Preparation and Triage
- Activate team and assign roles
- Prepare the trauma room (airway and IV equipment, fluid warmer, pediatric or bariatric equip)
- Don PPE (consider potential safety threats to the team or need for decontamination)
General Impression
Assess for obvious uncontrolled hemorrhage, unresponsiveness, apnea and need to re-prioritize to C-ABC
When alterations identified, intervene and reassess:
-assess for pulse
-control external hemorrhage
-initiate chest compressions
-initiate IV resuscitation for significant blood loss with signs of very poor perfusion
Alertness and Airway
- Assess level of consciousness using AVPU
- Open airway - may need 2nd person to provide manual cervical spinal stabilization if spinal injury is suspected. If alert ask to open mouth.
- Assess for:
-boney deformity, burns, edema, fluids (blood, vomit or secretions), foreign objects, inhalation injury, loose or missing teeth, sounds (snoring/gurgling/stridor), tongue obstruction, vocalization) - When alterations identified, intervene and reassess:
- Anticipate need for intubation
-Insert an oral or nasopharyngeal airway
-Remove any loose teeth or foreign objects
-Remove any loose teeth or foreign objections
-Suction the airway
Breathing and Ventilation
- Assess breathing effectiveness:
-breath sounds, depth/pattern/respiratory rate, increased WOB, open wounds or deformities, skin color, spontaneous breathing, subcutaneous emphysema, symmetrical chest rise and fall, tracheal deviation or jugular venous distention - When alterations identified, intervene and reassess:
-Anticipate need for chest tube
-Anticipate need for drug assisted intubation
-anticipate need for decompression of pneumothorax
-anticipate need for oxygen
provide bag mask ventilations - If intubated, assess ETT placement:
-Attach a CO2 detector device. After 5 to 6 breaths assess for evidence of exhaled CO2
-Observe rise and fall of chest with ventilation
-Auscultate over the epigastrium for gurgling and the lungs for bilateral breath sounds - If intubated assess ETT position by noting number at teeth and secures ETT
- If intubated state need to begin mechanical ventilation
Circulation and Control of Hemorrhage
- Assess circulation: Inspect and palpate the skin for color, temperature, moisture AND palpate central pulse
- When alterations are identified, intervene and reassess:
-Anticipate need for goal directed therapy for shock
-Apply a cardiac monitor
-Apply a pelvic binder
-Apply a traction splint
-Assess patency of prehospital IV line
-Compare central and peripheral pulses
-Consider sources of internal hemorrhage
-Control of external hemorrhage
-Draw labs
-Facilitate FAST and/or radiographs to identify source
-Initiate chest compressions
-Obtain IV or IO access
-Palpate central pulse if peripheral pulse is absent
-Tilt pregnant patient or manually displace the uterus
Disability (Neurologic Status)
- Assess neurologic status using the GCS
- Assess pupils
- Assess bedside glucose
- When alterations identified, intervene and reassess:
-Anticipate the need for a head CT
-Anticipate need for intubation
Exposure and Environmental Control
- Remove all clothing AND inspect for obvious injuries
- When newly identified life threatening alterations are identified, intervene as appropriate and reassess:
- If transport device is in place, remove now
- If no contraindications, patient may be turned to assess the posterior. This is deferred until after head-to-to and imaging if need to evaluate spinal and pelvic stability.
- Provide warmth: blankets, increase room temperature, warmed fluids, warming lights
Full Set of Vital Signs and Family Presence
- Obtain a full set of vital signs
- Facilitate family presence
Get Adjuncts and Give Comfort (LMNOP)
L - Labs (blood gases, Type & screen, Lactate, Pregnancy, Tox, CBC, BMP, Coags)
M - Attach patient to cardiac monitor and get EKG
N - Consider need for naso or orogastric tube
O - Assess oxygenation and continuous end-tidal capnography. Intervene as appropriate: increase or decrease rate of assisted ventilation and/or wean oxygen.
P - Assess pain using an appropriate pain scale. Give appropriate non-pharmacologic comfort measures: Distraction, Family presence, Place padding over bony prominences, Repositioning, Splinting, Verbal reassurance. THEN, consider obtaining order for analgesic medication.
Consider Need for Definitive Care
At this time is there a need to transfer to a trauma center, surgery or critical care?
History and Head-to-Toe
- Obtain pertinent history: Medical records/documents, Pre-hospital report,SAMPLE
- Inspect and palpate head for injuries
- Inspect and palpate face for injuries
- Inspect and palpate neck for injuries. Demonstrate removal AND reapplication of cervical collar.
- Inspect and palpate chest for injuries
- Auscultate breath sounds
- Auscultate heart sounds
- Inspect the abdomen for injuries, auscultate bowel sounds, palpate all four quadrants
- Inspect and palpate the flanks for injuries
- Inspect and palpate the pelvis for injuries
- Apply gentle pressure over iliac crests downward and medially
- Apply gentle pressure on the symphysis pubis
- Inspect the perineum for injuries
- Consider how to measure urinary output
- Inspect and palpate all four extremities for neuro-vascular status and injuries
Inspect Posterior Surfaces
- Inspect and palpate posterior surfaces
-Not required if suspected spinal or pelvic injury
-If suspected spinal or pelvic injury, imaging is obtained PRIOR to turning the patient.
Potential Interventions
- Identify at least 3 intervention or diagnostics:
-Antibiotics
-Consults
-Head CT
-Imaging (US, interventional radiology)
-Law enforcement
-Mandatory reporting
-Psychosocial support
-Social services
-Splinting
-Tetanus
-Wound care
Just Keep Re-evaluating
- Vital Signs
- Injuries and effectiveness of interventions
- Primary survey
- Pain
Definitive Care or Transport
- Consider need for transfer to a trauma center or admission.
