Initial Assessment and Resuscitation

in Trauma Patient

According the World Health Organization (WHO) and the Centers for

Disease Control (CDC), more than 9 people die every minute from injuries or

violence with 5.8 million people of all ages die every year from unintentional

injuries and violence. Motor vehicle crashes referred to as road traffic injuries cause

more than 1 million deaths annually, with the highest distribution of death related

injury are in developing countries. The death trimodal of first peak are due to lethal

injuries, second peak because of life threatening injury, and third peak is due to the

complication of injury.

The approach of managing injury is following ATLS sequence consist of

pre hospital phase and hospital phase adjusted accordingly to categorize based on

triage concept for multiple and mass casualties. Standard primary survey (ABCDE)

with adjunct and resuscitation of patients with life-threatening injuries is followed

by whether secondary survey for stable patient or damage control for the unstable

one. The primary and secondary surveys are repeated frequently

to identify any change in the patient’s status that indicates the need for additional

intervention.

Pre hospital phase consist of Airway maintenance, Control of external

bleeding and shock, Immobilization of the patient, Immediate transport to the

closest appropriate facility, preferably a verified trauma center. Prehospital

providers must make every effort to minimize scene time, a concept that is
supported by the Field Triage Decision Scheme. Hospital phase is the hand-over

between prehospital providers and those at the receiving hospital should be a

smooth process, directed by the trauma team leader, ensuring that all important

information is available to the entire team. The critical aspect in hospital preparation

are:

 Resuscitation area is available for trauma patients

 Properly functioning airway equipment (e.g., laryngoscopes and

endotracheal tubes) is organized, tested, and strategically placed to

be easily accessible.

 Warmed intravenous crystalloid solutions are immediately available

for infusion

 A protocol to summon additional medical assistance.

 A protocol to summon additional medical assistance.

The triage concept involves the sorting of patients based on the resources

required for treatment and the resources that are actually available. The order of

treatment is based on:

 the ABC priorities

 The severity of injury

 Ability to survive

 Available resources

In triage concept there is a difference based on the number of casualty. Multiple

casualty is incidents are those in which the number of patients and the severity of
their injuries do not exceed the capability of the facility to render care. Mass

casualties the number of patients and the severity of their injuries does exceed the

capability of the facility and staff.

Primary survey is simultaneously done with resuscitation consists of:

1. Airway maintenance with restriction of cervical spine motion

2. Breathing and ventilation

3. Circulation with hemorrhage control

4. Disability(assessment of neurologic status)

5. Exposure/Environmental control

In managing airway maintenance with restriction of cervical spine motion,

First assess the airway to ascertain patency. Establish a patent airway while

restricting cervical spine motion. This rapid assessment is to find any signs of

airway obstruction includes inspecting for foreign bodies, identifying facial,

mandibular, and/or tracheal/laryngeal fractures, other injuries that can result in

airway obstruction. Initially, the jaw-thrust or chin-lift maneuver often suffices as

an initial intervention.

Establish a definitive airway if there is any doubt about the patient’s ability

to maintain airway integrity. If the patient is unconscious and has no gag reflex, the

placement of an oropharyngeal airway can be helpful temporarily. If Patients with

severe head injuries or GCS < 8, require the placement of a definitive airway (i.e.,

cuffed, secured tube in the trachea). While assessing and managing a patient’s

airway, take great care to prevent excessive movement of the cervical spine. Based

on the mechanism of trauma, assume that a spinal injury exists. The spine must be
protected from excessive mobility to prevent development of or progression of a

deficit. The cervical spine is protected with a cervical collar.

The next step is assessing the breathing and ventilation. To adequately

assess jugular venous distention, position of the trachea, and chest wall excursion,

expose the patient’s neck and chest. Visual inspection and palpation can detect

injuries to the chest wall that may be compromising ventilation. Percussion of the

thorax can also identify abnormalities, but during a noisy resuscitation this

evaluation may be inaccurate, and also perform auscultation to ensure gas flow in

the lungs. Injuries that significantly impair ventilation are:

 Tension pneumothorax

 Massive hemothorax

 Open pneumothorax

 Tracheal or bronchial injuries

Injury that can compromise ventilation to a lesser degree and are usually identified

during the secondary survey are:

 Simple pneumothorax

 Simple hemothorax

 Fractured ribs

 Flail chest

 Pulmonary contusion

Every injured patient should receive supplemental oxygen. If the patient is

not intubated, oxygen should be delivered by a mask-reservoir device to achieve

optimal oxygenation. Use a pulse oxymeter to monitor adequacy of hemoglobin

oxygen saturation. A simple pneumothorax can be converted to a tension

pneumothorax when a patient is intubated and positive pressure ventilation is

provided before decompressing the pneumothorax with a chest tube.

