Editing Trauma - initial assessment

== Preparation ==
Pre-hospital:

* Notify hospital of incoming trauma so team can be mobilised
* Prioritise airway, bleeding control/shock, immobilisation, immediate transport
* Field Triage Decision Scheme --->

Hospital:

* Smooth handover between team leader and paramedics
** Hands off handover - "MIST"
** Mechanism
** Injuries found and suspected
** Symptoms and signs
** Treatment initiated
* Critical aspects:
** Resus area available
** Airway equipment accessible - tracheostomy, video laryngoscopy
** Warmed crystalloid solution
** Protocol to guide rapid response by medical, pathology, radiology
** Idea of transfer processes to trauma centre
** Standard precautions for all attendees
** Equipment - RIC lines, collar, binder, blood
* Mass casualty events:
** Suspend elective activity
** Mobilise resources
** Pre-empt injuries based on mechanism and prepare
** Ensure staff safety including PPE
** Establish command structure
** Redistribute juniors
** On-site triage - START
** Damage-control approach
** Establish communications and pathways for transfer

== Triage ==

* ?activate trauma team
** Airway
** Circulation
** Lines
** Drugs
** Scribe
** Team leader
* See separate topic
== Primary survey ==

* <blockquote>Goal: is the patient shocked, and what is the cause of shock?</blockquote>
* Rapid primary survey with simultaneous initial resus, followed by detailed secondary survey, then definitive care
** Introduce yourself
** Ask the patient's name
** Ask what happened
** If appropriate answers - ABCD is ok

==== '''Airway maintenance, restriction of C-spine''' ====
** Keep neck still for now - can clear C-spine later
** Oxygen
** Inspect for foreign bodies/facial and neck fractures
** Clear airway
** Suction
** Open/secure airway
*** Jaw thrust/chin lift
*** If GCS<8, early intubation, with exact timing depending on other factors including sats
**** Or surgical airway if intubation can't happen for whatever reason
*** If unconscious with no gag reflex, NPA can be helpful

==== '''Breathing and ventilation (adequate gas exchange)''' ====
** Expose neck and chest
** Inspect neck: tracheal deviation and jugular venous distension and absent unilateral breath sounds = tension PTX -> needle decompression and chest tube
** Inspect chest: injuries and symmetrical rise
** Auscultate lungs
** Specifically exclude and immediately treat
*** tension PTX
*** Massive haemothorax
*** Open PTX
*** Tracheal/bronchial injuries
** Give oxygen and monitor oximetry

==== '''Circulation with haemorrhage control''' ====
** Hypotension is due to blood loss until proven otherwise
*** Can look at pulse pressure
** Level of consciousness
** Skin perfusion
** Pulse
** If bleeding externally
*** Direct pressure
*** Tourniquet if direct pressure not working and life is in danger
** Internal bleeding
*** Chest
*** Abdomen - FAST scan
*** Retroperitoneum
*** Pelvis
**** Needs stabilisation device?
*** Long bones
** Get vascular access
*** FBE, UEC, LFT, COAG, bHCG, ?TROP, XM/G+H, VBG
** 1L IV crystalloid if any sign of shock
*** If unresponsive, blood
** IV tranexamic acid if uncontrollable bleeding

==== '''Disability (neurologic)''' ====
** GCS
*** If low, immediately re-evaluate ABC
*** Assume CNS injury until proven otherwise
*** Consider drugs/alcohol
** Pupils

==== '''Exposure/environmental control''' ====
** Completely undress patient then warm

==== '''Adjuncts to primary survey''' ====
** ECG
** ?IDC
*** Need to examine perineum/urethral meatus
*** If concern for urethral injury, need retrograde urethrogram prior to IDC
** X-rays
*** Even in pregnant patients
*** Don’t interrupt resus
** ?NGT
** FAST/DPL

* Obesity

== Secondary survey ==
* Wait until primary survey is complete, resus is under way, and patient is improving/stable

==== History ====
** Allergies
** Meds
** Past hx/pregnancy
** Last meal
** Events leading up to injury
* MVA:
** ?seat-belt
** ?steering wheel deformation
** ?airbags
** ?direction of impact
** ?damage to car
** ?patient position in vehicle
** ?ejection

==== Examination ====
** Head
*** Scalp - ?lacerations, contusions, fractures
*** Eyes - VA, pupils, conjunctival haemorrhage, penetrating injury, contact lenses (remove before oedema occurs), lens dislocation, ocular entrapment)
** Maxfacs
*** Palpate all bony structures
*** Intra-oral exam
*** Assess soft tissues
*** These can all be managed later
*** Be wary of cribriform plate fractures
** C-spine/neck
*** Assume injury until cleared if maxillofacial or head trauma
*** Can use Nexus low-risk criteria to clear spine if
**** No focal neurologic deficit
**** No midline tenderness
**** GCS 15
**** No intoxication
**** No distracting injury
*** Inspect neck
**** Subcutaneous emphysema
**** Tracheal deviation
**** Laryngeal fracture
**** Palpate carotids - ?seatbelt mark or bruise
*** Do not explore wounds that penetrate platysma
*** Any active bleeding, expanding haematoma, arterial bruit or airway compromise requires operative evaluation
** Chest
*** Visual inspection and palpation
**** Entire chest cage
*** Auscultate high anterior (PTX) and low posterior (HTX)
*** Consider tamponade (distant heart sounds, low pulse pressure, tachycardia, distended neck veins)
** Abdo/pelvis
*** ?Pelvic fractures - ecchymosis over iliac wings, pubis, labia, scrotum
**** Pain on compression of pelvic ring
**** FAST or DPL if unexplained hypotension, neurologic injury, impaired sensorium, or any abdo findings
*** Seatbelt sign - often a/w mesenteric laceration or small bowel perforation or pancreatic injury
** Perineum/rectum/vagina
*** Contusions
*** Haematomas
*** Lacerations
*** Urethral bleeding
*** Rectal exam - blood, sphincter tone
*** Pregnancy test
** MSK
*** Palpate long bones
*** X-ray anything odd
*** Consider compartment syndrome
** Log roll
*** Each vertebra
*** Check for bruising
** Neurological
*** Motor and sensory evaluation of extremities
*** Re-evaluation of pupils and GCS
*** If deterioration neurologically - reassess oxygenation, adequacy of ventilation and perfusion of the brain
** Adjuncts
*** X-rays
*** CT
*** Contrast urography/angiography
*** TTE/TOE
*** Bronchoscopy
*** Oesophagoscopy
** Reassess need for transfer
[[Category:Trauma]]