Specialists Without Borders

Seminar in Surgery
Rwanda, September 2010

Early Assessment and

Management of Trauma
Frank Stening
Australia
 Objectives

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 patients history
and mechanism of injury
Anticipate pitfalls
 KEY QUESTION

How do we minimise MISSED injuries ?

How do we improve survival rates ?

( Who needs transfer

When do they need transfer )
 Concepts of Initial Assessment

Rapid primary survey

Resuscitation
Adjuncts to primary survey/resuscitation
Detailed secondary survey
Adjuncts to secondary survey
Re-evaluation
Definitive care
 INITIAL MANAGEMENT AND
ASSESSMENT
1. Preparation
2. Triage
3. Primary survey (ABCs)
4. Resuscitation
5. Secondary survey (Head-to-toe)
6. Continued post resuscitation monitoring
and re-evaluation
7. Definitive care
 Initial Assessment

Primary survey and

resuscitation of vital
functions are done
simultaneously
= a team approach
 Triage

Sorting of patients according to:

ABCDEs
Available resources
Multiple casualties
Mass casualties
A quick, simple way to assess the
patient in 10 seconds

Identify yourself
Ask the patient his / her name
Ask the patient what happened
 ... an appropriate response
suggests:

Patent airway
Sufficient air reserve to permit speech
Clear sensorium

Now proceed to a rapid primarysurvey

 Primary Survey EMST

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
 Special Groups to Consider

Children
Elderly
Pregnant women
 Primary Survey

Establish Patent Airway

Beware C-spine injury
Pitfalls
Equipment failure
Caution
Inability to intubate
Occult airway injury
Progressive loss of airway
 Primary Survey

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

Assessment of Organ Perfusion

Level of consciousness
Skin colour and temperature
Pulse rate and character
 Primary Survey

Circulatory Management
Control haemorrhage
Restore volume
Reassess

Pitfalls
Caution Elderly Children
Athletes Medications
 Primary Survey

Disability
Baseline neurologic evaluation
GCS scoring
Pupillary response

Caution Observe for

neurologic
deterioration
 Primary Survey

Exposure / Environment
Completely undress the patient

Caution Prevent hypothermia

 Adjuncts to Primary Survey

Vital signs
ECG ABGs
Urinary Adjuncts
Pulse
output oximeter
and CO2
Urinary/gastric
catheters unless
contraindicated
 PRIORITY PLAN

X-RAYS
(should be used judiciously and should
not delay resuscitation)

Lateral cervical spine

AP chest
AP pelvis
 Adjuncts to Primary Survey

Diagnostic Tools
Chest and pelvic x-rays
DPL
Ultrasound
 Secondary Survey

What is secondary survey?

Available history and head-to-toe examination

When do I start?
After primary survey complete
After ABCDEs re-assessed
Vital functions are returning to normal
 Secondary Survey

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

History
A Allergies
M Medications
P Past illnesses
L Last meal
E Events / Environment
 Secondary Survey
Mechanisms of Injury
 Secondary Survey

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

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

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

Neck (Soft tissues)

Mechanism: Blunt vs Pitfalls
penetrating Delayed
Symptoms: Airway symptoms/signs
obstruction, Progressive
hoarseness airway
obstruction
Findings: Crepitus,
Occult injuries
haematoma, stridor,
bruit
 Secondary Survey

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

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

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

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

Musculoskeletal: Pelvis

Pain on palpation
Symphysiswidth
Leg length uneven
X-rays as needed
 Secondary Survey

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

NEUROLOGIC
Spine / Cord
Complete motor and sensory exam
Imaging as indicated
Reflexes
 Secondary Survey

Neurologic
Pitfalls
Incomplete immobilisation
Subtle in ICP with manipulation
Rapid deterioration
 Re-evaluation

Minimising Missed Injuries

High index of suspicion
Frequent re-evaluation and monitoring
 Re-evaluation

Pain Management
Relief of pain/anxiety as appropriate
Administer intravenously
Careful monitoring is essential
 PRIORITY PLAN

DEFINITIVE CARE

After identifying the patients injuries,

managing life threatening problems and
obtaining special studies
 SUMMARY

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