a nurse is conducting a primary survey of a client who has sustained life threatening injuries This is a topic that many people are looking for. passionistsisters.org is a channel providing useful information about learning, life, digital marketing and online courses …. it will help you have an overview and solid multi-faceted knowledge . Today, passionistsisters.org would like to introduce to you Trauma: Primary Survey, ABCDE-Assessments & Take-home points – Emergency Medicine | Lecturio. Following along are instructions in the video below:
Now were going to talk about the overall approach to the traumatically injured patient patient management of trauma. Always begins with a primary survey. The primary survey is a way of performing your initial assessment of all trauma.
Patients and it should be done exactly the same way every single time in every single case. So you dont miss anything there are two major goals of the primary survey. One is to identify life threats quickly and two is to provide stabilization when life threats are identified.
Its very important to remember that the primary survey isnt just about diagnosis and involves simultaneous assessment and treatment of the patient to ensure that they remain stable and that life threats are quickly addressed the primary survey follows the same order every time it begins with airway followed by breathing circulation disability. And lastly exposure of the patient and assessment of the environment. So when we talk about assessing the airway.
The first thing to do is simply speak to the patient gas. Them their name get them to tell you what happened to them any patient whos able to talk by definition has a payton airway. And thats clearly a good sign.
However. Remember just because you have a patent airway right now doesnt mean youre gonna have a patent airway. Fifteen or thirty minutes from now so you want to not only identify current airway obstruction.
But also risks for potential future airway obstruction. What if the patients not actually talking to you well the question you should ask yourself is why if the patient is unconscious or unresponsive. Then that suggests a head injury.
And if they have a significantly depressed gcs. You probably want to go ahead and provide definitive airway management in the form of intubation. If the patient is conscious.
But theyre unable to phone eight theyre trying to speak. But there this is a sign of emerge of significant airway injury and you want to make sure that you address that quickly this is a situation where youre going to want to emergently intubate. The patient or otherwise manage the airway of intubation is impossible.
So what are the kinds of things were looking for in terms of airway life threats well for patients who have a currently payton airway. But you want to know whether theyre gonna lose their airway in the future things you want to look for are swelling so any kind of hematoma in the face and neck any kind of edema in the face or neck. These can compress the airway you want to look for bleeding in particular nasopharyngeal bleeding.
Thats going from the pharynx back into the oral cavity can cause aspiration. So we want to be aware of that and address. It and then lastly want to palpate for crepitus and we do that by feeling for that crispy crunchy feeling in the neck and upper chest this suggests some kind of injury to the airway structures.
Either the larynx or the trachea. Which again would mandate definitive. Airway management.
While were thinking about the airway. We always want to think about the cervical spine. So the cervical spine should be immobilized in trauma patients.
In case. They do have an injury. And any time.
A patient has a high c spine injury. They can actually lose their respiratory drive. Theres a rhyme.
See three four five keeps the diaphragm alive. So patients who have injuries in those regions of the spinal cord might have impaired respiration. Not because of an airway problem.
But because of difficulty breathing from diaphragmatic paralysis lastly. We just want to think about burns. We have a whole separate lecture about burns and well talk about the burned airway there.
But for patients who do have any kind of burn as part of their trauma. You want to just remember that thermal injury can cause airway edema and inhalational injury can cause damage to the lungs. Which in turn can make the patient hypoxic.
So these are all things that you want to think about for the airway of an injured patient whenever you do identify airway compromise either currently or you think its going to imminent.
Ly develop you want to go ahead and intubate your patient however in trauma. Theres often distortion of the normal anatomy. If the patient has swelling or bleeding or facial fractures those kinds of things.
The airway might be very technically challenging and to further add to our technical challenges we have to maintain spinal immobilization. We cant just crank the patients neck in any direction. Because we dont know whether or not they have an underlying injury.
So you need to be really proficient with airway management. If you are going to tackle a trauma. Airway and if this isnt something you have a lot of experience with you probably want to get back up from an anesthesiologist.
Although for emergency physicians of course. We would expect this as something you would be able to handle always bear in mind that if youre unable to intubate successfully in a non invasive way you need to think about the possibility of a surgical airway. So a surgical cricothyrotomy would be the procedure.
We would use for patients who have severe facial or neck injuries that preclude intubation and again if youre going to be managing trauma airways. This is a procedure that you need to master now were going to move on to breathing and ill tell you in my 15 years of practice experience. I can tell you that traumatic injuries to the airway are actually relatively rare.
Ive only seen a handful in all my years of practice where as pulmonary injuries chest injuries that lead to respiratory compromise. These are very common and these are something that you see regularly in the emergency department. So airways incredibly important and airway injuries are really life threatening.
But breathing is where youre going to find more pathology and more often need to intervene when youre assessing a patients breathing in trauma. One of the first things you want to do is listen to their breath sounds bilaterally and what youre listening for are the presence of equal bilateral breath sounds on both sides of the chest you also want to look and just get an overall feel for their respiratory effort. You know of course youre going to note their respiratory rate.
