INITIAL ASSESSMENT &

ABCs in TRAUMA

Jorge M. Concepcion, MD,FPCS

General Surgery & Trauma
 Objectives
At the end of this session, the participant is
expected to be able to:

• Discuss the social impact of trauma and the

importance of trauma prevention.

• Provide the correct sequence of priorities in

assessing multiply injured patient.

• Provide guidelines and techniques in the initial

management of multiply injured patient.
INJURY (WHO definition)
-a bodily lesion resulting from exposure
to energy
Mechanical
Thermal
Radiation
Electrical
Chemical
interacting with the body in the amounts that
exceed the limits of physiologic tolerance.
 INJURIES

“NOT ACCIDENTS”

PREDICTABLE

PREVENTABLE

VEHICULAR
“VEHICULAR
ACCIDENT
CRASH”

Not random events but occur in

predictable patterns
 TRIMODAL PATTERN OF DEATH IN INJURY

CRITICAL CARE &

THIRD PHASE
REHABILITATION
20 %
SECOND PHASE TRAUMA SYSTEM
30 %

FIRST PHASE 50 % PREVENTION

YEAR MORTALITY MORBIDITY
RANK RANK
1980 7th 7th

1985 7th 6th

1990 9th 5th

1995 6th 5th

1998 5th 5th

UNDERREPORTED???
2002 3rd 4th
 Epidemiology
TRAUMA IS A
DISEASE!!!
 Trauma Concepts
1. Treat the greatest threat to life.
2. Lack of definitive diagnosis should not
impede the application of an indicated
treatment.
3. Detailed history is not essential to begin
the evaluation of an acutely injured
patient.
Approach To Severely
Injured Patient
1. PRIMARY SURVEY

2. RESUSCITATION

3. SECONDARY SURVEY

4. DEFINITIVE MANAGEMENT

5. TERTIARY SURVEY

REASSESSMENT
 Primary Survey

A - AIRWAY & C-SPINE CONTROL

B - BREATHING

C - CIRCULATION – HEMORRHAGE CONTROL

D - DISABILITY (NEURO EXAM)

E - EXPOSURE / ENVIRONMENT
AIRWAY
 Assessment of Airway Patency
• Look
• Listen
• Feel

PCS Committee on Trauma

 Look
• Apprehension • Retracting cervical
• Agitation/restlessness soft tissues
• Unresponsiveness • Use of accessory
• muscles of respiration
Sweating and pallor
• • Alar flaring
Cyanosis
• • Neck hematoma
Dyspnea/tachypnea
• • Profuse bleeding
Rib retraction on
inspiration • Gastric contents in
oropharynx

PCS Committee on Trauma

 Listen
• Cough • “I can’t breathe!”
• Hoarseness • Snoring
• Stridor • No air entry
• Decreased or absent • Wheezing
breath sounds
• Gurgling

PCS Committee on Trauma

 Feel
• Subcutaneous emphysema
• Tracheal deviation
• Chest wall deformity/crepitus
• No air flow on exhalation
• Diaphoretic skin

PCS Committee on Trauma

 Factors Affecting Airway Patency

• Maxillofacial trauma
– Direct trauma
– Hemorrhage
– Aspiration of broken
teeth, blood, dentures
– Collapse of bony
support
– Soft tissue edema
– Altered sensorium 2°
to brain injury

PCS Committee on Trauma

 Factors Affecting Airway Patency

• Impaired sensorium
– Due to associated brain injury or alcohol/drug
intoxication
– Absent gag/cough reflex
– Aspiration of blood/gastric contents
– Inadequate ventilatory drive/apnea

PCS Committee on Trauma

 Factors Affecting Airway Patency

• Cervical trauma
– Hematoma/swelling compressing airway
– Direct airway injury
• Laryngeal fracture (e.g., direct blow, strangulation,
clothesline injury)
• Vocal cord paralysis
– Cervical spine precautions mandatory

PCS Committee on Trauma

 Factors Requiring Airway Control

• Resuscitation of trauma patients in

impending arrest due to shock / hypoxia
• Impaired ventilatory mechanics
– Flail chest
– Pneumo/hemothorax
– Diaphragmatic breathing
• Transport/sedation requirements

