Chapter 3 - Initial assessment

Question 1

Steps for initial assessment

Answer 1

1. preparation and triage
2. Primary survey + corresponding interventions
3. re-evaluation (including TRANSFER / HIGHER LEVEL CARE)
4. Secondary survey + corresponding interventions
5. Re-evaluation and post reusustiation care
6. Definantive care of the transfer to an appropriate traume ceter

Question 2

Considerations of a patient when first entering a trauma bay

Answer 2

• Universal precautions
• PPE
• Hazardous exposure

Question 3

Across the room observation

Answer 3

evaluation can allow for rapid determination of a patients overall physiologic stability

Question 4

Uncontrolled hemorrhage

Answer 4

• IF noted during across-the-room observations would go (<C> ABC)</C>
• leading cause in combat casulty death

Question 5

MARCH Mnemonic (Battlefeilds)

Haemorrhage

Answer 5

<M>assive hemorrhage - control with the use of tourniquets - REPLACE Blood loss @ ratios of 1:1:1 (Platelets, red blood cells and plasma)

<a>irway - establish and maintain

<R>espiration - decompress suspected tension pneumothorax and support vent. oxygen required

<C>irculation - IO / IV

<H>ead injury / hypothermia - PREVENT and treat
</H></C></R></a></M>

Question 6

Airway +

Answer 6

Alertness, Airway and CSpine

Question 7

C spine

Answer 7

C-spine
- considered in all multi-trauma patients
- Need CT or radiography
- Older adult with blunt trauma

HOW?
1. Manual stabilisation - two hands holding the patient’s head and neck in alignment
2. Spinal motion restriction: semi rigid cervical collar

**minimum of 2 people for inline stabilisation to remove helemt

Question 8

Alertness assessment

Answer 8

Alert - maintain an airway and talk to you

Verbal - responds to verbal stimuli; may need an adjunct to protect the tongue from obstructing the airway

Pain - may not be able to maintain airway ; may need adjunct or may need a definitive airway

Unresponsive - airway needed. pulse vs no pulse

Question 9

Assessment of the airway

Answer 9

Open mouth
- assessment of obstructions or potential
- jaw thrust if any issues
*if Cpsine > 2 people to complete, one for manual stabilisation and second to do the jaw thrust

INSPECT: anything loses, foreign
LISTEN: any airway sounds (indicate partial obstruction)
PALPATINE: possible bone deformity / subcutaneous emphysema

DEFINITIVE AIRWAY :
1. C02 after 5-6 breaths assess for exhaled co2
2. Observe rise and fall
3. Auscultate for the absence of gruelling and presence of bilateral breathe sounds

Question 10

What situations need a definitive airway ?

Answer 10

• GCS >8
• serve maxilllofacial fractures
• Apena
• facial burns
• largenal , neck or tracheal hematomia
• high risk aspertation
• high risk of detertaion of neurological satus

Question 11

Can’t intubate?

Answer 11

Do 10-15L / minute NRB

Question 12

Breathing / Ventilation - INSPECT

Answer 12

INSPECT Spontaneous, symmetrical, A+E (looking), skin colour. looking for any continuous, abrasions or deformities that may be a sign of underlying injury.

*open pneumo - sucking chest wound

• JVD + deviation of the tracea are late signs of a tension pneumo.

Question 13

Breathing / Vent: Auscultate

Answer 13

resp. assessment

Question 14

Breathing/vent - palpate

Answer 14

• the integrity of boney structures
• subcutaneous emphysema (sign of a pnenumo)
• soft tissue injury

Question 15

What would happen if a patient couldn’t oxygenate their body?

Answer 15

Hypoxemia , resulting in anerobic metabilism and acidosis.

Question 16

ETCO2 - what is good and what is bad?

Answer 16

IDEAL 35-45 mmHg
>50 mmHg = depressed ventiltaion

Question 17

Ideal ventilation

Answer 17

10-12 breaths per minute, (one every 5 to 6 seconds).

