What Do You Know About Trauma Survey

The principal survey is the initial assessment and management of a trauma patient. Information technology is conducted to detect and treat actual or imminent life threats and prevent complications from these injuries. A systematic arroyo using ABCDE is used. If a group of clinicians is assembled to perform the initial assessment, there volition exist multiple simultaneous activities occurring and resuscitation does not always proceed in a purely linear, sequential fashion.
On arrival to the emergency department, the patient should have total non-invasive monitoring practical, and initial management including:

• ECG monitoring.
• Non-invasive claret pressure cuff.
• Oxygen saturation probe.
• The patient's temperature should be recorded.
• Removal of the patient' apparel is encouraged so that they can be fully assessed.
• Oxygen should be applied to achieve saturation of 94-98%

The chief survey of a trauma patient involves:

A irway – with cervical spine control
B reathing
C irculation including control of exsanguinating external bleeding
D isability
E xposure ^vi

In single responder settings these may demand to be addressed in a linear or sequential mode; however, when a team is assembled, these elements may be addressed simultaneously. The term 'survey' is somewhat misleading in that it implies that merely assessment is occurring; however, each phase requires simultaneous assessment for, and management of, any life threats detected.

Control of exsanguinating external haemorrhage

Failure to recognise and control large-volume external haemorrhage has been establish to exist a frequent occurrence in trauma resuscitation.^seven Obvious large book external blood loss must be managed as an firsthand priority in the field and on inflow of the patient into the emergency department, with the aim being to control life-threatening external bleeding.

ECG Monitoring
_{Image used with permission from Department of Health, Victoria}

Airway with cervical spine protection

An assessment of airway patency and stability should be performed during the primary survey and a programme for airway management instituted if required. Unless the patient is in cardiac abort, immediate securing of the airway with endotracheal intubation is rarely required upon inflow of a major trauma patient.

Life threats

The following airway life threats must be assessed and managed:

• Airway obstacle;
  • Vomit, blood, dislodged teeth. Remove with suction.
• Edgeless or penetrating neck injury;
  • Consider early endotracheal intubation if neck wounds or haematomas are causing the airway obstruction or if there is an airway disruption. (Run across beneath).

Circumspection: Rapid-sequence intubation in patients with edgeless or penetrating neck injuries carries the gamble of total loss of airway patency upon assistants of allaying and/or muscle relaxant medication.

• Reduced conscious country;
  • This can lead to hypoventilation and/or airway obstruction and hypoxia

Assess for airway stability

• Attempt to elicit a response from the patient.
• Expect for signs of airway obstruction (use of accessory muscles, paradoxical breast movements and see-saw respirations).
• Listen for signs of upper-airway noises and jiff sounds. Are they absent, diminished or noisy?

Assess for soiled airway

If the patient has vomit, blood or excessive secretions on their airway, these should exist removed with suction. If in that location is excessive bleeding into the airway that cannot be removed with suction, it may be necessary to manage the patient on their side to allow drainage of blood from the mouth or nose, while maintaining C spine immobilisation. Patients can be placed on their side past performing a log-roll manoeuvre.
If this is bereft consideration should be given to sitting the patient upright. The take chances of potential spinal injury must exist weighed confronting the potential for complete airway obstruction or choking from aspirated blood. If there is uncertainty nigh the condom of this, a senior md with airway experience should be involved or the ARV clinician tin exist contacted for advice or for telehealth review of the situation.

Endeavor simple airway manoeuvres if required

• Open the airway using a mentum lift and jaw thrust.
• Suction the airway if excessive secretions are noted or if the patient is unable to clear their airway independently.
• Insert an oropharyngeal airway (OPA)/nasopharyngeal airway (NPA) if required.

Intendance should be taken to not extend the cervical spine.
Circumspection: NPA should not exist inserted in patients with a head injury in whom a base of skull fracture has non been excluded.^eight
If the patient is already intubated, document the size and position of the endotracheal tube, including lip level, finish-tidal carbon dioxide trace, gage pressure and any intubation difficulty (or Mallampati score).
Where possible, delegate ongoing airway management to an airway doctor/nurse and go on the initial assessment.

Secure the airway if necessary (treat airway obstruction as a medical emergency)

Consider intubation early if at that place are any signs of:

• A decreased level of consciousness, unprotected airway, uncooperative/combative patient leading to distress or farther risk of injury.
• A pending airway obstacle, indicated by signs such equally a stridor or hoarse voice.

Maintain full spinal precautions if indicated

Suspect spinal injuries in all poly-trauma patients. Ensure a cervical collar, head blocks or in-line immobilisation is maintained throughout patient intendance.

 Breathing and ventilation

Life threats

• Tension pneumothorax.
• Massive haemothorax.
• Open pneumothorax.
• Flail chest.
• Ruptured diaphragm.

Oxygen administration

Administer oxygen to achieve oxygen saturations between 94-98%.

