Assessing trauma — primary and secondary survey

 

Life-threatening injuries are more likely if

  • Bad car crash — roll over, thrown from car, car badly damaged, someone killed or car going more than 60km/hr
  • Motorcyclist
  • Pedestrian hit by a vehicle
  • Fall from more than 1m OR fall from horse, ladder, bicycle
  • Explosion
  • Pulse more than 100/min or less than 50/min (adult)
  • More than 1 fractured bone, especially femur or humerus
  • Coma scale score less than 14

Signs of shock

  • Increased RR
  • Pulse weak and fast or difficult to feel (adult more than 100bpm, child. Older people with heart problems may not get fast pulse)
  • Central capillary refill longer than 2 seconds
  • Pale, cool, moist skin
  • Restless, confused, drowsy, occasionally unconscious
  • Low BP  for age or relative to person's previously recorded values

Multiple casualty events

  • If more than one of you — decide who is in charge (the leader) before you arrive at scene
  • Stop before entering the scene
  • Get an overview — what happened, where are the victims, safe access, what could happen next
  • Call for help — what resources are required
  • Identify dangers
  • Mitigate risks to prevent more accidents or trauma and keep you safe
  • Take charge and identify possible assistants
  • Identify line of approach — where to start, which way to walk through and where to finish
  • Multiple casualty triage (help the most with what you have — may mean not helping the most injured to save the most lives). Allocate jobs if helpers, keep moving
    • Immediate need — bleeding and breathing difficulties, primary survey
    • Impending deterioration
    • Walking wounded and uninjured
    • Deceased — including those who cannot maintain an airway in coma position
  • If no evidence of trauma — see  Life support — DRS ABC
  • Task an assistant to care for walking wounded and nominate a safe place for them — shelter, out of harm’s way, good access
  • When able to do so have another careful sweep to find concealed victims
  • Participate in a debrief when appropriate

Trauma assessment has 2 main parts 

Primary survey — rapid examination to find and start managing life-threatening injuries

  • Look for most life-threatening injuries first
  • Keep rechecking person’s condition as you go through examination

Secondary survey — do after life-threatening problems dealt with

  • If they get worse — go back to ABC D

Primary survey — using DRS ABC DE

D – Danger — make sure scene is safe

Medical consult  — let doctor know you are responding to a potentially serious situation and will update them. Make sure they know where you are going and what communication options you are likely to have on scene

  • To prevent more accidents and keep you safe
    • Park your vehicle safely, put on fluoro vest or jacket and PPE
    • If on road — have someone manage traffic and crowd, put out hazard signs
    • Check for dangers — alcohol-fueled mob, car engine running, leaking petrol/chemicals/battery and anyone smoking, electricity cables, undeployed airbags

Scene survey — consider mechanism of injury

  • What happened
  • If vehicles involved 
    • How many, what state are they in — accidents at high speeds (over 60km) usually cause more serious injuries
    • Any casualties outside vehicles — thrown from vehicle or taken out, pedestrians
    • If deceased person — may be other people with serious injuries
  • If drowning victim — risk of hypothermia, remove wet clothing, dry and warm person as soon as possible — do not delay CPR if needed
    • Hypothermia may mask signs of life. If this a possibility — continue CPR

R – Response

  • Your response to scene (eg multiple casualty or single person incident)
  • Person's response to you

S – Send for help

  • If you need help — send for it straight away
  • Medical consult early — let doctor know you are responding to a potentially serious situation
  • If doctor on standby — call as soon as you arrive. Talk with them as much as you can

Start with person with most life-threatening injury in most circumstances

A – Airway and cervical spine

  • Airway most important but try to protect cervical spine. Use manual in-line immobilisation until able to apply alternative methods in accordance with local protocols (eg foam collar and light weight bolsters)
  • Risk of spinal injury — diving injury, dumped in heavy surf, life threatening injury mechanism — see Immobilising the spine
  • If only one or two rescuers use modified HAINES technique to roll person
  • Check for face, jaw and neck injuries that may cause blocked airway

If unconscious or having trouble breathing

Open airway

  • Adult or child
    • Do not tilt head backward. May be neck injuries
    • Use head tilt/chin lift. Place one hand on the forehead. The other hand is used to provide chin lift. The head (not the neck) is tilted backwards. Grip chin and gently lift it up — Figure 3.1
    • OR jaw thrust. Hold jaw at point under ears, push upward and forward until chin juts out and airway opens — Figure 3.2

Figure 3.1  

Figure 3.2  
  • Infant (under 1 year)
    • Put folded towel or nappy under shoulders and back — Figure 3.3

Figure 3.3  

   

Clear airway

  • Remove visible solid material using 2 ‘hooked’ fingers in downward sweeping motion
  • For liquid (blood, vomit, water) use suction if available OR log-roll  OR HAINES roll onto side, open mouth, turn downward to allow to drain using gravity
  • If unconscious after drowning — expect vomit. Put in recovery position to clear airway — Figure 3.4
  • To keep airway open, may need nasopharyngeal airway or oropharyngeal airway — Figure 3.5

