Early Assessment and Management of Trauma

1. Specialists Without Borders Seminar in Surgery Rwanda, September 2010 Early Assessment and Management of Trauma Frank Stening Australia

2. Identify management priorities Understand concept of Primary and Secondary Survey Institute appropriate resuscitation and monitoring within first 60-120 minutes Recognize the value of the patient’s history and mechanism of injury Anticipate pitfalls Objectives

3. KEY QUESTION How do we minimise MISSED injuries ? How do we improve survival rates ? ( Who needs transfer When do they need transfer )

4. Rapid primary survey Resuscitation Adjuncts to primary survey/resuscitation Detailed secondary survey Adjuncts to secondary survey Re-evaluation Definitive care Concepts of Initial Assessment

5. INITIAL MANAGEMENT AND ASSESSMENT 1. Preparation 2. Triage 3. Primary survey (ABC’s) 4. Resuscitation 5. Secondary survey (Head-to-toe) 6. Continued post resuscitation monitoring and re-evaluation 7. Definitive care

6. Primary survey and resuscitation of vital functions are done simultaneously = a team approach Initial Assessment

7. Sorting of patients according to: ABCDEs Available resources Multiple casualties Mass casualties Triage

8. Identify yourself Ask the patient his / her name Ask the patient what happened A quick, simple way to assess the patient in 10 seconds

9. Patent airway Sufficient air reserve to permit speech Clear sensorium ... an appropriate response suggests: Now proceed to a rapid primarysurvey

10. Adults, paediatric, pregnant women Priorities are the same! A Airway with c-spine protection B Breathing C Circulation with haemorrhage control D Disability E Exposure / Environment Primary Survey EMST

11. Children Elderly Pregnant women Special Groups to Consider

12. Establish Patent Airway Caution Primary Survey • Beware C-spine injury • Pitfalls • Equipment failure • Inability to intubate • Occult airway injury • Progressive loss of airway

13. Breathing Oxygenate Assess Ventilate Caution Primary Survey • Pitfalls • Airway vs ventilation problem? • Iatrogenic pneumothorax/ tension pneumothorax

14. Assessment of Organ Perfusion Level of consciousness Skin colour and temperature Pulse rate and character Primary Survey

15. Circulatory Management Control haemorrhage Restore volume Reassess Caution Primary Survey • Pitfalls • Elderly • Athletes • Children • Medications

16. Disability Baseline neurologic evaluation GCS scoring Pupillary response Caution Primary Survey Observe for neurologic deterioration

17. Exposure / Environment Completely undress the patient Caution Primary Survey Prevent hypothermia

18. Vital signs Adjuncts to Primary Survey ECG ABGs Adjuncts Urinary output Pulse oximeter and CO2 Urinary/gastric catheters unless contraindicated

19. PRIORITY PLAN X-RAYS (should be used judiciously and should not delay resuscitation) Lateral cervical spine AP chest AP pelvis

20. Diagnostic Tools Chest and pelvic x-rays DPL Ultrasound Adjuncts to Primary Survey

21. What is secondary survey? Available history and head-to-toe examination When do I start? After primary survey complete After ABCDE’s re-assessed Vital functions are returning to normal Secondary Survey

22. Key Components History Physical examination: Head-to-toe “Tubes and fingers in every orifice” Complete neuro exam Special diagnostic tests Re-evaluation Secondary Survey

23. History A Allergies M Medications P Past illnesses L Last meal E Events / Environment Secondary Survey

24. Mechanisms of Injury Secondary Survey

25. Head Complete neurologic exam GCS score determination Comprehensive eye exam Pitfalls Unconscious patient Periorbitaloedema Occluded auditory canal Secondary Survey

26. Maxillofacial Bony crepitus/stability Palpable deformity Pitfalls Potential airway obstruction Cribriformplate fracture Frequently missed injury Secondary Survey

27. Cervical Spine Palpate for tenderness Complete motor/sensory exams Reflexes C-spine imaging Pitfalls Altered LOC for any reason Other severe, painful injury Secondary Survey

28. Neck (Soft tissues) Mechanism: Blunt vs penetrating Symptoms: Airway obstruction, hoarseness Findings: Crepitus, haematoma, stridor, bruit Secondary Survey • Pitfalls • Delayed symptoms/signs • Progressive airway obstruction • Occult injuries

29. Chest Inspect Palpate Auscultation Percussion X-rays Secondary Survey • Pitfalls • Elderly • Children

30. Abdomen Inspect, auscultate, palpate, and percuss Re-evaluate frequently Special studies Pitfalls Hollow viscus and retroperitoneal injuries Excessive pelvic manipulation Secondary Survey

31. PerineumContusions, haematomas, lacerations, urethral blood RectumSphincter tone, high-riding prostate, pelvic fracture, rectal wall integrity, blood VaginaBlood, lacerations PitfallsUrethral injury in women, pregnancy Secondary Survey

32. Musculoskeletal: Extremities Contusion, deformity Pain Perfusion Peripheral neurovascular status X-rays as needed Secondary Survey

33. Musculoskeletal: Pelvis Pain on palpation Symphysiswidth ­ Leg length uneven X-rays as needed Secondary Survey

34. Musculoskeletal Pitfalls Potential blood loss Missed fractures Soft-tissue or ligamentous injury Occult compartment syndrome (especially with altered LOC/hypotension) Secondary Survey

35. NEUROLOGIC Spine / Cord Complete motor and sensory exam Imaging as indicated Reflexes Secondary Survey • CNS • Frequent re-evaluation • Prevent secondarybrain injury

36. Neurologic Pitfalls Incomplete immobilisation Subtle ­ in ICP with manipulation Rapid deterioration Secondary Survey

37. Minimising Missed Injuries High index of suspicion Frequent re-evaluation and monitoring Re-evaluation

38. Pain Management Relief of pain/anxiety as appropriate Administer intravenously Careful monitoring is essential Re-evaluation

39. PRIORITY PLAN DEFINITIVE CARE After identifying the patients injuries, managing life threatening problems and obtaining special studies

40. SUMMARY 1. Primary survey 2. Resuscitation Adjuncts 3. Secondary survey 4. Definitive care