Trauma part 1 1ry and 2dry survey

Trauma
1ry and 2dry
survey
(2020)
surgical club red sea university SC(RSU)

 Prepared by:
 Dr. Amani abdelazim 18
 Dr. Samah yagoob 18
 Dr. Aisha Omar Hamid 18
 Presented by:
 Dr: Amar Yahia
 Registrar of General Surgery
 Surgical Club Red Sea University SC(RSU)24/7/2020

Trauma
 Trauma is a major public health problem in all countries .
50% death in the first 10 minute after the accident.
 mortality from trauma can be consider in 3 phases:
1- immediate phase death : they include massive brain
injuries , great vessels injuries ( aortic avulsion) , air way
occlusion , spinal cord transection and massive
hemorrhages. surgical club red sea university SC(RSU)

2- early phase death : occur within the first minutes to hours (
called golden hours).
3-late phase death: occurs days to weeks after the injury.
Death can occurs duo to sepsis and multiple organ system
failure.

Triage
Triage means “To sort” in French.
Triage means sorting and treating patients according to
priority, which is usually determined by:
Medical need
Personnel available
Resources available.

-When there is sufficient treatment capacity to deal with
multiple casualties, patients with life threatening and
multisystem injuries are treated first.
-When there is insufficient treatment capacity to deal
with multiple casualties, patients with the greatest
chance of survival are treated first.

Triage Tags:
1. Red: Immediate
2. Yellow: Delayed
3. Green: Walking Wounded, Minor
4. Black: Expectant, deceased

How do we determine what color a patient gets?
• Respirations: If > 30 or < 8
• Perfusion: If the patient has no radial pulses

Anyone who gets up and walks to the designated
area is given a green tag
Anyone who is not breathing is given a black tag
Anyone who fails one of the RPM assessments is given
a red tag
Anyone who cannot walk but passes all of the
assessments is given a yellow tag

Biomechanics of injury
 Trauma may be sustained by means of:
-Blunt trauma .
-Penetrating injury.
-Deceleration injury.
-Crush injury.
-Burn injury.
-Hypothermia and hyperthermia.
-Barotrauma. surgical club red sea university SC(RSU)

Blunt trauma:
RTAs are the most common cause of blunt trauma and
are usually associated with:
 head and neck (50%),
 chest (20%), or
 abdominal and pelvic trauma (25%).

A careful history of the:
1. mechanism of injury,
2. combined impact speed,
3. whether a seat belt was worn or an airbag inflated,
4. whether pedestrian or motorcyclist,
will enable the trauma surgeon to develop an idea of
which areas of the body and underlying organs are at risk.

Investigations are useful but should not delay an
essential laparotomy.
laparotomy is necessary in about 10% of blunt trauma
patients.

Penetrating injury:
 May be solitary or multiple injuries
 sucks dirt, clothing and skin into the wound, increasing
the risk of secondary infection

Advanced trauma life support (ATLS) is essential for
first hour care of an injured patient.
Pre-hospital trauma life support (PHTLS) is to prevent
deaths while injured patients are transported to the
hospital.

Pre hospital care :
✓ The primary role of pre-hospital care is to:
o Temporarily stabilize the patient
o Early transport of the severely injured patient to the
site of definitive treatment
✓ Pre-hospital treatment is driven by rapid
assessment and the principles of ATLS.

Pre-hospital resuscitation follows ATLS principles:
1. C-spine immobilization : in-line immobilization
with a hard collar, sandbags and tape

2. Airway management:
 Can be difficult.
 Can often be maintained with basic measures.
 Intubation without anesthesia and rapid sequence
induction is ill-advised because it can induce
vomiting and raise intracranial pressure ·

Breathing :
 give oxygen.

Circulation:
 hemorrhage should be controlled with direct pressure
 ensure good venous access before releasing from
vehicle.
 Fluid resuscitation should be given to a systolic blood
pressure of 90 mmHg

Disability:
fractured limbs should be splinted and the patient
prepared for transport.

