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1. Initial assessment and management of the trauma patient.pptx

The document outlines the initial assessment and management of trauma patients, emphasizing the importance of following a strict algorithm prioritizing airway, breathing, circulation, and disability. It presents a clinical scenario of an injured patient from a motor vehicle collision, detailing vital signs, injuries, and required interventions. Effective preparation, rapid identification of critical injuries, and timely transfer to capable facilities are crucial for improved patient outcomes.

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Initial Assessment and Management of the Trauma Patient Unfolding scenario Reflective self-assessment April 2020 © The Royal College of Surgeons of England 2020. All rights reserved
Initial Assessment Learning objectives: • Identify the correct sequence of priorities for assessment of a multiply injured patient - the primary survey. • Consider how the mechanism of injury contribute to the identification of injuries. • Recognize patients who will require transfer for definitive management.
Initial Assessment
Initial Assessment PPE is needed ● Cap ● Gown ● Gloves ● Mask ● Shoe covers ● Protective eyewear / face shield
Clinical Scenario M 18-year-old male, unrestrained driver in MVC vs. tree. I None reported. S Observations not reported. T Prolonged extrication; transported to ED by ambulance; O2 by mask; fluids via single IV; spinal motion restricted on long spine board.
Initial Assessment Video: Hospital preparation Self-assessment questions (suggested responses on next slide): • How would you prepare for the arrival of this patient? • What other information would be helpful to know in order to prepare? • From the history, what are the potential injuries this patient may have suffered?
Initial Assessment • All equipment for an ABC evaluation to be available including oxygen, airway devices, iv cannulae and warmed isotonic fluids. • Introduce and brief members of the Trauma Team. As Team Leader, assess capabilities of team members. • It would be helpful to have a report of vital signs, interventions and GCS score from the pre-hospital team. • Likely injuries include head, spine, chest, abdomen, pelvis and long bones in this high energy impact.
Clinical Scenario Case progression Patient arrives at hospital. Vital signs: HR 120; BP 90/65; RR 20; SpO2 82% on O2, temp 35.5°C. Video: Handover Self-assessment questions (suggested responses on next slide): What are your management priorities? What are your clinical concerns?
Clinical Scenario • The patient is hypoxic, tachycardic, and hypotensive. • There may be an airway issue, but there certainly is a breathing issue (e.g., pulmonary contusion, haemothorax/pneumothorax, aspiration). • The patient is in shock (hemorrhagic and/or obstructive). • Potential sources of bleeding are chest, abdomen, pelvis and femur. • Ongoing hemodynamic instability leads to the potential for secondary brain injury. • Management priorities cover ABCD. The rationale for the order of priority (airway, breathing, circulation, disability) is to assess and manage problems in an order that addresses the most life-threatening injuries first – for example an obstructed airway will usually kill a patient before haemorrhagic shock.
Initial Assessment • Initial Assessment (Primary Survey) follows a strict algorithm based on a hierarchy of what injuries and patient compromises are going to kill the patient most rapidly. • Thus • Compromise of airway (A) will need correction before • Interventions to correct breathing (B) problems • And control of bleeding and resuscitation of haemorrhagic shock (C) is done after A and B • Assessment of Disability (D) Follows A B and C • And finally consideration is given to full exposure (E) of the patient whilst remembering to prevent patient cooling • If a life-threatening problem is identified it is important to manage the problem when found before proceeding with assessment. • Any intervention should be followed by reassessment before proceeding with the primary survey to ensure appropriate response. • Priorities for all trauma patients are the same. Video: Initial assessment
Clinical Scenario Case progression Primary survey reveals: Vital signs: HR 120; BP 90/65; RR 20; SpO2 82% on O2 A: Obvious facial trauma and mumbling incoherently. B: Decreased breath sounds in L chest. No visible neck veins. C: Minimal bleeding from open L femur fracture. Left chest bruising. Possible pelvic fracture. D: Localizes to pressure with upper extremities. Moans to pressure stimuli. Does not open eyes.
Clinical Scenario Self-assessment questions (suggested responses on next slide): What are your priorities and your clinical concerns now?
Clinical Scenario • Establish a patent airway (A) while maintaining restriction of cervical spine movement. • Confirm adequate breathing (ventilation) (B). • Control bleeding and support the circulation (C). • Evaluate the patient for evidence of brain injury and prevent secondary brain injury if present (D). • Undress the patient while preventing hypothermia to fully assess (including the back) (E). • AND RE-EVALUATE!
Clinical Scenario • Hemorrhage is the commonest cause of shock in trauma patients. • This patient likely has class III estimated blood loss (30-40%). • All other types of shock are secondary (neurogenic, cardiogenic, obstructive, and septic). • Signs that indicate shock include tachycardia and hypotension, evidence of poor organ perfusion (e.g. to the brain - decreased mental status vs. head injury), pallor, and thready pulse.
Clinical Scenario Case progression • Chest drain sited in L chest. • Femur fracture reduced and immobilized; pelvic binder applied. • 500 mL warmed crystalloid and 1 unit unmatched pRBCs given iv. • Vital signs: HR 97; BP 110/64; RR 24; SpO2 96%. • Patient begins to respond to verbal stimuli, opens eyes, and tries to brush away your hands.
Initial Assessment Self-assessment questions (suggested responses on next slide): What additional adjuncts and treatments would you order at this time? When should a transfer occur and what tests are necessary before transferring a patient?
Initial Assessment • Additional adjuncts should include chest x-ray, pelvic x-ray, and FAST. • Insert a gastric tube and a urinary catheter, assuming there is no evidence of blood at the urethral meatus or perineal bruising. • If your facility has the capabilities to definitively treat this patient, x-ray of left femur as well as full trauma CT scan of head, C-spine, chest, abdomen and pelvis could be performed. • If transfer needed do not delay for additional investigations.
Initial Assessment • Transfer should occur as soon as possible after you determine that the patient’s needs exceed the capabilities of your facility. • Transfer must not be before the patient has been resuscitated and stabilized to the best of your available capabilities. • Only perform tests that directly affect your care of the patient (e.g., do not delay transfer to perform a head CT if a neurosurgeon is not available). • See Transfer Module for more information.
Clinical Scenario Case progression • Patient’s conscious level decreases. • Patient opens his eyes to pressure and withdraws. • Vital signs: HR 100; BP 100/60; RR 20. • Good breath sounds bilaterally.
Clinical Scenario Case progression: Re-evaluation reveals: • Pupils: LEFT 5 mm, minimally reactive; RIGHT 6 mm, reactive. • Laceration and soft tissue injury L temporal-frontal region; no active bleeding. • Bruising L anterior chest. • Abdomen soft, non-distended.
Clinical Scenario Self-assessment questions (suggested responses on next slide): What do you think has happened to the patient? What should be done?
Clinical Scenario • The patient has developed an intracranial bleed. • If your hospital does not have neurosurgical capability the patient must be transferred to one that does AFTER all primary survey problems have been addressed and the patient is stabilized. • This patient will need intubation prior to transfer.
Clinical Scenario Case progression The patient is transferred to a trauma center via air, and goes to surgery for evacuation of an intracranial hematoma.
Initial Assessment You have learned: • The initial management of the injured patient requires: • Coordination with prehospital providers • Preparation for receiving the patient • Anticipation of injuries based on the mechanism of injury • The evaluation of all trauma patients follows a precise algorithm. • Patients who exceed the capability of the institution should be identified rapidly and process for transfer begun. • Evaluate the patient according to priority using the ABCDEs.