Trauma: Primary Survey
Trauma care has been much improved with systematic protocols that enable effective prioritisation of treatment. The first time one sees a trauma patient arriving in the Emergency Department can be confusing and intimidating as there are many things going on simultaneously.
The ABC order of treatment reflects the relative importance of the different things that can go wrong. Under most circumstances, Airway problems will kill the patient before Breathing problems, before lems.
Problems are treated as they are found. If a problem is found and treated, or the patient deteriorates, one starts again with A and works through B and C.
Cervical spine protection is given highest priority to avoid catastrophic spinal injury.
Major trauma is managed by a trauma team of up to five doctors and nurses, led by a senior doctor. Team members perform specific roles, e.g. airway management, procedures. The role of the leader is to stand back and have an overview rather than perform procedures, but in a smaller Emergency Department this is not always possible.
Penetrating vs non-penetrating trauma Penetrating trauma, caused by knives and guns, is relatively rare in Europe and Australia, where most trauma is ‘blunt’, e.g. motor vehicle crashes, falls, crush injuries. In penetrating trauma (and ruptured abdominal aortic aneurysm or ectopic pregnancy), blood may be lost faster than it can be replaced: it is essential for ongoing bleeding to be controlled immediately. This may require wound compression, tourniquets to stop bleeding, or immediate surgery.
Ambulance transfer and handover
Trauma patients are prepared for transfer by placing them onto a spinal board with their head and neck immobilised. When the ambulance arrives, the trauma team listens carefully to their struc- tured handover: DeMIST.
• Demographics: age, sex, background.
• Mechanism of injury.
• Injuries sustained.
• Signs and symptoms.
• Treatment given.
The key points should be summarised back by the team leader to confirm understanding and prevent errors.
A: Airway and cervical spine protection
If a patient is not talking, check for stridor, or obstruction with blood/teeth/food, and normal chest wall movement with breath- ing. The tongue can fall back and cause an obstructed airway in a supine, unconscious patient.
• Oxygen: 15 L/min using a mask with a reservoir bag.
• Inspect mouth and suction: only suck down side of mouth.
• Does the patient need a definitive airway? See Chapter 6.
• Cervical spine immobilisation (see opposite).
B: Breathing and ventilation
While there are many potential injuries to the chest, there are four breathing problems that are immediately life-threatening.
1 Tension pneumothorax
Tension pneumothorax occurs when a lung injury pumps air into the pleural space, building up pressure. Hypotension and respiratory difficulty are caused by high intrathoracic pressure and kinking of the great vessels. This causes distended neck veins, loss of breath sounds, and a trachea deviated away from the pneumothorax. Tension pneumothorax is a clinical diagnosis, not a radiological one. Insert a large (16 or 14 G) intravenous cannula perpendicularly into the anterior chest wall in the second intercostal space in mid-clavicular line. A hiss of escaping air will be heard: leave in place and insert a chest drain as soon as possible.
2 Massive haemothorax
The patient may be in shock, and may have reduced air entry and dull percussion note, although this is often difficult to detect with the patient supine.
Ensure good intravenous access before placing a large bore (e.g. 32 Fr) chest drain, as draining the blood may precipitate bleeding, which may require resuscitation and immediate surgery. 3 Open pneumothorax
A large open chest wound gives a collapsed lung, loss of breath sounds and ‘surgical emphysema’ (air in the subcutaneous tissues that gives a crinkly feel).
Treat by applying an occlusive dressing over the wound that is secured on three sides only, thus acting as a one-way valve.
4 Flail chest
If multiple ribs are broken in more than one place, a segment of chest wall can move paradoxically, i.e. in the opposite direction to the rest of the chest during respirations. This markedly increases the work of breathing.
If a patient is becoming tired, intubation is necessary. If the flail segment is small, and respiratory function is good, analgesia can be achieved by an epidural or nerve blocks, but the patient should be closely monitored.
Pulse and blood pressure are the key information – shock is described in Chapter 3.
Intravenous access should be a minimum of two 16 G cannulae. Blood should be sent to the laboratory for FBC (full blood count), U+E (urea and electrolytes), clotting, group and save, cross- matching, depending on clinical status of patient.
Stop the bleeding, warm the patient
Obvious bleeding sites should be compressed and dressed. Litres of blood can be lost into the pelvis or into femoral shaft fractures. A pelvic sling should be applied if there is a pelvic injury. Pelvic stability should never be assessed by compressing the pelvis. A traction splint, e.g., Thomas splint, stabilises and reduces pain and bleeding resulting from a femoral shaft fracture.
This produces similar signs to tension pneumothorax, with shock and distended neck veins, but no tracheal deviation. Heart sounds and ECG complex size may be reduced. Focused abdominal scanning in trauma (FAST) ultrasound scan should detect tamponade. Treatment depends on the nature of the trauma and clinical status of the patient, but is likely to require urgent thoracotomy.
Disability and neurological status
The Glasgow Coma Scale is described in Chapter 10.