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The primary surveyThe purpose of the primary survey is to rapidly identify and manage impending or actual life threats to the patient. IntroductionAlways assume all major trauma patients have an injured spine and maintain spinal immobilisation until spine is cleared. Priorities are the assessment and management of:
Prior to arrival:
On arrival:
Airway and the cervical spineThe life threat to identify and manage when assessing the Airway is airway obstruction This is typically the responsibility of the "Airway Doctor" although it is a role which may be shared with the "Assessment Doctor". The Airway Doctor is typically responsible for assessing the airway, the anterior neck and the GCS. Their goal is to ensure and maintain a patent airway, through which the patient can be successfully oxygenated. When assessing the airway. The airway doctor should start with assessing for:
Where the patient has suffered a burn, the airway doctor should look in particular for:
A complete airway assessment also requires an assessment of the anterior neck - looking in particular for signs of blunt or penetrating trauma, or an impending airway life threat. This requires the airway doctor to open the C-spine collar whilst an assistant maintains manual in-line stabilization of the cervical spine. The Airway doctor should then examine the anterior neck to look / feel for the following (TWELVE-C):
The airway doctor also needs to assess the GCS The life threat to identify when assessing the Airway is airway obstruction. Causes of airway obstruction may be due to:
The management of airway obstruction is to ensure a patent airway through which the patient can effectively be oxygenated. This may require some or all of the following techniques:
The cervical spine should be protected by manual in-line stabilisation, followed by the rapid (gentle) application of a properly fitted hard collar. (see cervical spine assessment clinical practice guideline) BreathingThe life threats to identify and manage with regards to breathing include:
The assessment of breathing, in the spontaneously ventilating child, is the responsibility of the assessment doctor. Where a child requires positive pressure ventilation (either bag-valve-mask ventilation, or intubated) there will be a shared responsibility for the assessment of breathing by the airway and the assessment doctors. At the start of the assessment, ensure all patients who are spontaneously breathing have high flow oxygen applied – typically 10-15L O2 via a non-rebreather mask. The child’s breathing is then assessed by looking at:
Assessment of the thoracic cage requires feeling for:
Assessment also requires listening for:
The life threats to identify with regards to breathing include:
The management of these life threats is typically carried out by the procedure doctor under direction from the Team Leader. Once a life threat has been identified, the assessment doctor should communicate this to the Team Leader, and then continue on with the primary survey allowing the procedure doctor to carry out any interventions. Typical interventions include:
Intubated children may also benefit from the early insertion of a large oro-gastric tube to treat and prevent gastric dilatation which in infants and young children especially, can impair effective ventilation. CirculationThe major life threat to identify and manage with regards to circulation is haemorrhagic shock. However, obstructive shock does also occur, and causes for this should also be actively sought and managed. The assessment of the circulation is the responsibility of the “Assessment” Doctor. They should assess the child’s circulatory state by:
It is useful for the assessment doctor to calling out the patients vital signs at this stage of the assessment - so the team is aware of them. The assessment doctor should continue with a focused assessment that involves looking for sites of potential bleeding. These include the following sites:
The assessment doctor should, in consultation with the Trauma Team Leader, consider the need for a pelvic x-ray (see also Pelvic Injury CPG). The major life threat to identify with regards to circulation is haemorrhagic shock However, care should be taken to actively look and exclude:
The management of haemorrhagic shock is to identify and stop the source(s) of bleeding whilst concurrently resuscitating the patient. The management of these life threats may need multiple team members and is co-ordinated by the Trauma Team Leader. Once the assessment doctor has identified these life threats, they must communicate their findings to the Trauma Team Leader, then continue with the primary survey. The management of haemorrhagic shock may include:
Assess the child's circulatory state by observing:
Disability (mental state)The life threat to identify is traumatic brain injury The assessment of 'Disability' is typically the responsibility of the airway doctor - although the assessment doctor may add and complement to this by assessing peripheral function. Initial assessment of the level of consciousness may be done using the AVPU assessment:
