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CHAPTER 1 - Initial assessment and Management
What does the initial assessment include? |
1. Preparation
2. Triage 3. Primary survey - ABCDEs** 4. Resuscitation 5. Adjuncts to primary survey + resuscitation 6. Consider need for patient transfer 7. Secondary survey - head-to-toe evaluation and patient history** 8. Adjuncts to secondary survey 9. Continued post-resuscitation monitoring and re-evaluation 10. Definitive care **repeat FREQUENTLY to: - identify deterioration - institute Rx if adverse changes are identified |
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CHAPTER 1 - Initial assessment and Management
How do I prepare for a smooth transition from the prehospital to the hospital environment? |
1. Prehospital phase
- Co-ordination - Notify the receiving hospital before arrival - so that necessary personnel + resources are present in ED - Emphasis on: 1. airway maintenance 2. control of external bleeding + shock 3. pt immobilisation 4. immediate transport to closest facility, pref trauma centre 5. MINIMISE scene time 6. obtain and report info needed for hospital triage - time of injury, events related to injury, pt hx 7. Mechanism of injury- suggests degree and specific injuries 2. Hospital phase - resuscitation area - proper airway equipment - laryngoscope, tubes - warmed iv crystalloid solutions - monitoring equipment - method to summon additional medical assistance - personnel wear standard precautions - FACE MASK, EYE PROTECTION, WATER-IMPERVIOUS APRON, LEGGINGS, GLOVES - these are the MINIMUM precautions |
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CHAPTER 1 - Initial assessment and Management
What is triage? |
TRIAGE involves the sorting of patients based on their need for treatment and the resources available to provide that treatment.
Treatment is based on ABC priorities - Airway with cervical spine protection - Breathing - Circulation with haemorrhage control |
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CHAPTER 1 - Initial assessment and Management
What are the 2 types of triage situations? |
1. Multiple casualty incidents
- the number of patients and the severity of their injuries do NOT exceed the ability of the facility to render care. - Patients with life-threatening problems and those sustaining multiple systen injuries are treated first 2. Mass casualties - Number of patients and the severity of their injuries EXCEED the capability of the facility and staff - Patients with the greatest chance of survival and requiring the least expenditure of time/equipment/personnel are treated first |
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CHAPTER 1 - Initial assessment and Management
What is a quick, simple way to assess the patient in 10 seconds? (THINK PRIMARY SURVEY) |
PRIMARY SURVEY
1. AIRWAY maintenance with cervical spine protection 2. BREATHING and ventilation 3. CIRCULATION and haemorrhage control 4. DISABILITY- neurologic status 5. EXPOSURE/ ENVIRONMENTAL control - completely undress the patients but prevent hypothermia |
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Is the risk of death from ANY given injury greater for elderly males or females?
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MALES greater than females
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CHAPTER 1 - Initial assessment and Management:
How do you assess the airway? |
Airway maintenance with cervical spine protection. 1. Any signs of airway obstruction? (stridor, foreign body , facial/ mandibular/ tracheal/ laryngeal fractures, severe head injuries with GCS</=8. Use chin-lift or jaw-thrust. Do not hyper-extend, hyper-flex or rotate the neck. If immobilisation devices must be removed temporarily, one member of the trauma team should MANUALLY STABILISE the patients head and neck using INLINE IMMOBILISATION TECHNIQUES
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CHAPTER 1 - Initial assessment and Management:
How do you check for adequate breathing and ventilation? |
1. Expose the chest - look for chest wall excursion and auscultate. 2. Inspect and palpate the chest to detect injuries to the chest wall. (Percussion is unreliable during a noisy resuscitation). DURING THE PRIMARY SURVEY LOOK FOR: tension pneumothorax, flail chest with pulmonary contusion massive haemothorax and open pneumothorax. (secondary survey may identify simple pneumothorax/haemothorax, rib #, pulmonary contusion)
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CHAPTER 1 - Initial assessment and Management: Circulation with haemorrhage control. What do you look for?
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BLOOD VOLUME AND CARDIAC OUTPUT - hypotension following injury is due to hypovolemia until proven otherwise.
Look for: 1. Level of consciousness- decreased due to reduced cerebral perfusion. 2. Skin colour- pink vs ashen grey/white. 3. Pulse- quality/ rate/ regularity ?rapid/thready ?irregular 4. External haemorrhage- manual pressure, splinting. (Occult blood loss often via chest/abdo/retroperitoneum/pelvis/long bones) |
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CHAPTER 1 - Initial assessment and Management: DISABILITY- What is the rapid neurologic evaluation?
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RAPID NEUROLOGIC EVALUATION -
1. level of consciousness- GCS esp best motor response, ?decreased cerebral perfusion ?brain injury ?low BGL ?EtOH/narcotics 2. pupillary size and reaction, 3. lateralising signs, 4. spinal cord injury level NB. talk and die - think of acute epidural haematoma |
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How does hypovolemia affect the elderly/children/athletes?
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1. Elderly - limited ability to increase HR. BP has little correlation with CO
2. Children (abundant reserve)- often have few signs. Deterioration = precipitous/catastrophic 3. Athletes (good compensation)- may have bradycardia, not usual tachycardia |
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CHAPTER 1 - Initial assessment and Management: What are the steps of resuscitation
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RESUSCITATION:
1. AIRWAY +protect c-spine - protect and secure, jaw-thrust, chin-lift ?definitive airway 2. BREATHING/ VENTILATION/ OXYGENATION- supplemental O2. ?tension ptx 3. CIRCULATION and BLEEDING CONTROL- 2 x large IVC, pressure, definitive control of haemorrhage (operation, angioembolisation, pelvic stabilisation), warm IVF resuscitation and blood products |
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CHAPTER 1 - Initial assessment and Management: What are the adjuncts to the primary survey?
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1. ECG monitoring ?dysrhythmia ?tachy ?PEA?brady
2. IDC - monitor UO, volume status 3. NGT- reduce stomach distension and reduce risk of aspiration 4. Monitor RR, pulse oximetry, BP, temp 5. ABG 6. XRay- CXR, pelvis XRay |
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When should a urethral injury be suspected?
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1. blood at urethral meatus
2. perineal ecchymosis 3. blood in scrotum 4. high-riding or non-palpable prostate 5. pelvic fracture IDC should not be inserted before rectum/genitalia have been examined. |
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What is the AMPLE history?
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A- allergies
M- Medications currently used P- past illness/pregnancy L- last meal E- events/environment related to the injury - mechanism ?blunt vs penetrating |