Question 18

What is the number one priority when “looking across the room”

Answer 18

<C> replaces A in ABC if massive hemorrhage
</C>

Question 19

What would muffled heart sounds indicate?

Answer 19

pericardial tamponade

Question 20

Number 1 sign of pericardial tamponade

Answer 20

muffled heart sounds

Question 21

Causes (possible) of PEA

Answer 21

• a penetrating wound to the heart
• pericardial tamponade
• rupture of great vessels
• intra abdominal hemorrhage

Question 22

What would a rapid and thready pulse indicate? in a hemorrhage

Answer 22

hypovolemia

Question 23

What would an irregular pulse indicate in a hemorrhage?

Answer 23

potential cardiac dysfunction

Question 24

Volume resuscitation

Answer 24

Traditionally, it isotonic crystalloid.
However, raising BP in this manner can dislodge clots the body has formed and promote further bleeding. it can also lead to dilutional coagulopathy.

NOW = red blood, platelets and plasma.

• this helps to optimise delivery of oxygen, acidosis is corrected and coagulopathy is prevented.

Question 25

Disability

Answer 25

CT ABC BGL Toxicology

Question 26

Exposure

Answer 26

cut the clothes * hypothermia, hypotension and acidosis are a potentially lethal combination in the injured patient. - need to prevent heat loss

Question 27

F - full set of vital signs and family presence

Answer 27

monitor effectiveness of resussitation

Question 28

Primary assessment (A-G)

Answer 28

Airway, alertness and Cspine Breathing & Ventillation Circulation control or hemorrhage Disability (Neurological status) Exposure and environmental control Full set of vital signs and family presence Get the monitoring devices and give comfort

Question 29

G - Get monitoring devices and give comfort

Answer 29

LMNOP L - lab studies ; *lactic acid is a KEY indicator of tissue perfusion. High levels = hypoperfusion. >2 to 4 mmol/L are associated with poor outcomes *An Abnormal base deficit may indicate poor perfusion and tissue hypoxia, which generates hydrogen ions and metabolic acidosis... Base deficit >6 = poor outcomes M - monitor cardiac rate and rthym N - Nasogestic + Orogstic considtation. Can help to optomise infataion of the lungs P - pain assessment and management

Question 30

Re-evaluation considerations

Answer 30

- portable radiography - consider need for patient transfer - definitive / specalised

Question 31

Secondary survey steps (H-J)

Answer 31

Head to toe Inspect posterior surface Just keep reevaluating

Question 32

History - MIST

Answer 32

Mechanism of injury injuries signs and symptoms treatment

Question 33

History - SAMPLE

Answer 33

symptoms allergies medications past medical hx last oral intake. output. period event and environmental factors

Question 34

Others factors with history

Answer 34

Age Burns Preg. Disabilities

Question 35

Head to toe

Answer 35

Use of eFAST (resus)

Question 36

Head to toe - "LACE" for each section

Answer 36

LACE Lacertaions Abratuions / avulsios cotutaions Edema, Ecchmosis

Question 37

Head to toe

Answer 37

1. general appearance 2. eyes; diplopia can mean entrapment of cranial nerves 3, 4 and 6. REMOVE contacts 3. Ears; Do NOT pack ear (in case of CSF leak). check for glucose *approx 2/3 of the BGL. test for B2 -transferrin. 4. neck and spine 5. chest 6. abdomen. flanks 7. pelvis/perineum 8. extremities

Question 38

URINE OUTPUT? WHY

Answer 38

reflects end-organ perfusion and is considered a sensitive indicator of the patient's volume status IDC

Question 39

Secondary survey - rectal tone

Answer 39

Rectal tone can indicate spinal cord injury. A DRE is performed by a physician - the presence of rectal tone or the absence - the presence of a high-riding prostate

Question 40

Secondary survey - Just keep reevaluating

Answer 40

Major componenets (VIPP) -Vital signs -Injuries sustained and interventions performed - Primary survey - Level of pain

Question 41

Secondary survey - what to consider for other tests/treatments

Answer 41

CT Wound care Splints Traction TETANUS ABs