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ABCD Assesment

1. Trauma Triage and Scoring 

2. Trauma Assesment

 

Resuscitation and primary survey

For speed and efficacy a logical sequence of assessment to establish treatment priorities must be gone through sequentially although, with good teamwork, some things will be done simultaneously (resuscitation procedures will begin simultaneously with the assessment involved in the primary survey, i.e. lifesaving measures are initiated when the problem is identified). Special account should be taken of children, pregnant women and the elderly10 as their response to injury is modified. The primary survey is according to:

A = Airway maintenance cervical spine protection

Are there signs of airway obstruction, foreign bodies, facial, mandibular or laryngeal fractures? Management may involve secretion control, intubation or surgical airway (e.g. cricothyroidotomy, emergency tracheostomy).

 

 Establish a clear airway (chin lift or jaw thrust) but protect the cervical spine at all times. If the patient can talk, the airway is likely to be safe; however, remain vigilant and recheck. A nasopharyngeal airway should be used in a conscious patient; or, as a temporary measure, an oropharyngeal airway in an unconscious patient with no gag reflex. Definitive airway should be established if the patient is unable to maintain integrity of airway; mandatory if Glasgow Coma Scale (GCS) less than 8.

Cervical spine protection is critical throughout the airway management process. Movement of the cervical spine could cause spinal injury so movement of the cervical spine should be avoided unless absolutely necessary for maintaining an airway. The trauma mechanism or history may suggest the likelihood of a cervical spine injury, but always assume there is a spinal injury until proven otherwise, especially in any multisystem trauma or if there is an altered level of consciousness. Inline immobilisation and protection of the spine should be maintained and X-rays can be taken once immediately life-threatening conditions have been dealt with.

B = Breathing and ventilation

Provide high flow oxygen through rebreather mask if not intubated and ventilated. Evaluate breathing: lungs, chest wall, diaphragm. Chest examination with adequate exposure: watch chest movement, auscultate, percuss to detect lesions acutely impairing ventilation:

Tension pneumothorax - requires needle thoracostomy followed by drainage.

Flail chest - management involves ventilation.

Haemothorax - will usually require intercostal drain insertion.

Pneumothorax - may require intercostal drain insertion.

Note: it can be difficult to tell whether the problem is an airway or ventilation problem. What appears to be an airway problem, leading to intubation and ventilation, may turn out to be a pneumothorax or tension pneumothorax which will be exacerbated by intubation and ventilation.

C = Circulation with haemorrhage control:

Blood loss is the main preventable cause of death after trauma. To assess blood loss rapidly observe:

 Level of consciousness.

Skin colour.

Pulse.

Bleeding should be assessed and controlled:

IV access should be achieved with 2 large cannulae (size and length of cannula is determinant of flow not vein size) in an upper limb. Access by cut down or central venous catheterisation may be done according to skills available. At cannula insertion, blood should be taken for crossmatch and baseline investigations.

IV fluids will need to be given rapidly usually as 500 ml to 1 L warmed boluses (10-20 ml/kg in children). Often 2-3 litres in total is necessary, after 40 ml/kg blood is usually needed (O negative, if typed blood is not available). Ringer's lactate is the preferred initial crystalloid solution.

Direct manual pressure should be used to stem visible bleeding (not tourniquets, except for traumatic amputation, as these cause distal ischaemia).

Transparent pneumatic splinting devices may control bleeding and allow visual monitoring; surgery may be necessary if these measures fail to control haemorrhage.

Occult bleeding into the abdominal cavity and around long-bone or pelvic fractures is problematic but should be suspected in a patient not responding to fluid resuscitation.

 

Note: response to blood loss differs in:

Elderly - limited ability to increase heart rate; poor correlation between blood loss and blood pressure.

Children - tolerate proportionately large volume loss but then rapidly deteriorate.

Athletes - do not show the same heart rate response to blood loss.

Chronic conditions and medication may affect response and early on in trauma management will not be known about.

D = Disability: neurological status:

After A, B and C above, rapid neurological assessment is made to establish:

Level of consciousness, using GCS.

Pupils: size, symmetry and reaction.

Any lateralising signs.

Level of any spinal cord injury (limb movements, spontaneous respiratory effort).

Oxygenation, ventilation, perfusion, drugs, alcohol and hypoglycaemia may all also affect the level of consciousness.

