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chapter 1. Initial Assessment and Management

Anesthesiology RS Husada
Initial Assestment :
• Preparation
• Triage
• Primary survey (ABCDEs)
• Resuscitation
• Adjuncts to primary survey and resuscitation
• Consideration of the need for patient transfer
• Secondary survey (head-to-toe evaluation and patient history)
• Adjuncts to the secondary survey
• Continued postresuscitation monitoring and reevaluation
• Definitive care

The primary survey should be repeated frequently to identify any deterioration

in the patient’s status that indicates the need for additional intervention.

The primary and secondary surveys should be repeated frequently to identify

any change in the patient’s status that indicates the need for additional
Prehospital Phase
During the prehospital phase,
emphasis should be placed on
airway maintenance, control of
external bleeding and shock,
immobilization of the patient, and
immediate transport to the closest
appropriate facility, preferably a
verified trauma center.
Hospital Phase
• A resuscitation area should be available for
trauma patients.
• Properly functioning airway equipment
(e.g., laryngoscopes and tubes) should be
organized, tested, and strategically placed
where it is immediately accessible. Warmed
intravenous crystalloid solutions should be
immediately available for infusion, as should
appropriate monitoring devices.
• All personnel who are likely to have contact
with the patient must wear standard
precaution devices.
• A protocol to summon additional medical
assistance should be in place, as well as a
means to ensure prompt responses by
laboratory and radiology personnel.
• Triage involves the sorting of patients based on their needs for treatment and the
resources available to provide that treatment. Treatment is rendered based on the
ABC priorities (Airway with cervical spine protection, Breathing, and Circulation
with hemorrhage control).

• Other factors that may affect triage and treatment priority include injury severity,
salvageability, and available resources.

• Triage also includes the sorting of patients in the field so that a decision can be
made regarding the appropriate receiving medical facility. It is the responsibility of
prehospital personnel and their medical directors to ensure that appropriate
patients arrive at appropriate hospitals.
Triage situations are categorized as multiple casualties or mass casualties.

• In multiple-casualty incidents, although there is more than one patient,

the number of patients and the severity of their injuries do not exceed the
capability of the facility to render care. In such situations, patients with
life-threatening problems and those sustaining multiple-system injuries
are treated first.

• In mass-casualty events, the number of patients and the severity of their

injuries exceed the capability of the facility and staff. In such situations,
the patients having the greatest chance of survival and requiring the least
expenditure of time, equipment, supplies, and personnel, are treated first.
Primary Survey (ABCDEs) +
– Airway maintenance with cervical spine protection
– Breathing and ventilation
– Circulation with hemorrhage control
– Disability: Neurologic status
– Exposure/Environmental control: Completely undress the patient, but
prevent hypothermia

What is a quick, simple way to assess a patient in 10 seconds?

ASKING THE PATIENT FOR HIS OR HER NAME, and asking what happened.
?? An appropriate response suggests that there is no major airway compromise
(ability to speak clearly), breathing is not severely compromised (ability to generate
air movement to permit speech), and there is no major decrease in level of
consciousness (alert enough to describe what happened).
?? Failure to respond to these questions suggests abnormalities in A, B, or C that
warrant urgent assessment and management.
• Upon initial evaluation of a trauma
patient, the airway should be
assessed first to ascertain patency.

• This rapid assessment for signs of

airway obstruction should include
suctioning and inspection for foreign
bodies and facial, mandibular, or
tracheal/laryngeal fractures that can
result in airway obstruction.
Airway maintenance
with cervical spine protection
• The airway should be protected in all patients and secured when there is a
potential for airway compromise. The jaw-thrust or chin-lift maneuver may
suffice as an initial intervention.
• If the patient is unconscious and has no gag reflex, the establishment of an
oropharyngeal airway can be helpful temporarily.
• A definitive airway (i.e., intubation) should be established if there is any doubt
about the patient’s ability to maintain airway integrity. Patients with Glasgow
Coma Scale score of 8 or less (severe head injuries) usually require the
placement of a definitive airway (i.e., cuffed, secured tube in the trachea).
• An airway should be established surgically if intubation is contraindicated or
cannot be accomplished.
This procedure should be performed with continuous protection of
the cervical spine.
Airway maintenance
with cervical spine protection
Assume a cervical spine injury in patients
with blunt multisystem trauma, especially
those with an altered level of consciousness
or a blunt injury above the clavicle.

