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Initial Assessment and Management
 Preparation

o Prehospital

 Coordinate events with clinicians at rec hospital

 Airway maintenance

 control of external bleeding and shock

 immobilization

 immediate transport

 Triage

o Sorting of patients based on needs for treatment and resourced available

o Treatment rendered based on ABC priorities

o Determine appropriate receiving facility

o Multiple vs Mass casualties

o Page 5. Figure 1-2

 Primary Survey

o ABCDE

 Quick assessment: ask pt to id self and ask what happened

 Appropriate response= no major airway compromise, breathing not

severely impaired, no major decrease in level of consciousness

o Airway

 Suction, inspect for FB, look for facial/jaw fractures

 Initial chin lift/jaw thrust is recommended to achieve patency

 All pts with GCS <8 should be intubated

 Finding of non-purposeful motor responses strongly suggest the need for

definitive airway management

 Prevent excessive movement of cervical spine

 No flexing, extending, rotating

 Assume loss of stability of the cervical spine

o Evaluate later

 Lateral films only ID 85% of all injuries

o Breathing and ventilation

 Evaluate: jugular vein distention, chest rise/symmetry, position of trachea

 Auscultate to ensure air flow

 Palpation may reveal injuries that may compromise ventilation

 Percussion may ID injuries

o Dull vs hyperresonant

o Circulation and hemorrhage control

 Hemorrhage is predominant cause of preventable deaths after injury

 Evaluate

 Level of consciousness

 Skin Color

o Pt with pink skin especially in face and extremities rarely has

critical hypovolemia after injury

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o Look for ashen/gray facial skin and pale extremities

 Pulse

o Easily accessible central pulse (carotid/femoral)

 Bilaterally for quality, rate, regularity

 Full, slow, regular pulses= relative normovolemia in a pt

not taking BB

 Normal pule rate does not neccesarily equal

normovolemia

 Irregular pulse warns of cardiac dysfunction

 Elderly: impaired compensatory mechanisms… rate may

not increase

 Children: high physiologic reserve… rate may not

increase

 Athletes: may have bradycardia

 Bleeding

o Determine if internal or external

o Direct manual pressure on wound is best

 Tourniquet may be good for extremity but carry risk of

ischemic injury so only use when direct pressure not

effective.

 Use of hemostats can result in damage to nerves and

veins

o Disability (Neuro evaluation)

 Rapid neuro eval at the end of primary survey

 Level of consciousness, pupillary size and reaction, lateralizing signs,

spinal cord injury level

 GCS: particularly motor response

 Decrease in consciousness: low perfusion or direct brain injury or toxins/drugs

 Prevention of secondary brain injury by maintaining oxygenation and perfusion

are the main goals of initial management

o Exposures and environmental controls

 Completely undress patient

 Cover with warm blankets to prevent hypothermia

 IV fluids should be warmed to before infusing

 PTs body temperature is more important than healthcare providers comfort!

 Resuscitation

o Follows ABCs and occurs simultaneously with evaluation

o Airway

 Jaw-thrust or chin lift

 Definitive airway if any doubt about pts ability to maintain airway integrity

 Establish airway surgically if intubation is contra-indicated

o Breathing, ventilation, oxygenation

 EVERY injured patient should get oxygen

 Tension pneumothorax suspected → decompress chest

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o Distance btw thyroid notch and floor of mouth 2 finger breadths

 M: MALLAPATI

o 1: soft palate, uvula, fauces, pillars

o 2: soft palate, uvula, fauces

o 3: soft palate, base of uvula

o 4: hard palate only

 O: OBSTRUCTION

o Epiglottitis…. Peritonsillar abscess… trauma

 N: NECK MOBILITY

o Ask pt to place chin on chest then extend neck to look towards

ceiling

o Page 38; figure 2-3

o Pts with decreased consciousness… tongue can fall backward and obstruct the

hypopharynx

 Readily corrected by chin lift or jaw thrust

 Then airway can be maintained with oro or nasopharyngeal airway

o LMA (laryngeal mask airway) (intubated LMA)

 Does not provide definitive airway

 ILMA: allows for intubation through LMA

o LTA (laryngeal tube airway)

 Not a definitive airway device

 Placed without visualization of the glottis and does not require significant

manipulation of the head or neck

o Page 41; table 2-1

o Endotracheal intubation

 All patients with GCS of 8 or less should be intubated

 Orotracheal route has fewer ICU related complications than nasotracheal

 If pt has apnea, orotracheal intubation is indicated

 Blind nasotracheal intubation requires a patient who is spontaneously

breathing and is contraindicated in patients with apnea

 Facial, frontal sinus, basilar skull, and cribriform plate fractures are all relative

contraindications to nasotracheal intubation

 Bilateral ecchymosis in periorbital region, postauricular ecchymosis,

possible CSF leaks (rhinorrhea or otorrhea)

 Gum elastic bougie

 Use if first attempt is unsuccessful or when vocal cords cant be

visualized

 Stick in blindly; position in tracheal position is confirmed by feeling

clicks as the distal tip rubs along cartilaginous tracheal rings

 Once in… place an endotracheal tube over it pass it through and then

remove the GEB

o Correct positioning?

