Last Updated on July 26, 2022
Introduction
Trimodal model of trauma mortality
• First peak — death within minutes of injury
• Second peak — ‘early death’, i.e. death within hours of arrival to hospital
• Third peak — ‘late death’, i.e. death after 24 hours of trauma (days to weeks post injury)
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Further reading:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603725/#:~:text=The%20first%20peak%20in%20the,after%20arrival%20to%20the%20hospital.
Polytrauma
• A clinical syndrome with severe injuries, involving two or more major organs OR physiological system, which will initiate an amplified metabolic and physiological response
Primary Survey — ABCDE
A – Airway + Cervical collar
Any hoarseness of voice?
Any stridor?
Facial or mandibular fracture?
Any foreign body?
On cervical collar?
Neck / Cervical region pain?
B – Breathing — Remember IPPA
Trachea central?
Neck vein distended?
Any chest wall bruises?
Any open wound at chest?
Equal chest rise?
Presence of flail chest?
Chest wall palpation / chest spring
Others
• Respiratory rate
• SpO2
•Lung examination
C – Circulation
Pink?
Warm peripheries?
CRT <2 sec in bilateral upper limbs and lower limbs?
Pulse — volume? rate?
BP, HR
CVS
Abdomen examination
Pelvic spring
D -Disability
AVPU or GCS?
Pupil size & reaction
Spine fracture & spinal cord injury level:
• Log roll – no spine tenderness, no step deformity?
• PR – anal tone intact, BCR (bulbocavernous reflex) present?
E – Exposure
Expose for complete examination
Document all abrasion/ any visible wound or deformity
Adjunct to primary survey
• Vital signs, Pulse oximetry (SPO2)
• ECG
• ABG
• CBD
• Chest X-rays. Pelvic X-rays
• FAST scan
Resuscitation
Airway Maintenance & Cervical Spine Protection
(a) Airway maintenance
Usually in unconscious patients:
• Suction & assess for gag reflex
• Gentle chin lift / jaw thrust
• Oropharyngeal / Nasopharyngeal airway
Definitive airway (intubation) if indicated
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(b) Cervical spine protection
• Apply cervical collar if suspect cervical injury
Breathing Maintenance
• Oxygen supplement
• Chest tube insertion if presence of tension pneumothorax
Circulation Maintenance
• Avoid hypothermia
• Fluid resuscitation
• Control of bleeding
Important signs
• Raccoon sign
• Battle sign
Others
Trauma triad of death // Lethal triad
(i) Hypothermia
(ii) Coagulopathy
(iii) Metabolic acidosis
Further reading – wikipedia
Lethal diamond
(iv) Hypocalcaemia
Further reading – Article
Other Notes
• Do not insert CBD if pelvic injury / urethral injury is suspected
Related Posts
Take Home Message
1. Do not proceed with secondary survey if primary survey is incomplete / patient still unstable / patient still with ongoing resuscitation
2. Bleeding is the predominant cause of preventable death post injury
3. In reality, we will do all the elements of primary survey simultaneously, but the flow is important to ensure no important thing missed