PCS Committee on Trauma

 Factors Requiring Airway Control

• Continuing threats to airway patency

– Soft tissue edema (eg, thermal inhalational
injury, massive fluid resuscitation, local
trauma)
– Deteriorating sensorium
– Aspiration risk:
• Full stomach/abdominal distention
• Continued bleeding/hemoptysis

PCS Committee on Trauma

 Airway Risk Factors

I nstability, hemodynamic
N eck hematoma/trauma
T rauma to the face (maxillofacial)
U nresponsive (GCS < 8)
B leeding from oropharynx
A pnea
T hermal inhalational injury
E mesis/epistaxis/hemoptysis/

PCS Committee on Trauma

 Airway Algorithm
Trauma patient with
airway risk factors

Oxygenate

Airway compromise No airway compromise

Ventilate/Intubate with cervical Y

E Observe/reassess
in-line stabilization
S
Unable to intubate Airway compromise?
NO
Continue monitoring
Cricothyroidotomy
patient’s progress

Reassess adequacy of ventilation

 Airway Maintenance Measures
• Finger sweep
• Chin lift
• Jaw thrust
• Oropharyngeal/nasopharyngeal airway
• Laryngeal mask airway
• Needle cricothyroidotomy

PCS Committee on Trauma

Oropharyngeal Airway
Laryngeal Mask Airway
 Definitive Airway Methods
• Intubation
– Orotracheal
– Nasotracheal
• Surgical Airway
– Cricothyroidotomy
– Tracheostomy

PCS Committee on Trauma

 Orotracheal Intubation

PCS Committee on Trauma

 Cricothyroidotomy

PCS Committee on Trauma

 Associated Skills
• Assisted/bag-mask ventilation
• Esophageal compression
• Checking tube placement
• Anchoring

PCS Committee on Trauma

 BREATHING
• Guarantee adequate oxygenation and ventilation
• Give supplemental oxygen
• Ventilation (lungs, chest wall & diaphragm)
• Assess respiratory effort, breath sounds &
oxygen delivery
• Use of pulse oximetry
BREATHING: Problem Recognition
• Objective Signs:
• Inspection
• Palpation
• Percussion
• Auscultation
 Oxygenation
Oxygen L/min. Approx. FiO2
delivery
Nasal cannula 1 0.24
2 0.28
4 0.35
6 0.42
Face mask 5-6 0.40
6-7 0.50
7-8 0.60
Face mask w/ 6 0.60
reservoir 8 0.80
10 1.00
 Management
• Ventilation • Pleural
Decompression
– Mouth to pocket face – Needle thoracentesis
mask
– Closed-tube
– Bag-valve-mask thoracostomy
– ( 2 person technique)
– Three-sided dressing
BREATHING
 Bag Mask Ventilation

PCS Committee on Trauma

 Needle Thoracentesis
• Indication
Tension Pneumothorax

Complications:
Local hematoma
Pneumothorax
Lung laceration
 Closed Tube Thoracostomy
• Indications
– Simple Pneumothorax

– Massive Hemothorax

– Tension Pneumothorax

– Open Pneumothorax
Closed Tube Thoracostomy

Complications:
Laceration or puncture of
thoracic &
abdominal organs
Pleural infection
Damage to intercostals
nerves, artery or vein
Incorrect tube position
Chest tube kinking, clogging
or dislodging
 Three-sided Dressing
• Indications
– Open pneumothorax
 Pulse Oximetry
• The pulse oximeter is designed to
measure oxygen saturation and pulse rate
in peripheral circulation.
CIRCULATION
 CIRCULATION
• Assure adequate
oxygen delivery and
control bleeding
• Assess vital signs
• Control bleeding by
direct pressure
• Reduction of fractures
in long bones and
pelvis
 Recognition of Shock
• Tachycardia

• Cutaneous vasoconstriction

• Narrowed pulse pressure

• Hypotension
 Pitfalls of Shock Recognition
• Extremes of age
• Athletes
• Pregnancy
• Medications
– beta blockers
– pacemakers
• Hypothermia
 Classes of Hemorrhage
Class I Class II Class III Class IV
Blood Loss (ml) Up to 750 750-1500 1500-2000 >2000
Blood Loss (% blood Up to 15% 15-30% 30-40% >40%
volume)
Pulse Rate <100 >100 >120 >140
Blood Pressure normal normal decreased decreased
Pulse Pressure normal or decreased decreased decreased
decreased
Respiratory Rate 14-20 20-30 30-40 >35
Urine Output (mL/hr) >30 20-30 5-15 negligible

CNS/mental status Slightly Mildly anxious Anxious, Confused,

anxious confused lethargic
 Initial Management
• Recognize shock

• Stop the bleeding!