And youre probably going to pay attention to specifically what theyre doing when theyre breathing. But at the beginning. If you just get a visceral sense of whether theyre kind of chilling breathing comfortably or if theyre working really hard to breathe theyre using additional muscles and theyre having a pull air that should give you a sense of the severity of their respiratory compromise.
You of course want to count the respiratory rate again this is a vital sign that is often documented incorrectly and one that you really want to double check yourself. And you should always be concerned about a patient with significant to kipp nia. Because thats somebody who could tire out and really get themselves into trouble shortly and then lastly your respiratory vital sign is your oxygen saturation the whole purpose of the lungs is to get oxygen into the blood.
So you need to know if they are fulfilling that purpose effectively or not while were assessing breathing. We want to be looking for evidence of pulmonary life threats and there are four major ones. We want to think about tension pneumothorax is by far the most common and most serious in the trauma setting.
But you can also see open pneumothorax flail chest. Which is always associated with underlying pulmonary contusion and then massive hemothorax whenever you suspect that a patient has a compromise of their breathing we always want to initiate supplemental oxygen you should give them whatever flow they need to keep their oxygen saturation normal. Which is typically going to be above 95 for somebody with healthy lungs.
You also want to initiate emergency treatment for any patient in whom you identify a life threatening pulmonary injury now we have a whole other lecture on chest trauma and im not going to get into each of these too much right now. But there are immediate interventions for each one of these injuries that you can perform during the primary survey to stabilize your patient once your patient is stable and youre satisfied you dont have an immediate life threatened the pulmonary domain. We want to get a chest x ray to evaluate their lungs and get a sense of whats going on with them from a pulmonary injury standpoint.
But we dont want to be getting chest x. Rays. Until.
Were satisfied that the patient is stable moving on to c. Circulatory. Insufficiency is very common in trauma.
Obviously trauma is associated with bleeding so we very often see patients who have significant blood loss and circulatory compromises of that the things you want to look for when youre thinking about a patients circulation is just their overall appearance are they pink and perky or are they pale or cyanotic or altered. These are things that should help you get sort of an overall global sense of the adequacy of their perfusion. You can also look at things like capillary refill and obviously want to look for signs of external bleeding because a patient who has a wound thats actively hemorrhaging youre clearly going to want to control that bleeding before you do much of anything else.
We also want to feel their peripheral pulses and the peripheral pulses are really important because they give you a quick sense of the patients blood pressure. Which is really the bottom line on the adequacy of their perfusion. So.
A patient who has a nice bounding easily palpable dorsalis pedis pulse. Has a systolic blood pressure of 90 or more. So.
Thats a pretty quick way if you feel those dorsalis pedis.
Pulses. And youre satisfied that theyre that theyre palpable and normal. That is a pretty quick way to say.
Yeah. You know what my patient. Circulatory status.
Is probably adequate at least right at this moment moving farther. Approximately. Radial pulses indicate.
A systolic of at least eighty femorals can indicate a systolic of at least seventy and you dont lose your carotid pulse. Until your systolic goes below sixty. So really getting a feel for which pulses are present in which pulses are absent can give you a pretty accurate sense of what your patients blood pressure.
Is and whether or not their perfusion is adequate of course once you get your patient hooked up to the monitor you want to know what their heart rate is and you want to know what their blood pressure is because these are circulatory. Vital signs and theyre going to be used to guide our resuscitation and help us decide whether or not our resuscitative efforts are effective. So our big circulatory life threat like i already mentioned.
Its going to be hemorrhagic. Shock trauma is strongly associated with blood loss. And this is by far the most common cause of death among traumatically injured patients.
However we want to consider other causes of shock as well specifically tension pneumothorax and cardiac tamponade both of these are forms of obstructive shock. Where the injury. Prevents normal blood flow back to the heart from the venous circulation and impairs cardiac output that way again were going to talk about both of these disease entities.
And some detail in future lectures. But you should be aware that not all shock in trauma is going to be related to hemorrhage. There are these other disease processes that can lead to shock all right while were managing circulation.
I already alluded to this before but clearly if a patient has blood spurting out of a wound. Youre gonna want to apply some direct pressure to that to get that bleeding under control. This is going to be one of our immediate maneuvers that we do during the primary survey to stabilize the patient in addition.
We want to make sure that our patient has adequate iv access this means. Two large bore peripheral ivs. So you dont want just one you want to because you want to backup in case.
Yours falls. Out or infiltrates. You want to make sure theyre large bore.
So that you can get a lot of fluid through them. If you need to if you cant get large bore peripheral access you have other alternatives you can place an intraosseous line or you can place a trauma line. Which is a specialized central venous catheter thats very large in diameter and allows large volume resuscitation when you do initiate fluid.
Youre always going to start with isotonic crystalloid. So generally normal saline or lactated ringers for most patients now every now and then if you know up front. There was a large amount of blood loss either because the patient is actively losing blood right in front of you or because the paramedics report that there was a lot of blood at the scene you might consider going straight to blood transfusion.
