Trauma Assessment Flashcards
Aims of the initial evaluation of trauma patients
- Stabilise the patient.
- Identify life-threatening conditions in order of risk and initiate supportive treatment.
- Organise definitive treatments or organise transfer for definitive treatments.
Preparation and co-ordination of care:
Assessment and management will begin out of hospital at the scene of injury and good communication with the receiving hospital is important. The preparatory measures are outlined below to ‘set the scene’.
The pre-hospital phase:
- Co-ordination and communication with the receiving hospital so that the trauma team can be alerted and mobilised.
- Airway maintenance.
- Control of external bleeding shock.
- Keeping the patient immobilised.
- Information gathering: time of injury; related events; patient history. Key elements are the mechanism of injury to alert the trauma team to the degree and type of injury.
- Keeping time at the scene to a minimum
The hospital phase:
- Preparation of a resuscitation area.
- Airway equipment - laryngoscopes, etc (accessible, tested).
- Intravenous (IV) fluids (warming equipment, etc).
- Immediately available monitoring equipment.
- Methods of summoning extra medical help.
- Prompt laboratory and radiology backup.
- Transfer arrangements with trauma centre.
Triage and organisation of care:
- Triage: is done according to the ‘ABCDE’ principles
- Selection of hospital: is according to available services
- Multiple casualties: (no of patients do not exceed capacity) life-threatening injuries and multiple system injuries are treated first.
- Mass casualties: (no of patients exceed capacity of the treatment centre) patients are selected for treatment according to best chance of survival with least expenditure of resources.
Initial assessment
This comprises:
- Resuscitation and primary survey.
- Secondary survey.
- Definitive treatment or transfer for definitive care.
Resuscitation and primary survey:
A = Airway maintenance cervical spine protection
- Are there signs of airway obstruction, foreign bodies, facial, mandibular or laryngeal fractures? Management may involve secretion control, intubation or surgical airway (eg, cricothyroidotomy, emergency tracheostomy).
- Establish a clear airway (chin lift or jaw thrust) but protect the cervical spine at all times.If the patient can talk, the airway is likely to be safe; however, remain vigilant and recheck.
- Cervical spine protection is critical throughout the airway management process
Resuscitation and primary survey:
B = Breathing and ventilation
Provide high-flow oxygen through a rebreather mask if not intubated and ventilated.Evaluate breathing: lungs, chest wall, diaphragm. Chest examination with adequate exposure: watch chest movement, auscultate, percuss to detect lesions acutely impairing ventilation:
- Tension pneumothorax - requires needle thoracostomy followed by drainage.
- Flail chest - management involves ventilation.
- Haemothorax - will usually require intercostal drain insertion.
- Pneumothorax - may require intercostal drain insertion.
Resuscitation and primary survey:
C = Circulation with haemorrhage control
Blood loss is the main preventable cause of death after trauma. To assess blood loss rapidly observe:
Level of consciousness.
Skin colour.
Pulse.
Bleeding - this should be assessed and controlled:
- IV access should be achieved with two large cannulae (size and length of cannula is determinant of flow not vein size) in an upper limb. Bloods taken for crossmatch and baseline
- IV fluids will need to be given rapidly, usually as 250 ml to 500 ml warmed boluses (10-20 ml/kg in children). Often a total of 2-3 L of IV fluids is necessary (40 ml/kg in children), which will then need to be followed by blood transfusion (O negative to begin with, if typed blood is not available). Ringer’s lactate is the preferred initial crystalloid solution
- Direct manual pressure should be used to stem visible bleedin
- Transparent pneumatic splinting devices may control bleeding and allow visual monitoring;
- Occult bleeding into the abdominal cavity and around long-bone or pelvic fractures is problematic but should be suspected in a patient not responding to fluid resuscitation.
Resuscitation and primary survey
D = Disability: neurological status
- Level of consciousness, using GCS.
- Pupils: size, symmetry and reaction.
- Any lateralising signs.
- Level of any spinal cord injury (limb movements, spontaneous respiratory effort).
- Oxygenation, ventilation, perfusion, drugs, alcohol and hypoglycaemia may all also affect the level of consciousness.
Resuscitation and primary survey:
E = Exposure/environmental control
Undress the patient, but prevent hypothermia. Clothes may need to be cut off but, after examination, attend to prevention of heat loss with warming devices, warmed blankets, etc. Also check blood glucose levels
Secondary survey
The secondary survey is essentially a head-to-toe examination with completion of the history and reassessment of progress, vital signs, etc. It requires repeat physical examinations and may require further X-ray and laboratory tests. It comprises:
- A = Allergies.
- M = Medication currently used.
- P = Past illnesses/Pregnancy.
- L = Last meal.
- E = Events/Environment related to injury