• Replace effective circulating volume

• Restore tissue perfusion

 Initial Management
• Physical examination
– ABCDEs
– gastric and bladder decompression
• Vascular access
– basic principles
– initial blood tests
• Fluid therapy
– isotonic fluid
 Hemorrhage Control
Techniques
• Direct pressure
• Inflow occlusion
• Tourniquets
• Reduction of pelvic volume
maneuvers
• Application of folded sheets
• PASG
Severe Pelvic Fractures

C-CLAMP
 Vascular Access
• 2 large bore peripheral IV
lines
• Venous cutdown
– saphenous vein
• Central access
– femoral
– jugular
– subclavian
• Intraosseous
• Obtain blood for type
and cross matching
 Fluid Therapy
• Warmed crystalloid solution

• Rapid fluid bolus

– Adult 2 liters
– Child 20 mL/kg

• “3 for 1 rule”

• Monitor response to therapy

 Fluid Therapy

Size (gauge) Time

18 12 min.
16 9 min.

14 7 min.
Response to Fluid Resuscitation

• Rapid response

• Transient response

• Minimal or no response
 Response to Fluid Resuscitation
Rapid Response Transient Response No response

Vital Signs Return to normal Transient Remain abnormal

improvement
Estimated blood loss Minimal (10-20%) Moderate and Severe (>40%)
ongoing (20-40%)
Need for more fluids Low High High

Need for blood Low Moderate to high Immediate

Blood preparation Type and Type specific Emergency blood

crossmatch release
Need for surgery Possibly Likely Highly likely

Early presence of Yes Yes Yes

surgeon
 Disability
Assess GCS, pulses, sensory and motor functions
GCS
BEST MOTOR RESPONSE – 6 3 - 15
BEST VERBAL RESPONSE – 5
EYE OPENING – 4
? V=? M=4 E=3
V = M(0.5) + E(0.4)
GCS = 7

V = 4 (0.5) = 2 + 3 (0.4) = 1.2

V = 2 + 1.2 = 3.2
V=3 M=4 E=3 GCS = 10
 Exposure and Environmental
Control
• Undress (cut clothing!)
• Keep patient warm
• Logroll
• Often missed injuries
Axilla
Perineum
Back
 Resuscitation

EXPLORATORY X-FIX ED THORACOTOMY

LAPAROTOMY

CHEST TUBE
PERICARDIOCENTESIS INSERTION IV ACCESS
 Secondary Survey
• History
A - ALLERGIES

M - MEDICATIONS

P - PAST ILLNESSES
L - LAST MEAL

E - EVENTS PRECEEDING THE INCIDENT

 Secondary Survey
• Physical Examination
Detailed, meticulous head-to-toe exam
Finger and tubes in all orifices
Look, listen, feel everywhere
DEFINITIVE MANAGEMENT

TERTIARY SURVEY
 DON’T
PANIC

INSERT NGT IN PATIENT WITH SUSPECTED

FACIAL FRACTURE

REMOVE IMPALED OBJECTS

FORGET TO WARM THE PATIENT
(ESP. CHILDREN)
INSERT A FOLEY CATHETER IN PATIENTS
SUSPECTED OF URETHRAL INJURY
OVERLOOK THE PERINEUM, BACK
AND AXILLA
 DO
PRIMUM NON NOCERE

SPLINT PATIENTS WHERE THEY LIE

COMFORT THE PATIENT

ALLEVIATE PAIN

HONE YOUR SKILLS

ASK FOR HELP

 Summary
1. Rapid but thorough assessment.
2. Treat the greatest threat to life:
a. Control airway
b. Provide oxygen and adequate ventilation
c. Control bleeding and restore blood volume
3. Continuously monitor patient’s condition:
treat continuing threats to life and limb
4. Prompt definitive treatment