Trauma Assessment and Management Flashcards
Assessment and Management Priorities? 4
- Rapid Primary Survey
- Resuscitation of vital functions
- Detailed Secondary Survey
- Initiate Definitive Care
PRIMARY SURVEY? 5
A – Airway maintenance and C-spine control B – Breathing and ventilation C – Circulation and hemorrhage control D – Disability: Neurological status E – Exposure: Completely undress patient
Trauma Assessment and Management
PRIMARY SURVEY: Airway/C-Spine
1. Open airway, suction airway, insert mechanical airway; but do not do what?
- Keep neck immobilized
You CANNOT immobilize the neck without what? - Assume IN ANY MULTI-TRAUMA PATIENT AND WITH ANY BLUNT INJURY ABOVE THE CLAVICLE?
- do not hyperextend neck
- complete spinal immobilization
- ASSUME A CERVICAL FRACTURE
Trauma Assessment and Management
PRIMARY SURVEY: Breathing
Expose the patient’s chest
- Need to be able to see what?
- Patent airway does NOT ensure what?
- Oxygen and volume need to be delivered so the what is optimal?
- CANNOT insure adequate oxygen with just what? 2
- Three conditions most often compromise ventilation?
- chest movements
- adequate ventilation
- BMV device
- simple mask or nasal cannula
- Tension pneumothorax
- Open pneumothorax,
- Large flail section with pulmonary contusion
Trauma Assessment and Management
PRIMARY SURVEY: Circulation
- Blood volume and circulation: Hypotension must be assumed to be what until proven otherwise?
- Rapid assessment is based on 3 key factors?
- Bleeding: Obvious external bleeding should be controlled during the primary survey… What is the best method?
- What may be necessary for traumatic amputation?
- hypovolemic
- State of consciousness
- Skin Color
- Pulse
- DIRECT PRESSURE
- Tourniquet
Rapid assessment is based on 3 key factors
1. State of consciousness: How you can assess how much blood has been lost just on primary assessment?
- Which symptoms = no significant hypovolemia? Which do?
- If carotid and femoral pulse are present? If they are not?
- When >50% blood volume is gone everyone is unconscious; therefore if they are awake, the brain is being perfused (less than 50%)
- Pink skin of face and extremities means no significant hypovolemia; ashen, grey skin and white, drained extremities = at least 30% loss
- Carotid or Femoral pulse present less than 50% loss; absent femoral and/or carotid pulse > 50% loss and death is imminent
Trauma Assessment and Management
PRIMARY SURVEY: Disability
1. Brief Neuro Exam? 4
- Eyes?
- Decrease in LOC during serial exams means decreased what?
- if so check? 3 - Secondary survey for neuro includes?
1. “AVPU” is a useful acronym Alert? V responds to Verbal stimuli P responds to painful stimuli Unresponsive
- Check pupillary size and reaction
- Decrease in LOC during serial exams means decreased cerebral perfusion….
- check oxygenation, perfusion, and ventilation status - Glasgow Coma Scale is for secondary survey
Trauma Assessment and Management
PRIMARY SURVEY: Exposure
- What should you do with the patients clothing?
- Field dressings?
- Remember, the ED is generally a cold place. What is the problem with this?
- Following Primary Survey, keep patient covered with what?
- All patients must be completely undressed. Cut awayall clothing, shoes etc
- Remove all field dressings and look underneath
- hypothermia will worsen shock states
- blankets or use Bair Hugger except while doing specific exams or procedures
Trauma Assessment and Management
What is involved in the resuscitation phase?
5
- Airway/Ventilate/Oxygenate
- IV Lines/Warm Fluids
- Shock Management
- Manage life-threatening injuries
- Foley catheter and NG tube may be placed if NOT contraindicated
How do we start shock management? 2
- Control bleeding/Start IV access lines
2. Crystalloids
Trauma Assessment and Management
Resuscitation Phase
- Supplemental O2 on all patients (sats >?)
- Start two (2) large-bore (16g) IV lines
-Draw “rainbow” when starting IV lines
Bolus with what to treat shock while awaiting blood? - Hypovolemic shock is never treated with what?
- Consider what after NS?
- ECG monitoring on all patients; what changes may indicate cardiac contusion? 3
- PEA may indicate what? 3
- Bradycardia may be due to what? 2
- NG tube and foley placement
- NO NG tube with possible what?
- NO Foley in males with what? 3
- 90%
- Bolus with 2-3L NS
- vasopressors
- type specific or O-neg blood
- atrial fibrillation,
- PVCs, and
- ST segment changes
- tamponade,
- tension pneumothorax or
- Class IV Hemorrhage
- hypoperfusion or
- hypothermia
- cribiform plate fractures
- blood at meatus or in scrotum or high-riding prostate
- What must be done before the secondary survey is considered?
- What is involved in this step?
- Primary Survey must be accomplished and resuscitation phase started before any secondary survey is considered
- This is where labs are drawn and diagnostic testing obtained
Secondary survey
1. Eyes? 6
- Maxillofacial trauma: If no Airway obstruction, treatment for these injuries can wait how long?
