened
Emphasize the need for adequate cardiac output to ensure clear sensorium.
The patient who fails this simple test needs immediate attention.
Inappropriate or no response requires urgent intervention.
Specielle considerationer ved primary survey?
Elderly – diminished reserve, cormobidity, meds → early decompensation.
Pediatric – early compensation, sudden deterioration – aggressive approach.
Pregnancy – 2 patients – best treatment is resuscitation of the mother.
Athlete – compensate because of reserve. Lack of tachycardia early.
A- Airway
Pittfalls
Occult airway injury
Progressive loss of airway
Equipment failure
Inability to intubate
Emphasize the need to protect the c-spine during airway management, especially avoiding the ACLS head-tilt maneuver.
B- Breathing
Pittfalls
Airway versus ventilation problem?
Iatrogenic pneumothorax or tension pneumothorax?
Emphasize the need to attend to adequate oxygenation and ventilation in the injured patient, recognizing that altered chest wall mechanics may be new to those doctors who have taken only the cardiac life support course.
C- Cirkulation
Pittfalls
Elderly
Children
Athletes
Medications
Emphasize the need to control hemorrhage or stop the bleeding.
Explain that hemorrhage is the major source of hypoperfusion in the trauma patient and the prime goal is to identify and stop the hemorrhage.
The different responses of the elderly, child and athlete to hypoperfusion and the effect of medications such as B-blocker should be discussed.
D- Disability
Pittfalls
Observe for neurologic deterioration
Emphasize that it is essential to identify neurologic injury using the tools of GCS score and pupil response early in order to avoid secondary brain injury, identify surgically correctible lesions rapidly, and provide a baseline GCS score to identify trends and changes.
E-Exposure
Pittfalls
Prevent
Hypothermia
Missed injuries
Emphasize the need to completely undress the patient to adequately assess the entire patient, while at the same time preventing hypothermia.
Resuscitation
Protect and secure airway
Ventilate and oxygenate
Stop the bleeding!
Blood resuscitation - balanced
Protect from hypothermia
Adjuncts to Primary Survey
EKG Vitale tegn Urin ABGs Puls Pximeter CO2 Katetre
Afhænger af skaden osv.
The primary purpose of these adjuncts during the primary survey is to determine where occult bleeding may be occurring that is not obvious on clinical exam.
Emphasize the need to determine the source of shock.
Portable chest and pelvic x-rays in the emergency department are the ONLY x-rays obtained during the primary survey.
These x-rays assist in identifying the cause of shock in “C” of the A, B, C’s of the primary survey.
Secondary Survey
The complete history and physical examination
Mechanisms of Injury
When do I start the secondary survey?
Primary survey is completed
ABCDEs are reassessed
Vital functions are returning to normal
Adjuncts to Secondary Survey
Special Diagnostic Tests as Indicated
Pittfalls:
- Patient deterioration
- Delay of transfer
- Deterioration during transfer
- Poor communication
These include specialized radiographic studies.
Emphasize that adjuncts should NOT delay appropriate transfer to definitive care.
How do I minimize missed injuries?
High index of suspicion
Frequent reevaluation and monitoring
_____
Emphasize that meticulous attention to detail, integrated with clues from the mechanism of injury and physical findings, and continued reassessment, are the best methods to avoid missed injuries.
Some institutions conduct a “tertiary” survey within 24 hours of admission to assess for missed injuries.
Missed injuries are avoided by frequent re-evaluation , monitoring and having a high index of suspicion.
