The Initial Assessment

OF THE MULTIPLY INJURED PATIENT

 Epidemiology

 Trauma is a disease.
 Trauma is predictable, preventable, and treatable.
 Trauma is the 4th leading cause of death in the US.
 Trauma is the leading cause of death in people
below the age of 45 in the US.
 3.8 M deaths/ year/ worldwide
 312 M injured
Epidemiology

•Trimodal distribution
of mortality
•Prehospital (Major
head injuries, rapid
exsanguination)
•Early Hospital
(Head, chest,
abdominal trauma)
•ICU (End result of
prolonged
hypoperfusion)
 History of Trauma Systems

The American College of Surgeons has developed

requirements for trauma center certification of commitment
of personnel and resources needed to maintain a state of
readiness to receive critically injured patients.
Importance of The Golden Hour
Objectives
1. Identify the correct sequence of priorities in the
assessment of an injured patient

2. Outline the components of the primary and secondary

surveys

3. Explain the techniques used in the initial resuscitation

phase.
 Initial Approach

 initial primary assessment,

 rapid resuscitation
 Thorough secondary survey followed by
diagnostic tests and ultimate disposition.

 Subsequent mortality and morbidity tied

directly to the initial assessment and
resuscitation.
 Introduction
The initial assessment aims:

 Rapid assessment
 Rapid life preserving therapy
 Prevents further damage to the patient.

It consists of:

 Preparation
 Triage
 Primary survey
 Resuscitation
 Secondary survey
 Continued resuscitation
 Definitive care
 Preparation and Triage
Preparation
A. Pre-hospital Phase
 Hospital notification
 Airway maintenance, control external bleeding, immobilization and
transportation.

B. In-hospital phase
 Fluids and equipment
 Adequate and appropriate personnel
 Universal precaution

Triage
Sorting patients based on the need for treatment and the available
facilities.
Primary Survey
A Airway with Cervical Spine Control
B Breathing and ventilation
C Circulation
D Disability: neurological status
E Exposure/ Environmental control
 A Airway with cervical spine control

Assume C-spine injury in all patients

DO NOT MOVE THE NECK

Assess airway compromise

 Is the patient talking or Apnoeic
 Look for signs of:
 Agitation and aggression
 Foreign bodies, dislodged teeth
 Facial fractures and injuries to the neck (trachea and Larynx).
 Listen for abnormal breathing sounds, stridor or hoarseness.
 Feel for the movement of air.
A Airway with cervical spine control
Management:

1. In-line immobilization of the neck

2. Remove foreign body and suction
3. Administer oxygen 100%
4. Chin lift and jaw thrust manoeuvres
5. Oro-pharyngeal air way
 Primary Survey - Airway

 Jaw thrust instead of head tilt chin lift

 Endotracheal intubation for airway protection or
expected clinical course (ie,obstruction from blood or
vomitus, neck hematoma, facial burns or trauma, GCS 8 or
less, combative patient, potential for airway compromise
while out of department.)
 Primary Survey - Breathing

 Auscultation for bilateral breath sounds

 Palpation for subcutaneous emphysema
-needle decompression followed by chest tube for pneumothorax

 Inspection for flail chest

 Observation of respiratory rate, oxygen
saturation, and overall work of breathing
-mechanical ventilation for inadequate ventilation or to decrease work of
breathing
B Breathing
1. Determine centrality of the trachea and apex beat
2. Look for symmetrical expansion and respiratory rate.
3. Look for obvious contusion, laceration or flail segments.
4. Listen for movements of air: normal, absent or decreased
5. Listen for heart sounds: normal or muffled
6. Recognise specific life-threatening conditions:

1. Tension pneumothorax
2. Flial chest with pulmonary contusions
3. Open pneumothorax
4. Massive hemothorax
.
 Primary Survey - Circulation

 Check peripheral pulses, heart rate, BP, pulse

pressure, capillary refill, cyanosis
 All hypotensive trauma patients are assumed to
be in hemorrhagic shock
 2 large bore peripheral IV’s (at least 18 gauge)
 Control external bleedingDraw blood for cross-
match and base line lab investigations and
pregnancy te
 Primary Survey - Circulation
Table 251-4 Estimated Fluid and Blood Losses Based on Patient's Initial
Presentation

Class I Class Class Class

II III IV
Blood loss (mL)* Up to 750 750–1500 1500–2000 >2000

Blood loss (percent blood Up to 15 15–30 30–40 40

volume)

Pulse rate <100 100–120 120–140 >140

Blood pressure Normal Normal Decreased Decreased

Pulse pressure (mm Hg) Normal or Decreased Decreased Decreased

increased

*Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.

 Primary Survey - Circulation

 Begin volume resuscitation with liter boluses of

crystalloid for class I or II hemorrhage.
 Begin crystalloid and blood for class III or IV
hemorrhage.
 O- blood until type specific is available
 Constant reevaluation is paramount
 If class I or II is patient still showing signs of shock after
3L of crystalloid, begin blood
 “3:1 rule” 3cc crystalloid for every 1cc of blood loss
 Primary Survey - Circulation

 5 Places life threatening hemorrhage can occur

-Chest
-Abdomen
-Pelvis
-Thighs
-Externally
 Primary Survey - Circulation

 Cardiac Tamponade can cause hypotension

with little blood loss.
 Becks triad: hypotension, distended neck veins,
muffled heart sounds
 Easily confirmed with ultrasound
 Pericardiocentesis
D Disability
A Alert
V Responsive to verbal stimuli
P Responsive only to painful stimuli
U Unresponsive

Altered level of consciousness may indicate:

a. Head injury
b. Shock
c. Hypoxia
d. Drug/ Alcohol
At the End of the Primary Survey
1. Assessment and management of:A,B,C,D is
completed.
2. ABG
3. ECG, pulse oximeter, BP Cuff placed
4. Urinary catheter and Naso-gastric tube inserted
5. X rays requested:
1. AP chest
2. AP pelvis
3. Lateral C-spine
6. Consider system involvement and surgical
specialities required.
7. Consider need for patient transfer
AMPLE Key terminology
A Allergies
M Medication
P Past illnesses
L Last Meal
E Ethanol/ Drug abuse

Mechanism of Injury

 Vehicle: Stationary / Slow or High Speed

 Pedestrian / Passenger (front or back) / Driver
 Head-on / Side impact / Rear impact collision
 Restrained / Unrestrained
 Helmets
 Role over accident
 Thrown out of the car.
 Primary Survey - Disability

 Quick assessment of ability to move all extremities

 Glascow Coma Scale
 Primary Survey – Exposure

 Completely undress the patient and inspect the

entire patient from head to toe both front and back.
 Maintain spinal precautions during logrolling
 Inspect both axillae and peritoneum
 Warm blankets!!!