TRAUMA

TRAUMA

PRIMARY SURVEY

The aim of Primary survey and resuscitative phase is to diagnose and treat life threatening problem.

a)      Airway and control of the cervical spine

-Always assume that the cervical spine is damaged especially if there is any suspicion of any injury above the clavicle. This keeps a rigid cervical collar. Do not move or turn patient unnecessarily.

-Ensure and secure a clear airway. Remove any liquid vomit with a rigid sucker. If there is no gag reflex the only safe way to ventilate the patient and the airway is by using a cuffed endotracheal tube.

-Every patient with multiple injuries should receive 100% oxygen

b)      Breathing

-Ensure that the air entry on both sides of the lungs is adequate.

-Inspect and auscultate the chest.

-Count the respiratory rate. If the respiratory rate is more than 20 per min, find the cause. Beware of tension pneumothorax, open pneumothorax, flail chest and lungs contusion.

c)       Circulation and control of haemorrhage

-Control any major external haemorrhage with direct pressure.

-Record the blood pressure and pulse rate.

Note: Carotid pulse palpable sys BP> 60mmHg

           Femoral pulse palpable sys BP> 70mmHg

           Radial pulse palpable sys BP> 80mmHg

-Shock in a multiply injured patient, the following need to be ruled out:

Haemorrhage- ext wounds, major fracture eg pelvic, thorax, peritoneal cavity, retroperitoneum

Tension pneumothorax

Cardiac tamponade, myocardial contusion and concurrent AMI. In the first two, there are suggested by distended neck veins.

Spinal shock

-In bleeding patient, insert 2 iv lines (large bore cannula size gauge 14 or 16)

-FBC, BUSE, RBS, GXM, ABG

-Consider CVP line

-Resuscitate with crystalloid, colloid, plasma expander, and blood transfusion is required in severe bleeding

-Insert NG tube and urinary catheter if not contraindicated

d)      Dysfunction of the central nervous system

-Rapid assessment-Alert

                                    Response to vocal stimuli

                                    Response to painful stimuli

                                    Unresponsive

e)      Exposure

-All clothing should be removed. Cut clothing to ensure minimal movement. However, keep the patient warm by covering him or her with blanket when not being examined.

Secondary survey

This entailed a full head to toe examination. In addition it is advisable to perform a lateral cervical spine, chest and pelvic x-ray for patient with blunt trauma or unconscious patient.

Scalp- Palpate from posterior to anterior. Palpate for fracture at the base of the laceration.

Neurological State- Record using Glasgow Coma Scale. Deterioration in GCS may not be due to the primary injury to the brain but may reflect hypoxia or hypotension.

Base of skull- Check for rhinorrhoea or otorrhoea (ENT bleed). Look for bruising of the mastoid process.

Eyes- Look for haemorrhage, foreign body and any signs of penetrating injury. Test papillary response.

Face- Palpate for deformities and tenderness. Check for loose or lost teeth.

Neck- Look for any deformity, bruising or laceration. Palpate each of the cervical processes to detect tenderness and step off deformities.

            Note: A lateral cervical spine x-ray showing all 7 cervical vertebrae is essential in patient with multiple injuries.

Chest- Inspect the chest for bruising, wounds, signs of respiratory obstruction and asymmetry of movements. The bruising resulting from pressure exerted by a diagonal seat belt may overlay a fracture clavicle, a tear in the thoracic aorta, pulmonary contusion and a lacerated pancreas. The mark caused by impact with the central steering wheel suggest a sterna fracture with cardiac contusion, palpate for the position of trachea. Palpate the chest for crepitus and tenderness. Auscultate to detect air entry between the two sides.

Heart- As mentioned above, sternal bruising and tenderness may be associated with cardiac contusion. Penetrating thoracic injury may damage the heart and produce pericardial tamponade.

            Signs of pericardial tamponade: Beck’s triad: Raised jugular venous pressure, muffeld heart   

                                                                      sound, reduced BP

                                                                      Pulses paradoxicus

                                                                      Raised pulse rate

Abdomen- Inspect for bruising, movement and wounds. Palpate the abdomen. Auscultate for bowel sounds. Squeeze the pelvis for tenderness. Check the perineum and genitalia. PR examination.

Limbs- Look for bruising, wound, and deformities.
Check distal pulses, sensation, and movement.
Splint all fractures

Spine
Spinal injuries can be partial and complete
Test for sensory and motor deficit
If there is evidence of spinal injury the patient should not be moved
X-ray of the affected site is required
If there is no neurological deficit, the patient can be log rolled and the whole of the back examined.

 Useful informations can maybe available from patient, relatives, ambulance crew

Allergies
Medicine
Past medical history
Last meal
Event leading to the injury