Figure 3.4  

Figure 3.5  

If airway still not open

If airway open 

  • If not breathing — go straight to B – breathing 
  • If person starts to vomit — log-roll into recovery position — Figure 3.4
  • If breathing and no other obvious life-threatening problems — immobilise cervical spine in accordance with local protocols 

If talking OK and breathing normally and if conscious and cooperative 

    • If you can, kneel down with knees gently but firmly bracing either side of head — Figure 3.6. Protects spine by stopping them moving head and neck when you talk to them
    • Tell person to keep their head still — not to move or shake head to say ‘yes’ or ‘no’ to your questions
    • Check if person knows you are there — call to them, ask their name

Figure 3.6  

 

B – Breathing

Look

  • At person’s bare chest — cut off clothing but keep warm
    • Are they breathing, how fast, how deeply, is it normal for age
    • Are both sides of chest moving the same, does one side suck in while other moves out
    • Do they look like they are working hard
  • Is trachea (windpipe) straight (in midline)
    • If tension pneumothorax — may be pushed away from affected side
  • Bulging/swollen neck veins may be caused by tension pneumothorax
  • Chest wounds. Log-roll if unexplained breathing difficulty — look for hidden wounds

Listen

  • Any unusual noises — grunting, gasping, snoring, wheezing, whistling

Feel

  • Is chest moving. One or both sides
  • Is trachea (windpipe) in middle of throat — Figure 3.7

Figure 3.7  
  • For subcutaneous emphysema (crackling feeling under skin)
  • For broken ribs. If no visible injury, gently squeeze chest from sides and from front and back.
    • Note tenderness

If not breathing and pulse not easily felt

If unconscious with slowed/inadequate breathing but pulse easily felt

  • Probably head injury
  • Support breathing with bag-valve-mask — Figure 3.8 OR mouth-to-mouth with mouth guard
    • 15 breaths/min child, 10 breaths/min adult

Figure 3.8  

 

If having trouble breathing

If breathing normally

C – Circulation and controlling haemorrhage (bleeding)

  • Assess colour and temperature of skin
  • Palpate a central pulse — femoral or carotid
  • Assess central capillary refill
  • Look for and control external bleeding
  • Put firm pressure with hand or pad to stop bleeding — Figure 3.9
  • If bleeding artery/vein

Figure 3.9  
  • Consider hidden bleeding — chest, abdomen, pelvis, long bones, back
    • If cause of shock not identified — stabilize pelvis first then log-roll on to side to check back for penetrating injury if not done before
  • If evidence of pelvic fracture — stabilise pelvis
  • Put in IV cannula, largest possible and start IV fluid, consider intraosseous needle if no IV access. Insert 2nd cannula if time
  • Run fluids — fluid balance chart
    • Adult — normal saline as fast as possible
    • Child — normal saline bolus at 20mL/kg (doses)
    • Newborn — normal saline bolus at 10mL/kg (doses)
    • If you can't weigh child — check for recent weight in file notes OR use age
    • If drowning victim — use warm IV fluid

If no pulse and unresponsive

  • If many casualties — leave and manage other seriously injured people first (triage as deceased)
  • If no other seriously injured people — start CPR. See Life support — DRS ABC

Check ABC under control before starting D. If not — go back and restart resuscitation steps.

D – Disability — head and/or spinal injury

  • Do rapid check for level of consciousness using AVPU. If only P or U — may need airway protection
    • Alert — eyes open, understanding, following commands, talking. Tell them not to move their head
    • Voice — not alert but responds to voice
    • Pain — responds only to pain - if only small response (eg low groan without opening eyes) — treat as unresponsive
    • Unresponsive — unconscious, not responding
  • To test for pain response - apply for 15 seconds but no more than 30 seconds
    • Firmly squeeze muscle on top of shoulder with thumb and 2 fingers (trapezius squeeze) — Figure 3.10 
    • OR press bony ridge along top of eye (supraorbital pressure) — Figure 3.11 — do not do this if they have facial fractures

Figure 3.10  

Figure 3.11  
  • Check pupils — same size, do they react to light by constricting (getting smaller)
  • BGL

E – Expose and examine

  • To check for significant injuries, take as much clothing off person as you can. Always protect dignity, respect culture and keep warm
  • Start at top, work down and around, front then back. Look, feel, listen
  • Only examine back if no other cause for breathing difficulty or shock found 
  • By end of primary survey you will have checked face, neck, chest, abdomen, pelvis (including genitals), arms, legs and back (if required) for immediate life-threatening injuries
  • Check surface person is lying on
  • Cover with blanket or sheet

