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1. Preparation
2. Triage
3. Primary Survey (ABCDEs)
4. Resuscitation
5. Adjuncts to primary survey & resuscitation
6. Secondary Survey (head to toe evaluation & history)
7. Adjuncts to secondary survey
8. Continued post-resuscitation monitoring & re-evaluation
9. Definite care.
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1. PREPARATION
A Pre-hospital phase
Receiving hospital is notified first.
Send to the closest, appropriate facility.
B In Hospital Phase
Advanced planning for the trauma pt arrival.
Method to summon extra medical assistance
Transfer agreement with verified trauma center established.
Protect from communicable disease.
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2. TRIAGE
A Multiple Casualties
no of severity & pt do not exceed the ability of
the facility.
B Mass Casualties
no & severity of pt EXCEED the capability of
the facility & staff.
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3. PRIMARY SURVEY
A : Airway with cervical spine protect.
B : Breathing
C : Circulation --control external bleeding.
D : Disability or neurological status
E : Exposure (undress) & Environment (temp control)
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PRIMARY SURVEY
Priorities for the care of Adult , Pediatrics
& Pregnancy women are all the same.
During the primary survey life threatening
conditions are identified and management is
instituted SIMULTANEOUSLY.
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A. Airway Maintenance with Cervical Spine
Protection.
* GCS score of 8 or less require the placement of definite
airway.
*Protection of the spine & spinal cord is the important
management principle.
*Neurological exam alone does not exclude a cervical spine
injury.
*Always assume a cervical spine injury in any pt with multi-
system trauma, especially with an altered level of consciousness
or blunt injury above the clavicle.
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B. Breathing & Ventilation
* Airway patency does not assure adequate ventilation.
C. Circulation with Hemorrhage Control.
1. Blood Volume & Cardiac Output
a. level of consciousness.
b. skin color
c. Pulse.
2. Bleeding
*external bleeding is identified & controlled in the
primary survey.
*Tourniquets should not be use.
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D. Disability ( Neurological Evaluation)
Simple Mnemonic to describe level of consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
Not forget to use also Glascow Coma Scale.
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E. Exposure / Environmental Control
*It is the pt’s body temp that is most important, not he
comfort of the health care provider.
*Intravenous fluid should be warm.
*Warm environment (room tem) should be maintained.
*early control of hemorrhage.
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4. RESUSCITATION
A. Airway
*definite airway if there is any doubt about the pt’s ability to
maintain airway integrity.
B. Breathing /Ventilation/Oxygenation
*every injured pt should received supplement oxygen
C. Circulation
*control bleeding by direct pressure or operative intervention
* minimum of two large caliber IV should be established
*pregnancy test for all female of child bearing age.
* Lactated Ringer is preferred & better if warm.
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5. ADJUNCT TO PRIMARY SURVEY &
RESUSCITATION
A. Electro-cardiographic Monitoring
B. Urinary & Gastric Catheter
1. Urinary catheter.
Urethral injury should be suspected if
*Blood at the penile meatus
*Perineal ecchymosis
*Blood in the scrotum
*High riding or nonpalpable prostate
*Pelvic fracture
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C. Monitoring
1. Ventilatory rate & ABG
2. Pulse oximetry
does not measure ventilation or partial O2 pressure
3. Blood pressure
poor measure of actual tissue perfusion.
D. X-Ray & Diagnostic Studies
C-spine, CXR, Pelvic film
Essential x-ray should not be avoid in pregnant pt.
*** Consider the need for patient transfer.
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6 SECONDARY SURVEY
Does not begin until the primary survey (ABCDEs)
is completed, resuscitative effort are well established
& the pt is demonstrating normalization of vital sign.
* Head to Toe evaluation & reassessment of all vital
signs.
* A complete neurological exam is performed including
a GCS score.
* Special procedure is order.
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History
A : Allergies.
M : Medication currently used.
P : Past illness/ Pregnancy.
L : Last Meal
E : Events/Environment related to the injury.
*blunt trauma/penetrating trauma/injuries due
to cold & burn/hazardous environment?
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PHYSICAL EXAMINATION
1. Head
Visual acuity
Pupillary size
Hemorrhage of conjunctiva and fundi
Penetrating injury
Contact lenses(remove before edema occurs)
Dislocation of lens
Ocular movement
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2. Maxillofacial Injury
no NG tube, definite airway?