Analgesia:
can be achieved with ketamine or Entonox
(contraindicated if possibility of pneumothorax or basal
skull fracture)

ATLAS Protocol
I. Primary survey
• Identify life-threatening conditions.
II. Adjunct to primary survey
• Investigations
III. Secondary Survey
• Re-evaluate the patient completely again.
IV. Definitive Care surgical club red sea university SC(RSU)

Resuscitation: the primary survey
 The ABCDE protocol is the standard management of
trauma patients.
 It is based on the ATLS format and involves

 The important principles to remember are:
✓ Always assess a trauma patient in this order (ABCDE).
✓ If there is an immediately life-threatening problem in A, you
cannot proceed to B until the airway is secured.
✓ continuous reassessment and adjustment in response to
changing needs.
✓ In a severely injured patient you may never get to E

Assessment of the airway in the primary survey :
Is the airway compromised?
1. No ventilatory effort.
2. Cyanosis, stridor, use of accessory muscles .
3. Patient unable to speak although conscious.

immediate management of air way by one of the following:
1. Clear mouth of foreign bodies or secretions
2. Chin lift, jaw thrust
3. Establish oral or nasopharyngeal airway with bag-and-mask
ventilation
4. Definitive airway (intubation) and ventilation.
5. Surgical airway and ventilation.

Trauma part 1 1ry and 2dry survey

- Is the airway at risk but currently not
compromised?
- Decrease GCS score
- Facial trauma
- Burn to face
- If so, call for anesthetic/ENT support and be prepared to
provide a definitive airway if needed. Constantly
reassess the situation. surgical club red sea university SC(RSU)

Eye Opening
Spontaneous 4
To speech 3
To pain 2
None 1
Verbal Response
Oriented 5
Confused 4
Inappropriate words 3
Moans 2
None 1
Best Motor Response
Follows commands 6
Localizes pain 5
Withdrawals 4
Decorticate (Flexion) 3
Decerebrate (Extension) 2
None 1
Note: Glasgow Coma Scale score = E
+ V + M; minimum score is 3,
maximum is 15.

 Hypoxia is the quickest killer of trauma patients, so
maintenance of a patent airway and adequate oxygen
delivery are essential.
 Remember that all trauma patients must be assumed to have
a cervical spine injury until proved otherwise.

Is the airway safe?
 Patient speaking
 Good air movement without stridor
 If so, give oxygen and move on to assess breathing

Control of the C-spine in the primary survey by:
1. In-line survey manual immobilization (assistant holds
patient's head with both hands) or
2. Hard cervical spine collar with sandbag and tape
The C-spine should be controlled throughout the
primary survey until it fully assessed by clinically and, if
necessary, radiologically.

Management of a compromised airway:
 Chin lift and jaw thrust
 Guedel airway
 nasopharyngeal airway
 Definitive airway:
• Nasotracheal • Orotracheal • Cricothyroidotomy
• Tracheostomy

Remember, if the airway is obstructed you cannot move
on to assess breathing until the airway is secured

The 'chin lift' and 'jaw thrust :
Advantages:
1. no additional equipment needed.
2. Holding both sides of the head may be combined with
temporary in-line stabilization of the C-spine.
3. Can be used in a conscious patient.
Disadvantages:
1. requires practice to maintain airway.
2. Difficult to maintain for long periods of time

The Guedel airway :
Used for temporary bag-and-mask ventilation of the unconscious patient
before intubation.
Advantages:
easy to insert, widely available, various sizes.
Disadvantages:
1. sited above vocal folds so does not prevent airway obstruction at this
site.
2. Can provoke gag reflex.
3. Does not prevent aspiration of stomach contents

Laryngeal mask airway

The nasopharyngeal airway
Used to prevent upper airway obstruction (e.g. in a drowsy/still-conscious patient).
Advantages:
fairly easy to insert; unlikely to stimulate gag reflex in comparison with
oropharyngeal (Guedel) airway.
Disadvantages:
1. less widely available,
2. uncomfortable for the patient,
3. sited above the vocal folds.
4. Insertion dangerous if facial trauma present.
5. Does not prevent aspiration of stomach contents.

The definitive airway
 If the above measures are insufficient then a
definitive air way is indicated.
 This will ensure free passage of oxygen to the trachea,
distal to the vocal folds.

Indications for a definitive airway :
1. Apnea
2. Hypoxia refractory to oxygen therapy.
3. Protection from aspiration pneumonitis.
4. Protection of the airway from impending obstruction due to
burns/edema/facial trauma/seizures.
5. Inability to maintain an airway by the above simpler measures .
6. Head injury with a risk of raised intracranial pressure (ICP).
7. Vocal fold paralysis. surgical club red sea university SC(RSU)

Types of definitive airway :
 Orotracheal intubation.
 Nasotracheal intubation .
 Surgical airway (e.g tracheostomy or cricothyroidotomy).

