The initial assessment and management of seriously injured patients is a challenging task and requires a rapid and systematic approach. Show
This systematic approach can be practised to increase speed and accuracy of the process but good clinical judgement is also required.[1, 2] Although described in sequence, some of the steps will be taken simultaneously. The aim of good trauma care is to prevent early trauma mortality. Early trauma deaths may occur because of failure of oxygenation of vital organs or central nervous system injury, or both. Injuries causing this mortality occur in predictable patterns and recognition of these patterns led to the development of Advanced Trauma Life Support (ATLS) by the American College of Surgeons. A standardised protocol for trauma patient evaluation has been developed.[3, 4] The protocol celebrated its 40th anniversary in 2018.[5] Good teaching and application of this protocol are held to be important factors in improving the survival of trauma victims worldwide.[6] Different systems of trauma scoring have been developed. Aims of the initial evaluation of trauma patients
Preparation and co-ordination of careAssessment and management will begin out of hospital at the scene of injury and good communication with the receiving hospital is important. The preparatory measures are outlined below to 'set the scene'. The pre-hospital phase
The hospital phase
Guidelines on protection when dealing with body fluid should be followed throughout this and subsequent procedures. Triage and organisation of careSee the separate related article Trauma Triage and Scoring. This is the sorting of patients according to their need for treatment and the resources available. It starts at the scene (see above) and continues at the receiving hospital.[7] Priority is given to patients most likely to deteriorate clinically and triage takes account of vital signs, pre-hospital clinical course, mechanism of injury, age and other medical conditions. In trauma centres, teamwork should ensure critically injured patients are evaluated, as diagnostic procedures are performed simultaneously, thus reducing the time to treatment. A team approach is demanding of personnel and resources and, in smaller institutions, non-hospital settings or with mass casualties, available personnel and resources can rapidly be overwhelmed:
*NB: see however the comments below regarding catastrophic haemorrhage, the development of the cABCD approach and the re-evaluation of cervical spine protection. Initial assessmentThis comprises:
Resuscitation and primary surveyFor speed and efficacy a logical sequence of assessment to establish treatment priorities must be gone through sequentially although, with good teamwork, some things will be done simultaneously (resuscitation procedures will begin simultaneously with the assessment involved in the primary survey, ie lifesaving measures are initiated when the problem is identified). Special account should be taken of children, pregnant women and the elderly as their response to injury is modified.[8] The primary survey is according to: A = Airway maintenance cervical spine protection
B = Breathing and ventilation
NB: it can be difficult to tell whether the problem is an airway or ventilation problem. What appears to be an airway problem, leading to intubation and ventilation, may turn out to be a pneumothorax or tension pneumothorax which will be exacerbated by intubation and ventilation. C = Circulation with haemorrhage control To assess blood loss rapidly observe:
NB: response to blood loss differs in:
D = Disability: neurological status
Patients should be re-evaluated frequently at regular intervals, as deterioration can occur rapidly and often patients can be lucid following a significant head injury before worsening. Signs such as pupil asymmetry or dilation, impaired or absent light reflexes, and hemiplegia/weakness all suggest an expanding intracranial mass or diffuse oedema. This requires IV mannitol, ventilation and urgent neurosurgical opinion. Hypertonic saline can be used as an alternative to mannitol especially in hypovolaemic patients. E =
Exposure/environmental control Additional considerations to primary survey and resuscitationECG monitoring: this can guide resuscitation by diagnosing dysrhythmias, ischaemia, cardiac injury, pulseless electrical activity (PEA) - which may indicate cardiac tamponade - hypovolaemia, tension pneumothorax, and extreme hypovolaemia. Hypoxia or hypoperfusion should be suspected if there is bradycardia, aberrant conduction, and premature beats. Hypothermia produces dysrhythmias. Urinary/gastric catheters:
Other monitoring: monitoring of resuscitation by measuring various important parameters measures adequacy of resuscitation efforts. Values for various parameters should be obtained soon after the primary survey and reviewed regularly. Important parameters are:
Remember: blood pressure is a poor measure of perfusion. Diagnostic procedures: care should be taken that these do not hamper resuscitation. They may be best deferred to the secondary survey. Modifications to the ATLS guidelines have been suggested.[14, 15] X-rays most likely to guide resuscitation early on, especially in blunt trauma, include:
Other useful procedures include FAST (= focused assessment with sonography for trauma), eFAST (= extended focused assessment with sonography for trauma) and/or CT scanning to detect occult bleeding.[16] The National Institute for Health and Care Excellence (NICE) advocates FAST in patients who are haemodynamically unstable and not responding to volume resuscitation.[17] Secondary surveyThis begins after the 'ABCDE' of the primary survey, once resuscitation is underway and the patient is responding with normalisation of vital signs. The secondary survey is essentially a head-to-toe examination with completion of the history and reassessment of progress, vital signs, etc. It requires repeat physical examinations and may require further X-ray and laboratory tests. It comprises: History
Physical
examination Beware: burns (fluid requirements, inhalation injury); cold injury (continue resuscitation until rewarmed); high-voltage electricity injuries (extensive muscle injury likely to be concealed). Additional considerations to secondary surveyA range of further diagnostic tests and procedures may be required after the secondary survey. These include CT scans , ultrasound investigations, contrast X-rays, angiography, bronchoscopy, oesophageal ultrasound, etc. Definitive careChoosing where care should continue most appropriately will depend on results of the primary and secondary surveys and knowledge of the facilities available to receive the patient. The closest appropriate facility should be chosen. Records and legal considerationsRemember:
Practice tipsRegular training in resuscitation by the whole practice team is recommended. Attention to a team approach is essential. Involvement in medical cover at schools, sports events, and car accidents (British Association for Immediate Care (BASICS)) requires higher-level training and regular refresher courses. What is the priority assessment for a trauma patient?Advanced Trauma Life Support (ATLS), developed by the American College of Surgeons, promotes the primary survey sequence as airway, breathing, circulation, disability, exposure (ABCDE). Once the airway is secured or maintained by the patient, breathing and ventilation should be assessed.
What is the initial priority during the primary assessment of the patient experiencing trauma?Primary survey. The steps of the primary survey are encapsulated by the mnemonic ABCDE (airway, breathing, circulation/hemorrhage, disability, and exposure/environment). The airway is the first priority.
What are the five general guidelines for the priorities of care for trauma patients?As always, start with the ABCs.. Airway. The first part of the primary survey is always assessing the airway. ... . Breathing. Assess your patient's breathing next. ... . Circulation. Once you've assessed and supported your patient's breathing, attend to his circulatory status. ... . Disability. ... . Exposure.. |