Initial Assessment
16 INITIAL ASSESSMENT
Eric L. Sarin M.D., John B. Moore M.D.
1. What is the “golden hour”?
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The first hour after injury provides a unique opportunity to provide life-saving interventions. Because more than half of trauma deaths occur early due to bleeding or brain injury, rapid transport, appropriate triage, evaluation, resuscitation, and intervention can affect outcomes. The “golden hour” concept needs to be extended to several hours in the rural setting, but with the same structured approach. Trauma surgeons harbor the unique idea that an injured patient is their responsibility before they reach the hospital.
2. Name the major components of the initial assessment of the trauma patient.
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Primary survey, resuscitation, secondary survey, reevaluation, and definitive care.
3. What is the purpose of the primary survey?
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To identify life-threatening injuries in a prioritized time frame.
4. Define the ABCDE mnemonic of the primary survey that reinforces the fact that life-threatening injuries kill in a predictable order.
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* A Airway control with cervical spine (C-spine) protection
* B Breathing with oxygenation and ventilation
* C Circulation with hemorrhage control
* D Disability or neurologic status
* E Exposure of patient with temperature control
5. What are the adjuncts to the primary survey?
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All trauma patients should receive high-flow supplemental oxygen by nasal cannula or facemask. Continuous monitoring should include pulse oximetry, cardiac ECG monitor, and a cycled blood pressure cuff. Two large-bore IV lines are placed as blood is drawn for screening tests, including blood type and crossmatch. Nasogastric or orogastric tubes are placed for gastric decompression and to prevent aspiration. A Foley catheter is inserted to assess urine flow and character of urine. Radiographs should include the “big three” for major trauma “mechanism”: cervical spine, chest x-ray, and pelvic x-ray.
6. Identify the one concept that can prevent unexpected acute deterioration of the trauma patient during initial assessment.
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Re-evaluation. If deterioration occurs, proceed back to the ABCs and start over again.
7. Name the two major causes of death during the first 24 hours after injury.
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Exsanguination and central nervous system injury.
8. How is the airway assessed?
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Ask the patient a question. A response in a normal voice suggests that the airway is not in immediate danger. A hoarse, weak, or stridorous response may imply airway compromise. An agitated or combative response indicates hypoxia (agitation or confusion in any surgical patient always means hypoxia)-until proved otherwise. No response indicates the need for a “definitive airway”(a cuffed tube in the trachea).
9. Name the most common causes of upper airway obstruction in the trauma patient.
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The tongue, followed by blood, loose teeth or dentures, vomit, and soft tissue edema.
10. What are the initial maneuvers used to restore an open airway?
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The chin lift and jaw thrust physically displace the mandible and the tongue anteriorly to open the airway, and manual clearance of debris and suctioning of the oropharynx optimize patency. Oropharyngeal and nasopharyngeal airways (trumpets) are useful adjuncts in maintaining an open airway in obtunded patients. All of these maneuvers must be accomplished with in-line stabilization of the cervical spine.
11. What are the indications for a definitive airway?
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Apnea, inability to maintain or protect the airway (compromised consciousness), inability to maintain oxygenation, hemodynamic instability, need for muscle relaxation or sedation, and need for hyperventilation.
12. List the types of definitive airway that are available.
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* Orotracheal intubation
* Nasotracheal intubation
* Surgical airway (cricothyroidotomy or tracheostomy)
13. When should a surgical airway be performed?
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In any circumstance in which the patient requires a definitive airway but neither orotracheal nor nasotracheal intubation can be accomplished safely, such as in patients with extensive maxillofacial trauma or high-risk anterior neck trauma. Cricothyroidotomy should not be performed in patients with direct laryngeal trauma, patients with tracheal disruption, or patients < 12 years old. Tracheostomy and transtracheal ventilation are the preferred alternatives under these circumstances.
14. How does one “clear the C-spine”?
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Injury to the cervical spine (C-spine) must be excluded before moving the head or neck of the trauma patient. Alert patients without other significant injuries may be moved without x-rays if they are asymptomatic and have no cervical spine tenderness to direct palpation. Patients with symptoms or other major (distracting) injury require a three-view cervical spine series (anteroposterior, lateral, and odontoid) to evaluate the cervical spine. Visualization to the level of C7-T1 is mandatory because 10% of unstable cervical spine fractures occur at this level. If the standard three-view series is inadequate, a “swimmer’s view” (patient’s arm extended above the head with the x-ray focused through the axilla) can be performed. In high-risk patients with symptoms and equivocal films or sedated/intubated intensive care unit patients, computed tomography (CT) scan of the neck may be necessary to rule out unstable bony injury. Persistent symptoms in the absence of bony injury may require evaluation of potential ligamentous injury with flexion-extension films, CT, or magneticresonance imaging.
15. Do cervical spine collars adequately immobilize the cervical spine?
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No. Soft collars allow for almost 100% of normal flexion, extension, and rotation. A semirigid (Philadelphia) collar allows 30% normal flexion and extension, > 40% normal rotation, and > 60% lateral movement. Proper immobilization of the cervical spine is achieved with the patient on a backboard in a semirigid collar, lateral sandbags, and anterior 3-inch adhesive taping.
KEY POINTS: CERVICAL SPINE CLEARANCE
1. Alert patients without other significant potentially distracting injuries can be cleared without radiographic evaluation in the absence of neck pain and midline cervical tenderness on palpation.
2. Obtunded, comatose, or alert patients with distracting injuries (e.g., long bone fractures) require maintenance of C-spine precautions and radiographic evaluation of the C-spine with three-view cervical spine series.
