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in this lecture we're going to review
the primary and secondary survey how we
manage trauma patients during the first
few minutes that come into the emergency
room what you should remember is that
children are very different than adults
in a lot of ways but there are some
similarities between the way we manage
adults in the traumatic situation and
the way we manage children I'll try to
highlight some of those for you during
this lecture remember about how we first
think about a trauma typically you're
standing with the doctors and nurses and
other therapists in the ER and you get a
call saying patient in a motor vehicle
accident five-year-old rollover is
coming in and that's really all you know
the first thing you want to do is use
the mechanism of injury that's been
reported to you to assess the severity
of trauma and the likelihood of injury
so when a rollover for example
all-hands-on-deck then we're going to
consider also in children which is a
little bit different than adults the
risk for child abuse frequently children
coming into the trauma Bay
have been abused shaken they may not
have outward signs of trauma but may
have internal signs of trauma and so
sometimes we worry that the severity of
the injury is sort of worse than we
expected then we got from the report so
think about that as a special
consideration consider the possibility
of an acute event precipitating the
trauma in other words an adolescent who
has a seizure while driving results in
an accident is it possible this
adolescent who's now down actually had a
problem say drug use resulting in
seizure and you're dealing with more
than you think right off the bat so the
way we describe patients in with trauma
is using the Glasgow Coma Scale this is
important because the scale is going to
make you help us with certain decisions
such as when to intubate but it's also a
very effective method of communication
with between professionals in terms of
assessing quickly how injured generally
is this page
in terms of their CNS so we do have the
adult and children score which you're
probably familiar with but there's also
a infant score that's adapted from the
children an adult score which we can use
as well so generally the eyes section of
the Glasgow Coma Scale which is a four
point scale is the same we give four
points if the patient is spontaneously
open their eyes three points if they
open it to voice two points if they open
it to pain and one point if they are not
opening their eyes then we look at the
verbal response here obviously infants
will be different
they won't express whether they're
oriented so instead of oriented four or
five points we have coos and babbles if
a patient is confused it may be that the
infant is irritable and not consoling
for an adult who's inappropriate for
three points for an infant's we say
cries to pain for incomprehensible in
children adults we use an infant's moans
to pain and of course if there's no
verbal response that's only one point
and lastly the motor response in an
infant it's unlikely they would obey a
command in the first place so we have to
adapt this scale again six points four
obeys commands correlates with just
spontaneous movements localizing the
pain correlates to withdraws to touch
withdraws to pain is the same and then
we still use the flexion and extension
motor score which indicates decorticate
and D cerebral activity and of course
flaccid is only one point so this will
give you basically the GCS score in both
children and adults and infants it's up
to your discretion looking at a child as
to what degree they're going to be and
this is an approximation but it's
important to be able to rapidly assign a
Glasgow's comma scale remember 15 points
is perfect and three is the worst you
can be okay so you're in the ER and the
doctors and nurses and therapists are
all together and they're waiting for the
trauma to come in you've heard over the
radio five-year-old and an M
va roll over non-responsive coming in by
ambulance that's all you know the EMTs
are typically to bring the child in
they're gonna give you a quick report at
what they saw at the scene you listen
carefully roles have already been
assigned and your role was to do the
primary survey so here's how we're gonna
go through the primary survey first you
need to do a airway airway and cervical
spine control come together because if
you're trying to manipulate that airway
say to open an obstructed airway and you
tip the head back you could cause more
cervical spine damage so we don't want
to do that the patients in a firm caller
they should be and if they're not you're
gonna place them in one and then you're
gonna adjust the airway by generally
doing a jaw thrust then you're gonna
inspect the airway and see if there's
any problems with the airway if the
airway is patent we can move on next is
breathing if the patient is not
breathing this is the point at which you
would start breathing for the patient if
the patient is spontaneously breathing
you're going to assess the lung fields
and see whether the air is entering well
we may at this point do more
interventions if there's no breathing so
let's go through those first
when do we intubate you need to intubate
when you are unable to effectively bag
ventilate a patient who is not breathing
you need to intubate
if the Glasgow Coma score scale is less
than or equal to 8 you need to intubate
when the patient has impending brain
herniation because you may want to
hyperventilate as a way of prophylaxis
against that we need to intubate if a
patient is in respiratory distress
you should intubate if a patient is in
uncompensated shock in other words the
patient just hasn't adjusted to the
shock and the heart rate is very high
and you need to intubate
when there is no laryngeal reflex when
they can't protect their own airway they
need a stable airway so let's say that
patient needed to be intubated and you
have successfully intubated the patient
that
take some skill and practice and that's
perhaps another lecture for another time
but you get that tube in nice job the
patient is now being ventilated
adequately now and only now can you move
on to circulation circulation is
generally done by auscultate in the
heart and checking the cap refill and
the femoral pulses those should all be
there if they're not you may have a
problem with hemorrhage either external
or internal you want to control the
hemorrhage next before you move on to
some other problem so we're gonna
control any external hemorrhaging we're
gonna assess for internal hemorrhaging
and if there is a good pulse you can
move on next is disability
decontamination and dextrose so let's go
through those DS disability is generally
understanding whether the patient has a
problem in terms of their mental
capacity we can use the mnemonic F puh
to help us decide whether a patient has
a disability and we'll talk about that
in a second decontamination is if
there's some kind of toxin on their skin
or they've been burned or you want to
get the clothes off and typically at
this point we will make them completely
naked and roll them and expose them in
