START: C-spine protection, 15L NRBmask, monitor (RR, p, sat), venous access

Situation: description of trauma mechanism and environment

AVPU: Alert, Voice, Pain, Unresponsive

 

Airway                                                                                                      

 

LOOK

–          Behaviour: agitation (hypoxia/hypercapnia)

–          Obstruction: foreign body, blood/mucus (suction),  hematoma neck, carbon/burns

LISTEN

–          Breathing sounds, stridor, hoarseness

FEEL

–          Trachea deviation

–          Subcutaneous emphysema

–          Jaw and larynx fractures

DO

–          Protect airway (jaw trust, chin lift, mayo-tube, endotracheal intubation, cricothyroidostomy)

 

Breathing                                                                                                   

 

LOOK

–          Expose chest: open pneumothorax, risk for contusion/fractures

–          Breathing: accessory muscle use, abdominal breathing, symmetrical

–          Breathing efficiency:  tachypnea, insufficient breathing, cyanosis

–          Asymmetrical excursions

 

LISTEN/FEEL

–          Equal breathing excursions (flail thorax, rib fractures, pneumothorax, pain)

–          Hyperresonance or dullness percussion

–          Equal breath sounds (pneumothorax, hemothorax, contusion crepitations)

DO

–          Oxygenate (15L NRB)

–          Bag-mask ventilation

–          Thorax drain (if necessary after immediate needle decompression)

 

Circulation                                                                                                 

 

LOOK

–          Hemorrhage (external, thorax, abdomen, retroperitoneum, pelvis, long bones)

–          Normotensive, normocard, warm, normal diuresis, awake

–          Shock (hypotension, tachycardia, cold extremities, oliguria, confused)

–          Central venous pressure ( cardiac tamponade )

 

DO

–          Stop external blood loss, compress pelvic fracture

–          Venous entrance, take blood

–          2-4L NaCl warm, 3:1 rule, after 5PC 2FFP, and follow 1:1

–          US FAST à prepare for laparotomy if indicated

–          RT before CAD placement

 

Disability                                                                                                   

 

Pupil response

–          PEARL: Pupils Equal And Reactive to Light, size

 

Glasgow coma scale

E             4             closed – pain – request – spontaneously

M           6             none – extension – flection – withdrawl – localize – commands

V             5             none – sounds – inadequate – confused – orientated

 

DO

–          Prevent hypocapnia (cerebral vasoconstriction) eg prevent hyperventilation

–          Treat cause first (hypotension before trauma capitis)

–          EMV<8 endotracheal intubation

–          Maintain MBP >90mmHg for cerebral perfusion

–          Convulsion: diazepam

 

Exposure                                                                                                        

–          Head to toe examination (undress fully, prevent hypothermia)

 

 

Additional                                                                                                 

–          Additional examination: Blood, ABG, temperature, glucose, ECG, catheters, echo cor, CO2

–          Insert urinary and gastric catheters unless contraindicated, monitor urine output

–          Chest and pelvic x-rays

–          Indication FAST (Focused Assessment with Sonography in Trauma)

–          Reassessment and consider need for transfer

 

 

 

 

Secondary survey                                                                                         

AMPLE

–          Allergies

–          Medication

–          Past illnesses/pregnancy

–          Last meal

–          Event/environment related to injury

 

Obtain history of injury producing event and mechanisms

 

Head to toe examination

–          Head and face:

• Inspect and palpate for: lacerations, contusions, evidence of fractures
• Reevaluate pupils
• Reevaluate level of consciousness/EMV
• Eyes: hemorrhage, penetrating injury, visual acuity, lens dislocation, presence of contact lenses
• Cranial nerve function (ocular movements, tongue, facial nerves,
• Nose and ears for CSF leakage
• Mouth for bleeding, CSF leakage, lacerations, lose teeth

–          Spine and neck:

• Signs of trauma, tracheal deviation, use of accessory muscles
• Palpate for tenderness, deformity, swelling, emphysema, deviation, symmetry of pulse, laryngeal fracture.
• Auscultate carotid arteries
• Obtain x-CWK or CT

–          Chest:

• Inspect: movements, wounds, contusions, fractures
• Auscultate for breath sounds and heart sounds
• Palpate for injury, emphysema, tenderness, crepitation
• Percuss for dullness or hyper resonance

–          Abdomen:

• Inspect for signs of injury and bleeding
• Auscultate for presence of bowel sounds
• Percuss for subtle rebound tenderness
• Palpate for tenderness, muscle guarding, rebound tenderness, gravid uterus
• Obtain pelvic x-ray and fixate if necessary
• Preform FAST or DPL if warranted
• Obtain CT if stable and if necessary
• Frequent reevaluation

–          Perineum/rectum/vagina: hematomas, lacerations, urethral blood, high prostate, sphincter tone

–          Extremities and back

• Inspect for injury, contusions, lacerations, deformity
• Palpate for tenderness, crepitation, abnormal movement, sensation
• Peripheral pulses
• Assess pelvis and pelvic x-ray
• Inspect and palpate thoracic and lumbar spine for injury, contusions, lacerations, tenderness, deformity, sensation, risk of compartment syndrome
• Obtain x-ray films of suspected sites
• Complete neurovascular examination of extremities
• Obtain x-ray films if suspected

Neurological examination

–          Pupils and EMV

–          Motor and sensory functions

–          Lateralizing signs

 

Additional radiology examinations

–          CWK

–          Odontoid (jaw)

–          TWK/LWK

–          Extremities/face on indication

–          FAST abdominal US

–          CT cerebrum, th/abd, CWK

–          Angiography

–          Contrast urography

–          Transesophageal ultrasound

–          Bronchoscopy

–          Esophagoscopy

 

Addional treatment

–          Administer tetanus immunization if indicated

–          Administer medications as indicated or directed by specialist

–          Consider possibility of compartment syndrome

Courtesy of Sandra Vennix