Initial Assessment and Management

Initial Assessment and Management

When I can provide better care in the field with limited resources than what my children and I received at the primary care facility --there is something wrong with the system and the system has to be changed.

Initial Assessment and Management

The Concept Treat the greatest threat to life first Lack of a definitive diagnosis should never impede treatment A detailed history was not an essential prerequisite to begin the evaluation of an acutely injured patient

Initial Assessment and Management

The Result A Airway with cervical spine control B Breathing C Circulation D Disability or neurologic status E Exposure (undress) with temperature control

Initial Assessment and Management

INITIAL ASSESSMENT (A systematic approach that can be reviewed and practiced) 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

Primary Survey
A - Airway maintenance with cervical spine control B - Breathing and Ventilation C - Circulation with hemorrhage control D - Disability ; Neurologic status E - Exposure / Environmental Control; Completely undress the patient, but prevent hypothermia Life threatening conditions are identified and management is begun simultaneously Priorities for the care of the pediatric patient are basically the same as for adults

Primary Survey
Airway with Cervical Spine Control Ascertain patency foreign bodies facial, mandibular, tracheal or laryngeal fractures Chin-lift or jaw-thrust maneuver Cervical spine immobilization C-7 to T-1 cross-table lateral cervical spine x-ray Multi-system trauma, altered level of consciousness, or a blunt injury above the clavicle

Primary Survey
Breathing Assure adequate ventilation Function of the lungs, chest wall, and diaphragm Injuries that acutely impair ventilation Tension pneumothorax Flail chest with pulmonary contusion Open pneumothorax Injuries that compromise ventilation to a lesser degree Hemothorax, simple pneumothorax, fractured ribs, and pulmonary contusion

Primary Survey
Circulation with Hemorrhage Control Blood volume and cardiac output Level of consciousness Skin color Pulse Bleeding External, severe hemorrhage is identified and controlled in the primary survey External blood loss is managed by direct manual pressure Hemorrhage into the thoracic or abdominal cavities, into muscles surrounding a fracture, or as a result of penetrating injury can account for major blood loss

Primary Survey
Disability (Neurologic Evaluation) Level of consciousness and pupillary size and reaction A Alert V Responds to Vocal stimuli P Responds to Painful stimuli U Unresponsive Decreased level of consciousness Decreased cerebral oxygenation and/or perfusion Alcohol and drugs

Primary Survey
Exposure / Environmental Control Patient should be completely undressed Cover and protect from hypothermia Warm blankets Intravenous fluids should be warmed Maintain warm environment

Resuscitation
Airway Jaw-thrust or chin-lift maneuver Nasopharyngeal airway Oropharyngeal airway Breathing / Ventilation / Oxygenation Endotracheal intubation Surgical airway Chest decompression Supplemental oxygen therapy

Resuscitation
Circulation Two large-caliber IV catheters Blood type, crossmatch, pregnancy test Balanced salt solution Blood transfusion
Type-specific blood, O-negative blood, unmatched type specific blood

Resuscitation
Urinary and Gastric Catheters Routine urine analysis Urethral injury is suspected if there is:
Blood at the penile meatus Blood in the scrotum Prostate is high-riding or can not be palpated

Blood in the gastric aspirate may represent:

Swallowed blood Traumatic insertion Actual injury to the stomach

Hypovolemic shock should NOT be treated by:

vasopressors, steroids, or sodium bicarbonate

Hypothermia ECG monitoring

If the cribriform plate is fractured or fracture is suspected, NGT should be inserted orally

Resuscitation
Monitoring Ventilatory rate and arterial blood gases End-tidal carbon dioxide monitoring Pulse Oximetry Appropriate oxygenation is a reflection of proper airway, breathing and circulatory status Blood pressure ECG monitoring

Resuscitation
Consider the need for patient transfer Remember: Life-saving measures are initiated when the problem is identified, rather than after the primary survey During the primary survey and the resuscitation phase, the evaluating physician frequently has enough information to indicate the need for transfer of the patient to another facility Referring physician to receiving physician communication is essential

Resuscitation
Roentgenograms Should be used judiciously and NOT delay patient resuscitation In blunt trauma, x-rays to be obtained: Cervical spine Chest (AP) Pelvis (AP) After all life-threatening injuries are identified: Complete cervical, thoracic and lumbar spine In penetrating injuries, x-rays are: Chest (AP) Films pertinent to the site of wounding

Secondary Survey
Tubes and fingers in every orifice The secondary survey does not begin until the primary survey (ABCs) is completed, resuscitation is initiated, and the patients ABCs are reassessed Head-to-toe evaluation Complete neurologic examination (GCS) Special procedures Peritoneal lavage, radiologic evaluation, and laboratory studies

Secondary Survey
History A Allergies M Medication currently taken P Past illnesses L Last meal E Events / environment related to the injury Blunt trauma Penetrating trauma Burns Hazardous environment

Secondary Survey
Physical Examination Head Scalp and skull examination Eye and ear examination Maxillofacial Cribriform plate fracture - orogastric intubation Cervical spine and Neck presume injury in patients with maxillofacial or head trauma Extreme care must be taken when removing helmet

Secondary Survey
Physical Examination Chest Visual evaluation
Open pneumothorax, flail chest

Secondary Survey
Physical Examination Abdomen A normal initial examination of the abdomen DOES NOT exclude intra-abdominal injury Candidates for peritoneal lavage
Unexplained hypotension Neurologic injury Impaired sensorium secondary to alcohol or drugs

Palpation
Fractures

Auscultation
Cardiac tamponade - distant heart sounds and narrow pulse pressure, distended neck veins Tension pneumothorax - decreased breath sounds, shock, distended neck veins

Chest X-ray
Widened mediastinum, pneumohemothorax, fractures

Fractures of the pelvis or lower rib cage may hinder adequate abdominal examination

Secondary Survey
Physical Examination Perineum / Rectum / Vagina Rectal Examination
Presence of blood within the bowel lumen High-riding prostate Pelvic fractures Integrity of the rectal wall Quality of the sphincter tone

Secondary Survey
Physical Examination Musculoskeletal Extremities
Deformity, abnormal movement, tenderness, crepitation

Pelvis
Pressure over anterior iliac spine and symphisis pubis Assessment of peripheral pulses

Vaginal Examination
Blood in the vaginal vault Vaginal lacerations Pregnancy test

Ligament rupture, muscle-tendon injury, nerve injury or ischemia

Secondary Survey
Physical Examination Neurologic Motor, sensory, level of consciousness, pupillary reaction Immobilization of the entire patient Cervical collar If there is neurologic deterioration, ABCs must be reassessed

Re-Evaluation
New findings are not overlooked Discover deterioration Underlying medical problems Effective analgesia Monitoring Vital signs Urinary output Arterial blood gas Cardiac monitoring devices

Definitive Care

Roentgenogram

The CLOSEST APPROPRIATE hospital should be chosen based on its overall capabilities to care for the injured patient

Cervical Spine X-ray Cross-table lateral C-1 to C-7

Airway
Chin-lift maneuver

Airway
Nasopharyngeal airway

Airway
Endotracheal Intubation

Surgical Airway
Cricothyroidotomy

Roentgenogram

Roentgenogram

Chest X-ray (AP) Pneumothorax

Pelvic fracture