the next step also in for kids
especially we add dextrose we add
dextrose for kids because remember
children have less liver capacity to
store glycogen and infants and children
are an increased risk for hypoglycemia
next is exposure we're going to cut off
the clothes and we're going to a
team-oriented log roll all together
coordinated one two three roll and
you're gonna look at the front back
sides in the groin everywhere you can
see
lay an eye on every square inch of skin
on this patient you may be surprised at
what you see there may be a lesion on
the back which will tell you oops the
patient was shot with a gun or you may
find burn marks or you may find evidence
of child abuse you don't know what
you're gonna find you have to look
next is f we've pretty much finished the
primary survey but it's important to
know when the patient last drank or ate
because that may affect our decision as
to when we can move on with anesthesia
and going to the operating room and then
lastly is G which is General Health
understand the baseline health of the
child if the patient has say cerebral
palsy or some underlying condition like
spina bifida it's important to
understand that and what that patient's
normal expectations are if the patient
has spina bifida and doesn't normally
move their legs that's obviously
important to know when you're assessing
their leg function okay we've done the
primary survey and you may actually
repeat the primary survey several times
now we're gonna move on to the secondary
survey the patient is stable you've
solved the problem maybe you're planning
on going to the O R and a bit but we
really want to do a head-to-toe history
and physical exam once the patient is
stable so we've done the primary
secondary primary survey we're on to the
secondary here's an overview of your
secondary survey head and neck we're
gonna look intraoral II for any evidence
of trauma we will inspect the eyes ears
and nose for evidence of blood or CSF
drainage from the ears and the nose we
will assess for things like raccoons
eyes or battle sign which are evidence
of significant head trauma we need to
assess for c-spine tenderness if the
patient is awake they can report it
hurts or it doesn't but you want to
palpate every single cervical vertebrae
and make sure there's no deformity or no
tenderness there if they're awake and
can report that to you it's always
important to assess for tracheal
deviation hopefully you would have
noticed that during the primary survey
because these patients will have a
circulatory problem as well as a
breathing problem in that you will
auscultate no lung sounds on one side
but certainly you want to assess the
trachea and make sure there's no
deviation look anteriorly to the entire
neck next the chest assess whether is
accessory muscle use that will give you
a sign that there's inter parenchymal
problems in the lungs and also listen to
heart and lung sounds and report those
out to the person who's taking the notes
from the trauma
next is the abdomen and pelvic exam
assess for guarding rebound tenderness
it's also important to assess for pelvic
stability by pushing on the anterior
superior iliac crest and what we call
rocking the pelvis but do it gently and
just assess for any pelvic instability
if there's pelvic instability that's
important to know about because that
could be a major source of internal
bleeding next the urogenital exam is
important you should inspect everywhere
down there and also we will do a rectal
exam when we do the rectal exam there's
two things we're noting we're noting
whether there's good rectal tone which
is a sign of spinal injury if there's
low tone and also we're going to send
any stool for a guaiac tests to verify
that there's not intra intestinal
bleeding next the extremities in the
spine you're gonna palpate every joint
and every bone in this patient to make
sure there's no abnormalities in the
extremity of the spine palpate the spine
also with a log roll for tenderness or
step off all the way down every single
vertebra must be palpated one after
another and you're gonna assess all
pulses I would recommend the dorsalis
pedis pulse as the lowest pulse there
and also the wrist pulses generally if
you've got those you're in good shape
the easiest to feel is the femoral pulse
unless it's a newborn baby in which case
is the umbilical pulse but that's
usually not a trauma last is neurologic
this is where we can do that F puh F who
is a quick way of remembering what can
we say about this patients awakeness
status a is awake
V is response to verbal P is response to
pain and U is unresponsive get their
baseline neurologic status if they're
awake and compliant check the cranial
nerves even if they're not you can still
check some cranial nerves
like pupillary response or whether
there's a facial palsy next checks
strength if they're awake and compliant
you can check strengthen all the
extremities and looking for a
generalized sense of strength and also
sensation you don't need to do a super
careful neurologic sensation exam we're
not so worried about the finer details
like whether it's light touch or
pinprick you want to just get a general
sense of can they feel up and down the
body in the most of the major areas and
then also don't forget to check the deep
tendon reflexes looking for things like
clonise at the ankles or if they're
having any brisk reflexes implies that
there may be some CNS damage so when we
see these patients we've done the
primary and secondary survey we often
will get labs and we may just get
something called a trauma panel I don't
actually mind that I think that's a good
idea I don't like this shotgun approach
for most disease processes I don't think
it's indicated to do a shotgun labs
approach for example the patient with
pneumonia but in a patient with a trauma
it's generally beneficial because you
don't have time really to think about
things very carefully before they're
whisked off to the o.r in all
circumstances so what are the labs that
are part of the trauma panel we get a
type and screen this is for obvious
reasons if they need blood either now or
during the operating room we get a CBC
again we can assess for loss of red
blood cells and acute anemia and we can
also see if there's an underlying
problem
we'll check l.f.t.s and lipase as that's
a reasonable way of assessing for
hepatic and pancreatic damage we'll get
a basic metabolic panel that's important
to assess the acid base and the
hydration status of a patient if it's
applicable we'll get a tox screen so any
infant who's found with altered Mental
Status or anybody who's been in an MVA
certainly we want to check a tox screen
because it's important to know whether
there's underlying chemicals that may be
affecting their vital signs and lastly
we'll check a pregnancy test
if
it's any girl who's over about 13 years
of age you want to check a pregnancy
test because we need to know whether
there's a fetus involved in terms of
issues around end organ damage so that's
my quick review of the primary and
secondary survey and the labs we get in
patients with trauma thanks for your
time
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