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Updated: Dec 28 2021

Primary Survey and Resuscitation

  • 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.
  • introduction
    • 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

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