Trauma Assessment

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Introduction

The steps to trauma care are as follows:

• initial assessment of condition
• initial recuscitation of life-threatening conditions
• assessment of care needs, and for transport as required

The primary survey provides a rapid assessment of critical functions and resucscitate simultaneously.

 

Life-threatening problems are addressed immediately, as they are identified.

 

 

As you walk into the room, say 'two IVs, oxygen, and a monitor'.

As the patient is getting ready to transfer, place a sheet on the bed.

Get a very quick history.

 

 

 

Airway and C-spine

The first question is always "is the airway open?" Is the patient protection their airway? A quick way of assessing is to ask what their name is.

Assess whether the airway is obstructed:

• teeth
• debris
• tongue
• maxillofacial fractures
• ethanol

 

Airway protection

It is critical that the patient maintains their C-spine; if a C-spine collar is not already on, immediately stabilize the airway.

• collar
• manual immobilization

A chin lift and jaw thrust can be used to open the airway.

 

Intervention: is intubation required?

• flail chest
• GCS <8, or decreasing level of consciousness below this
• failure of ixygenation or ventilation
• upper airway burns
• severe maxillo-facial fracture
• risk of aspiration: bleeding or vomiting
• risk of obstruction: neck hematoma, laryngeal or tracheal injury; stridor
• imminent need for OR

Before intubating, do a quick neurological screen: GCS? PERL? moving all limbs? Babinski? rectal exam?

Before intubating, remove the collar and stabilize the head manually.

 

 

 

Breathing and Ventilation

It is important to remove cloting to observe chest. Look at the patient:

• is their chest moving?
• is there parodoxical movement?
• is their neck in the midline?
• what is their respiratory rate?
• what is their oxygen saturation?

Auscultate the chest, listening for breath sounds. Absolute silence predicts significant pathology, though may also be seen with normal lungs and significant splinting due to pain.

 

Feel for subcutaneous emphysema.

 

Always use 100% supplemental oxygen at 15L/min.

 

threats:

• tension pneumothorax
• open pneumothorax
• flail chest
• pulmonary contusion
• massive hemothorax (blood in the pleural space)
• cardiac tamponade (blood in the pericardial space)

Intervention: Significant pneumothorax or hemothorax - needle or chest tube decompression

Intervention: intubate

• flail chest
• GCS <8, or decreasing level of consciousness below this
• failure of ixygenation or ventilation
• upper airway burns
• severe maxillo-facial fracture
• risk of aspiration: bleeding or vomiting
• risk of obstruction: neck hematoma, laryngeal or tracheal injury; stridor
• imminent need for OR

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Circulation

Does this person have

pulse

blood pressure

respiratory rate

capillary refill

urine output

fluid replacement

 

Causes for hypotension (or shock) include:

• tension pneumothorax (dealt with above)
• neurogenic shock
• cardiac tamponade
• bleeding

To assess for hemodynamic stability, check pulse and blood pressure. Ask for two blood pressures, given the significance of this information. If they are on a beta-blocker, don't believe their heart line.

Ensure they have adequate IV access: two large-bore peripheral lines, central lines, or intraosseous lines.

 

As time continues, monitor urine output.

Intervention: if hemodynamic stability is an issue, insert an arterial line.

Intervention: FAST scan

the floor: how much blood was on the floor? pleural space: surgical consult abdomen (6L): clinical exam, FAST surgical consult

retroperitoneum: FAST surgical consult pelvis (3-6L): tender? immobility? bind the pelvis femur (1L):

 

 

 

Hemorrhage

• pressure
• gloved hand on squirting blood
• blood pressure cuff
• wrap the pelvis
• femur traction

Intervention: fluid resuscitation

• immediately hang crystalloids
• 4 units pRBC with a pressure bag; O+ if a man, O- if a woman
• 1:1:1 pRBC, platelets, FFP therafter

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Deficit

Deficit

AVPU

GCS

pupils: is one pupil blown?

Are they moving all four limbs?

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Exposure

Completely expose the patient. Look at every square inch of body surface.

logroll the patient

rectal examination (rectal tone, high-riding prostate, gross blood)

urethral meatus for blood

• Foley catheter

Keep the patient warm.

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Secondary Survey

 

 

Adjuncts and tests

pulse oximeter

cardiac monitor

Foley catheter (avoid with blood at the meatus, high-riding prostate, or perianal bruising)

NG tube

 

Diagnostic tests

• chest X-ray
• pelvic X-ray
• C-spine X-ray
• ECG
• pregnancy test
• labs:

 

Definitive Management

Trauma series: CXR, lateral C-spine, pelvis

DPL, US, CT

FAST: focused abdominal sonography for trauma

• pericardial
• perihepatic
• perisplenic
• pelvic

 

Resources and References

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