Primary trauma examination

• (AT) MIST
  • A - Age - name, age, sex
  • T - Time of incident
  • M - Mechanism of injury and Medical Complaint
  • I - Injuries sustained and Illness
  • S - Signs and Sx
  • T - Treatment

ABCDE

• Systematic and simultaneously assess and treat

AIRWAY and C-spine

• Early ETT with cervical spine protection
  • In severe trauma when unconscious or in shock
  • Indications for Surgical Airway Cricothyroidotomy
    • Laryngeal #
    • Penetrating throat and neck injuries
    • Severe maxfax injuries with bleeding, deformity, oedema
    • Airway burns/inhalation injuries
    • Can’t intubate can’t ventilate
• Options
  • Emergency cricothyroidotomy
  • Elective tracheostomy
• Priorities
  • Clear upper AW
  • Give high flow O2
  • Obtain definitive airway → ETT (cuffed tube) or surgical

BREATHING

• Midline trachea
• Dilated neck veins
• RR/Sats/adequacy of breathing
• Tension PTX
  • Finger thoracostomy and 3 sided occlusive dressing
  • Then chest drain
• Massive HTX/flail chest/contusion/tamponade/tracheobronchial injury
  • Chest drain

CIRCULATION

• = assessment for shock, IVL large bore, bloods (FBC, G+H, coags, gas), resus fluids, MTP, prevent and treat lethal triad
• Shock
  • Cool/pale peripheries, prolonged CRT, thready pulse, reduced LOC
• Blood on the floor and 4 more
  • Floor - External bleeding
  • Chest - CXR
  • Abdomen - eFAST
  • Pelvis – Pelvic XR
  • Extremities/long bones - Clinical exam and XR
• Neck veins and shock
  • Assume hypovolaemic hemorrhagic shock if flat
  • If dilated then assess for:
    • Tension Pneumothorax
    • Tamponade
    • Myocardial contusion (cardiogenic)
    • MI (cardiogenic)
    • Air Embolism
• Tension PTX - CXR/clinical dx → Chest drain
• Tamponade
  • Penetrating torso injuries → Cardiac box (nipples, clavs and costal margin)
  • Distended neck veins, peripheral shut down, pulsus paradoxus
  • Drop in BP on inspiration by > 10mmHg
  • USS dx
  • Options for tx
    • Needle pericardiocentesis (not preferred in trauma)
      • Guided with USS
    • Subxiphoid pericardial window via emergency thoracotomy
• Myocardial contusion - rare
• MI - common in elderly and may have caused the trauma
• Air Embolism
  • Air in systemic system due to bronchopulmonary fistula
  • Causes - blunt trauma (rib #) or gunshot/stab
  • Can have neurology without hx of head injury - air bubble occlusion
  • Check fundoscopy - air bubbles in retinal vessels
  • Surgery
    • Thoracotomy and hilar clamping
    • Resuscitate (expand IV volume) and aspirate air from heart
    • Repair or lobar resection
• Haemorrhagic shock
  • Goal
    • Stop the bleeding - if not possible
      • IV access, blood sample and appropriate resus
      • Identify cause/location of bleed
      • Prevent and treat coagulopathy
      • Prevent and treat hypothermia
  • Access - Preferably central
    • Subclavian/jugular/femoral
    • Seldinger vs open cut down
  • Bloods - Routine and blood gas
  • Assess for occult blood loss
    • Pleural cavity → CXR/USS
    • Thigh → Clinical and X-ray
    • Abdomen (incl retro and pelvis)
    • If CXR/USS and leg ok → laparotomy
  • Resuscitation fluids
    • Crystalloid to start but quick change to blood products
    • MTP activation
      • Use of 2 units
      • Ongoing bleeding requiring transfusion
      • Local protocol for ratios
      • Monitoring with bloods (incl. goal directed TEG/ROTEM)
    • TXA when indicated
    • Permissive hypotension in unstable bleeders
    • Criteria for adequate resuscitation
      • Maintain peripheral perfusion
      • UO 0.5mL/kg/hr (1mL/kg/hr child)
      • Keep atrial filling P at normal level
• Don’t give 2L crystalloid bolus
• Early haemostatic resuscitation
• Guided by TEG
• 1:1:1 ratio early and minimize crystalloid in hypotensive shock

DISABILITY

• GCS, pupils, gross neuro (lateralizing signs)
• Key components
  • Determine LOC
  • Assess pupil size and reactivity
  • Check eye movements and oculovestibular responses
  • Document skeletal and spontaneous movements
  • Determine pattern of breathing
  • Peripheral sensory exam
• GCS
  • Consciousness made up of:
    • Awareness - Goal directed/purposeful behaviour
      • Use of language
      • Protection from painful stimulus
    • Arousal - Simple wakefulness
    • Brainstem function - Any eye opening
    • Coma - Loss of awareness and arousal
• Key marker is deterioration in GCS - prompts emergent CT head

ENVIRONMENT/ EXPOSURE

• Remove clothes and log roll

• Check temperature and warming measures

• Body temperature fluids via rapid infusers, warmed mattresses, warm air blankets

• Prevent heat loss - blanket, Bair hugger, environment

• Hypothermia shifts O2 curve left → Reduced oxygen delivery

  • Reduce ability for liver to metab citrate/lactic acid
  • Arrhythmia

• Primary Survey Diagnostic Studies for unstable pt ADJUNCTS

  • CXR
  • Pelvic XR
  • FAST scan - blood in abdomen/chest/pericardium/tension PTX
    • Focused Assessment with Sonography for Trauma
      • LUQ - Between Spleen and Kidney
      • RUQ - Between Liver and Kidney
      • Pelvis - Between Bladder and Rectum
      • eFAST - Pericardial window and HTX as well
    • Can be repeated if clinical change

• Blood gas

• ECG

• NGT

• IDC

• Monitoring - oximetry, BP

• Then figure out disposition: based on haemodynamics and resus response

  • CT
  • Surgery

Secondary Survey

• Cannot do it until patient is stable
• What is it
  • AMPLE HISTORY
    • Allergies
    • Meds
    • PMHx or pregnant
    • Last meal
    • Events and environment
      • Pt, responders, family
    • Tetanus
• Top to toe and front to back examination
• If H/D normal pt - time for full assessment and CT
• If H/D stable pt - time for CT
• If H/D unstable
  • Can’t leave resus
  • Fast USS/XR chest and pelvis
  • DPL if FAST neg but still suspicious or in mass casualty setting
• Penetrating Trauma
  • Knives, missiles and impalement
  • Velocity dependent on type
  • Secondary effects → Infection - FB introduction and intra-abdo soiling
  • Can use paperclips to see wounds on x rays - Help determine what is injured