- Cribiform plate fractures – place NG through?
- Eyes:
- Pupil size and reactivity
- fundi for hemorrhage
- lens for dislocation
- evidence of conjunctival laceration or penetrating trauma.
- Test VA by confrontation.
- Remove contact lenses. - Maxillofacial Trauma: 7-10 days.
- mouth.
Trauma Assessment and Management
SECONDARY SURVEY
Neck/C-Spine
- All blunt injury to maxillofacial area have what until proven otherwise?
- Absence of what does NOT rule-out C-Spine injury?
- Any/all sports or other helmets must be removed while maintaining what?
- Penetrating trauma through the what should NOT be explored in the ED?
- C-Spine injury
- neurological deficit or pain
- C-Spine immobilization
- platysma
Trauma Assessment and Management
SECONDARY SURVEY
Chest
Visually inspect the entire chest (anterior and posterior)
- Palpate the entire chest: such as? 3
Auscultate the chest
2. High on anterior chest for
- Posterior bases for what?
- Distant heart sounds may indicate what?
- Neck veins may not be distended due to what?
- and narrow pulse pressure may be only sign of what?
- Feel each rib and follow its course
- Feel each clavicle
- Palpate the sternum for fracture or tenderness
- pneumothorax
- hemothorax
- tamponade
- hypovolemia
- tamponade
Trauma Assessment and Management
SECONDARY SURVEY
Abdomen
Abdominal injuries may be occult and potentially dangerous
Specific diagnosis is not as important as recognizing that abdominal injury has occurred
- Initial abdominal exam may be negative; what must be done after this?
- Call surgeons on what timeline?
- What has replaced DPL as a quick, noninvasive approach to detect free fluid (blood) in the abdomen?
- serial abdominal exams over 1 - several hours must be done
- early and frequently
- FAST
Trauma Assessment and Management
SECONDARY SURVEY
Rectal Exam
Essential part of every secondary survey
What are we assessing with this? 5
- Assess for presence of blood in bowel lumen
- A high-riding prostate
- Presence of pelvic fracture
- Integrity of the rectal wall
- Quality of sphincter tone
Trauma Assessment and Management
SECONDARY SURVEY
Fractures
- Visualize extremities for what? 2
- Palpate bones
Include what? 3 - Document all what on extremities? 2
Don’t forget T and L spine injuries which may be masked
- contusions or deformities
- Checking for tenderness, crepitation, abnormal movements
- Anterior/Posterior pressure on iliac wings for pelvis
- Pressure over symphysis pubis
- peripheral pulses and
- distal neurological status
Trauma Assessment and Management
SECONDARY SURVEY
Neurological
- Comprehensive neuro exam including what? 2
- Any evidence of paralysis or paresis suggests what?
- and you need to do what? - Any evidence of epidural/subdural hematomas, depressed skull fractures, or other intracranial injuries should be considered for what?
- motor and sensory (check major dermatomes)
- spinal cord injury
- keep the entire spine immobilized - transfer to nearest neurosurgeon ASAP
Trauma Assessment and Management
Definitive Care Phase
Comprehensive management is accomplished
1. Fracture _________ is obtained?
2. _________ intervention is done as needed?
3. Stabilization and arrangements made for transfer to what?
- stabilization
- Operative
- tertiary center
Trauma Assessment and Management
HISTORY
SAMPLE
Ask about mechanism of injury
- Energy wave extends from what?
- Energy wave extends laterally from what?
AMPLE history is a useful mnemonic S A – Allergies M – Medications currently taking P – Past illnesses/surgeries L – Last meal E- Events/environment related to injury
- blunt trauma
- from missile trauma
Trauma Assessment and Management HISTORY Blunt trauma 1. what account for most blunt trauma? 2. Direction of impact determines what?
- Talk to which personnel?
- Patient’s injuries often “mirror” what?
- Frontal impact, bent steering column, star windshield
may be signs that what injuries have happened? 4 - Side impact: in car may lead to what? 5
- Auto accidents
- pattern of injuries
- prehospital
- the car’s damage
- C-Spine injuries,
- Central flail chest,
- Myocardial contusion,
- Fractured spleen/liver
- Contralateral neck sprain or cervical fracture,
- lateral flail chest,
- pneumothorax,
- acceleration injury to aorta,
- fractured pelvis or acetabulum
Trauma Assessment and Management
HISTORY
- Restate the Primary survey?
- Three main componenets in resuscitation?
- PRIMARY SURVEY
- Airway and cervical spine control
- Breathing
- Circulation and hemorrhage control
- Disability: Brief Neuro Exam
- Exposure: Completely undress the patient - RESUSCITATION
- Shock management – IV lines with RL or NS
- Management of life threatening problems
- ECG monitoring
Trauma Assessment and Management
SUMMARY
What is involved in the secondary survey?
10
Secondary Survey
- Head and skull
- Maxillofacial injuries
- Neck
- Chest
- Abdomen
- Perineum/Rectum
- Extremities – fractures
- Complete neuro exam
- Appropriate X-Rays, labs, special studies
- “Tubes and fingers” in every orifice