K1 - Initial Assessment
K1 - Initial Assessment
K1 - Initial Assessment
and
Management of Trauma
Patients
OBJECTIVES
• Preparation
• Triage
• Primary survey ( ABCDEs )
• Resuscitation
• Adjuncts to primary survey and resuscitation
• Secondary survey ( head-to-toe evaluation and history )
• Adjuncts to the secondary survey
• Continued postresuscitation monitoring and reevaluation
• Definitive care
• Repeat primary and secondary survey when finding any
deterioration in the patient’s status
• Prehospital
– Airway maintenance
– Control of external bleeding & shock
– Immobilization of the patient
– Communication with receiving hospital & immediate transport to
the closest, appropriate facility
– History taking ( include events )
• Inhospital
– Advanced planning ( especially massive casualty )
– Equipment & personnel
– Communicable disease protection
– Transfer agreements
TRIAGE
• Exceed the capacity of the facility ( mass casualties ) ==> Treat the
greatest chance of survival, with the less time, less equipment & less
personnel
PRIMARY SURVEY
• Exposure/Environmental Control
– Undress patient completely
– Protect from hypothermia
– Pitfall:
• early control of the hemorrhage is the best method to keep
body temperature( early surgical intervention)
RESUSCITATION
• Monitor:
– Ventilatory rate and ABGs/ end-tidal CO2
Pitfalls: Combative patients often extubate or bite
endotracheal tube
– Pulse oximetry
– ECG & BP monitor
– Temperature
– urine output
X-RAY AND DIAGNOSTIC STUDIES
• Establish resuscitation
• History taking
• Complete neurologic exam.
• Head-to-toe evaluation
• Roentgenograms
• Special procedure
• Tubes and fingers in every orifice
• Re-evaluation
SECONDARY SURVEY
• History
– A. Allergies
– M. Medications currently used
– P. Past illness / pregnancy
– L. Last meal
– E. Events / Environment related to injury
HISTORY
Mechanisms of injury
• Blunt
– Automobile collisions
• Seat belt usage
• Steering wheel deformation
• Direction of impact
• Ejection of passenger form the vehicle
• Burns and Cold injury
– Inhalation injury and CO. intoxication in fire field
• Hazardous environment
• Penetrate
– Anatomy factors
– Energy transfer factor
• Velocity and caliber of bullet
• Trajectory
• Distance
SECONDARY SURVEY
• Physical Examination
– Head
– entire scalp and head
– eye:
» pupil
» visual acuity
» EOM
» foreign body ( soft contact lens….)
– Pitfalls:
Severe facial swelling or unconsciousness p’t still need eye
exam.
SECONDARY SURVEY
• Physical Examination
– Maxillofacial
• No airway obstruction or massive bleeding ==> treat later
• Midfacial fracture ==> R/O cribriform plate fracture
Pitfalls:
Some facial bone fracture is difficulty identified early ==>
reassessment is crucial
SECONDARY SURVEY
• Physical Examination
– C-spine and Neck
• Maintain immobilization
• Complete evaluation
• Complete radiology study
• Cautions helmet removed
• Penetrating injury: Not be explored in the emergency
department; explored & treat in the operative room
Pitfalls:
Blunt injury to Neck: Carotid artery intima injury or
dissection ( delay onset )
Immobilization ==> decubitus ulcer
SECONDARY SURVEY
• Physical Examination
– Chest
• Pitfalls:
– Poor tolerance to minor pulmonary trauma in
elderly patients
– A normal CXR can’t role out chest injury in children
SECONDARY SURVEY
• Physical Examination
– Abdomen
• Identify a surgical abdomen is more important than doing a
specific diagnosis ==> early consult surgeon
• Close observation & frequent reevaluation of the abdomen
• DPL, sonography, abdomen CT
Pitfalls:
– Excessive manipulation of the pelvis should be avoid ==>
just do pelvic x-ray
– Retroperitoneal organs ( pancreatic & hollow organ ) are
very difficult to identify
SECONDARY SURVEY
• Physical Examination
– Perineum / rectum / vagina
• Perineum: Contusions, hematomas, urethral
bleeding…….
• Rectum: Sphincter tone, high riding prostate,
blood…..
• Vagina: Blood, laceration
Pitfalls:
Female urethral injury is difficult to detect
SECONDARY SURVEY
• Physical Examination
– Musculoskeletal
• Extremities / pelvis: Contusion, deformity, pain
crepitation, abnormal
movement
• Vascular: Assess all peripheral pulses
• Spine: Physical findings, mechanism of injury
SECONDARY SURVEY
• Physical Examination
– Neurologic
• Determine GCS score
• Re-evaluate pupils
• Sensory / motor evaluation
• Maintain immobilization
• Prevent secondary CNS injury ( keep stable vital signs, avoid
increased ICP and treat IICP )
• Early neurosurgical consultation
Pitfalls:
Intubation should be done expeditiously and as smoothly as
possible ( Intubation will increase ICP )
REEVALUATION
• Continuous monitoring
• Pain relief
DEFINITIVE CARE
• Trauma center
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