Patients should be re-evaluated frequently at regular intervals as deterioration can occur rapidly and often patients can be lucid following a significant head injury before worsening. Signs such as pupil asymmetry or dilation, impaired or absent light reflexes, hemiplegia/weakness all suggest an expanding intracranial mass or diffuse oedema. This requires IV mannitol, ventilation and urgent neurosurgical opinion. 

E = Exposure/ environmental control:

undress the patient, but prevent hypothermia.

Clothes may need to be cut off but, after examination, attention to prevention of heat loss with warming devices, warmed blankets etc. Also check blood glucose levels.

 

Additional considerations to primary survey and resuscitation

 

ECG monitoring: this can guide resuscitation by diagnosing dysrhythmias, ischaemia, cardiac injury, pulseless electrical activity (PEA) - which may indicate cardiac tamponade - hypovolaemia, tension pneumothorax, extreme hypovolaemia. Hypoxia or hypoperfusion should be suspected if there is bradycardia, aberrant conduction, premature beats. Hypothermia produces dysrhythmias.

Urinary/gastric catheters:

Output of urine can guide fluid replacement (reflects renal perfusion). Adequate output is 0.5-1 ml/kg/hour.

Note: prior to catheter insertion urethral injury should be excluded - suspect if there is blood at meatus, pelvic fracture, scrotal blood, perineal bruising. Per rectum (PR) and genital examination are mandatory prior to catheter insertion.

Gastric catheters are inserted to reduce aspiration risk. Suction should be applied.

Note: care should be taken not to provoke aspiration by triggering gagging.

Other monitoring:

monitoring of resuscitation by measuring various important parameters measures adequacy of resuscitation efforts. Values for various parameters should be obtained soon after the primary survey and reviewed regularly. Important parameters are:

Pulse rate,13 blood pressure, ventilatory rate, arterial blood gases, body temperature and urinary output.

Carbon dioxide detectors may identify dislodged endotracheal tubes.

Pulse oximetry measures oxygenation of haemoglobin colorimetrically (sensor on finger, ear lobe, etc.).

 

Remember: blood pressure is a poor measure of perfusion.

Diagnostic procedures: care should be taken that these do not hamper resuscitation. They may be best deferred to the secondary survey. Modifications to the ATLS guidelines have been suggested.14,15 X-rays most likely to guide resuscitation early on, especially in blunt trauma, include:

Chest X-ray.

Pelvic X-ray. It has been suggested that CT scans may be used in some stable patients.14

Lateral cervical spine X-ray. 

Other useful procedures include diagnostic peritoneal lavage (DPL) and abdominal ultrasound to detect occult bleeding.

 

Secondary survey

This begins after the 'ABCDE' of the primary survey, once resuscitation is underway and the patient is responding with normalisation of vital signs. The secondary survey is essentially a head-to-toe examination with completion of the history and reassessment of progress, vital signs, etc. It requires repeat physical examinations and may require further X-ray and laboratory tests. It comprises:

History:

A = Allergies

M = Medication currently used

P = Past illnesses/Pregnancy

L = Last meal

E = Events/Environment related to injury

Physical examination: this will repeat some examinations already undertaken in the primary survey and will be further informed by the progress of the resuscitation. It aims to identify serious injuries, occult bleeding, etc. A review of neurological status including GCS score is also undertaken. Back and spinal injuries are commonly missed and pelvic fractures cause large blood loss which is often underestimated.

Beware: burns (fluid requirements, inhalation injury); cold injury (continue resuscitation until rewarmed); high voltage electricity injuries (extensive muscle injury likely to be concealed).

Additional considerations to secondary survey

A range of further diagnostic tests and procedures may be required after the secondary survey. These include CT scans , ultrasound investigations, contrast X-rays, angiography, bronchoscopy, oesophageal ultrasound, etc.

Definitive care

Choosing where care should continue most appropriately will depend on results of the primary and secondary surveys and knowledge of the facilities available to receive the patient. The closest appropriate facility should be chosen.

Records and legal considerations

Remember:

Keep meticulous records (times for all entries, etc.). Teamwork with timekeeping and recording of clinical measurements, and observations can be helpful. Some units have a member of the nursing staff whose sole role is accurately to record and collate patient care information.

Consent for treatment is not always possible with lifesaving treatment and consent may have to be given later.

Forensic evidence may be required in injuries caused by criminal activity.

Practice tips

Regular training in resuscitation by the whole practice team is recommended. Attention to a team approach is essential. Involvement in medical cover at schools, sports events, car accidents (BASICS) requires higher level training and regular refresher courses.

 

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