INITIAL ASSESSMENT AND

MANAGEMENT OF
TRAUMA PATIENT
10 SECOND ASSESSMENT
ASKING THE PATIENT FOR HIS OR HER
NAME, AND ASKING WHAT HAPPENED
GCS takes time, so do rapid
assessment
A – alert
V – verbal response
P – painfully response
U – unresponsive
 AVPU

STABLE UNSTABLE

HEAD TO TOE EXAMN ABCDE (PRIMARY SURVEY)

SECONDARY SURVEY-HEAD TO TOE EXAMN

RELEVANT XRAYS

XRAYS
DEFINITIVE PLANNING

DO NOT MISS OUT IMPORTANT INJURIES DEFINITIVE PLANNING

AS PER FRACTURE SITE
COMMON THINGS SKIPPED
• Assume a cervical spine injury in any patient with multi-system
trauma, especially with an altered level of consciousness or a blunt
injury above the clavicle
• Cut off/ remove all clothes in major trauma
• Examine front and back using log rolling
• Examine all orifices
SECONDARY SURVEY
• Complete physical exam with updating of patient’s history
Mechanism of injury
Environment
Pre-injury status and predisposing factors
Pre hospital observations and care
MECHANISM OF INJURY
• Can help identify injuries which may not be apparent immediately
• Whether the patient was walking, two-wheeler or four wheeler?
• Was the patient driving or a pilon rider?
Where was the patient located before the crash?
Where was the patient located after the crash?. Inside or ejected
Did the patient fall. What was the height of fall?
Was the patient crushed by an object?
ENVIRONMENT
Did the fracture occur in a contaminated environment?
Were there any glass injuries?
Were there any sources of bacterial contamination such as dirt,
farmyard injuries?
PRE-INJURY STATUS AND CO-MORBIDITIES
Ingestion of alcohol or drugs
Emotional problems or illnesses
Previous musculoskeletal injuries
Pre-injury walking status. Eg. In inter-trochanteric fracture if the
patient was already bed ridden before the injury - can be managed
conservatively.
PRE HOSPITAL OBSERVATIONS AND
CARE
The time of injury
Position in which patient was found
Open wounds
Changes in limb function in terms of neuro vascular function after
immobilization or during transfer to the hospital
Any dressings, splints applied or suturing done
Reduction in fractures or dislocations during extrication or splinting
PHYSICAL EXAMINATION
• Assess the extremities for:
- Wounds-
1. size
2. Location
3. structures visible underneath with a diagram
4. Fat globules in case of open fractures
DESCRIBE WITH DIAGRAM:
- LOCATION OF FRACTURE
- TYPE OF FRACTURE
- NEUROLOGICAL STATUS

Eg. TRANSVERSE FRACTURE MID

SHAFT HUMERUS WITH RADIAL
NERVE PALSY
SIGNS OF FRACTURE
• Deformity
• Unnatural mobility
• Tenderness

EVALUATION
• Inspect the entire body for lacerations and
abrasions
• Assess patient’s neurologic function and vascular
function
AREA SPECIFIC EXAMINATION
• Clavicle #, scapular fracture – rib #, pulmonary contusion

• Proximal humerus # and/or dislocations -- axillary nerve injury

(function of deltoid and sensations over lateral aspect of arm-
proximal half)
DISTAL NEUROVASCULAR
• Humerus shaft # – MC -- radial nerve, ulnar and median nerve
Take care for nerve injury during reduction. Evaluate nerve after CR.

• Distal humerus # -- children- anterior interosseous nerve, ulnar and

radial nerve
• Elbow- median nerve

• Proximal radius # -- PIN

• Wrist and hand injuries – distal neurological examination by checking

for sensations, Ulnar nerve in hand

• Hand injuries – mostly crush injuries.

check for distal circulation by Capillary refill
• Pelvis – also look for perianal sensations, sciatic nerve

• Post dislocation of hip – sciatic nerve, distal pulses

• Shaft femur – sciatic nerve, distal pulses

 INJURIES AROUND THE KNEE

• Distal femur – dorsalis pedis and post. Tibial artery pulsations

• Knee dislocation – dorsalis pedis and post. Tibial artery pulsations,

common peroneal nerve

• Proximal tibia – CPN

• Shaft and distal tibia – sensations on dorsal aspect of foot
--As long flexors already supplied in middle leg

• Foot injuries – mostly crush injuries. Be sure for vascularity by looking

at the capillary refill time
XRAYS

SCREENING XRAYS Of the suspected fracture or dislocation region

Imp points:
1. Image one joint above and one joint below

2. Splintage should not interfere in imaging

3. In polytrauma pts. – Xray pelvis-ap view

-- Xray c spine-lateral view

• FOCUSED XRAYS TO GUIDE IN

SURGICAL PLANNING
• Proper notes
• Proper diagnosis
• Investigations – children – Hb, PTI, Urine- albumin, sugar
< 40 years – Hb, RFT, RBS, PTI, Urine– albumin, sugar
> 40 years – As required as per co-morbidities
AIRWAY
• Secure airway
 Manual
 Jaw thrust/ chin lift
 Suction
 Manual clearance
 Simple adjuncts
 Oropharyngeal airway/
nasopharyngeal airway
BREATHING
• If inadequate, then
• Artificial
ventilation
Mouth to face mask
• Mask + Oxygen if
available
• Decompression
of tension
pneumothorax/
haemothorax
• Closure of open
chest injury
HAEMORRHAGIC SHOCK VS
NEUROGENIC SHOCK
• Due to loss of sympathetic tone
• Spinal cord injury
• Hypotension with bradycardia
• No vasoconstriction of skin
HYPOVOLEMIC SHOCK
• First priority- stop bleeding
• Limbs- pressure dressing/ packing
• Chest- chest tube+intermittent
suction+ analgesia (ketamine
• Abdomen- damage control
laparotomy- gauze pack bleeding
abdominal and do a formal
laparotomy when patient stabilized-
may be done under ketamine
• Scalp – temporary sutures
CIRCULATION
• Second priority- volume
replacement, warming
• Venous access ( 2 nos. of 16 G IV
cannulae, take samples for cross
match)
• If IV cannulation not possible with 2
attempts, do cut down
• IV fluids ( crystalloids) which should
be pre-warmed
• Blood transfusion
INITIATION OF FLUID RESUSCITATION
• CRYSTALLOIDS/COLLOIDS-
• Early prehospital care/ till blood bank facility not available.
• Too much of crystalloids cause unnecessary dilution and overload.
Should be avoided.
• ABG to look for blood lactate levels. Elevated levels signify blood
products needed.
• Greater emphasis on more balanced product administration
• Damage control resuscitation
--1:1:1 ratio of pRBC:FFP:platelets
ADEQUACY OF FLUID RESUSCITATION
• Lactate level <2.0 mmol/l
• Temperature >350c
• pH >7.25
• Platelets >1.2 lac or INR<1.5
• Urinary output >1ml/kg/hr
• No requirement of inotropic support