Any impairment on detected on the AVPU scale should prompt a formal assessment of the patient’s GCS (link to GCS-level of consciousness in Head Injury CPG). Pupil response to light should be noted, as should movement in all four limbs. The assessment doctor should check for this as well as reflexes if the prior to intubation where possible. The blood glucose level should be measured on arrival and periodically during the management of the trauma patient. The life threat to identify is traumatic brain injury - whilst the primary brain injury cannot be reversed, secondary brain injury can be minimised by the prevention of hypoxia/hypotension and instigation of neuroprotective strategies to minimise intracranial pressure, along with the expedited progress of the patient to CT imaging of the brain, and then to a site capable of any necessary neurosurgical intervention. Exposure and environmental controlRemove clothing initially and look for any other obvious life threatening injury. Avoid hypothermia by limiting exposure of the body, and by warming all ongoing fluids. Radiology
References
-Trauma (Major) Secondary surveyIntroductionThe secondary survey is commenced after the primary survey has been completed, immediate life threats identified and managed, and the child is stable. Continue to monitor the child’s:
Any unexpected deterioration in these parameters require reassessment and management of evolving life threats. Preparation:Before commencing the examination:
Performing the examination:Head and faceInspect the face and scalp. Look for:
Look specifically at the:
Palpate the:
Test eye movements, pupillary reflexes, vision and hearing NeckInspect the neck - it is necessary to open the collar to do this - whilst maintaining manual in-line stabilisation of the neck. Examine the anterior neck (as per the primary survey) checking for:
Asses the c-spine by palpation of the cervical vertebrae (see Cervical spine assessment CPG) ChestInspect the chest, observe the chest movements. Look in particular for:
Palpate for clavicular and rib tenderness and auscultate the lung fields and heart sounds. Abdomen Inspect the abdomen, the perineum and external genitalia. Look for in particular for:
Palpate for areas of tenderness especially over the liver, spleen, kidneys and bladder, and auscultate bowel sounds. Pelvis Inspect the pelvis for grazes over the iliac crest. Examine for bruising, deformity, pain or crepitus on movement. Limbs Inspect all the limbs and joints, palpate for bony and soft tissue tenderness and check joint movements, stability and muscular power. Examine sensory and motor function of any nerve roots or peripheral nerves that may have been injured. BackA log roll should be performed either in the primary survey or in the secondary survey.
Urinalysis Interpretation of the urine dipstick in blunt paediatric trauma suffers from high rates of false positive and false negative results – formal microscopy is the better test where renal injury is suspected. Disposition planning During the examination, any injuries detected should be accurately documented, and any urgent treatment required should occur, such as covering wounds and splinting fractures. Appropriate analgesia, antibiotics or tetanus immunisation should be ordered. Following the secondary survey, the priorities for further investigation and treatment may now be considered and a plan for definitive care established. At this stage the patient may require advanced imaging in CT, or transfer to the ward, intensive care or theatre. Typically the trauma team leader will remain responsible for the patient until they have completed their imaging and arrived at their inpatient destination. Handover of care may occur sooner than this – for example if the anaesthetist is present in the ED and will accompany the patient to theatre or intensive care. On these occasions formal handover where the new team leader and team acknowledge that responsibility for the patient has been transferred. A departure checklist made aid in this process. References
-Trauma (Major) When performing a primary assessment how should you check the person's circulation?(3) Circulation: Check for a carotid pulse. This pulse check should not take more than 5-10 seconds. If no pulse is palpable begin CPR. (4) Defibrillation: If there is no pulse, check for a shockable rhythm with the AED or defibrillator as soon as it arrives.
What should you check for during a primary assessment?Primary survey:. Check for Danger.. Check for a Response.. Open Airway.. Check Breathing.. Check Circulation.. Treat the steps as needed.. How long do you check for a pulse and breathing during the primary assessment?If no signs of life such as breathing (or only gasping breathing) are found, check the pulse. If patient is alert and talking clearly or crying loudly then the airway is open. If airway is not open or is endangered, take measures to open. Check the pulse for no longer than 10 seconds.
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