- 1 Initial assessment and management

- I: the primary survey and resuscitation

Peter Driscoll, David Skinner

More than 90% of the injured patients seen in British emer- "',""
gency departments have been subjected to blunt trauma.
These patients are often difficult to assess because many of
their injuries are hidden. They should be managed using a
team approach and a predetermined plan for the initial
assessment and urgent resuscitation. All members of the
team must be familiar with their own roles and those of
their colleagues. These two essential elements will enable the
members of the team to carry out their individual tasks
simultaneously. "

The tra1Ulla teaDl f

Personnel-The trauma team should initially comprise four ,~
doctors, five nurses, ~nd a radiographer. The medical team Trauma team in action.
consists of a team leader, an "airway" doctor and two
"circulation" doctors. The nursing team comprises a team
leader, an "airway" nurse, two "circulation" nurses and a
"relatives" nurse.
Teammembers'roles-Examples of paired roles and tasks are
given on page 2,. but assignments may vary among units
depending on the resources available. To avoid chaos and
disorganisation, no more than six people should be touching Objectives of the tra1Ulla teaDl
the patient. The other team members must keep well back. . IdentifYand correct life threatep,ing injuries
. Resuscitate the patieht ancfstabilise the vital

Before the patient arrives . SIgnS

Determine the nature and extent of other

..
Many emergency departments are warned by the ambulance lllJunes
service of the impending arrival of a seriously injured patient. Categomse the'injuii'es in order of priority
This communication system can also provide the trauma team Prepare and transport the patient to a place
with helpful information about the patient's condition and the of defmitive care
paramedics' prehospital interventions.
. After the warning, the team should assemble in the
resuscitation room and put on protective clothing. The
absolute minimum is rubber latex gloves, plastic aprons and
eye protection because all blood and body fluids should be
assumed to carry HIV and hepatitis viruses. Ideally, full
protective clothing should be worn by each member of the
t,eam, and all must have been immunised against tetanus and
the hepatitis B virus. Trauma patients often have sharp objects ,..':
such as glass and other debris in their clothing, hair and on
their skin. Ordinary surgical gloves give no protection against 1
this, so the staff who undress the patient should initially wear
more robust gloves.
While protective clothing is being put on, the team leaders
need to brief the team, ensuring that each member knows the
task for which he or she is responsible. A final check of the
equipment by the appropriate team members can then be
made. As the resuscitation room must be kept fully stocked and
ready for use at any time, only minimum preparation should
be necessary. The resuscitation room: preparing for the patient's arrival.

,
 ABC of Major Trauma

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Reception and transfer and
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If the ambulance bay is a long way from the resuscitation spm
. allo\
room, the staff in charge of the airway should assess the
patient in the back of the ambulance. Provided there is no
urgent airway problem requiring immediate intervention, the
. ation

. patient can be moved. Once the patient arrives in the Bre:

Liste
resuscitation room, the nursing team leader should start the
.
stop clock so that accurate times can be recorded.
The transfer of the patient from stretcher to trolley must be
coordinated to avoid rotation of the spinal column or
. cone
thq
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exacerbation of pre-existing injuries (see chapter 8). Team cov
members should also check that lines and leads are free so that resp
,
they do not become disconnected or snagged. . beca
cont
the
Primary survey and resuscitation exan
wou
The objectives of this phase are to identify and treat any imme- tam]
diately life threatening condition. Each patient should be pent
assessed in the same way, and the appropriate tasks performed bec3
automatically and simultaneously by the team. It is vital that . seen
problems are anticipated and prepared for, rather than reacted .or \\
to. If the patient deteriorates at any stage, the medical team
leader must reassess the patient, beginning again with the airway.
. with
resp

L I
 Initial assessment and management

Airway management, protecting the cervical spine

It is important to assume that the cervical spine has been
damaged if there is suspicion of injury above the clavicles or if
there is a history of a high speed impact. The doctor dealing
withthe airway should talk to the patient while the neck is kept
manually in a neutral position by the airway nurse. If the
patient replies in a normal voice, and gives logical answers to
nous
sensible questions, the airway is patent and the brain is being
d
perfused adequately with oxygenated blood. If there is no reply,
the patient's mouth should be opened and any solid foreign
objects removed with Magill forceps and fluid sucked out.
The complications of alcohol ingestion and possible injuries
of the chest and abdomen increase the chance of the patient
Guedal airway.
vomiting. If the patient vomits, no attempt should be made to
turn the patient's head to one side unless a cervical spine injury
has been ruled out radiologic ally and clinically. If the patient is
properly secured to a spinal (back) board, however, the whole
body can be turned. In the absence of a spinal board the trolley
I\1Cal
should be tipped head down by 200 and the vomit sucked away
with a rigid sucker as it appears in the mouth.
Chin lift or jaw thrust manoeuvres can be used to correct
befed the position of the tongue, which often obstructs the airway in
unconscio.us patients. Those with a gag reflex can maintain
their own airway. As the use of Guedel airways in these patients
can precipitate vomiting, cervical movement, and a rise in
intracranial pressure, a nasopharyngeal airway is preferred
ill Nasopharyngeal airway.
provided that there is no evidence of a base of skull fracture.
ce If the patient is apnoeic, ventilation with a bag-valve-mask
rtion device may lead to gastric distension with air and can induce
vomiting. Therefore patients without a gag reflex should be
the intubated so that ventilation can be carried out safely.
Orotracheal intubation with in-line stabilisation of the neck is
recommended, rather than nasotracheal intubation. If this
proves impossible then a surgical airway must be provided.
Once the airway has been cleared and secured, every patient /
should receive 100% oxygen at a flow rate of 15 litres per min-
ute. The neck must then be examined for wounds, tracheal
ft
position, venous distension, surgical emphysema and laryngeal
crepitus. Consideration can now be given to securing the cervi-
cal spine so that the airway nurse can safely release the patient's
head and neck. This is done with a semirigid collar, sand bags Patient with rigid collar in place.
and tape, or a commercially available spine support. The' only
exception is the resdess and thrashing patient. Here the cervical
spine can be damaged by immobilising the h~ad and neck while
allowing the rest of the body to move. Suboptimal immobilis-
ation with just a semirigid collar .is therefore accepted.
..
Immediately life threateniJ).g
Tensi()iJ.pneufiJ.()thor~
thoracic conditions

. Breathing
Listed in the box are five immediately life threatening thoracic
.. Cardiac tamponade
Open chest wound
Massive haemothorax
conditions that must be urgently identified, and treated, during .Flail
the primary survey and resuscitation phase (see chapter 4).
To see if any of these conditions is present, all the clothes
covering the front and sides of the chest must be removed. The
respiratory rate, effort and symmetry should then be recorded
-because these are sensitive indicators of underlying pulmonary
contusion, haemothorax, pneumothorax and fractured ribs. At
.
Common causes
Bilateral
of inadequate ventilation

J:.~$piratorytract
the same time, the medical team leader should visually
examine both sides of the chest for bruising, abrasions, open
wounds, and evidence of penetrating
tamponade
trauma. Cardiac
after trauma is usually associated with a
. - leak between the face: aI1d !TIask
Unilateral
-intubation Qf the right main bronchus
penetrating injury. The team leader should also remember that
~pneumothorilX
because of intercostal muscle spasm, paradoxical breathing is
i. .haemothorax
seen with a flail chest only if the segment is large, or central,
.or when the patient's muscles become fatigued. The patient -foreign. body in a main bronchus
with a flail chest usually has a rapid, shallow, symmetrical, -significant lung contusion
respiratory pattern initially.