Primary Survey

Disability

-Conduct a brief neurologic examination as part of the primary survey. -The patient's level of consciousness is a measure of the degree of disability. Determine the patient's response to verbal and/or painful stimuli to assess level of consciousness. -A simple mnemonic to remember is AVPU: A = alert V = responsive to voice P = responsive to pain U = unresponsive. -In addition, use the Glasgow Coma Scale (GCS) to determine the level of consciousness. Finally, assess the pupils for size, shape, equality, and reactivity.

Fluid of choice

-Crystalloids are administered, Warmed lactated ringers -Normal saline may be used but it may raise chloride level of patient and may lead to acidosis secondary to bicarb loss -D5W is contraindicated because it would dilute sodium (SHOULD BE AVOIDED IN ALL TRAUMA PATIENTS) -Colloid classification may be administered later, used with two large bore IV for volume infusion, 16 g or higher -After 2 L of fluid, then blood administration is done -Failure to respond means a surgical intervention is required

Signs and symptoms of Cardiac Tamponade

-Hypotension, Muffled heart tones due to fluid increase in CVP and JVD

E= Exposure or Environmental Control

-Remove all trauma patients' clothing to perform a thorough physical assessment. -This often requires cutting off the patient's clothing. Be careful not to cut through any area that may provide forensic evidence (e.g., bullet hole). -Once the patient is exposed, use warming blankets, overhead warmers, and warmed IV fluids to limit heat loss, *prevent hypothermia, and maintain privacy. -Hypothermia complications associated with coagulopathies, decrease cardiac output, and myocardial dysfunction -***Pay attention to heat conservation measures MUST PREVENT HYPOTHERMIA

Ineffective circulation Signs and Symptoms

-Tachycardia -Problems with level of consciousness -Uncontrolled bleeding -Distended JVD -Pale, cool, diaphoretic skin -Distant heart sounds -Often the cause is fluid volume deficit -Hypovolemia, and cardiac tamponade

Primary Survey

-focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started -You may identify life-threatening conditions related to ABCs at any point during the primary survey. When this occurs, start interventions immediately, before moving to the next step of the survey.

Disability Glascow Coma Scale

After ABC's are assessed, do quick neuro assessment

Primary Survey Disability Assessment

Brief Neurologic Assessment: -Establish Baseline • Assess level of consciousness by determining response to verbal and/or painful stimuli (e.g., AVPU, Glasgow Coma Scale). • Assess pupils for size, shape, equality, and reactivity. Identify Deformities: • Inspect extremities for any obvious deformities. • Determine range of movement and strength in extremities Brief Pain Assessment: • Assess pain (e.g., PQRST [see Table 34-7]). Exposure and Environmental Control: • Assess full body for additional or related injuries

Hemorrhagic Shock

Is the most common form of shock in trauma patients

Recognition of source of blood loss

is critical. Areas of large blood loss to produce a shock state are the chest, abdomen, pelvis, retroperitoneum -If a patient has central pulses such as carotid and femoral, are palpated first If the patient exhibits these pulses, then the systolic BP is usually atleast 60 to 80 mmHg -If patient has more peripheral pulses, then systolic BP is usually higher than 80 mmHg -If NO CIRCULATION, must START CPR

Primary Survey Airway Assessment

• Assess for respiratory distress. • Assess airway for patency. • Check for loose teeth or foreign bodies. • Assess for bleeding, vomitus, or edema.

Primary Survey Breathing Assessment

• Assess ventilation. • Scan chest for signs of breathing. • Look for paradoxic movement of the chest wall during inspiration and expiration. • Note use of accessory muscles or abdominal muscles. • Observe and count respiratory rate. • Note color of nail beds, mucous membranes, skin. • Auscultate lungs. • Assess for jugular venous distention and position of trachea.

Primary Survey Circulation Assessment

• Check carotid or femoral pulse. • Palpate pulse for quality and rate. • Assess skin color, temperature, and moisture. • Check capillary refill. • Assess for external bleeding. • Measure blood pressure. -Identify hypovolemia

Primary Survey Breathing Intervention

• Give supplemental O2 via appropriate delivery system (e.g., non-rebreather mask). • Ventilate with bag-valve-mask with 100% O2 if respirations are inadequate or absent. • Prepare to intubate if severe respiratory distress (e.g., agonal breaths) or arrest. • Have suction available. • If absent breath sounds, prepare for needle thoracostomy and chest tube insertion.

Primary Survey Circulation Intervention

• If absent pulse, initiate cardiopulmonary resuscitation and advanced life-support measures. • If shock symptoms or hypotensive, start two large-bore (14- to 16-gauge) IVs and initiate infusions of normal saline or lactated Ringer's solution. • Control bleeding with direct pressure and pressure dressings, if appropriate. • Administer blood products if ordered. • Consider autotransfusion if isolated chest trauma. • Consider use of a pneumatic antishock garment or pelvic splint in the presence of pelvic fracture with hypotension. • Obtain blood samples for type and crossmatch.

Primary Survey Airway Intervention

• Open airway. • Use jaw-thrust maneuver. • Remove or suction any foreign bodies. • Insert oropharyngeal or nasopharyngeal airway, endotracheal tube, cricothyroidotomy. • Immobilize cervical spine using rigid cervical collar and cervical immobilization device. Secure forehead to backboard.

Primary Survey Diability Intervention

• Periodically reassess level of consciousness, mental status, pupil size and reactivity. • Immobilize (e.g., splint) any obvious deformities. • Periodically reassess pain using standardized pain scale. • Remove clothing for adequate examination. • Keep patient warm with blankets, warmed IV fluids, overhead lights to prevent heat loss, if appropriate. • Maintain privacy. -**If there is a priority assessment/intervention question it is always AIRWAY. "Disability" will always be last choice