But generally were gonna start off with isotonic crystalloid and only move on to blood if we dont get a satisfactory response from crystalloid again were also going to be looking for specific injury patterns and were going to be providing treatments based on those underlying injuries. Were gonna talk about tension pneumothorax and cardiac tamponade in future lectures. So dont worry too much about that right now.
But understand that certain disease processes have specific treatments that you need youre not just going to treat all hypotension or shock with fluid all right moving on to our disability assessment. So once weve covered a b and c. The next thing.
We want to think about is our patients neurologic status. So we always want to formally assess their level of consciousness. But glasgow coma scale is whats used most commonly for this and were going to talk about that in some detail in our head injury lecture.
However you can also use the abbreviated ave pugh scale which stands for alert verbal pain or unresponsive meaning your patient is alert and normal they respond only to verbal stimuli. They respond. Only to painful stimuli or theyre completely unresponsive and as you can imagine patients who only respond to pain or dont respond at all are clearly very ill and you should be very concerned about them while were doing our neurologic survey.
We always want to look at the pupils pupillary function gives us a sense of whether the patient has a focal neurologic lesion or not we want to look for for extremity movement to make sure that theres not any evidence of neurologic vocality that might suggest a brain or a spinal cord injury.
We want to look for external signs of head or neck trauma. That might point us in the direction of a significant head or neck injury and lastly. If our patient is in any way shape or form altered.
We want to check their glucose now clearly trauma doesnt make you hypoglycemic. But remember trauma is always precipitated by some event right and its not uncommon that people with medical illnesses will sustained trauma. So if your patient became hypoglycemic that made them confused and then they crash their car.
You know clearly theyre going to have both the medical problem that precipitated the event as well as the traumatic injury for you to deal with so you want to make sure that youre considering the big picture for your patient checking their glucose and checking other for other signs of medical illness that might have contributed to the current event today all right there are a number of neurologic life threats that were looking for our primary survey and were gonna talk in more detail about these in future lectures. But these include any type of penetrating cranial injury interest cranial hemorrhage diffuse. Axonal injury.
And also high spinal cord injuries like c. Spine injuries in the realm of intracranial hemorrhage. We have a variety of different disease entities to think about weve got our subdural hematomas.
Our epidural hematomas our traumatic. Subarachnoid and then lastly intraparenchymal and intraventricular bleeding all of these are managed differently. And were going to talk about them in detail in a future lecture.
So what are we going to do initially in our primary survey for patients who show signs of significant neurologic impairment well first and foremost if their gcs is below 8. We want to go ahead and intubate patients who are significantly comatose are not going to be able to maintain their own airways. So its very very important that we manage the airway and make sure that that the patient maintains a stable airway for the duration of their care.
Were also of course going to optimize their oxygenation and their perfusion so were going to be giving them supplemental oxygen. If theyre intubated were going to be placing them on a ventilator and were going to give fluids blood etc to ensure that they have adequate systemic perfusion. We do want to obtain emergent cranial imaging for any patient who has a significant neurologic disability on our evaluation and the test of choice is really non contrast head ct.
But obviously were not going to initiate that until the patient is stable from an abc perspective and again there are specific disease entities that were looking for and how we manage those is going to vary depending on our ct findings. So were going to talk in more detail about how we would approach each one of these injury types as we move forward lastly after weve covered a b c. And d.
We want to think about exposing the patient. This is really really important youve got to take all their clothes off youve got to get all the coverings off you dont want to miss any injuries and i cant tell you how many times in my own practice. Ive seen injuries that are missed because people dont undress their patients.
So get the clothes off get the sheets off get a good look head to toe at the patients entire skin. While youre doing that however you want to avoid hypothermia. So hypothermia causes coagulopathy and exacerbates bleeding and trauma.
So you want to expose your patient and look at them. But once youve done that get them covered up again make sure you keep the room warm make sure you use warm blankets. Because trauma.
Patients can actually become hypothermic. Very quickly lastly. Youre going to complete a head to toe exam.
So you want to make sure that you look not only at the obvious stuff. But in all the nooks and crannies you want to look up in the axilla in the perineum. You want to roll the patient over to examine the back obviously.
While maintaining c. Spine. Immobilization.
And you want to also make sure you get a look at the back of the head and the neck. Which is especially important in patients wearing cervical collars. We often miss those if we dont remove the collar to examine the patient so take home points from this lecture.
Youve got to do a primary survey and all of your trauma. Patients. Youve got to do it.
The same way every single time. So that you dont miss things youve got to be super systematic about this you want to make sure that you look for specific life threats in the abc and d domains. And you want to treat those as you identify them you want to know the differential of consequence for a b c and d.
So that you know what youre looking for when you are doing your primary survey. And if you follow these steps youre going to have a successful trauma resuscitation for all of your patients. Thank you .
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