Primary Survey with Simultaneous Resuscitation

Encompasses the ABCDEs of trauma care and identifies/treats life-threatening conditions by adhering to the sequence:

  1. Airway maintenance with Cspine restriction
  2. Breathing and ventilation
  3. Circulation with hemorrhage control
  4. Disability (neurologic status)
  5. Exposure/environmental control

Airway Maintenance with Restriction of Cervical Spine Motion

  1. assess the airway - fractures, FOB, suctioning, injuries and hematomas
  2. can the patient communicate verbally? if yes, then likely airway is fine.
  3. consider placement of definitive airway for GCS ≤8
  4. consider OPA, jaw thrust, chin lift interventions if required
  5. nonpurposeful motor responses suggest the need for definitive airway management
  6. Based on the mechanism of injury, assume a spinal injury exists. Prevent the spine from excessive mobility to prevent development or progression of a deficit.
    1. C-spine: C collar or manual restriction 2.
  7. Continually reassess the airway
  8. Establish a surgical airway if intubation is contraindicated or cannot be accomplished.

Breathing and Ventilation

  1. is the function and structure of the lungs, chest wall, and diaphragm intact?
    1. Jugular venous distension
    2. tracheal position
    3. chest wall excursion
    4. auscultation
    5. visual inspection
  2. rule out tension PTN, massive hemothorax, open PTX, tracheal and bronchial injuries
  3. address these issues as they arise (chest decompression)
  4. every injured patient should receive supp O2 -- mask-reservoir device. Monitor SpO2

Circulation with Hemorrhage Control

  1. Identify, control, and resuscitate hemorrhage. Hypotension is due to blood loss unless proven otherwise (once tension PTX is ruled out)
    1. Markers of poor perfusion: dec LOC, skin perfusion (cap refill), tachycardia, low pulse pressure
  2. Is the bleeding internal or external?
    1. External -- direct pressure if possible, consider tourniquet
    2. Internal -- chest, abdomen, retroperitoneal, pelvis, long bones
      1. Physical examination
      2. FAST
      3. DPL
    3. Chest decompression, pelvic stabilization, extremity splints may be needed
    4. Consider urgent surgical or IR or ortho treatments.
  3. Obtain adequate vascular access. Send for basic studies including G&S, coags, hCG, lactate, cross match
  4. Obtain definitive bleeding control. Continued volume resuscitation is NOT a substitute.
    1. IV fluids should be warmed
  5. Consider rapid transition to a Massive Transfusion Protocol.
  6. Consider giving Tranexamic Acid if presenting within 3 hours of injury.

Disability

  1. Level of consciousness (GCS), pupillary size and reaction, lateralizing signs, spinal cord injury level if present.
  2. LOS
    1. GCS: motor score correlates with outcome.
    2. fix oxygenation issues
    3. check a glucose
    4. consider tox workup
  3. decreased LOC is a brain injury unless proven otherwise.

Exposure and Environmental Control

  1. Completely undress the patient and cut off garments.
  2. Cover the patient with warm blankets or a warming device after completing the assessment.
  3. Avoid hypothermia - this is a potentially lethal combination (lethal triad of trauma). Warm IV fluids. When fluid warmers are not available, a microwave can be used to warm crystalloid fluids, but it should never be used to warm blood products.

Adjuncts

  1. Continuous ECG
  2. Continuous pulse ox
  3. CO2 monitoring and blood gas measurements
  4. Urinary catheter placement
    1. Transurethral bladder catheterization is contraindicated for patients who may have urethral injury. Suspect a urethral injury in the presence of either blood at the urethral meatus or perineal ecchymosis.
    2. When urethral injury is suspected, confirm urethral integrity by performing a retrograde urethrogram before the catheter is inserted.
  5. Gastric catheter - stomach decompression and ?GIB. Avoid NG in ?cribiform plate fractures.
  6. Consider CXR, pelvic XR, FAST, eFAST, DPL, other bloodwork.
    1. The finding of intraabdominal blood indicates the need for surgical intervention in hemodynamically abnormal patients. The presence of blood on FAST or DPL in the hemodynamically stable patient requires the involvement of a surgeon as a change in patient stability may indicate the need for intervention

Consider ?Patient Transfer

  1. Do not delay transfer to perform in-depth diagnostic evaluations