Trauma Resuscitation — Primary Survey: Organized Evaluation — Clinical Pathway: Emergency

Trauma Resuscitation Clinical Pathway — Emergency Department

Primary Survey: Organized Evaluation

Considerations for decontamination: Decontamination Team

Primary Survey Goal: Rapidly identify life-threatening injuries/problems and intervene as indicated

Any unexpected deterioration in ABCDE status requires re-assessment and intervention.

  Exam Example Script Life-Threatening Injuries
Negative/Normal Findings Positive findings
Catastrophic Hemorrhage Identify and control active exsanguination early. Mark each GSW location with paperclip before plain film; call out each wound as marked.
Airway
(with cervical immobilization)
  • Patency: Look, listen
    • Speaking, crying, hoarseness
  • Ability to Protect: Inspect, rule out obstruction
    • Emesis, blood, foreign body
    • Soot in mouth, nose, saliva, facial burns
    • Head, signs of facial fracture
    • Anterior neck injury, neck swelling
  • C-spine
    • Consider unstable until proven otherwise in most patients and immobilize
  • “Airway patent”
  • “C-spine immobilized”
  • “Airway intubated with__ (size tube) at (depth) cm at the lip (or gum)”
  • “Airway obstructed by__”
Breathing
  • Inspect and Auscultate
    • Bilateral breath sounds (listen at bilateral axillae)
    • Chest rise and fall
    • Respiratory rate, WOB
    • Trachea midline, evidence of JVD
    • O2 saturation
    • Monitor ET- CO2 if intubated, BVM ventilation
    • Can also monitor by nasal cannula if desired
  • “Breath sounds and chest wall movement equal”
  • “Trachea midline”
  • “No labored breathing or tachypnea”
  • “Breath sounds decreased on ___ side”
  • “Chest wall movement decreased on ___ side”
  • “Trachea deviated to side”
  • “WOB seen with ___”
    (retractions/abdominal breathing/tachypnea)
  • Tension pneumothorax
  • Suspected pneumothorax
  • Pulmonary contusion
  • Massive hemothorax
Circulation
  • Inspect and Palpate
    • Central pulses-femoral
    • Heart rate, rhythm, BP
    • Capillary refill, skin color, perfusion, temp
    • Active bleeding
    • Other signs of hypoperfusion:
      • AMS, hypoxia, bradypnea
    • Vascular access presence
  • “Normal femoral pulses BL”
  • “Cap refill < 2 seconds”
  • “___ gauge IV in (location)” or “IO in (location)”
  • “Femoral pulses unequal/weak/not palpable”
  • “Tachycardia, bradycardia"
  • “Cap refill > 3 seconds in (location)”
  • “Distal extremities cold/pale”
  • “Continued active bleeding/oozing from ___ (location).”
  • “No vascular access”
  • Hemorrhagic shock
  • Massive hemothorax
  • Cardiac tamponade
  • Blunt trauma
  • Penetrating trauma
  • Pelvic fracture
  • Long bone fracture
  • Vascular injury
Disability
  • Assess consciousness and cognitive ability
  • Inspect
    • Pupillary size, response
    • Lateralizing signs
  • Bedside glucose check as indicated
  • Consider toxins, drugs
  • “Pt is alert”
  • “GCS 15”
  • “Pupils equal and reactive _cm to _cm bilaterally”
  • “Pt moving all 4 extremities equally”
  • “Mental status depressed –
    • Patient responds to pain or
    • Patient unresponsive”
  • “GCS of ___ with points taken off for ___”
  • “Pupils unequal: ___ on right, ___ on left”
  • “Pupils fixed and dilated”
  • “Pupils _cm and unreactive”
  • “Pt not moving ___ (extremity)” or “Pt appears weak in __ (extremity)”
  • Severe traumatic brain injury
  • Intracranial injury
  • Spinal shock
Exposure
  • Inspect for concealed injury
    • Fully remove clothing
    • Temperature (avoid hypothermia)
    • Chemical injury, decontamination
  • “Normothermic”
  • “Deformity ___ tibia, no pulse”
  • Concern for toxins
  • Hypothermia
Log Roll
  • Perform immediately after Primary Survey
  • Inspect, palpate
    • C/T/L spine tenderness, step-off
    • Wounds (posterior, axillary)
    • Perineum, anus
      • Digital rectal exam for SC injury only
  • “No cervical spine tenderness”
  • “No tenderness to cervical, thoracic, lumbar spine”
  • “No step off, contusions, abrasions along spine”
  • “Bilateral axilla clear, perineum clear”
  • “Midline tenderness ___ (level) to ___ (level)”
  • “Blood at penile urethral meatus/perineum”
  • Spinal cord injury
Re-evaluate as indicated after each resuscitative intervention