Initial Assessment and Management

Presented by Fayez Abillama, MD

UMC-RH
ALS, ACLS, ATLS, APLS

 Simple

 Safe
 Systematic
 Initial Assessment and Management

To have a systematic approach for the

management of multiple trauma patients

To know how to identify and manage

life threatening conditions

To know when and what diagnostic

procedures you need

To know how to transfer the patients to

definitive care
Triage and organization of care:

1.Prioritize patients;
obstructed airway receives greater
priority than a stable patient with a
traumatic amputation.
Triage and organization of care:
2.Resource intensive;
how to maximize the number of
patients who are salvaged under the
prevailing conditions.
In this situation you treat those with
best survival chances with the need of
least time and supplies
Triage and organization of care:

3.The care team should be organized

before patient arrival,

leadership and unity of command are

essential.
 Initial Assessment and Management

Pre Hospital Phase :

1. Airway – C spine
2. Immobilization
3. Control of bleeding
4. IV line , Lab test
5. Immediate appropriate transfer
(1) 1ry. Survey and Resuscitation (3) Reevaluation
AB C DE
• Adjuncts to 1ry. Survey

(2) 2ry. Survey (4) Definitive care

Head to toe examination
Tubes and fingers in every orifice
• Adjuncts to 2ry. survey (5) Transfer
 Initial Assessment and Management

1ry. Survey and Resuscitation

Identify and treat life threatening conditions

A Airway + C spine protection

B Breathing + Ventilation

C Circulation + Control of Hemorrhage

D Disabilities ( Neurologic evaluation )

E Exposure + Environmental control

 Initial Assessment and Management

1ry. Survey and Resuscitation

A Airway + C spine protection

• Signs and causes of airway obstruction
• Methods to open the airway
• airway protection is needed when GCS<8
• In line stabilization of C spine :
• Multi system trauma with altered LOC
• Blunt trauma above the clavicle

Rule 1: Frequently evaluate the airway

Rule 2: Definitive airway is indicated if there is doubt

 Establishment of a definitive airway may require
emergency placement of a surgical airway
when facial trauma precludes orotracheal intubation.
Courtesy of Kevin Kilgore, MD; Carson Harris, MD;
and David Hale, MD, Regions Hospital, St Paul, Minn.
 Initial Assessment and Management

1ry. Survey and Resuscitation

A Airway + C spine protection

Pitfalls
• Obese short neck patient
• ET tube in patient with incomplete upper airway transection

or laryngeal fracture
• Inability to intubate after paralysis
• Equipment failure
 Initial Assessment and Management

1ry. Survey and Resuscitation

B Breathing and Ventilation

1. Expose the chest and Assess RR, R depth and Type
2. Give oxygen
3. Check chest wall, lungs and diaphragm by inspection , palpation,
percussion and auscultation
4. Pulse oximeter
5. Identify and treat:Tension Pneumothorax
Flail chest
Massive Hemothorax
6. Needs for assisted ventilation
 Initial Assessment and Management

1ry. Survey and Resuscitation

B Breathing and Ventilation

Rule 1: CXR is needed after intubation and ventilation, but

not to diagnose Tension Pneumothorax
Pitfalls
• Differentiation of ventilation problems from airway
obstruction may be difficult
• Intubation of Pneumothorax patient with ventilation may result
in further deterioration of the patient
 This chest radiograph demonstrates bilateral
pulmonary contusions in a trauma patient.
Courtesy of Kevin Kilgore, MD; Carson Harris, MD;
and David Hale, MD, Regions Hospital, St Paul, Minn.
 Initial Assessment and Management

1ry. Survey and Resuscitation

C Circulation with Hemorrhage control

• Blood Volume and Cardiac output assessment depend on
level of consciousness, skin color and the pulse
• Start 2 I.V. lines, draw blood samples ( Central line ? )
• Identify the need of blood transfusion
• Control Bleeding: Direct pressure on the wound
Pneumatic splinting devices
No Tourniquet except in amputation
• Identify occult blood loss
• Assess for the need of operative intervention
 Initial Assessment and Management

1ry. Survey and Resuscitation

C Circulation with Hemorrhage control

Pitfalls
• P.R., ABP has little correlation with cardiac output in older
patients
• Children show few signs of hypovolemia
• Use of medications affect the response to hypovolemia
 Initial Assessment and Management

1ry. Survey and Resuscitation

D Disabilities (Neurologic Evaluation)

Level of consciousness L.O.C.
A alert
V to verbal stimuli
P to painful stimuli
U unresponsive
Pupils size and reaction
 Initial Assessment and Management

1ry. Survey and Resuscitation

D Disabilities (Neurologic Evaluation)

