basic trauma

7/29/2019 Basic Trauma

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Trauma: Initial Survey

Primary and Secondary SurveysDr. Jason Alexander

Dr. Melanie Walker

Huntington Memorial Hospital


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Prehospital Phase

z Prehospital information can be invaluable if

available


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Valuable Prehospital

Information

z Victim age

z Mechanism of injury

z Vital signs

z IV access

z Glasgow Coma Score

z Obvious injuries (eg. Open fractures, evisceratedbowel)


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Additional Paramedic

Information

z Field blood loss

z Pre-hospital fluids


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Primary Survey

z A

z B

z C

z Dz E

z Should take no more than 2-5 minutes


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Primary Survey

z Airway management with cervical spine

protection

z Breathing and ventilation

z Circulation with hemorrhage control


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Primary Survey

z Disability: Neurologic status

z Exposure/Environmental control: Completely

expose patient


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Glasgow Coma Scale (Adults)

z Quick neurologic assessment which provides

the information about:

z Prognosis

z Victims ability to maintain patent airway on own

z Best score in three categories

z Total


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Glasgow Coma Score (Adults)

Best MOTORBest VERBAL +Best EYE +

6= follows commands

5= localizes pain5= orientated

4= withdraws to pain4= confused4= openspontaneously

3= flexes to pain3= inappropriate3= open to voice

2= extends to pain2= incomprehensible2= open to pain

1= none1= nonverbal1= do not open

MotorVerbalEyes


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Airway Maintenance with

Cervical Spine Protection

z Attempt to get verbal response from patient

z Inspect for foreign bodies

z Assess for facial, mandibular, tracheal /

laryngeal injuriesz Oxygen

z Maintain cervical spine precautions

z Quick Glasgow Coma Score Assessment


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Airway

z Jaw Thrust Maneuver

z Place 2-3 fingers under each side of lower jawangle

z Lift jaw upward and outward

z Head tilt Chin lift Maneuver

z Do not perform if cervical injury suspected


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Airway: Head tilt Chin lift

Maneuver

z Infant

z Head in neutral position

z Do NOT overextend head and neck

z Child and adult

z Head and neck slightly extended

z Line from chin to jaw angle perpendicular to floor

z Use other hand's fingers under bony part of chin

z Do NOT use thumb to lift chinz Lift mandible upward and outward


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Breathing and Ventilation

z Directed at acutely life-threatening disease

processes that impair breathing

z Observe respiratory rate and use of

accessory musclesz Listen for breath sounds

z Inspect chest for crepitus and open wounds


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Breathing and Ventilation:

Life-Threatening Insults

z Tension Pneumothorax

z Open Pneumothorax

z Massive Hemothorax

z Flail chest with pulmonary contusion


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Tension Pneumothorax

z Diagnosis

z Absent breath sounds

z Tympanitic chest

z Distended neck veins

z Tracheal deviation

z Treatment

z Needle thoracostomyz Tube thoracostomy


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Open Pneumothorax

z Open thoracic wound causes immediate

equilibration between intra-thoracic andatmospheric pressure

z This leads to lung collapse

z Close defect with large sterile occlusivedressing

z Remote placement of thoracostomy tube


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Massive Hemothorax

z Diagnosis

z Diminished breath sounds

z Dullness to percussion over thorax

z Shock

z Treatment

z Tube thoracostomy

z >1500cc output=Thoracotomy


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Flail Chest with Pulmonary

Contusion

z Paradoxical movement between segment of

chest wall with multiple contiguous rib fx andthorax

z Pulmonary dysfunction is due to theunderlying pulmonary contusion and splintingsecondary to discomfort

z

Management is oxygen, pain control and ifunable to maintain oxygenation, mechanicalventilation


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Circulation with Hemorrhage

Control

z Three aspects of circulation

z Control of external bleeding

z Efficiency of the cardiac pump

z Volume status (degree of shock)


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Control

z Must have adequate IV access

z Inadequate circulation is a clinical diagnosis

augmented by vital signs.

z

Young victims will often manifest atachycardia when they are hypovolemicfollowed by hypotension

z Older patients or medicated patients may notbe able to mount a tachycardia


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Control

z Significant bleeding can only be found in a

few anatomic locations

z Chest: Massive hemothorax

z Abdomen: Hemoperitoneum

z Retroperitoneal bleed

z Pelvis

z Secondary to major closed fractures (pelvis orfemur)


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Circulation and Hemorrhage

Control

z Additional locations of hemorrhage most

often forgotten are:z Active external hemorrhage

z Hemorrhage in the field


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Circulation and Hemorrhage

Control

z During the primary survey the goal is not to

stop hemorrhage but to support thecirculatory system with one exception

z This is done by rapid infusion of IV fluids

z Adult patients who do not respond to bolus of2 liters IV fluids need blood products

z Do stop all active external hemorrhage


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Disability: the Brief Neurologic

Evaluation

z Glasgow Coma Score (GCS): re-evaluate

z Orientation

z Any change in level of consciousness or

depreciation in the GCS should promptexaminer to return to the beginning of primarysurvey


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Exposure/Environmental

z Important balance

z Expose patient entirely to allow globalassessment of patient as well as remove anydetrimental coverings (eg. Wet clothes,

smoldering coverings)z Cover patient with warm blankets following

exposure to prevent hypothermia


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The Secondary Survey

z Should not take more than 5 -10 minutes

z Examine patient from head to toe


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z Headz

Scalpz Pupilsz Auditory canalsz Mouth

z Neckz Tracheaz Neck veins

z Chestz Claviclesz Ribs Breath Soundsz Heart Tones


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z Abdomen

z Rectum

z Prostate (in males)

z Sphincter

z Genitalia

z Extremities

z Bonesz Soft tissues


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z Neurologic system

z Reflexes

z Sensation

z Hemispheric function

z Spinal function


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Assignment of Priorities

z The goal in the first few hours after trauma is

not to treat individual injuries but to determineand manage threats to the patients life


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z Airway management takes first priority

z Treatment of bleeding can be delayed for a

few minutes if intensive resuscitation isnecessary


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z Any injuries which would lead to

complications or loss of function if diagnosisor treatment is delayed

z peripheral vascular injuries, tendon and nerves

injuries, eye injuries, amputations of limbs


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z Closed fractures, dislocation and small soft

tissue wounds are the only lesions for whichtreatment can be delayed for several hours

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