Secondary survey

  • Don’t start until ABC DE complete and no-one with more serious injuries
  • Check top to bottom, front and back so you don’t miss life-threatening injury
  • Make notes of what you find as you go
  • Always keep checking ABC D under control before moving onto next step

3 parts to secondary survey

  • History
  • Examination
  • Treatment

History using DeMIST, AMPLE, PQRST

  • Can be done at same time as examination
  • Record what you are told by witnesses, what you see for yourself, what person tells you

Document (DeMIST)

  • Description of incident 
  • Mechanism of injury
  • Injuries sustained
  • Signs and Symptoms
  • Treatment so far

Then ask questions (AMPLE)

  • Allergies
  • Medicines or current illness
  • Past history of illnesses, injuries, surgical operations, times in hospital
  • Last time they ate or drank
  • Event — what happened to cause the injuries (eg vehicle accident, burns)

To find out how severe a symptom is ask (PQRST)

  • Provoking/Palliating factors — what makes it worse or better
  • Quality — what is it like
  • Region and Radiation — where is it, does it spread or stay in one place
  • Severity — how bad is it
  • Timing — when did it start, is it there all the time

Examination

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • Head-to-toe exam
  • Look — use eyes, torch, auroscope, ophthalmoscope
  • Listen — with ears, stethoscope
  • Feel — with your hands for injuries, percuss chest 

Head (scalp) and face

  • Symmetry
  • Wounds, deformities, bruising, bleeding, swelling, depressions in bones
  • Blood or fluid draining from ears or nose
  • Feel for tenderness. Ask about pain, numbness and tingling
  • Eyes and lids
    • Pupil reactions
    • Bleeding or bruising
    • Check vision with fingers and hands
  • Mouth opening, teeth, tongue, jaw clench, tenderness
  • Hoarseness or stridor
  • Coma scale score

Neck

  • Using in-line immobilisation, open cervical collar if used, inspect neck
  • Wounds, deformities, bruising, swelling
  • Large swollen (distended) neck veins
  • Position of trachea — in middle of throat or pushed to one side
  • Tenderness, especially midline at back
  • Air under the skin (subcutaneous emphysema)
  • Refit cervical collar  as required by local protocols

Chest

  • Breathing — RR and effort
  • Chest movement — same on both sides, symmetrical rise and fall
  • Wounds, deformities, bruising, swelling, depressions in bones
  • Listen to chest sounds with stethoscope — is air coming into lungs properly on both sides
  • ECG to exclude heart trauma

Abdomen

  • Wounds, bruising or swellings on skin, swelling of whole abdomen (distension)
  • Palpate for tenderness, rigidity, guarding — may be bleeding in abdomen

Pelvis, rectum, genitals  — consider person’s privacy and dignity

  • Do not do vaginal or rectal exam unless skilled, know what to look for
  • Wounds, deformities, bruising
  • Bleeding from urethra
  • Bleeding in or around scrotum, rectum, vagina
  • Signs of pelvic fracture 
  • Man with priapism (erection) — could indicate spinal injury

Arms and legs

  • Wounds, deformities, bruising, swelling
  • Shortening or rotation of lower limbs — hip/pelvic fracture
  • Tenderness
  • Check peripheral pulses — Figure 3.12

Figure 3.12  
  • Temperature of limbs, hands and feet (hot or cold)
  • Capillary refill
  • Screen for sensory loss with light touch all peripheries

Back — if helpers to log-roll

  • Log-roll to check back — take off clothes to see properly
  • Wounds, deformities, bruising, swelling, depressions in bones
  • Tenderness
  • Bleeding from anus

Treatment

  • Pain relief as needed, positioning, splints, analgesia
  • Fluids — consider nil by mouth — check IV and fill in fluid balance chart
  • Put in nasogastric tube if
    • Severe multi-trauma
    • Severe abdominal injury
    • Quadriplegia, paraplegia
    • Head injury
    • Child with air swallowing and abdominal distention
    • Do not put in if facial injuries or suspected fracture at base of skull (black eyes, bruising behind the ear, or blood or fluid draining from the ears or nose). Use orogastric tube after intubation
  • Put in indwelling urinary catheter — female, male if
    • Fluid resuscitation needed
    • Immobilised or trouble voiding
    • Impaired level of consciousness
    • Do not put in if signs of urethral or bladder injury (eg blood in urethra, bruised scrotum) 
  • If needed — close wounds, dress wounds, splint injuries
  • Record findings including Temp, pulse, RR, BP, O2 sats, REWS, coma scale score, pupils, neurovascular observations, wounds. Get paperwork in order 
  • Monitor person. Use cardiac monitor and/or oximetry, if you have them
  • Get person ready to send to hospital
    • Consider antiemetic for nausea, more pain relief
    • Tetanus prophylaxis if indicated
    • Consider antibiotics: Concern for compound fractures, facial fractures, base of skull fractures, wounds with lots of tissue injury or dirt — medical consult