• Evaluation and diagnosis of specific spinal

injury, including imaging, should be done

• If immobilization devices must be removed

temporarily, one member of the trauma
team should manually stabilize the patient’s
head and neck using inline immobilization
• Adequate gas exchange is required to
maximize oxygenation and carbon
dioxide elimination.
• Injuries that severely impair ventilation in
the short term include tension
pneumothorax, flail chest with
pulmonary contusion, massive
hemothorax, and open pneumothorax.
These injuries should be identified during
the primary survey and may require
immediate attention for ventilatory efforts
to be effective.
• Simple pneumothorax or hemothorax,
fractured ribs, and pulmonary contusion
can compromise ventilation to a lesser
degree and are usually identified during
the secondary survey.
Breathing, Ventilation, and
• A tension pneumothorax compromises ventilation and
circulation dramatically and acutely; if one is suspected, chest
decompression should follow immediately.
• Every injured patient should receive supplemental oxygen. If
not intubated, the patient should have oxygen delivered by a
mask-reservoir device to achieve optimal oxygenation. The pulse
oximeter should be used to monitor adequacy of oxygen
hemoglobin saturation.
• Maintaining oxygenation and preventing hypercarbia are critical
in managing trauma patients, especially those who have
sustained head injuries.
• Circulatory compromise in trauma
patients can result from many different
injuries. Blood volume, cardiac output,
and bleeding are major circulatory
issues to consider.
• Once tension pneumothorax has been
eliminated as a cause of shock,
hypotension following injury must be
considered to be hypovolemic in origin
until proven otherwise.
• Definitive bleeding control is essential
along with appropriate replacement of
intravascular volume.
• The elements of clinical observation
that yield important information within
seconds are level of consciousness,
skin color, and pulse.
Circulation with hemorrhage control
• Rapid, external blood loss is managed by direct manual pressure on
the wound. Tourniquets are effective in massive exsanguination
from an extremity, but carry a risk of ischemic injury to that
extremity and should only be used when direct pressure is not
• The major areas of internal hemorrhage are the chest, abdomen,
retroperitoneum, pelvis, and long bones.

• The source of the bleeding is usually identified by physical

examination and imaging (e.g., chest x-ray, pelvic x-ray, Diagnostic
Peritoneal Lavage [DPL] or Focused Assessment Sonography in
Trauma [FAST]).
• Management may include chest decompression, pelvic binders,
splint application, and surgical intervention.
Exposure/Enviromental Control
After the patient’s clothing has been removed and the assessment is
completed, the patient should be covered with warm blankets or an
external warming device to prevent hypothermia in the trauma receiving
area. Intravenous fluids should be warmed before being infused, and a
warm environment (i.e., room temperature) should be maintained.
Adjuncts to Primary Survey and
• Adjuncts that are used during the primary survey include :
– Electrocardiographic monitoring; urinary and gastric catheters;
other monitoring, such as ventilatory rate, arterial blood gas
(ABG) levels, pulse oximetry, blood pressure, pulse rate, body
temperature, and x-ray examinations (e.g., chest and pelvis)

• Urethral injury should be suspected in the presence of one

of the following:
– Blood at the urethral meatus
– Perineal ecchymosis
– High-riding or nonpalpable prostate
Adjuncts to Primary Survey and

Consider Need for Patient Transfer

• During the primary survey and resuscitation phase, the evaluating
physician frequently obtains enough information to indicate the
need to transfer the patient to another facility.
Secondary Survey
What is the secondary survey, and when does it start?
The secondary survey does not begin until the primary
survey (ABCDEs) is completed, resuscitative efforts are
underway, and the normalization of vital functions has
been demonstrated.
When additional personnel are available, part of the
secondary survey may be conducted while the other
personnel attend to the primary survey. In this setting the
conduction of the secondary survey should not interfere with
the primary survey, which takes first priority.
Secondary Survey
The secondary survey is a head-to-toe evaluation of the
trauma patient, that is, a complete history and physical
examination, including reassessment of all vital signs.
– AMPLE history (Allergies ; Medications currently used ; Past
illnesses/Pregnancy ; Last meal ; Events/Environment related to
the injury)
– Complete patient evaluation requires repeated physical
examinations. During the secondary survey, a complete
neurologic examination is performed, including a repeat GCS
score determination.
– Special procedures, such as specific radiographic evaluations
and laboratory studies, also are performed at this time.
Adjuncts to the Secondary Survey
These include :
• Additional x-ray examinations of the spine and extremities; CT scans of the
head, chest, abdomen, and spine; contrast urography and angiography;
transesophageal ultrasound; bronchoscopy; esophagoscopy; and other
diagnostic procedures

Trauma patients must be reevaluated constantly to ensure that new findings
are not overlooked and to discover deterioration in previously noted

Definitive Care
Which patients do I transfer to a higher level of care? When should the
transfer occur?