Updated: 3/2/2019

Primary Survey and Resuscitation

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Snapshot
  • A 30-year-old man presents to the ED after being hit by a large truck. He is brought on a backboard with a cervical collar. Oropharyngeal airway mask and one peripheral IV with fluid running are in place. Multiple lacerations on his scalp and thighs are wrapped in dressings. Blood pressure is 80/40 mmHg, pulse is 140/min, respirations are 40/min, and SaO
    2
    is 92% on RA.
Overview
  • Most common method of initial trauma assessment in the United States is based on Advanced Trauma Life Support (ATLS) course from American College of Surgeons
    • goal is to treat greatest threats to life immediately
    • lack of definitive diagnosis and detailed history should not impede therapy
Presentation
  • Trauma patient can present to the ED from multiple different scenarios
    • blunt trauma, motor vehicle collisions, falls are most common
    • penetrating trauma (guns/knives/others)
    • environmental injuries
      • burn
      • cold
      • electric
      • smoke
      • bite
  • Precipitating factors to trauma must also be considered: 6 S's
    • Seizure, Syncope, Sugar (hypoglycemia), Suicide, Sleep (abnormality), Sauce (alcohol)
Diagnosis
  • Primary survey (often concurrent with resuscitation): ABCDE
    • Airway
      • signs of obstruction: agitation, confusion, respiratory distress, failure to speak, cyanosis
    • Breathing
      • observe for altered mental status, chest movement, nasal flaring
      • listen for signs of obstruction (stridor, asymmetry, air escape)
      • feel for trachael shift, crepitus, flail segments, subcutaneous emphysema
      • objective signs: rate, oximetry, ABG, A-a gradient
    • Circulation
      • look for evidence of shock
        • shock in trauma patient is hemorrhagic until proven otherwise
      • early signs: tachycardia, tachypnea, narrow pulse pressure, reduced capillary refill, cool extremities
      • late signs: hypotension, altered mental status, reduced urine output
    • Disability
      • level of consciousness assessed by Glasgow Coma Scale (GCS) 
        • good indicator of injury severity and neurosurgical prognosis
        • change in GCS with time is more relevant than absolute number
        • reported as 3-part score based on eye movement, verbal response, motor response 
          • score 13 - 15: mild injury
          • score 9 - 12: moderate injury
          • score < 9: severe injury
            • must protect airway in this situation
    • Exposure/Environment
      • undress patient completely and assess entire body for injury
      • logroll to examine back
      • digital rectal exam
Management
  • Resuscitation done at the time as primary survey, with focus on ABC
    • Airway
      • temporizing measures
        • protect C-spine
        • head-tilt or jaw thrust to open airway
        • nasopharyngeal airway if gag reflex present without concern for airway loss (i.e., conscious)
        • oropharyngeal airway if impending concern for airway loss or gag reflex absent (i.e., unconscious) - preferred method of airway protection 
      • definitive measures
        • endotracheal tube intubation
          • indications
            • unable to protect airway (GCS < 8; airway trauma)
            • inadequate oxygenation (SaO
              2
              <90% on 100% O
              2
              )
            • profound shock
            • anticipatory: in trauma, overdose, CHF, asthma, COPD, smoke inhalation injury
            • anticipated transfer of critically ill patient 
          • contraindication: supraglottic / glottic pathology
          • does not provide 100% protection against aspiration
        • surgical airway (if unable to intubate and unable to ventilate)
          • cricothyroidotomy
    • Breathing
      • in order of increasing FiO
        2
        : nasal cannula, face mask, non-rebreather, CPAP/BiPAP
      • bag-valve mask and CPAP/BiPAP used to supplement inadequate ventilation
    • Circulation
      • monitor vital signs, ECG, oxygen saturation
      • if bleeding externally, apply direct pressure and elevate extremities if possible
        • do NOT remove impaled objects as they tamponade hemorrhage
          • impaled objects are only removed in the OR
        • tourniquet as last resort
      • resuscitation
        • 1 to 2 L crystalloid (NS, LR) with large bore IVs (warmed if possible)
        • consider pRBC transfusion if severely hypotensive
          • crossmatched or type-specific blood ideal
          • if unavailable, use O-negative in children/women of child-bearing age or O-positive in all others
        • with significant hemorrhage, massive transfusion protocol may be necessary
      • Advance Cardiac Life Support (ACLS) algorithm as necessary for arrhythmias
      • Foley catheter and NG tube if indicated
        • contraindications to Foley insertion
          • blood at urethral meatus
          • scrotal hematoma
          • high-riding prostate on digital rectal exam
        • contraindications to NG tube insertion
          • significant mid-face trauma
          • basilar skull fracture
    • proceed to detailed secondary survey and definitive care

References

 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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