Chapter 1

Initial Assessment
and
management

OBJECTIVES

Identify the correct sequence of priorities in assessing the

multiply injured patient
Apply the primary and secondary evaluation surveys to
assessment of the multiply injured patient
Apply guidelines and techniques in the initial resuscitative
and definitive--case phase
Anticipate the pitfalls associated with the initial assessment
and management ( minimize their impact )
Conduct an initial assessment survey on a simulated
multiply injured patient

CONCEPTS OF INITIAL
ASSESSMENT

Preparation
Triage
Primary survey ( ABCDEs )
Resuscitation
Adjuncts to primary survey and resuscitation
Secondary survey ( head-to-toe evaluation and history )
Adjuncts to the secondary survey
Continued postresuscitation monitoring and reevaluation
Definitive care

Repeat primary and secondary survey when finding

any deterioration in the patients status

Primary survey and resuscitation are done

simultaneously

PREPARATION

Prehospital
Airway maintenance
Control of external bleeding & shock
Immobilization of the patient
Communication with receiving hospital & immediate transport
to the closest, appropriate facility
History taking ( include events )
Inhospital
Advanced planning ( especially massive casualty )
Equipment & personnel
Communicable disease protection
Transfer agreements

TRIAGE

Sorting of patients according to ABCs and available

resources

Triages is the responsibility of prehospital

personnel

Not exceed the ability of the facility ==> treat life -- threatening patient first

Exceed the capacity of the facility ( mass casualties ) ==> Treat the greatest
chance of survival, with the less time, less equipment & less personnel

PRIMARY SURVEY

Adult / Pediatric priorities same

Identified the life-threatening conditions and simultaneously
managed
A: Airway maintenance with cervical spine protection
B: Breathing and ventilation
C: Circulation with hemorrhage control
D: Disability ( Neurologic status )
E: Exposure / Environmental control: Undress the patient &
prevent hypothermia

PRIMARY SURVEY

Airway Maintenance with Cervical Spine Protection

Oral foreign bodies, facial, mandibular, or tracheal / laryngeal
fractures may result in airway obstruction
Assume C-spine injury
Multisystem trauma
Altered level of consciousness
Blunt injury above clavicle
Pitfalls:
Difficult airway
Obesity: surgical airway cannot be performed smoothly
laryngeal fracture or incomplete upper airway transection

PRIMARY SURVEY

Breathing and Ventilation

Airway patency adequate breathing & ventilation
injury that may acutely impair ventilation
1. Tension pneumothorax
2. Flail chest with pulmonary contusion
3. Massive hemothorax
4. Open pneumothorax
above problems need to be identified in the primary survey and
managed
Pitfall: Differentiation of ventilation problems from airway compromise
may be difficult

PRIMARY SURVEY

Circulation with Hemorrhage Control

Assess blood volume and cardiac output
level of consciousness
skin color
pulse
Bleeding control: direct manual pressure on the wound
Pitfall:
The response of elderly, children, athletes and others with
chronic medical conditions to hypovolemia is different
from normal people

PRIMARY SURVEY

Disability ( Neurologic Evaluation )

Level of consciousness
A. Alert
V. Response to voice
P. Response to pain
U. Unresponsive
Pupils
Pitfall:
Lucid interval ( talk and die ) : EDH, frequent neurologic
reevaluation can minimize this problem

PRIMARY SURVEY

Exposure/Environmental Control
Undress patient completely
Protect from hypothermia
Pitfall:
early control of the hemorrhage is the best method to
keep body temperature( early surgical intervention)

RESUSCITATION

Protect/Secure airway & protect C-spine

Breathing/Ventilation/Oxygenation
Vigorous shock therapy
At last two large - caliber IV line
Crystalloid solution ( Ringers lactate 2~3 litter)
Type-specific blood
surgical intervention
Protect from Hypothermia : 39oC warm IV fluid
Urinary/gastric catheters unless contraindication

ADJUNCTS TO PRIMARY SURVEY AND

RESUSCITATION

Monitor:
Ventilatory rate and ABGs/ end-tidal CO2
Pitfalls: Combative patients often extubate or bite
endotracheal tube
Pulse oximetry
ECG & BP monitor
Temperature
urine output

