Initial Evaluation of The Trauma Patient
Airway and ventilation
- The objectives of the initial evaluation of the trauma patient are
- To stabilize the trauma patient,
- To identify life-threatening injuries and to initiate adequate supportive therapy, and
- To efficiently and rapidly organize either definitive therapy or transfer.
- Triage And Organization Of Care Q
- The objective of triage is to prioritize patients with a high likelihood of early clinical deterioration.
- When performing a triage with patients having different types of injuries, the priorities of the primary survey help to determine precedence (eg, a patient with an obstructed airway receives greater priority for initial attention than a relatively stable patient with a traumatic amputation).
- Initial Assessment
- The initial evaluation follows a protocol of primary survey, resuscitation, secondary survey, and either definitive treatment or transfer to an appropriate trauma center for definitive care.
- Primary survey
Assessment of ABC: (Assessment and management occur simultaneously)
- Airway and cervical spine control
- Circulation with haemorrhage control.
- Disability: Brief neurological evaluation
- Exposure: Completely undress the patient.
look in the mouth/oropharynx; Stridor; Cyanosis; Level of consciousness
- Treatment Q
- Administer 100% O2 in every case.
- Try chin lift, jaw thrust
- Oral airway
- Intubation + Ventilation
- The airway should be secured as the initial action in trauma resuscitation
- A cervical spine injury should be assumed until proven otherwise
- Oxygen should be delivered at high concentration
- Hypercarbia should be prevented
- The patient should be asked a simple question
- If he responds appropriately
- The airway is patent
- Ventilation is intact
- The brain is being adequately perfused
- Agitation is often a sign of hypoxia
Basic life support
- The aims of airway management are:
- To secure an intact airway
- To protect a jeopardised airway
- To provide an airway when none is available
- These can be achieved with basic, advanced and surgical techniques
- Foreign bodies should be removed from the mouth and oropharynx
- Secretions and blood should be removed with suction
- Airway can usually be secured with a chin lift or jaw thrust
- An oropharyngeal or nasopharyngeal airway may be required
- Oxygen should be delivered at a rate of 10-12 l/min
- Should be administered via a tight fitting mask with reservoir (e.g. Hudson mask)
- An FiO2 of 85% should be achievable
- If absent gag reflex, endotracheal intubation is required
- If no cervical spine fracture orotracheal intubation is preferred
- If cervical spine injury can not be excluded consider nasotracheal intubation
- The position of the tube should be checked
- Complications include:
- Oesophageal intubation
- Intubation of right main bronchus
- Failure of intubation
- If unable to intubate the trachea a surgical airway is required
- There are few indications for an emergency tracheostomy
- Surgical airway can be achieved with a needle or surgical cricothyroidotomy
- Cricothyroid membrane is punctured with a 12 or 14 Fr cannula
- Connected to oxygen supply via a Y connector
- Oxygen supplied at a rate of 15 l/min
- Jet insufflation achieved by occlusion of Y connection
- Insufflation provided one second on and four seconds off
- Jet insufflation can result in significant hypercarbia
- Should only be used for 30 - 40 minutes
- Small incision made over cricothyroid membrane
- 5 mm incision made in membrane
- Small tracheostomy tube inserted
- Complications of surgical airways include:
- Haemorrhage / haematoma
- False passage
- Subglottic stenosis
- Mediastinal emphysema
- In the non-intubated patient ventilation can be achieved with either
- Mouth to face-mask
- The later is more efficient if performed with a two person technique
- One maintains face seal - other ventilates patient
- If endotracheal intubation required
- Should be performed with cricoid pressure
- If rib fractures present need to insert chest drain on side of injury to prevent pneumothorax
- Life Threatening Problems
- Airway obstruction
- Tension/ Open pneumothorax
- Massive haemothorax
- Flail Chest
Insert 12g cannula into second intercostal space mid clavicular line if tension pneumothorax is suspected. If the patient is in extreme distress, suspect and treat for tension pneumothorax, prior to applying positive pressure ventilation.
Hypovolemia is the commonest cause of shock in trauma
- Fluids: Give colloids promptly and in large volumes. Resuscitate not only the BP and pulse but also the urinary output, peripheral return and gut.
- Ongoing Assessment
- Other Causes of Shock in Trauma
- Cardiogenic Q
- Tamponade; Cardiac Contusion; Air Embolism; Acute Myocardial infarct
- High cervical cord lesion; Decreased blood pressure, decreased heart rate and peripherally vasodilated
- Determine if there is any neurological deficit. Assess the GCS.
- Expose the patient
- Perform log roll and examine the back
- Attend to PR examination. This should be done prior to male catheterisation.
- Resuscitation phase
- During the primary survey, when making diagnoses and performing interventions, continue until the patient condition is stabilized,
- The diagnostic workup is complete, and resuscitative procedures and surgeries are complete.