Orotracheal intubation.

Surgical
cricothyroidotomy

tracheostomy

Breathing:
Assessment of breathing in the primary survey:
 Full examination
 Check saturation and/or arterial blood gases.
 Provide supplemental oxygen .

1. Clinical signs that should initially be evaluated include
symmetric chest movement.
cyanosis.
open chest wounds.
jugular venous distention (JVD).
respiratory rate.
use of accessory muscles of respiration (e.g.,
sternocleidomastoid).

2. During auscultation one should assess for
bilateral breath sounds.
wheezing.
stridor.

3. Palpation should be performed to assess for
tracheal position (a deviated trachea may indicate a
tension pneumothorax).
gross deformities.
subcutaneous emphysema.
flail segments.

Identify any of the six immediately life-threatening chest
injuries and treat them immediately (ATOM FC).
 Airway obstruction
 Tension pneumothorax
 Open pneumothorax
 Massive hemothorax
 Flail chest
 Cardiac tamponade . surgical club red sea university SC(RSU)

Ensure ventilation is adequate before moving on to
assess circulation Supplemental oxygen must be
delivered to all trauma patients.

Circulation:
 Assess hemodynamic status
 Identify sites of hemorrhage
 Establish IV access
 Send off blood for cross-matching and other
investigations
 Give a bolus of intravenous fluid if the patient is
shocked .

1. Evaluate
peripheral pulses.
heart rate.
blood pressure.
mental status.
the appearance of the skin.

b. In children
an appropriate initial bolus is 20 mL/kg.
c. A type and crossmatch
should be performed immediately, although
Type O negative (O—;universal donor) blood should also
be immediately available.

2. Aggressive fluid resuscitation
should be initiated at this time.
a. In adults
an initial 2 L bolus of crystalloid (e.g., lactated Ringer's) should
be given through two large-bore intravenous (IV) lines (i.e., 14–
16 gauge).

 If the patient is hemodynamically unstable and losing blood,
action must be taken before moving on with the primary survey.
 This may mean transferring the patient to the operating theatre
at this stage of the primary survey if there is uncontrolled internal
bleeding.

IV cannula color and sizes

intraosseous line

Disability :
1. A rapid assessment should be performed of
mental status.
gross motor function.
gross sensory function.

2. The AVPU mnemonic
is a quick method to describe the patient's level of
consciousness.
A = Alert.
V = responds to Vocal stimuli.
P = responds to Painful stimuli.
U = Unresponsive.

3. The Glasgow Coma scale (GCS)
is essential for quantitative assessment of the patient's
neurologic status
4. Asymmetry in pupillary size and reactivity
suggests the presence of an intracranial injury.

5. The main disabilities discovered during this phase
include
head injury.
altered level of consciousness secondary to ethanol or
other drugs (diagnosis of exclusion).

Exposure and environment
1. Remove the patient's clothes
to facilitate a thorough examination.
2. Examine the entire body surface
including log-rolling the patient to view the back and
buttocks for potential injuries.

3. Maintain normothermia
with warm IV fluids, loose application of warm blankets,
and a warm environment.
4. Consider tetanus immunization
and antibiotic administration, if necessary.
5. Perform initial chest and pelvic radiographs.

1-Take an AMPLE history
AMPLE mnemonic:
 Allergies.
 Medication.
 Past medical history.
 Last name.
 Event of the injury. surgical club red sea university SC(RSU)
Completing the primary survey:
Monitoring and important investigations :

2- Give analgesia.
3- Monitor:
 Urine output.
 Conscious level
 Set up:
 Pulse oximetry ·
 ECG leads.

4- Send blood investigations if not already done
Do the three trauma radiographs:
1. Anteroposterior (AP) chest .
2. Pelvis.
3. C-spine.
Fully reassess the ABCDEs
You are now ready to progress to the secondary survey.

