What is the initial priority during the primary assessment of the patient experiencing trauma?

Trauma Room (Crisis Resource Management – Brindley, Cardinal)

Background: Addressing traumatic injuries is a major component of Emergency Medicine (EM) practice. Providers are asked to quickly evaluate these patients, address major life threats, and make a full inventory of injuries. Having a systematic approach is essential to a rapid assessment that minimizes the chance of missing injuries. This post will outline a step-by-step approach to evaluation.

Pre-Arrival

• All providers should don appropriate personal protective equipment including gowns, gloves, facemasks, and face-shields
• If patients are coming in by Emergency Medical Services (EMS), the pre-hospital team will often call ahead with vital signs and information about mechanism of injury
  • Mechanism of injury guides evaluation and raises or lowers probability of certain injuries
    • Majority of presentations categorized as blunt versus penetrating trauma
    • Specific mechanistic considerations include speed of collisions, damage to vehicles, presence of blood at the scene, and other victims or fatalities
    • Use this information to prepare for anticipated interventions
  • Field vital signs can be used to anticipate potential injuries and prepare interventions
• Patients are usually triaged based on mechanism of injury or physiologic criteria
  • Specific criteria will trigger activation of a trauma team and route patient to resuscitation area
  • Most trauma centers have two tiers of activation (eg. level I and level II)
  • Multiple providers often respond, including nurses, EM physicians, and trauma surgeons based on level of activation

Trauma Resuscitation (http://www.lasvegasemr.com/)

Arrival

• Most important first step in major trauma (eg. Level I or II) is completion of EMS hand-off
  • Give the pre-hospital team silence in the room to give report before beginning patient assessment
  • Immediate life threats (agonal respirations, risk of exsanguination) will require immediate management and are often identified by the pre-hospital team

Primary Survey

• Goal is to find and address immediate life threats
• Typical approach is ABCDE mnemonic, standing for airway, breathing, circulation, disability, and exposure
• Although often taught as dictating priority or order of assessment (eg. airway before circulation), all components should be assessed in parallel

Airway

• Look externally for potential obstructions like facial injuries, blood, or vomit
• Have the patient say their name, listening for any gargling or noisy breathing
• Quickly assess mental status and determine whether they are able to clear secretions and keep their tongue from obstructing the airway

Breathing

• Inspect and palpate chest wall for injury. Look at the position of the trachea and for JVD. Inspect work of breathing
  • Visualization of the neck will require temporary removal of the C-collar
• Listen for breath sounds bilaterally
• Assess the patient’s O2 saturation as a marker of oxygenation. Attach EtCO2 or observe respirations to assess ventilation

EFAST in Trauma (Army.mil)

Circulation

• Look for any major sources of external bleeding. Assess for internal bleeding with rapid physical exam
  • Often augmented by an Extended Focused Assessment with Sonography in Trauma (E-FAST)
  • 5 major locations patients can exsanguinate
    • Chest
    • Abdomen/pelvis
    • Retroperitoneum
    • Long bone (eg. femur)
    • Street (externally)
  • Pediatric patients can bleed out from head injuries due to lower blood volume (scalp lacerations or, rarely, intracranial hemorrhage)
• In blunt trauma, the presence of any vital sign abnormalities may prompt empiric placement of a pelvic binder
• Check the patient’s blood pressure
• Palpate radial and dorsalis pedis pulses bilaterally
  • Assess for presence, quality, and rate
  • Presence of pulses in particular anatomic locations were previously used as markers of a certain BP, however this has found to be inaccurate (Deakin 2000, Poulton 1988)

Disability

• Examine the pupils
• Calculate the Glasgow coma scale (GCS)
• Look for movement of all extremities

Exposure

• Remove all clothing from the patient
• Re-cover the patient with warm blankets
• Log roll to assess for injuries in the back

Secondary Survey

• Divided into focused AMPLE history and head to toe physical exam
• May be abbreviated in unstable patients as they progress to surgery, imaging, or interventional radiology

AMPLE History

• If patient is unable to provide history, try to obtain information from pre-hosptial team, family members or witnesses
• AMPLE mnemonic is often used
  • Allergies
  • Medications
    • Ask specifically about anticoagulants
  • Past medical history
  • Last meal
  • Events/Environment
    • Obtain a clear history of the events leading up to and after the injury
    • Ask in general about injuries sustained and specifically about head injures
      • If there is concern for a head injury, ask about loss of consciousness and vomiting

Physical Exam

• HEENT
  • Examine the scalp for bleeding
  • Palpate the scalp, face and jaw for tenderness
  • Examine the pupils again for size and reactivity
  • Examine the ears for hemotympanum
  • Examine the nose for septal hematoma
  • Examine the oral cavity for injuries or broken teeth
    • Ask the patient to close their mouth and ask if teeth alignment feels normal
• C-Spine
  • If your patient is in a C-collar, have an assistant maintain spinal precautions while you remove the collar
    • Note that patients with penetrating trauma should not be placed in C-collars due to increased mortality (Oteir 2015)
  • Palpate the cervical spinous processes for tenderness
    • Midline tenderness is concerning for spine injury and should prompt consideration of cervical spine imaging
    • Be specific with location tenderness
• Thorax
  • Feel the shoulder girdle for instability or fractures
  • Check the ribs for tenderness or instability
  • Recheck lung sounds and perform a cardiovascular exam

• 

  Seat Belt Sign (regionstraumapro.com)

  Abdomen/Pelvis

  • Examine the abdomen for bruising
  • Palpate for tenderness, guarding and rebound
  • Avoid rocking pelvis
    • If examining for stability, press inward to avoid further injury
  • Any suspicion for pelvic injury should dictate placement of a pelvic binder and further manipulation should be minimized (manipulation can lead to worsening of injuries and additional blood loss)
• Extremities
  • Check all extremities for strength, sensation, and presence of a pulse
  • Range the joints
  • Palpate for tenderness and deformity
• Back
  • Roll the patient with assistance, maintaining spinal precautions if necessary
  • Palpate the spinous processes for tenderness or step-offs
  • Digital rectal exam
    • Historically included as part of assessment
    • Recent literature has questioned the necessity of this practice (Esposito 2005)
    • ATLS now recommends DRE as a selective intervention before inserting a urinary catheter (Kortbeek 2008)
    • Motor function of L5-S2 can be assessed by asking the patient to flex their gluteal muscles (“squeeze your butt-cheeks”)

Take Home Points

• Development of a systematic approach is essential to rapidly assessing the wide diversity of trauma patients and minimizes missed injures
• Prepare with whatever information is available before the patient arrives and remember to get a good handoff from the pre-hospital team
• Complete the primary survey (ABCDEs) and address immediate life threats
• Obtain a good medical history and remember to complete a comprehensive head-to-toe exam

References

Deakin CD, Low JL. Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study. BMJ. 2000;321(7262):673-4. PMID: 10987771

Poulton TJ. ATLS paradigm fails. Ann Emerg Med. 1988;17(1):107. PMID: 3337405

Oteir AO, et al. Should suspected cervical spinal cord injury be immobilised?: a systematic review. Injury. 2015;46(4):528-35. PMID: 25624270

Esposito TJ, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma. 2005;59(6):1314-9. PMID: 16394903

Kortbeek JB, et al. Advanced trauma life support, 8th edition, the evidence for change. J Trauma. 2008 Jun;64(6):1638-50. PMID: 18545134

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