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welcome back thanks for joining me on
this discussion of the initial survey
and management under the section of
trauma right off the bat to let you know
trauma is a very favorite question of
the USMLE examination so we're going to
spend a fair amount of time discussing
possible injury patterns let's start
with the clinical scenario you're
presented with a 32 year old man who is
drinking alcohol and sustained a
front-end collision with an incoming
traffic here's what his car looked like
after the fact what's going on in your
mind the question is did the passenger
make it I'll give you a few seconds to
think about this in trauma no matter how
severe or the mechanism of injury we
always follow the a TLS protocol or the
advanced life advanced trauma life
support system and the priorities are
easily delineated for us using alphabets
a for airway B for breathing and Cu for
circulation let's stop for a moment in
the initial survey and management there
are hard stops at every step along the
way we don't move on until the next
system to the next system if something
needs to be addressed for example if the
airway airway is not intact one needs to
obtain a definitive airway before moving
on to the next step in sequence a again
it's for airway in assessing airway we
are evaluating the patency of the early
delivery conduit this includes the mouth
the posterior pharynx upper Airways and
the trachea and several divisions of the
trachea what can potentially compromise
the airway a patient who has a Glasgow
Coma Scale that's deny we will review
the Glasgow Coma Scale but the Glasgow
Coma Scale is basically a assessment of
the patient neurological status
additionally clear and obvious facial
trauma particularly with active bleeding
maybe may pose a risk for an airway
compromise and lastly direct laryngeal
trauma such as a hanging victim or
direct blow to the neck
can cause compromised airway with
additional risk of airway compromise is
the burn patient to secure an airway we
first bag-mask the patient bag masking a
patient allows us to deliver oxygen
remember there's a disadvantage of bag
masking a patient significant amounts of
air enters the stomach imposes a threat
to vomiting patients we then achieve
definitive airway by performing
endotracheal intubation
sometimes endotracheal intubation is
impossible in which case we would have
to do an emergency surgical
cricothyrotomy as depicted by this image
a needle or a knife is inserted through
the cricothyroid membrane remember
cricothyroid membrane and in neck
Anatomy is actually named from a caudal
to cranial direction next after airway
has been ascertained we move on to
breathing B for breathing in breathing
we're evaluating whether or not the
patient is moving air to allow
ventilation just because the patient has
an intact airway meaning the conduit is
not obstructed does not necessarily mean
that the patient is actually moving air
through the conduit what are some
reasons why someone might not be moving
air despite having an intact airway for
example a very high spinal cord injury
can vendor the diaphragms paralyzed
somebody who has significant traumatic
brain injury may be comatose or have
their respiratory centers damaged injury
to the diaphragm or the ribs can
significantly alter the patient's
ability to move air when you have
secured airway and ascertained that
breathing our patient is moving air we
then move on to see
for circulation in circulation we
evaluate the heart's ability to pump
blood and oxygen a or profuse the
tissues how do we evaluate circulation
well quick checks of Mental Status if
the patient is oriented and
conversational they likely have
perfusion to the brain check their
pulses through our patients have distal
pulses such as the radial pulse or DP
pulses or dorsalis pedis pulses in the
feet they have to at least have enough
of a pressure head and lastly to assess
whether or not somebody has
intra-abdominal bleeding we perform
what's called a fast examination let me
pose a question to you what is a very
quick way to assess ABC all at once I'll
give you a second to think about this
it's quite easy all you have to say is
hi sir can you tell me your name and if
the patient is able to tell you their
name it suggests number one that their
mental status is intact a the airway
conduit is intact B air has to be moving
through the conduit and pass the vocal
cords for them to answer and C they have
enough of a perfusion to the brain to be
able to answer your question what if
there's a clinical change during the
survey at any point during this survey
I'll give you a few seconds to think
about this if there's a clinical change
during your initial assessment it's
always prudent to go back to the
beginning of your ABCs start with airway
again make sure that the patient's
conduit has now been obstructed remember
sometimes when the patient has altered
Mental Status during the clinical
examination the tongue may fall back
obstructing their way next reassess on
breath sounds listen to their breath to
make sure the air is moving and lastly
we continue on circulation assessment
after you've completed an initial survey
and your ABC the last two letters are
actually D and E D for disability and
efore exposure D is in the section which
will be discussed later is where we
assign the patient of Glasgow
scale and exposure is thoroughly taking
a look from head to toe of the
examination and it completely exposed
patients remember in a completely
exposed patient hypothermia can
institute within minutes make sure you
cover the patient now we can move on to
a secondary survey a secondary survey is
a fancy name for basically a head-to-toe
examination of the patient we also
obtain an abbreviated history it's
called an ample history to the most
pertinent information that we need to
help manage the traumatic patient and
lastly we like to call for a transfer
hot center to a higher level of care for
definitive trauma resuscitation let me
post another question to you you must be
wondering what happened to our initial
patient well thankfully because of your
initial assessment and management the
patient survived important clinical
pearls the patient may have an intact
airway but may not be actually breathing
remember the Airways just the conduit
the breathing is the mechanics of moving
air through this conduit and a
high-yield fact anytime your clinical
scenario shows clinical change or
deterioration make sure you go back to
the beginning of your ABCs thank you
very much for joining me on this
discussion of the initial assessment and
management of traumatic patients
you
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you