Initial Assessment and Management Initial Assessment and Management

Initial Assessment and Management

When I can provide better care in the field with limited resources than what my children and I received at the primary care facility --there is something wrong with the system and the system has to be changed.

The Concept Treat the greatest threat to life first Lack of a definitive diagnosis should never impede treatment A detailed history was not an essential prerequisite to begin the evaluation of an acutely injured patient

The Result A Airway with cervical spine control B Breathing C Circulation D Disability or neurologic status E Exposure (undress) with temperature control

INITIAL ASSESSMENT (A systematic approach that can be reviewed and practiced) 1. Preparation 2. Triage 3. Primary Survey (ABCs) 4. Resuscitation 5. Secondary Survey (head-to-toe) 6. Continued post-resuscitation monitoring and re-evaluation 7. Definitive care
Primary Survey
A - Airway maintenance with cervical spine control B - Breathing and Ventilation C - Circulation with hemorrhage control D - Disability ; Neurologic status E - Exposure / Environmental Control; Completely undress the patient, but prevent hypothermia Life threatening conditions are identified and management is begun simultaneously Priorities for the care of the pediatric patient are basically the same as for adults
Primary Survey
Airway with Cervical Spine Control Ascertain patency foreign bodies facial, mandibular, tracheal or laryngeal fractures Chin-lift or jaw-thrust maneuver Cervical spine immobilization C-7 to T-1 cross-table lateral cervical spine x-ray Multi-system trauma, altered level of consciousness, or a blunt injury above the clavicle
Primary Survey
Breathing Assure adequate ventilation Function of the lungs, chest wall, and diaphragm Injuries that acutely impair ventilation Tension pneumothorax Flail chest with pulmonary contusion Open pneumothorax Injuries that compromise ventilation to a lesser degree Hemothorax, simple pneumothorax, fractured ribs, and pulmonary contusion
Primary Survey
Circulation with Hemorrhage Control Blood volume and cardiac output Level of consciousness Skin color Pulse Bleeding External, severe hemorrhage is identified and controlled in the primary survey External blood loss is managed by direct manual pressure Hemorrhage into the thoracic or abdominal cavities, into muscles surrounding a fracture, or as a result of penetrating injury can account for major blood loss
Primary Survey
Disability (Neurologic Evaluation) Level of consciousness and pupillary size and reaction A Alert V Responds to Vocal stimuli P Responds to Painful stimuli U Unresponsive Decreased level of consciousness Decreased cerebral oxygenation and/or perfusion Alcohol and drugs
Primary Survey
Exposure / Environmental Control Patient should be completely undressed Cover and protect from hypothermia Warm blankets Intravenous fluids should be warmed Maintain warm environment
Resuscitation
Airway Jaw-thrust or chin-lift maneuver Nasopharyngeal airway Oropharyngeal airway Breathing / Ventilation / Oxygenation Endotracheal intubation Surgical airway Chest decompression Supplemental oxygen therapy
Resuscitation
Circulation Two large-caliber IV catheters Blood type, crossmatch, pregnancy test Balanced salt solution Blood transfusion
Type-specific blood, O-negative blood, unmatched type specific blood
Resuscitation
Urinary and Gastric Catheters Routine urine analysis Urethral injury is suspected if there is:
Blood at the penile meatus Blood in the scrotum Prostate is high-riding or can not be palpated
Blood in the gastric aspirate may represent:

Swallowed blood Traumatic insertion Actual injury to the stomach
Hypovolemic shock should NOT be treated by:

vasopressors, steroids, or sodium bicarbonate
Hypothermia ECG monitoring
If the cribriform plate is fractured or fracture is suspected, NGT should be inserted orally
Resuscitation
Monitoring Ventilatory rate and arterial blood gases End-tidal carbon dioxide monitoring Pulse Oximetry Appropriate oxygenation is a reflection of proper airway, breathing and circulatory status Blood pressure ECG monitoring
Resuscitation
Consider the need for patient transfer Remember: Life-saving measures are initiated when the problem is identified, rather than after the primary survey During the primary survey and the resuscitation phase, the evaluating physician frequently has enough information to indicate the need for transfer of the patient to another facility Referring physician to receiving physician communication is essential
Resuscitation
Roentgenograms Should be used judiciously and NOT delay patient resuscitation In blunt trauma, x-rays to be obtained: Cervical spine Chest (AP) Pelvis (AP) After all life-threatening injuries are identified: Complete cervical, thoracic and lumbar spine In penetrating injuries, x-rays are: Chest (AP) Films pertinent to the site of wounding
Secondary Survey
Tubes and fingers in every orifice The secondary survey does not begin until the primary survey (ABCs) is completed, resuscitation is initiated, and the patients ABCs are reassessed Head-to-toe evaluation Complete neurologic examination (GCS) Special procedures Peritoneal lavage, radiologic evaluation, and laboratory studies
Secondary Survey
History A Allergies M Medication currently taken P Past illnesses L Last meal E Events / environment related to the injury Blunt trauma Penetrating trauma Burns Hazardous environment
Secondary Survey
Physical Examination Head Scalp and skull examination Eye and ear examination Maxillofacial Cribriform plate fracture - orogastric intubation Cervical spine and Neck presume injury in patients with maxillofacial or head trauma Extreme care must be taken when removing helmet
Secondary Survey
Physical Examination Chest Visual evaluation
Open pneumothorax, flail chest
Secondary Survey
Physical Examination Abdomen A normal initial examination of the abdomen DOES NOT exclude intra-abdominal injury Candidates for peritoneal lavage
Unexplained hypotension Neurologic injury Impaired sensorium secondary to alcohol or drugs
Palpation
Fractures
Auscultation
Cardiac tamponade - distant heart sounds and narrow pulse pressure, distended neck veins Tension pneumothorax - decreased breath sounds, shock, distended neck veins
Chest X-ray
Widened mediastinum, pneumohemothorax, fractures
Fractures of the pelvis or lower rib cage may hinder adequate abdominal examination
Secondary Survey
Physical Examination Perineum / Rectum / Vagina Rectal Examination
Presence of blood within the bowel lumen High-riding prostate Pelvic fractures Integrity of the rectal wall Quality of the sphincter tone
Secondary Survey
Physical Examination Musculoskeletal Extremities
Deformity, abnormal movement, tenderness, crepitation
Pelvis
Pressure over anterior iliac spine and symphisis pubis Assessment of peripheral pulses
Vaginal Examination
Blood in the vaginal vault Vaginal lacerations Pregnancy test
Ligament rupture, muscle-tendon injury, nerve injury or ischemia
Secondary Survey
Physical Examination Neurologic Motor, sensory, level of consciousness, pupillary reaction Immobilization of the entire patient Cervical collar If there is neurologic deterioration, ABCs must be reassessed
Re-Evaluation
New findings are not overlooked Discover deterioration Underlying medical problems Effective analgesia Monitoring Vital signs Urinary output Arterial blood gas Cardiac monitoring devices
Definitive Care
Roentgenogram
The CLOSEST APPROPRIATE hospital should be chosen based on its overall capabilities to care for the injured patient
Cervical Spine X-ray Cross-table lateral C-1 to C-7
Airway
Chin-lift maneuver
Airway
Nasopharyngeal airway
Airway
Endotracheal Intubation
Surgical Airway
Cricothyroidotomy
Roentgenogram
Roentgenogram
Chest X-ray (AP) Pneumothorax
Pelvic fracture

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