Circulation and hemorrhagic control are the next vital step. Major

circulatory issues to consider are blood volume and cardiac output and bleeding

which directly contribute to the ‘triad of death’. The elements of clinical

observation that yield important information within seconds are:

 Level of Consciousness

o When circulating blood volume is reduced, cerebral

perfusion may be critically impaired, resulting in an altered

level of consciousness.

 Skin Perfusion

o Helpful in evaluating injured hypovolemic patients

o Patient with pink skin, especially in the face and extremities,

rarely has critical hypovolemia after injury.

o Patient with hypovolemia may have ashen, gray facial skin

and pale extremities.

 Pulse

o Rapid, thready pulse is typically a sign of hypovolemia.

It is important to identify the source of bleeding whether it’s an external or internal

hemorrhage.
 The concept of resuscitation in circulation is that a definitive bleeding

control is essential. Vascular access must be established with two large-bore

peripheral venous catheters are placed to administer fluid, blood, and plasma. Blood

samples for baseline hematologic studies are obtained. To assess the presence and

degree of shock, blood gases and/or lactate level are also obtained. When peripheral

sites cannot be accessed, intraosseous infusion, central venous access, or venous

cut down may be used depending on the patient’s injuries and the clinician’s skill

level.

Aggressive and continued volume resuscitation is not a substitute for

definitive control of hemorrhage. Since shock associated with injury is most often

hypovolemic in origin, initiate IV fluid therapy with crystalloids as soon as

possible. All IV solutions should be warmed either by storage in a warm

environment (37°C - 40°C) or administered through fluid warming devices. A bolus

of 1 L of an isotonic solution may be required to achieve an appropriate response

in an adult patient. If the patient is unresponsive to initial crystalloid therapy, blood

transfusion is indicated. Fluids are administered judiciously, as aggressive

resuscitation before control of bleeding has been demonstrated to increase mortality

and morbidity. Awareness should be given in severely injured trauma patients since

they are at risk for coagulopathy, which can be further fueled by resuscitative

measures. One study that evaluated trauma patients receiving fluid in the ED found

that crystalloid resuscitation of more than 1.5 L independently increased the odds

ratio of death. European and American military studies demonstrate improved

survival when tranexamic acid is administered within 3 hours of injury. When

bolused in the field follow up infusion is given over 8 hours in the hospital.
 A rapid neurological evaluation as the next step in primary survey is to

identify the presence of patient’s level of consciousness, pupillary size and reaction,

lateralizing signs, determines spinal cord injury level. The GCS is a quick, simple,

and objective method of determining the level of consciousness.

There are several concept that should be remembered in the next step of

primary survey. Such as:

 Completely undress the patient

 Facilitate a thorough examination and assessment

 Cover the patient with warm blankets or an external warming device to

prevent from developing hypothermia in the trauma receiving area

 Warm intravenous fluids before infusing them, and maintain a warm

environment

Adjuncts to the primary survey such as:

 ECG

o Dysrhythmias—including unexplained tachycardia, atrial

fibrillation, premature ventricular contractions, and ST segment

changes—can indicate blunt cardiac injury

o Pulseless electrical activity (PEA) can indicate cardiac

tamponade, tension pneumothorax, and/or profound

hypovolemia
 o Bradycardia, aberrant conduction, and premature beats are

present, hypoxia and hypoperfusion should be suspected

immediately

o Extreme hypothermia also produces dysrhythmias

 Vital sign

 ABGs

 Pulse oxymeter and CO2

o The relative absorption of light by oxyhemoglobin (HbO) and

deoxyhemoglobin is assessed by measuring the amount of red

and infrared light emerging from tissues traversed by light rays

and processed by the device, producing an oxygen saturation

level

o In addition, hemoglobin saturation from the pulse oxymeter

should be compared with the value obtained from the ABG

analysis. Inconsistency indicates that one of the two

determinations is in error.

 Urinary / gastric catheters unless contraindicated

 Imaging X Ray

 Urinary output

The secondary survey does not begin until the primary survey (ABCDE) is

completed, resuscitative efforts are under way, and improvement of the patient’s

vital functions has been demonstrated. The secondary survey is a head-to-toe

evaluation of the trauma patient are a complete history, physical examination,

reassessment of all vital signs. History consist of AMPLE which stands for

Allergies, Medications currently used, Past illnesses/Pregnancy, Last meal, and

Events/Environment related to the injury. And followed by physical examination.

Physical examination consist of a complete examination from head to toe.