The Initial Assessment OF THE MULTIPLY INJURED PATIENT

1. The InitialAssessmentOF THE MULTIPLY INJURED PATIENT

2. Objectives • Identify the correct sequence of priorities in the assessment of an injured patient • Outline the components of the primary and secondary surveys • Explain the techniques used in the initial resuscitation phase.

3. Introduction The initial assessment aims: • Rapid assessment • Rapid life preserving therapy • Prevents further damage to the patient. It consists of: • Preparation • Triage • Primary survey • Resuscitation • Secondary survey • Continued resuscitation • Definitive care

4. Preparation and Triage Preparation • Pre-hospital Phase • Hospital notification • Airway maintenance, control external bleeding, immobilization and transportation. • In-hospital phase • Fluids and equipment • Adequate and appropriate personnel • Universal precaution Triage Sorting patients based on the need for treatment and the available facilities.

5. Primary Survey A Airway with Cervical Spine Control B Breathing and ventilation C Circulation D Disability: neurological status E Exposure/ Environmental control

6. A Airway with cervical spine control Assume C-spine injury in all patients Assess airway compromise • Is the patient talking or Apnoeic • Look for signs of: • Agitation and aggression • Foreign bodies, dislodged teeth • Facial fractures and injuries to the neck (trachea and Larynx). • Listen for abnormal breathing sounds, stridor or hoarseness. • Feel for the movement of air.

7. A Airway with cervical spine control Management: • In-line immobilization of the neck and triple neck support • Remove foreign body and suction • Administer oxygen 100% • Chin lift and jaw thrust manoeuvres • Oro-pharyngeal air way

8. B Breathing • Determine centrality of the trachea and apex beat • Look for symmetrical expansion and respiratory rate. • Look for obvious contusion, laceration or flail segments. • Listen for movements of air: normal, absent or decreased • Listen for heart sounds: normal or muffled • Recognise specific life-threatening conditions: Action: • Oxygen supplementation 100% reservoir mask. • Treatment of specific disease entities. • Definitive air-way and assisted ventilation.

9. C Circulation • Assess the severity of blood loss: • Conscious Level: if confused indicates 30-40%, 2L blood loss • Skin colour: dusky colour indicates at least 30% blood loss • Blood pressure: may be maintained in up to 30 % loss • Pulse: Carotid or femoral • If rapid may indicate hypovolaemia or pain and anxiety. • Irregular pulse may indicate cardiac contusion • Look for narrow complex tachy. • Be aware of differences due to age and physiological status. • Look for obvious source of bleeding Action: • 2 large bore cannulae established at the antecubital fossa • Draw blood for cross-match and base line lab investigations and pregnancy tests. • Rapid administration of warmed crystalloid solution • Administer type specific or O negative blood if patient not responsive • Prevent hypothermia • Start ECG monitoring

10. D Disability A Alert V Responsive to verbal stimuli P Responsive only to painful stimuli U Unresponsive Altered level of consciousness may indicate: • Head injury • Shock • Hypoxia • Drug/ Alcohol

11. At the End of the Primary Survey • Assessment and management of:A,B,C,D is completed. • ABG • ECG, pulse oximeter, BP Cuff placed • Urinary catheter and Naso-gastric tube inserted • X rays requested: • AP chest • AP pelvis • Lateral C-spine • Consider system involvement and surgical specialities required. • Consider need for patient transfer

12. AMPLE Key terminology A Allergies M Medication P Past illnesses L Last Meal E Ethanol/ Drug abuse Mechanism of Injury • Vehicle: Stationary / Slow or High Speed • Pedestrian / Passenger (front or back) / Driver • Head-on / Side impact / Rear impact collision • Restrained / Unrestrained • Helmets • Role over accident • Thrown out of the car.