aka Trauma Tribulation 014 Your trauma patient from Trauma Tribulation 013 has arrived… A trauma call was activated and the team assembled. The patient was transferred onto a bed in the trauma bay, and removed from a spinal board used fro transfer. Handover and vital signs are being obtained as the trauma team get to work. As the Trauma Team Leader, you’re going to need to know your stuff to be able to coordinate the team’s initial assessment and management of this trauma patient. QuestionsQ1. What are the 5 key components of the primary survey in major trauma? Answer and interpretation
ATLS (8th edition) emphasizes the ABCDE approach:
This assessment can usually be performed in less than 10 seconds. Handy tips:
Q2. What does airway maintenance with cervical spine control involve? Answer and interpretation
Airway assessment and maintenance:
Consider the need for a definitive airway, which may be required for A, B C or D reasons:
Intubation may also be advisable prior to invasive procedures (e.g. chest tube insertion) or patient transfer. All ED intubations should be regarded as difficult airways and every operator should have a ‘plan B’ prior to commencing. Surgical airways (e.g. cricothyrotmy) are required in the ‘can’t intubate, can’t ventilate scenario’. Patients that require urgent, but not emergent intubation (e.g. facial burns) may be best intubated by awake fiberoptic intubation with anesthesia and ENT in attendance.To learn more about airway management, check out the videos at Own the Airway! Major trauma patients should be suspected of having cervical spine injuries. Until the cervical spine is cleared, spinal precautions should be employed.
Appropriate cervical spine precautions is an evolving area of controversy… Q3. What does assessment and management of breathing and ventilation involve? Answer and interpretation
Assessment
Management
Handy tip
Q4. What does assessment and management of circulation with haemorrhage control involve? Answer and interpretation
Assessment
Management
To learn about the cutting edge approach to damage control resuscitation list to EMCrit Podcast 12 — Trauma Resus Part 1 and EMCrit Podcast 13 — Trauma Resus Part II: Massive Transfusion. Q5. What does disability (neurological evaluation) involve? Answer and interpretation
Assessment
Management
Q6. What does exposure and environmental control involve? Answer and interpretation
Exposure and environmental control:
Think before cutting of the patient’s clothes — it is not mandatory! Q7. What should be examined for in the neck of a trauma patient? Answer and interpretation
Look for TWELVE things (OK, there’s only six, so check them twice…):
These findings suggest life-threatening injuries to the neck or thorax (e.g. tension pneumothorax, cardiac tamponade). I like to look for these when I’m the airway doctor as part of an assessment of A and B. I’ve specifically stressed the importance of examining the neck because it is easily forgotten when hidden by a hard collar…Also, don’t forget to check for a Horner syndrome in possible neck trauma! Q8. What does the secondary survey involve? Answer and interpretation
The secondary survey is carried out after the primary survey and immediate management of potential life threats in a stable patient to identify the presence of other injuries missed in the focused primary survey. It involves a systematic ‘top-to-toe’ examination, including:
Q9. What are the key aspects of history required for assessment of trauma patients and how can they be obtained? Answer and interpretation
Around the time of the secondary survey clarification of the history is important to ensure that no injuries, or relevant comorbidities, are missed. More details can be obtained by
A useful mnemonic to guide information is the ‘AMPLE’ history:
Q10. What is the tertiary survey and what does it involve? Answer and interpretation
The tertiary survey is a repetition of the secondary survey that again aims to pick up ‘missed’ injuries. This may occur on multiple occasions over the days following injury. The multiply injured motorcyclist’s broken pinkie can be easy to miss during initial assessment! Q11. What is the appropriate disposition of a major trauma patient? Answer and interpretation
It depends on your location and the nature of the patient’s injuries. In a trauma center, major trauma patients are usually admitted under the Trauma Surgery team. The patient may go straight to the operating theatre for surgical management, or be conservatively managed in an ICU/HDU setting or be observed on the ward pending a tertiary survey. Major trauma patients, particularly in a country as large as Australia, are often first assessed and managed in smaller centres. As a result disposition can be a critical aspect of the patient’s care as delays to definitive care are associated with increased mortality. The transfer process should be commenced as soon as it becomes clear that injuries are beyond facilities capabilities.Efforts to further assess or stabilise the patient should not delay transfer. To optimize the care of major trauma patients in non-trauma centers systems should be in place locally to make the transfer process as quick and easy for the referring hospital. A dedicated member of staff may need to concentrate on the transfer process while others continue to assess and manage the patient. Teaching VIDEO from OME
This teaching video shows the stages of initial trauma assessment in an OSCE style format. The video is useful for demonstrating a traditional, comprehensive systematic approach. Note that in reality, many of the steps will occur simultaneously and be performed by multiple different team members. Some of the examinations performed (such as chest percussion) are not particularly useful are are rarely performed in practice.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education. He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference. His one great achievement is being the father of three amazing children. On Twitter, he is @precordialthump. | INTENSIVE | RAGE | Resuscitology | SMACC |