Appraise the chest

The breast should be fully exposed and inspected for whatever open wounds, bruising or deformity. The patient's respiratory effort, respiratory rate and oxygen saturation should be noted.
A mobile chest x-ray should be performed in the resuscitation bay at the earliest opportunity (and performed with a pelvic and lateral neck x-ray during the principal and secondary survey).
The breast should be auscultated for jiff sounds, the about reliable location being in the axillae.
If a tension pneumothorax is detected, direction should include:

1. Emergent decompression using a 14G needle in the second intercostal space in the mid-clavicular line.
2. Finger thoracostomy with blunt autopsy and digital decompression through the pleura.This is an essential step for pleural decompression. Decompression of the pleural infinite is a primary goal during the reception and resuscitation of the haemodynamically unstable patient with a haemothorax and/or pneumothorax.
3. Intercostal catheter insertion.Finger thoracostomy should exist followed by the insertion of an intercostal catheter continued to an underwater seal bleed as a secondary priority that can be completed at a later stage.⁹

Note: Finger thoracostomies crave definitive ongoing management with an ICC unless the patient is positive pressure level ventilated.
Record the oxygen saturation (SpO₂) and ETCO2 if available.

 Circulation with haemorrhage command

Assess apportionment and perfusion

Circulation assessment in major trauma focuses on detecting and managing shock, or reduced tissue perfusion. The most common cause of shock in a major trauma patient is hypovolaemic shock from blood loss.¹⁰ Blood loss may be external/visible, and therefore compressible, or internal/concealed and non-compressible.

Assess:

• Heart rate.
• Blood pressure.
• Peripheral circulation and pare (pale, cool, clammy).

Intravenous admission

Insert 2 large-diameter peripheral intravenous (IV) cannulas. If admission is difficult consider a key or intraosseous insertion if the equipment/skills are available.

If necessary, perform a FAST scan

Consider the need for FAST (Focused Assessment with Sonography in Trauma) if information technology is bachelor and staff are trained in its use. FAST is used primarily to detect pericardial and intraperitoneal blood in patients who are haemodynamically unstable. The FAST exam supplements physical test for detecting intra-abdominal injury.¹¹ If the patient is haemodynamically stable and shows no signs of pregnant internal haemorrhage then information technology may exist delayed until the secondary survey. The FAST test is reliable and repeatable.

Command of exsanguinating external haemorrhage

Control of external haemorrhage normally requires house compression bandaging with combine pads applied over the wounds, and firm crepe bandages applied circumferentially over the afflicted areas. Several layers may be required. Haemostatic dressings may be of employ if available. Uncontrolled limb bleeding requires placement of an arterial tourniquet. This should not exist removed until surgical haemorrhage control is achieved.
Causes include major amputations, severe crush injuries, open fractures, massive de-gloving injuries or multiple deep lacerations, especially of the scalp. Where external haemorrhage is identified an endeavour must be made to control it using straight force per unit area, elevation and/or tourniquets (if available).
Smaller injuries (for instance, puncture wounds) that are bleeding excessively should be managed by direct, local force per unit area over the wound with 10 cm × 10 cm gauze squares folded in half, and folded again to make a 5 cm × v cm gauze pad, and placed over the wound with business firm, unmarried digit pressure. This volition control haemorrhaging meliorate than loosely practical, large absorbent pads. It is helpful to have photos of the wounds and injuries to aid with ongoing management plans at the receiving facility.
It is best to avert suturing or stapling wounds closed prior to transfer, unless the haemorrhaging cannot exist controlled with direct pressure. If wounds are closed purely for haemostasis, this must be documented in the clinical tape and communicated to the receiving team as they may need to be re-opened and/or explored on arrival at a receiving hospital.

Continuous monitoring of vital signs is essential in major trauma
_{Image used with permission from Department of Health, Victoria}

 Disability

Assess level of consciousness

• Perform an initial Glasgow Blackout Calibration (best eye opening, motor response and verbalisation).
• Bank check pupil size and reactivity if conscious state is altered.

Test blood sugar levels

Ensure that whatever alterations in level of consciousness are non related to a metabolic cause.

Summit of page

 Exposure and environment

It is important to keep the patient normothermic

Past the end of the master survey the patient should be fully exposed to ensure no injuries posing an immediate life threat are missed.
Consideration must be given to the patient'southward age, gender and civilisation when exposing them for a trauma test. Exposure may need to be done sequentially, uncovering one torso region at a time to maintain patient dignity and temperature command.
Trauma patients are prone to hypothermia, so upon completion of the primary survey, they should be covered with dry, warm blankets. External warming devices may be required if the patient is even mildly hypothermic. All intravenous fluid or blood should be warmed prior to administration if a fluid warmer is bachelor.

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Source: https://trauma.reach.vic.gov.au/guidelines/early-trauma-care/primary-survey

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