3. C7-T1 must be visualized; otherwise the “swimmer’s view” is required.
4. If there is no radiographic evidence of injury but midline tenderness persists, obtain flexion-extension films to evaluate for ligamentous injury.
5. Spinal cord injury without radiographic abnormality is more common in children and usually can be detected with CT or MRI.
16. What technique can help increase the success of oral tracheal intubation?
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Rapid sequence intubation with manual in-line stabilization.
17. Discuss nonairway conditions that pose an immediate threat to breathing.
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Tension pneumothorax occurs from air in the pleural space under pressure. The most common culprit is an iatrogenic pneumothorax caused by overenthusiastic positive-pressure ventilation (watch out, it’s easy to get excited when you are “bagging” a recently intubated patient). Treatment consists of needle decompression of the chest followed by tube thoracostomy (36 tube midaxillary line at the fourth to fifth intercostal space). An open pneumothorax results from an open wound of the chest wall causing free communication of the pleural space with the atmosphere interfering with the thoracic bellows mechanism. The ineffective ventilation responds to coverage of the opening and insertion of a chest tube. Flail chest results from multiple rib fractures of contiguous ribs creating a free-floating segment that limits breathing. A small flail chest in a healthy patient responds to oxygen supplementation and adequate analgesia. Large flail chest in less healthy patients requires prompt endotracheal intubation and mechanical ventilation.
18. What are the preferred sites of emergent IV access?
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Peripheral venous access in the upper extremities (i.e., antecubital fossa) with a large-bore 14G or 16G catheter. Percutaneous or cutdown alternatives include the ankle or groin saphenous vein. Central venous access is indicated for measurement of central venous pressure after the initial fluid boluses and can help explain ongoing hemodynamic instability. Good flow rates can be achieved by using the shorter, larger introducing catheters during aggressive fluid infusion. In children < 6 years old, the interosseous route at the distal femur or proximal tibia provides a surprisingly effective alternative.
19. What are the key elements in assessing hemodynamic stability?
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Mental status (alert, verbal, pain, and unresponsive), skin perfusion (pink/warm versus pale/cool), and hemodynamic parameters (blood pressure, heart rate, respiratory rate). Remember the gross estimates of systolic blood pressure (SBP) by palpable pulses. The radial (wrist) pulse estimates SBP > 80 mmHg; femoral (groin) pulse, SBP > 70 mmHg; and carotid (neck) pulse, SBP > 60 mmHg. The urine flow rates assist in estimating end-organ perfusion.
20. Identify the three components to the minineurologic examination during the primary survey.
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Mental status (when you look the patient in the eye, does he look back?), pupillary status, and best motor activity. This brief interaction assists in differentiating a toxic metabolic insult versus mass lesion. The pupils should be examined for size, symmetry, and reactivity.
21. List the three main components of the Glasgow Coma Scale (GCS).
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1. Best eye-opening response, scored 1-4.
2. Best verbal response, scored 1-5.
3. Best motor response, scored 1-6.
Points from each component are added up. An overall score of 13-15 indicates a mild closed head injury, a score of 9-12 indicates a moderate head injury, and a score < 8 indicates a severe head injury. A general rule: A GCS score of ≤ 8 mandates endotracheal intubation.
22. What is the most common cause of shock in the trauma patient?
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Hypovolemia from acute blood loss. The other less common causes of shock include cardiogenic, neurogenic, or septic.
23. What fluids should be used for initial resuscitation?
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The mainstay of fluid resuscitation is rapid crystalloid infusion (lactated Ringer’s or normal saline). Colloid infusions are more expensive, show no proven advantages, and have no role in acute trauma resuscitation. Blood should be administered to optimize oxygen-carrying capacity when crystalloid infusion is > 50 mL/kg or if the patient presents with class IV hemorrhage. The general rule for crystalloid infusion to replace blood loss is a 3:1 ratio of crystalloid to blood.
24. Discuss the most common causes of cardiogenic shock after injury and how they are differentiated and treated.
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Acute pericardial tamponade is caused by the accumulation of blood or air within the pericardial sac under pressure. This accumulation results in impairment of venous return and right ventricular filling/emptying. Treatment is directed toward temporary pericardial sac decompression and movement to the operating room for definitive therapy. Tension pneumothorax, associated with increased intrathoracic pressure, likewise results in impaired venous return. Treatment should be urgent chest decompression by needle followed by chest tube. Air embolism results in cardiac dysfunction from the air within the coronary arteries. Treatment should include cross-clamping of the pulmonary hilum, aspiration of the left ventricle, and massaging of the coronary arteries (to milk out any air). Cardiac contusion rarely leads to shock. Treatment includes invasive cardiac monitoring with judicious fluid restoration and appropriate cardiotropic medications.
25. How can I learn proficiency at an initial assessment?
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Take the Advanced Trauma Life Support course promulgated by the American College of Surgeons, which emphasizes the skills of providing a definitive airway, a competent chest tube, and proper IV access.
26. Which diagnostic technique has expedited the localization of major blood loss, assisted in diagnosing pericardial tamponade, and replaced diagnostic peritoneal lavage?
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Ultrasound. This technique is rapid, noninvasive, user-friendly, portable, compact, and reproducible.
27. What does FAST mean with respect to evaluation of the trauma patient?
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Focused assessment for the sonographic examination of the trauma patient. The four areas examined in this sequence are pericardial area, right upper quadrant, left upper quadrant, and the pelvis.
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
