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Initial Assessment
and
Management
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© ACS

Objectives
 Identify Management Priorities
 Apply principles of primary and
secondary survey
 Institute appropriate resuscitation and
monitoring
 Recognize value of patient’s history and
biomechanics of injury
 Anticipate pitfalls
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Concepts of Initial Assessment

 Rapid Primary survey
 Resuscitation
 Adjuncts to primary survey / resuscitation
 Detailed secondary survey
 Adjuncts to secondary survey
 Reevaluation
 Definitive care
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Initial Assessment

Primary survey and

resuscitation of vital
functions are done
simultaneously –
a team approach
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Preparation

Prehospital System
 Transport guidelines / protocols
 On-line medical direction
 Mobilization of resources
 Periodic review of care
 Closest appropriate facility
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Preparation

Inhospital
 Preplanning essential
 Equipment, personnel, services
 Standard precautions
 Transfer agreement
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Standard Precautions

• Cap
• Gown
• Gloves
• Mask
• Shoe covers
• Goggles / face shields
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Triage
 Sorting of patients according to :
• ABCDEs
• Available resources
 Multiple casualties

 Mass casualties
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Primary Survey
 Adult / pediatric / pregnant women –
Priorities are the same !
A Airway with c-spine protection
B Breathing and ventilation
C Circulation with hemorrhage control
D Disability
E Exposure / Environment
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Special Considerations

Trauma in the Elderly

 5th leading cause of death

  Physiologic reserve

 Comorbidities : Diseases / medications

 Outcome depends on early, aggressive

care
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Primary Survey
Establish Patent Airway
 C-spine injury
 Pitfalls
• Equipment failure
Caution • Inability to intubate
• Occult airway injury
• Progressive loss of airway
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Primary Survey

Suspect C-Spine Injury

 Spinal protection

 C-spine x-ray when

appropriate
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Primary Survey
Breathing
 Assess
 Oxygenate

 Ventilate

Pitfalls
• Airway vs ventilation problem ?
Caution
• Iatrogenic pneumothorax /
tension pneumothorax
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Primary Survey
Assessment of Organ Perfusion
 Level of consciousness

 Skin color and temperature

 Pulse rate and character

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Primary Survey
Circulatory Management
 Control hemorrhage
 Restore volume
 Reassess
Pitfalls
Elderly Children
Caution
Athletes Medication
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Primary Survey

Disability
 Baseline neurologic evaluation
• GCS scoring
• Pupillary response

Observe for neurologic

Caution
deterioration
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Primary Survey
Exposure / Environment
• Completely undress the patient

Caution Prevent hypothermia

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Resuscitation
 Protect and secure airway
 Ventilate and oxygenate

 Stop the bleeding!

 Vigorous shock therapy

 Protect from hypothermia

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Adjuncts to Primary Survey

Vital sign

ECG ABGs

Urinary Adjuncts Pulse

Output oximeter
and CO2

Urinary / gastric catheters

unless contraindicated
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Adjuncts to Primary Survey

Diagnostic Tools
• Chest and pelvic
x-ray
• DPL
• Ultrasound
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Adjuncts to Primary Survey
Consider Early Transfer
 Do not delay transfer for diagnostic

tests
 Use time before transfer for

resuscitation
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Reevaluate
Proceed to Secondary Survey After :
 Primary survey completed

 ABCDEs are reassessed

 Vital functions are returning to

normal
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Secondary Survey

The complete

history and
physical
examination
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Secondary Survey
Key Components
 History
 Physical examination : Head-to-toe
 “Tubes and finger in every orifice”
 Complete neuro exam
 Special diagnostic tests
 Reevaluation
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Secondary Survey
History
A Allergies
M Medications
P Past Illnesses
L Last meal
E Events / Environment
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Secondary Survey
Mechanisms of Injury
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Secondary Survey
Head
 Complete neurologic examination
 GCS score determination

 Comprehensive eye/ear exams

Pitfalls
 Unconscious patient

 Periorbital edema

 Occluded auditory canal

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Secondary Survey

Maxillofacial
 Bony crepitus / stability
 Palpable deformity

Pitfalls
• Potential airway obstruction
• Cribriform plate fracture
• Frequently missed injury
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Secondary Survey
Cervical Spine
 Palpate for  Pitfalls
tenderness • Altered LOC
 Complete motor / for any reason
sensory exams • Other severe,
 Reflexes painful injury
 C-spine imaging
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Secondary Survey
Neck (Soft tissues)
 Mechanism : Blunt  Pitfalls
vs penetrating • Delayed symptoms
 Symptoms : Airway
obstruction,
and signs
hoarseness • Progressive airway
 Findings : Crepitus, obstruction
hematoma, stridor, • Occult injuries
bruit
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Secondary Survey
Chest
 Inspect  Pitfalls
 Palpate • Elderly
 Percuss • Children
 Auscultate
 X-ray
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Secondary Survey
Abdominal Evaluation

Blunt trauma Penetrating trauma

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Secondary Survey
Abdomen
 Inspect, auscultate, palpate, and percuss
 Reevaluate frequently
 Special studies
 Pitfalls
• Hollow viscus and retroperitoneal injuries
• Excessive pelvic manipulation
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Secondary Survey
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Perineum Contusions, hematomas,

lacerations, urethral blood

Sphincter tone , high–riding

Rectum prostate, pelvic fracture,
rectal wall integrity, blood

Blood, lacerations

Vagina Urethral injury in women,

pregnancy

Pitfalls
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Secondary Survey
Musculoskeletal : Extremities
 Contusion, deformity
 Pain
 Perfusion
 Peripheral neurovascular status
 X- rays as needed
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Secondary Survey
Musculoskeletal : Pelvis
 Pain on palpation
 Symphysis width ↑
 Leg length unequal
 Instability
 X-rays as needed
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Secondary Survey
Musculoskeletal

 Pitfalls
• Potential blood loss
• Missed fractures
• Soft-tissue or ligamentous injury
• Occult compartment syndrome (especially
with altered LOC / hypotension)
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Secondary Survey
Neurologic
Spine / Cord CNS
 Complete motor  Frequent reevaluation

and sensory exams  Prevent secondary

 Imaging as brain injury

indicated
 Reflexes
Early neurosurgical consultation
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Secondary Survey
Neurologic

 Pitfalls
• Incomplete immobilization
• Subtle ↑ in ICP with manipulation
• Rapid deterioration
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Adjuncts to Secondary Survey

 Special diagnostic test as indicated

 Pitfalls
• Patient deterioration
• Delay of transfer
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Reevaluation
Minimizing Missed Injuries

 High index of suspicion

 Frequent reeveluation and monitoring
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Reevaluation
Pain Management

 Relief of pain /anxiety as appropriate

 Administer intravenously
 Careful monitoring is essential
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Definitive Care

Local Facility

??
Transfer agreements
?? Local resources ??
??

Trauma Specialty
Center Facility
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Record , Legal Considerations

 Concise, chronologic documentation
 Consent for treatment

 Forensic evidence
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Questions

?
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Summary
 Primary Survey
 Resuscitation

Adjuncts
• Secondary Survey
Adjuncts
• Definitive care