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Primary Survey and Resuscitation

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Topic updated on 06/18/17 9:05am

Snapshot
  • A 30-year-old man presents to the ED after being hit by a large truck. He is brought on a backboard with a cervical collar. Oropharyngeal airway mask and one peripheral IV with fluid running are in place. Multiple lacerations on his scalp and thighs are wrapped in dressings. Blood pressure is 80/40 mmHg, pulse is 140/min, respirations are 40/min, and SaO
    2
    is 92% on RA.
Overview
  • Most common method of initial trauma assessment in the United States is based on Advanced Trauma Life Support (ATLS) course from American College of Surgeons
    • goal is to treat greatest threats to life immediately
    • lack of definitive diagnosis and detailed history should not impede therapy
Presentation
  • Trauma patient can present to the ED from multiple different scenarios
    • blunt trauma, motor vehicle collisions, falls are most common
    • penetrating trauma (guns/knives/others)
    • environmental injuries
      • burn
      • cold
      • electric
      • smoke
      • bite
  • Precipitating factors to trauma must also be considered: 6 S's
    • Seizure, Syncope, Sugar (hypoglycemia), Suicide, Sleep (abnormality), Sauce (alcohol)
Diagnosis
  • Primary survey (often concurrent with resuscitation): ABCDE
    • Airway
      • signs of obstruction: agitation, confusion, respiratory distress, failure to speak, cyanosis
    • Breathing
      • observe for altered mental status, chest movement, nasal flaring
      • listen for signs of obstruction (stridor, asymmetry, air escape)
      • feel for trachael shift, crepitus, flail segments, subcutaneous emphysema
      • objective signs: rate, oximetry, ABG, A-a gradient
    • Circulation
      • look for evidence of shock
        • shock in trauma patient is hemorrhagic until proven otherwise
      • early signs: tachycardia, tachypnea, narrow pulse pressure, reduced capillary refill, cool extremities
      • late signs: hypotension, altered mental status, reduced urine output
    • Disability
      • level of consciousness assessed by Glasgow Coma Scale (GCS)
        • good indicator of injury severity and neurosurgical prognosis
        • change in GCS with time is more relevant than absolute number
        • reported as 3-part score based on eye movement, verbal response, motor response
          • score 13 - 15: mild injury
          • score 9 - 12: moderate injury
          • score < 9: severe injury
            • must protect airway in this situation
    • Exposure/Environment
      • undress patient completely and assess entire body for injury
      • logroll to examine back
      • digital rectal exam
Management
  • Resuscitation done at the time as primary survey, with focus on ABC
    • Airway
      • temporizing measures
        • protect C-spine
        • head-tilt or jaw thrust to open airway
        • nasopharyngeal airway if gag reflex present (i.e., conscious)
        • oropharyngeal airway if gag reflex absent (i.e., unconscious)
      • definitive measures
        • endotracheal tube intubation
          • indications
            • unable to protect airway (GCS < 8; airway trauma)
            • inadequate oxygenation (SaO
              2
              <90% on 100% O
              2
              )
            • profound shock
            • anticipatory: in trauma, overdose, CHF, asthma, COPD, smoke inhalation injury
            • anticipated transfer of critically ill patient 
          • contraindication: supraglottic / glottic pathology
          • does not provide 100% protection against aspiration
        • surgical airway (if unable to intubate and unable to ventilate)
          • cricothyroidotomy
    • Breathing
      • in order of increasing FiO
        2
        : nasal cannula, face mask, non-rebreather, CPAP/BiPAP
      • bag-valve mask and CPAP/BiPAP used to supplement inadequate ventilation
    • Circulation
      • monitor vital signs, ECG, oxygen saturation
      • if bleeding externally, apply direct pressure and elevate extremities if possible
        • do NOT remove impaled objects as they tamponade hemorrhage
          • impaled objects are only removed in the OR
        • tourniquet as last resort
      • resuscitation
        • 1 to 2 L crystalloid (NS, LR) with large bore IVs (warmed if possible)
        • consider pRBC transfusion if severely hypotensive
          • crossmatched or type-specific blood ideal
          • if unavailable, use O-negative in children/women of child-bearing age or O-positive in all others
        • with significant hemorrhage, massive transfusion protocol may be necessary
      • Advance Cardiac Life Support (ACLS) algorithm as necessary for arrhythmias
      • Foley catheter and NG tube if indicated
        • contraindications to Foley insertion
          • blood at urethral meatus
          • scrotal hematoma
          • high-riding prostate on digital rectal exam
        • contraindications to NG tube insertion
          • significant mid-face trauma
          • basilar skull fracture
    • proceed to detailed secondary survey and definitive care

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