3. Cervical Spine & Neck
*Pt with maxillofacial or head trauma should be presumed
to have and unstable cervical spine.
4. Chest
*elderly pt are not tolerant of even relatively minor
chest injury.
*Children often sustain significant injury to the
intrathoracic structure without evidence of thoracic
skeletal trauma.
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5. Abdomen
*excessive manipulation of the pelvic should be avoided.
6. Perineum/rectum/vagina
7. Musculoskeletal
8. Neurologic
* Protection of spinal cord is required at all times until a
spine injury excluded, especially when the pt is transfer.
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7. ADJUNCT TO THE SECONDARY SURVEY
include additional x-ray and all other special procedure.
8. RE-EVALUATION
Adult urine output 0.5ml/kg/hr
Pediatric urine output 1mg/kg/hr
*Pain relief -- IM should be avoid.
9. DEFINITE CARE
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Indication For Definite Airway
* Unconscious
* Severe maxillo-facial fracture
* Risk for aspiration : Bleeding/ vomiting
* Risk for obstruction : neck hematoma/laryngeal,tracheal
injury/ stridor
* Apnea : Neuromuscular paralysis/unconscious
* Inadequate respiratory effort:
tachypnea/hypoxia/hypercapnia/cyanosis
* Severe closed head injury need for hyperventilation
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Normal Blood Amount:
Normal adult blood volume : 7% of body weight
Normal blood volume for child : 8-9% of body weight
Hemorrhage Classification :
Class I Hemorrhage : up to 15% loss
Class II Hemorrhage : 15-30% loss
Class III Hemorrhage : 30-40% loss
Class IV Hemorrhage : >40% loss
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3 for 1 Rule
a rough guideline for the total amount of
crystalloid volume acutely is to replace each
ML of blood loss with 3 ML of crystalloid
fluid, thus allowing for restitution of plasma
volume lost into the interstitial &
intracellular space
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Initial Fluid Therapy
Lactated Ringer is preferred
* For adult 1-2 liters bolus
* For child 20ml/kg bolus
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Intraosseous Puncture/Infusion
Children less than 6 y/o for IV access is
impossible due to circulatory collapse or
for whom percutaneous peripheral venous
cannulation had failed on two attempt.
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Head Injury Classification:
Mild : GCS 14-15
Moderate : GCS 9-13
Severe : GCS 3-8
Coma = GCS score of 8 or less
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Diagnostic Peritoneal Lavage Indication
A. Change in sensorium--Head injury/alcohol/drug.
B. Change in sensation--Spinal cord injury.
C. Injury to adjacent structure--lower
ribs/pelvic/lumbar spine.
D. Equivocal physical examination.
E. Prolong loss of contact with patient anticipated.
*** Positive Test: >100,000 RBC/mm3, >500 WBC/mm3
or Gram Stain with bacteria
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Determining the level of quadriplegia
a. Raise elbow to level of shoulder -- Deltoid C5
b. Flexes the forearm -- Biceps C6
c. Extend the forearm -- Triceps C7
d. Flexes wrist & finger -- C8
e. Spread finger -- T1
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Determine the level of paraplegia
a. Flexes the hip -- Iliopsoas L2
b. Extend knee -- Quadriceps L3
c. Dorsiflexes ankle -- Tibialis anterior L4
d. Plantar flexes ankle -- Gastrocnemius S1
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Fluid Therapy in
2nd or 3rd Degree Burn
Total amount of first 24 hours:
4 ml of Ringer lactate x BW(kg) x BSA
* give 1/2 in first 8 hrs
* 1/2 in remaining 16 hrs
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Referral to Burn Center
* 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y/o
* 2nd or 3rd degree burn > 20% BSA in other age group
* 2nd or 3rd degree burn of face/eye/ear/hands/feet/
genitalia/perineum or major joints
* 3rd degree burn >5% in any age group
* Significant electrical/lightning injury
* Significant chemical burn
* Inhalation injury
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Color Codes Triage Tag
RED : Most critical injury
YELLOW : Less critical injured
GREEN : No life or limb threatened injury
BLACK : Death or obviously fatal injury
