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

Goal: is the patient shocked, and what is the cause of shock?
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