Rule: Depressed L.O.C: may be due to decreased Cerebral

Oxygenation , Brain injury or Drugs

Pitfalls
• Lucid interval commonly occur with Acute Epidural Hematoma
( Talk and die ), this emphasizes the need for frequent
Neurologic Re-evaluation
 The head CT scan for trauma identifies space-occupying
lesions and directs operative evacuation. The lenticular
shape of this lesion identifies it as an epidural hematoma.
Courtesy of Kevin Kilgore, MD; Carson Harris, MD;
and David Hale, MD, Regions Hospital, St Paul, Minn.
 Periorbital ecchymosis, or “raccoon eyes”
" is a classic diagnostic sign of basilar skull fracture.
Courtesy of Kevin Kilgore, MD;
Carson Harris, MD; and David Hale, MD,
Regions Hospital, St Paul, Minn.
 Initial Assessment and Management

1ry. Survey and Resuscitation

E Exposure / Environmental control

• Undress completely ( use trauma scissor )
• Prevent hypothermia ( warm blanket, room temp. )
• Warm I.V. fluids and blood

Pitfalls
• Early control of hemorrhage will minimize hypothermia
 Initial Assessment and Management

1ry. Survey and Resuscitation: SUMMARY

A Air way obstruction + C-spine stabilization
B Open Pneumothorax
Breathing problems: Tension Pneumothorax,

C Circulation: Shock, Cardiac tamponade.

D Disabilities: AVPU, Pupils
E Exposure / Environmental control
 Initial Assessment and Management

ADJUNCTS to 1ry. Survey and Resuscitation

1 ECG monitoring

2 Urinary and Gastric Catheters

Monitoring: RR, ABG, Pulse Oximetry, ABP, PR,Urine O/P,

3 Temp.,CVP / JV

X-ray and diagnostic: CXR, Pelvis, Lat. C-spine and Diagnostic

4 abdominal ultra sound (FAST:focused abd sonogram for trauma)

CONSIDER Need for patient transfer

 Initial Assessment and Management

2ry. Survey
1 Complete History

2 Head to toe examination

3 Re-assessment of vital signs

4 Complete neurological examination GCS.

5 Special procedures, Specific X-rays and laboratory studies

 Initial Assessment and Management

2ry. Survey
1 Complete History

A allergies

M medications

P past illness / pregnancy

L last meal
E events / environment / mechanism of injury:blunt,
penetrating, burn, hazardous
environment
 Initial Assessment and Management

2ry. Survey
2 Head to toe examination

1. Head, Maxillofacial, Cspine and Neck

2. Chest
3. Abdomen
4. Perineum / Rectum / Vagina
5. Musculoskeletal / Pelvis / Back
6. Neurologic evaluation
e anteroposterior pelvis radiograph quickly helps identify major pelvic fractures and joint disruptions. Courtesy of Kevin Kilgore, MD; Carson Harris, MD; and David Hale, MD, Regions Hospital, St Paul, Min

The anteroposterior pelvis radiograph quickly helps identify

major pelvic fractures and joint disruptions.
Courtesy of Kevin Kilgore, MD; Carson Harris, MD; and David Hale, MD, Regions Hospital, St Paul,
Minn.
 Initial Assessment and Management

2ry. Survey
3 Re-assessment of vital signs

Objectives:
1. Identify new Clinical findings
2. Discover deterioration
3. Assure that life threatening injuries are managed
4. Diagnose underlying medical problems
 Initial Assessment and Management

2ry. Survey
3 Re-assessment of vital signs

Done by:
1. Clinical Reassessment
2. Monitoring of LOC, PR, Urine O/P, ABP, ABG,
CVP
3. Review of Diagnostic results
4. Use of Analgesia
 Initial Assessment and Management

2ry. Survey
4 Complete neurological examination GCS.

• LOC / GCS
• Pupils
• Complete neurological examination
 Initial Assessment and Management

2ry. Survey
5 Special procedures, Specific X-rays and laboratory studied

• Additional X-rays Extremities, Spine

• CT
• Contrast X-rays, Urography, Angiography
• Endoscopy
Not till the patient is stable
 Initial Assessment and Management

2ry. Survey
1 Complete History

2 Head to toe examination

3 Re-assessment of vital signs

4 Complete neurological examination GCS.

5 Special procedures, Specific X-rays and laboratory studies

 Initial Assessment and Management

Definitive care

According to the clinical and other data

the patient will be taken to OR, ICU
or others
 Initial Assessment and Management

Transfer

To other facility according to the

patient’s need and the institution’s
capability
 Never insert a nasogastric tube if there is
basal skull fracture

 Keep your patient in a normo or hypovolemic

state,maintain a low blood pressure if
tolerated by the patient

 The monitoring should be rigorous

Be aware of:
 Spinal cord lesions
 Tracheal rupture
 Aortic dissection
 Tamponnade
 Diaphragmatic rupture
 Rupture of a hollow viscera
 Never insert a urinary catheter in
case of suspicion of pelvic
fracture

 Theskull wound might bleed

enormously
CT scan of the abdomen identifies significant soft tissue
injury with high sensitivity and specificity. A traumatic
liver laceration due to blunt trauma with rib fragment
penetration into the liver parenchyma is shown.
Courtesy of Kevin Kilgore, MD; Carson Harris, MD;
and David Hale, MD, Regions Hospital, St Paul, Minn.
Thank you for your
attention