X-RAY AND DIAGNOSTIC STUDIES

Cant delay or interrupt the primary survey and resuscitation

Trauma series ( portable X-ray ): CXR, C-spine/ lateral view,
pelvic AP view
A negative or inadequate c-spine x-ray cant exclude cervical
spinal injury
Sonography / DPL

Pitfalls: obesity ( Sonography and DPL are difficult )

CONSIDER NEED FOR PATIENT

TRANSFER
Referring doctor -to -receiving doctor communication
Closest appropriate hospital

BEFORE SECONDARY SURVEY

Complete primary survey

Establish resuscitation

Normalization of vital functions

SECONDARY SURVEY

History taking
Complete neurologic exam.
Head-to-toe evaluation
Roentgenograms
Special procedure
Tubes and fingers in every orifice
Re-evaluation

SECONDARY SURVEY

History
A. Allergies
M. Medications currently used
P. Past illness / pregnancy
L. Last meal
E. Events / Environment related to injury

HISTORY
Mechanisms of injury

Blunt
Automobile collisions
Seat belt usage
Steering wheel deformation
Direction of impact
Ejection of passenger form the vehicle
Burns and Cold injury
Inhalation injury and CO. intoxication in fire field
Hazardous environment
Penetrate
Anatomy factors
Energy transfer factor
Velocity and caliber of bullet
Trajectory
Distance

SECONDARY SURVEY

Physical Examination
Head
entire scalp and head
eye:
pupil
visual acuity
EOM
foreign body ( soft contact lens.)
Pitfalls:
Severe facial swelling or unconsciousness pt still
need eye exam.

SECONDARY SURVEY

Physical Examination
Maxillofacial
No airway obstruction or massive bleeding ==> treat later
Midfacial fracture ==> R/O cribriform plate fracture
Pitfalls:
Some facial bone fracture is difficulty identified early ==>
reassessment is crucial

SECONDARY SURVEY

Physical Examination
C-spine and Neck
Maintain immobilization
Complete evaluation
Complete radiology study
Cautions helmet removed
Penetrating injury: Not be explored in the emergency
department; explored & treat in the operative room
Pitfalls:
Blunt injury to Neck: Carotid artery intima injury or
dissection ( delay onset )
Immobilization ==> decubitus ulcer

SECONDARY SURVEY

Physical Examination
Chest

Pitfalls:
Poor tolerance to minor pulmonary trauma in
elderly patients
A normal CXR cant role out chest injury in
children

SECONDARY SURVEY

Physical Examination
Abdomen
Identify a surgical abdomen is more important than doing a
specific diagnosis ==> early consult surgeon
Close observation & frequent reevaluation of the abdomen
DPL, sonography, abdomen CT
Pitfalls:
Excessive manipulation of the pelvis should be avoid
==> just do pelvic x-ray
Retroperitoneal organs ( pancreatic & hollow organ )
are very difficult to identify

SECONDARY SURVEY

Physical Examination
Perineum / rectum / vagina
Perineum:
Contusions, hematomas, urethral
bleeding.
Rectum:
Sphincter tone, high riding prostate,
blood..
Vagina:
Blood, laceration
Pitfalls:
Female urethral injury is difficult to detect

SECONDARY SURVEY

Physical Examination
Musculoskeletal
Extremities / pelvis: Contusion, deformity, pain
crepitation, abnormal
movement
Vascular: Assess all peripheral pulses
Spine: Physical findings, mechanism of injury

SECONDARY SURVEY

Physical Examination
Neurologic
Determine GCS score
Re-evaluate pupils
Sensory / motor evaluation
Maintain immobilization
Prevent secondary CNS injury ( keep stable vital signs,
avoid increased ICP and treat IICP )
Early neurosurgical consultation
Pitfalls:
Intubation should be done expeditiously and as smoothly
as possible ( Intubation will increase ICP )

REEVALUATION

New findings / deterioration / improvement

High index of suspicion ==> early diagnosis &

management

Continuous monitoring

Pain relief

DEFINITIVE CARE

Trauma center

Closest appropriate hospital

RECORDS AND LEGAL

CONSIDERATIONAS

Records: Concise, chronologic documentation

Consent for treatment

Forensic Evidence: preserve the evidence

SUMMARY

Initial assessment & management of multiply injured

patient

Primary survey ( ABCDEs )

Resuscitation & monitor ( life-threatening problems )

Secondary survey ( head-to-toe, history )

Definitive care ( early consultation, surgical intervention

or transport )