Initial Assessment

and Management
INITIAL ASSESSMENT

Preparation

Triage

Primary survey (ABCDEs)

Resuscitation

Adjuncts to primary survey and

resuscitation
Consideration of the need for patient
transfer
Secondary survey (head-to-toe
evaluation and patient history)

Adjuncts to the secondary survey

Continued postresuscitation
monitoring and Reevaluation

Definitive care
 PREPARATION

PREHOSPITAL PHASE

Airway maintenance, control of external bleeding and shock,

immobilization of the patient, and immediate transport to the closest
appropriate facility

HOSPITAL PHASE
TRIAGE

Triage involves the sorting of patients based on their needs for treatment and
the resources available to provide that treatment

In multiple-casualty incidents, although there is more than one patient, the

number of patients and the se- verity of their injuries do not exceed the
capability of the facility to render care. In such situations, patients with life-
threatening problems and those sustaining multiple-system injuries are treated
first.

In mass-casualty events, the patients having the greatest chance of survival and
requiring the least expenditure of time, equipment, supplies, and personnel, are
treated first.
PRIMARY SURVEY

Airway maintenance with cervical spine protection

Breathing and ventilation

Circulation with hemorrhage control

Disability: Neurologic status

Exposure/Environmental control: Completely

undress the patient, but prevent hypothermia
 PRIMARY SURVEY
AIRWAY MAINTENANCE WITH CERVICAL SPINE PROTECTION

Initial evaluation of a trauma patient, the airway should be assessed first

to ascertain patency

The patient’s head and neck should not be hyperextended, hyperflexed,

or rotated to establish and maintain the airway. Based on the history of a
traumatic incident, loss of stability of the cervical spine should be
assumed. Neurologic examination alone does not exclude a diagnosis of
cervical spine injury.

Patients with severe head injuries who have an altered level of

consciousness or a Glasgow Coma Scale (GCS) score of 8 or less
usually require the placement of a definitive airway (i.e., cuffed,
secured tube in the trachea). The finding of nonpurposeful motor
responses strongly suggests the need for defini- tive airway
management.
 PRIMARY SURVEY
Breathing and ventilation

Airway patency alone does not ensure adequate

ventilation

Ventilation requires adequate function of the lungs, chest

wall, and diaphragm

The patient’s neck and chest should be exposed to

adequately assess jugular venous distention, position of
the trachea, and chest wall excursion.

Injuries that severely impair ventilation in the short term

include tension pneumothorax, flail chest with pulmonary
contusion, massive hemothorax, and open pneumothorax.
 PRIMARY SURVEY
CIRCULATION WITH HEMORRHAGE CONTROL

Hemorrhage is the predominant cause of preventable

deaths after injury.

The elements of clinical observation that yield important

information within seconds are level of consciousness,
skin color, and pulse

The source of bleeding should be identified as either

external or internal
 PRIMARY SURVEY

DISABILITY (NEUROLOGIC EVALUATION)

A rapid neurologic evaluation is performed at the end of

the primary survey. This neurologic evaluation es-
tablishes the patient’s level of consciousness, pupillary size
and reaction, lateralizing signs, and spinal cord injury
level.

A decrease in the level of consciousness may indicate

decreased cerebral oxygenation and/or perfusion, or it
may be caused by direct cerebral injury
 PRIMARY SURVEY
EXPOSURE AND ENVIRONMENTAL CONTROL

Intravenous fluids should be warmed before being infused, and a warm

environment (i.e., room temperature) should be maintained. The patient’s body
temperature is more important than the comfort of the healthcare providers.
 Resuscitation

Resuscitation also follows the ABC sequence and occurs simultaneously

with evaluation.

AIRWAY

• The jaw-thrust or chin-lift maneuver may suffice as an initial intervention. If the patient is
unconscious and has no gag reflex, the establishment of an oropharyngeal air- way can be
helpful temporarily. A defnitive airway (i.e., intubation) should be established if there is any
doubt about the patient’s ability to maintain airway integrity.

BREATHING, VENTILATION, AND OXYGENATION

• Every injured patient should receive supplemental oxygen

CIRCULATION AND HEMORRHAGE CONTROL

• De nitive bleeding control is essential along with appropriate replacement of intravascular

volume.
• Aggressive and continued volume resuscitation is not a substitute for definitive control of
hemorrhage.
Adjuncts to Primary Survey and Resuscitation

ELECTROCARDIOGRAPHIC MONITORING
• Dysrhythmias—including unex- plained tachycardia, atrial fibrillation, premature ven- tricular
contractions, and ST segment changes—can indicate blunt cardiac injury
URINARY AND GASTRIC CATHETERS
• Urinary output is a sensitive indicator of the patient’s volume status and reflects renal perfusion.

Ventilatory Rate and Arterial Blood Gases

• Ventilatory rate and ABG levels should be used to monitor the adequacy of respirations.

Pulse Oximetry
• The pulse oximeter measures the oxygen saturation of hemoglobin colori- metrically, but it does not
measure the partial pres- sure of oxygen. It also does not measure the partial pressure of carbon dioxide,
which reflects the adequacy of ventilation.

Blood Pressure

X-RAY EXAMINATIONS AND DIAGNOSTIC STUDIES

CONSIDER NEED FOR PATIENT TRANSFER

During the primary survey and resuscitation phase, the evaluating physician frequently
obtains enough information to indicate the need to transfer the pa- tient to another
facility
 SECONDARY SURVEY

The secondary survey does not begin until the primary survey (ABCDEs) is
completed, resuscitative e orts are underway, and the normalization of vital functions
has been demonstrated

The secondary survey is a head-to-toe evalua- tion of the trauma patient, that is, a
complete history and physical examination, including reassessment of all vital signs.

The AMPLE history is a useful mnemonic for this purpose:Allergies, Medications

currently used, Past illnesses/Pregnancy, Last meal, Events/Environment related to the
injury

The patient’s condition is greatly influenced by the mechanism of injury, and some
injuries can be predicted based on the direction and amount of energy behind the
mechanism of injury
( Blunt Trauma, penetrating truma, thermal injury, Hazardous Environment )
Adjuncts to the Secondary Survey

Missed injuries can be minimized by maintaining a high index of

suspicion and providing continuous monitoring of the patient’s
status. Specialized diagnostic tests may be performed during the
secondary survey to identify specific injuries.
Reevaluation

Trauma patients must be reevaluated constantly to ensure that

new findings are not overlooked and to discover deterioration in
previously noted findings. As initial life threatening injuries are
managed, other equally life threatening problems and less severe
injuries may become apparent
THANK YOU
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