The secondary survey:
 starts after the initial resuscitation as the patient begins
to stabilize.
 It is carried out while continually reassessing ABC.
 Immediately life-threatening conditions should already
have been detected and treated.
 Obtain a complete medical history

 Complete head to toe examination
 Obtain all necessary investigations: bloods,
radiographs (of cervical spine, chest and pelvis).
Perform any special procedures
Monitor patient's response to treatment

 Looks for potentially life threatening which includes
(ATOM – PD):-
1) Aortic disruption
2) Trachea-esophageal disruption
3) Esophageal disruption
4) Myocardial contusion
5) Pulmonary contusion
6) Diaphragmatic disruption

 Follow up with 'Fingers and tubes in every orifice'
➢ Per rectum.
➢ Per vagina.
 Check ENT Nasogastric (NG) tube insertion (if no skull fracture).
 Urinary catheter insertion if no evidence of genitourinary trauma.

 The patient should be fully exposed in order to look for
any hidden injuries in the secondary survey.
 Remember that the patient may already be hypothermic
and so maintenance of their body temperature is vital:
1. warmed fluids.
2. warm resuscitation room.
3. External warming devices (blankets, bear-hugger etc).

Secondary survey of the head
 Neurological state :
1. Full GCS assessment
2. Pupils
3. eyes
 Examination of the face
1. Check facial bones for stability
2. Loose or absent teeth
 examination of the scalp
 Presence of soft-tissue injuries/hematoma

Signs of skull fracture:
• Periorbital hematoma
• Scleral hematoma with no posterior margin
• Battle's sign
• Cerebrospinal fluid (CSF)/blood from ears or nose

Secondary survey of the neck :
 Risk factors for cervical spine injury:
1. Any injury above the clavicle
2. High-speed RTA
3. Fall from height
 neck examination :
1. Thorough palpation of bony prominences
2. Check for soft-tissue swellings
3. Check for muscle spasm surgical club red sea university SC(RSU)

Radiograph of C-spine Exclude:
• Penetrating injuries of the neck
• Subcutaneous emphysema
• Elevated jugular venous pressure (JVP)

Secondary survey of the thorax
 Exclude pathology (pneumothorax, hemothorax, rib
fractures, mediastinal injury, cardiac contusion)
 Examine the full respiratory system, especially reassessing
air entry inspect chest wall (bony or soft tissue injury,
subcutaneous emphysema) Chest radiograph ECG
 ABG should be obtained to monitor whether ventilation is
adequate

Secondary survey of the abdomen:
 examine thoroughly (abdominal wall injury suggests internal
viscus injury)
 insertion of a NG tube to decompress the stomach is
suggested as long as there are no facial fractures or basal
skull fractures
 Involve surgeons early if suspect internal injury after general
resuscitation the main decision to be made in this area is
whether a laparotomy is necessary

Secondary survey of the pelvis :
 Check for bony instability which indicates significant
blood loss

urethral catheterization is performed only if there is no
evidence of genitourinary injury.

 identify any genitourinary system injuries suggested
by:
1. high-riding prostate felt per rectum;
2. blood found on rectal examination;
3. blood found on vaginal examination;
4. blood at external urethral meatus;
5. gross hematuria .

Secondary survey of the extremities :
 Examine the full extent of each limb (remember hands
and feet, including individual fingers and toes).
 Exclude soft-tissue injury, bony injury, vascular injury,
neurological injury.
 Control hemorrhage; elevate limb; apply direct pressure
(tourniquets are not favored).

 Correct any obvious bony deformity because this will
decrease: fat emboli; hemorrhage; soft-tissue injury;
requirement for analgesia; skin tension in dislocations.
 Caution: check and document neurovascular supply to
limb before and after any manipulation

Secondary survey of the spine :
 examine the spinal column for alignment, stepping and
tenderness .
 examine the peripheral and central nervous systems.
 Exclude sensory or motor deficits

Tetanus status and prophylaxis :
Major injuryMinor injuryTetanus status
Tetanus toxoid and tetanus
IgG
Tetanus toxoid only
Un known or fewer than three
doses
No treatment necessaryNo treatment needed
Full course received with last
booster < 10years ago
Tetanus IgGTetanus IgG
Full course received with last
booster > 10 years ago

References :
❑ MRCS Part A_ Essential Revision Notes_ Book 1).
❑ ATLS® Advanced trauma life support® student course manual Tenth edition
❑ Primary Trauma Care Course Manual 2015 Edition
❑ SRB manual of surgery 5th edition .
❑ Bailey & Love’s Short Practice Of Surgery 26th Edition
❑ BRS General Surgery 1st edition

Trauma part 1 1ry and 2dry survey

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