Survey
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Chapter 1 Apply principles of primary and secondary surveys Identify management priorities Institute appropriate resuscitation and monitoring procedures Recognize value of patient’s history and biomechanics of injury Anticipate pitfalls How do I prepare for a smooth transiiton from the prehospital to the hospital environments? What is a quick, simple way to assess the patient in 10 seconds? What is the secondary survey and when does it start? How can I minimize missed injuries? Which patients do I transfer to a higher level of care? When should the transfer occur? Primary survey Adjuncts Definitive care Resuscitation Reevaluation Reevaluation Detailed secondary survey Adjuncts Primary survey and resuscitation of vital functions are done simultaneously in a team approach Transport guidelines/protocols Online medical direction Mobilization of resources Periodic review of care Closest, appropriate facility Preplanning is essential Equipment, personnel, services Standard precautions Prearranged transfer agreements Cap Gown Gloves Mask Shoe covers Goggles/face shield Triage is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. Sorting of patients according to ◦ ABCDEs ◦ Available resources Identify yourself Ask the patient his/her name Ask the patient what happened A – patent airway B – sufficient air reserve to permit speech CD – clear sensorium If no response, proceed with rapid primary survey. A – Airway B – Breathing/ventilation/oxygenation C – Circulation: Stop the bleeding D – Disability (neuro status) E – Expose/environment/body temperature Trauma in the elderly Pediatric trauma Trauma in pregnant women Establish patent airway ◦ Protect c-spine ◦ Pitfalls? Equipment failure Inability to intubate Occult airway injury Progressive loss of airway Assess and ensure adequate oxygenation and ventilation Pitfalls ◦ Airway vs ventilation problem? ◦ Iatrogenic pneumothorax or tension pneumothorax Level of consciousness Skin color and temperature Pulse rate and character Circulatory Management ◦ Control hemorrhage ◦ Restore volume ◦ Reassess parameters Pitfalls? ◦ ◦ ◦ ◦ Elderly Children Athletes Medication Disability ◦ Baseline neurologic evaluation ◦ GCS scoring ◦ Pupillary response Observe for neurologic deterioration Exposure/Environment ◦ Completely expose the patient Prevent hypothermia Protect and secure airway Ventilate and oxygenate Stop the bleeding Vigorous shock therapy Protect from hypothermia Vital Signs Catheters/ Output ADJUNCTS ECG ABGs/Pulse oximeter Diagnostic tools FAST (Focused Assessment Sonography in Trauma) DPL (Diagnostic Peritoneal Lavage) Consider Early Transfer ◦ Do not delay transfer for diagnostic tests ◦ Use time before transfer for resuscitation The complete history and physical examination. After ◦ Primary survey is completed ◦ ABCDEs are reassessed ◦ Vital functions are returning to normal History Physical exam: Head-to-toe “Tubes and fingers in every orifice” Complete neurologic exam Special diagnostic tests Reevaluation History A M P L E = = = = = Allergies Medications Past illnesses Last meal Events/environment Mechanisms of injury HEAD ◦ Glascow Coma Score (GCS) ◦ Neuro exam ◦ Comprehensive eye and ear exam Pitfalls? ◦ Unconsciousness ◦ Periorbital edema ◦ Occluded auditory canal Maxillofacial ◦ Bony crepitus ◦ Deformity ◦ Malocclusion Pitfalls ◦ Potential airway obstruction ◦ Cribriform plate fracture ◦ Frequently missed Cervical spine ◦ ◦ ◦ ◦ Tenderness Complete motor/sensory exams Reflexes Imaging studies if warranted Pitfalls ◦ Altered consciousness ◦ Inability to cooperate with clinical exam Neck (soft tissues) ◦ Mechanism: Blunt vs penetrating ◦ Symptoms: Airway obstruction, hoarseness ◦ Findings: Crepitus, hematoma, stridor, bruit Neck (soft tissue): Pitfalls ◦ Delayed symptoms and signs ◦ Progressive airway obstruction ◦ Occult injuries Chest ◦ ◦ ◦ ◦ ◦ ◦ Inspect Palpate Percuss Auscultate (aka IPPA) Obtain X-rays if indicated Abdomen ◦ IAPP – in this case, auscultation is done before percussion ◦ Reevaluate ◦ Special studies (CT>FAST>DPL) Abdomen: Pitfalls? ◦ Hollow viscus injury ◦ Retroperitoneal injury ◦ Excessive pelvic manipulation Peritoneum Contusions, hematomas, lacerations, urethral blood Rectum Sphincter tone, highriding prostate, pelvic fracture, rectal wall integrity, blood Vagina Blood, lacerations Pitfalls? Urethral injury in women, pregnancy Musculoskeletal: Extremities ◦ ◦ ◦ ◦ ◦ Contusion, deformity Pain Perfusion Peripheral neurovascular status X-rays as indicated Musculoskeletal: Pelvis ◦ ◦ ◦ ◦ Pain on palpation Symphysis width increasing Leg length unequal Instability Musculoskeletal: Pitfalls? ◦ ◦ ◦ ◦ Potential blood loss Missed fractures Soft-tissue or ligamentous injury Compartment syndrome Neurologic: Brain ◦ ◦ ◦ ◦ ◦ GCS score Lateralizing signs Frequent evaluation Imaging as indicated Prevent secondary brain injury Early neurological consult Neurologic: Spinal cord ◦ Complete motor and sensory exams ◦ Imaging as indicated ◦ Reflexes Early neurological/orthopedic consult Special diagnostic tests as indicated Pitfalls: ◦ Patient deterioration ◦ Delay of transfer ◦ Missed injuries: High index of suspicion Relief of pain/anxiety as appropriate Administer IV Careful monitoring Those whose injuries exceed institutional capabilities When do I transfer? ◦ As soon as possible after stabilizing ◦ Avoid needless delay Primary survey Adjuncts Resuscitation Secondary survey Adjuncts Definitive care