 Check BL breath sounds to suggest (not confirm) proper placement

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 Borborygmi (rumbling/gurgling noises) in epigastrium → Suggest esophageal

intubation

 ETCO2

 If CO2 is not detected then esophageal intubation has occurred

 Best confirmed by X-ray

 Re-assess if patient is moved by auscultating BL

o Rapid sequence intubation

 Make sure everything is ready

 Apply cricothyroid pressure

 Etomidate .3 mg/Kg

 1-2 mg/kg succinylcholine (usual dose is 100mg)

 Risk of hyperkalemia… use with caution with crush injuries, major burns,

electrical injuries

 Once relaxed… intubate

 Release cricothyroid pressure

 Ventilate pt

 **when using sedation and neuromuscular blockade… if intubation is not

successful then provide bag mask ventilation

o Surgical airway

 Indications

 Intubation unsuccessful, edema of glottis, fracture of larynx, severe

oropharyngeal hemorrhage obstructs the airway

 Surgical cricothyroidotomy preferred over tracheostomy bc…

 Easier, less bleeding, less time

 Needle cricothyroidotomy

 Short term oxygen until definitive airway can be placed

 Can be adequately oxygenated for 30-45 minutes

 Only pts with normal pulmonary function who do not have significant

chest injury

 Surgical cricothyroidotomy

 Not recommended for children under 12

 Percutaneous tracheostomy not safe in acute trauma situation

 Management of oxygenation

o Pulse ox

 Cannot distinguish between hemoglobin, carboxyhemoglobin, and

methemoglobin

 Limits usefulness in pts with severe vasoconstriction and CO poisoning

 Profound anemia and hypothermia decrease reliability

 Management of ventilation



Spine and Spinal Cord Trauma

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1. Spectrum of injury
2. Abnormal EKG/monitor changes
3. Echocardiography if hemodynamic consequence. Have them on monitor

in case of arrhythmia.
4. Treat: dysrhythmias

viii. Traumatic Aortic Disruption
1. Rapid acceleration/deceleration

a. X-ray signs: wide mediastinum, loss of aortic notch, loss of
apical pleural cap, deviation of trachea to right. Deviation of
esophagus with NG tube. Scapular fractures etc.

b. High index of suspicion
c. Treatment: Control BP if stable, control with a drip that is short

acting.
d. With definitive diagnosis get Surgical consult.
e. Gold standard for diagnosis is CT or angiography.
f. Most do not make it alive and those that do 50% die in the

hospital
ix. Traumatic Diaphragmatic Injury

1. Most often left-sided
2. Blunt: large tear
3. Penetrating: small perforation
4. Frequently misinterpreted X-ray
5. Treatment is surgery

x. Blunt-Esophageal Rupture
1. Uncommon and difficult to diagnose

a. Mechanism is severe epigastric blow
b. Unexplained pain and shock
c. Radiographs show mediastinal aire
d. Treatment: OR

xi. Fractures and Associated Injuries- Rib, Sternum and Scapular fractures
1. Ribs 1-3 sever force, high mortality, aortic
2. Rib 4-9 pulmonary contusion, pneumo
3. Rib 10-13 intrabdominal; spleen and liver

xii. Traumatic Asphyxia
1. Signs: petechial, swelling, plethora, cerebral edema
2. Treatment: airway control and O2

xiii. Subcutaneous Emphysema.
1. Can result from airway injury, lung injury or rarely blast injury. Does not

require treatment.
2. If positive-pressure ventilation is required, tube thoracostomy should

be considered on the side of the subcutaneous emphysema in
anticipation of tension pneumothorax developing.

xiv. Pittfalls
1. Simple pneumo converts to tension pnemo
2. Retained hemothorax- complication is empyema . IF not working called

a thoracic surgeon and have it cleaned.
3. Diaphragmatic injury- missed early on, persistent pain and things don’t

look right reassess.