Objectives

Apply principles of primary and

secondary surveys
Identify Management priorities
Institute appropriate resuscitation and
monitoring procedures
Recognize value of patients history and
biomechanics of injury
Anticipate pitfalls

Key Questions
How do I prepare for a smooth transition
from the prehospital to the hospital
environments?
What is a quick, simple way to assess the
patient in 10 seconds?
What is the secondary survey and when
does it start?

More Key Questions

How can I minimized missed injuries?
Which patients do I transfer to a higher
level of care?
When should the transfer occur?

Prepare for a smooth transition

from the prehospital environ?
Transport guidelines / protocols
Online medical direction
Mobilization of resources
Periodic review of care
Closest, appropriate facility

Prepare for a smooth transition

to the inhospital environ?
Preplanning is essential
Equipment, personnel, services
Standard precautions
Prearranged transfer agreements

Standard Precautions
Cap
Gown
Gloves
Mask
Shoe Covers
Goggles / face
shield

Quick, simple way to asses the

patient in 10 seconds?
Identify yourself
Ask the patient his / her name
Ask the patient what happened

Primary Survey

The priorities are

the same for all
patients.

Special Considerations
Trauma in the elderly
Pediatric trauma
Trauma in pregnant women

Primary Survey
Establish patent airway
Protect c-spine
Pitfalls?
Equipment failure
Inability to intubate
Occult airway injury
Progressive loss of airway

Primary Survey
Assess and ensure adequate
oxygenation and ventilation
Pitfalls?
Airway vs ventilation problem?
Iatrogenic pneumothorax or tension
pneumothorax

Assess for organ perfusion?

Level of consciousness
Skin color and temperature
Pulse rate and character

Primary Survey
Circulatory Management
Control
hemorrhage
Restore volume
Reassess
parameters

Pitfalls?
Elderly
Children
Athletes
Medications

Primary Survey
Disability
Baseline neurologic evaluation
GCS scoring
Pupillary response
Observe for neurologic
deterioration

Primary Survey
Exposure / Environment
Completely undress the patient

Prevent hypothermia

Resuscitation
Protect and secure airway
Ventilate and oxygenate
Stop the bleeding
Vigorous shock therapy
Protect from hypothermia

Adjuncts to Primary Survey

Diagnostic Tools
DPL
FAST

When do I start it?

After
Primary survey is completed
ABCDEs are reassessed
Vital functions are returning to normal

What are the components?

History
Physical exam: Head-to-toe
Tubes and fingers in every orifice
Complete neurologic exam
Special diagnostic tests
Reevaluation

Secondary Survey
History
Allergies
Medications
Past illnesses
Last meal
Events / Environment

Secondary Survey
Head
GCS Score
Neurologic exam
Comprehensive
eye and ear exam

Pitfalls?
Unconsciousness
Periorbital edema
Occluded auditory
canal

Secondary Survey
Maxillofacial
Bony crepitus
Deformity
Malocclusion

Pitfalls?
Potential airway
obstruction
Cribriform plate
fracture
Frequently missed

Secondary Survey
Cervical Spine
Tenderness
Complete motor/
sensory exams
Reflexes
Imaging studies

Pitfalls?
Altered sensorium
Inability to
cooperate with
clinical exam

Secondary Survey
Neck (soft tissues)
Mechanism: Blunt vs penetrating
Symptoms: Airway obstruction, hoarseness
Findings: Crepitus, hematoma, stridor,
bruit

Secondary Survey
Neck (soft tissues): Pitfalls
Delayed
symptoms and signs
Progressive airway
obstruction
Occult injuries

Secondary Survey
Chest
Inspect
Palpate
Percuss
Auscultate
Obtain x-rays

Secondary Survey
Abdomen
Inspect
Auscultate
Palpate
Percuss
Reevaluate
Special studies

Secondary Survey
Abdomen: Pitfalls?
Hollow viscus injury
Retroperitoneal injury
Excessive pelvic manipulation

Secondary Survey
Perineum

Contusions, hematomas,
lacerations, urethral blood

Rectum

Sphincter tone , highriding

prostate, pelvic fracture,
rectal wall integrity, blood

Vagina
Pitfalls

Blood, lacerations
Urethral injury in women,
pregnancy

Secondary Survey
Musculoskeletal: Extremities
Contusion, deformity
Pain
Perfusion
Peripheral neurovascular
status
X-rays as needed

Secondary Survey
Musculoskeletal: Pelvis
Pain on palpation
Symphysis width
Leg length unequal
Instability
X-rays as needed

Secondary Survey
Musculoskeletal: Pitfalls
Potential blood loss
Missed fractures
Soft-tissue or ligamentous injury
Compartment syndrome
(especially with altered sensorium /
hypotension)

Secondary Survey
Neurologic: Brain

Early
neurosurgical
consult

GCS Score
Lateralizing signs
Frequent reevaluation
Prevent secondary brain injury

Secondary Survey
Neurologic: Spine and Cord
Complete motor and sensory
exams
Imaging as indicated
Reflexes
Early neurosurgical /
orthopaedic consult

Secondary Survey
Neurologic: Pitfalls
Incomplete immobilization
Subtle in ICP with manipulation
Rapid deterioration

Adjuncts to Secondary Survey

Special diagnostic test as indicated
Pitfalls?
Patient deterioration
Delay of transfer

Minimize missed injuries?

High index of suspicion
Frequent reeveluation and monitoring

Pain Management
Relief of pain /anxiety as appropriate
Administer intravenously
Careful monitoring is essential

Which patients do I transfer?

Those whose injuries exceed
institutional capabilities
Examples
Multisystem or complex injuries
Patient with comorbidity or age extremes

When do I transfer the patient?

As soon as possible after stabilizing
measures are completed
Airway and ventilatory control
Hemorrhage control (operation)

Avoid needless delay

Records, Legal Considerations

Concise, choronologic documentation
Consent for treatment
Forensic evidence

Primary Survey
Resuscitation

Secondary Survey
Definitive Care

Adjuncts

Adjuncts