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Initial assessment Primary survey
Dr Vinod Jain
Objectives
• To understand the ATLS principles during
primary survey
• To know the application of adjuncts
Case scenario
• 25 years old male, unrestrained car driver with high speed head-on collision, brought by police ambulance
• HR 110/mt, RR 32/mt, BP 100/80, Pale skin
• Unresponsive with alcoholic smell
• Bleeding wound right thigh and left hand with deformity
• Noisy breathing
• Bruises on anterior chest wall
Case scenario
• Should be managed by single person or
by a team?
• Is it important to assign work to different
team members?
• Prior basic information of patient’s
condition is helpful or not?
Case scenario
What is the sequence of priorities in assessing
this patient?
• Should we identify the specific injuries
before initial management of this patient?
• If not, how should we proceed?
ATLS way of trauma management
• Preparation
• Triage
• Primary survey (ABCDEs)
• Resuscitation
• Adjuncts to primary survey and resuscitation
• Secondary survey
• Adjuncts to secondary survey
• Continuous post resuscitation monitoring and re evaluation
• Definitive care
Preparation
• Take universal precautions
• Check the availability of medicines and
functioning of equipments
• Designate the role to each team member
• Utilize pre hospital information
Initial assessment
• Primary survey – Evaluates physiology
• Secondary Survey – Evaluates anatomy
Primary survey
Primary survey and resuscitation of vital
functions are done simultaneously using a
team approach
Primary Survey – ATLS way
• Airway with c-spine protection
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability: Neuro status
• Exposure with environmental control
Primary Survey
Always consider physiological
variations in special populations
● Elderly
● Infants and Children
● Pregnant Women
● Obese
● Athletes
The priorities are same for all the patients
Quick Assesment
What is a quick, simple way to assess a
patient in 10 seconds?
•Ask the patient his or her name?
•Ask the patient what happened?
Appropriate Response confirms
1 – Patent airway
2 – Sufficient air reserve to permit speech
3 – Sufficient perfusion
4 – Clear sensorium
Primary survey
Airway – Establish patent airway with c-spine
protection
• Clear the airway using wide bore suction
• Chin lift / Jaw thrust manoeuvre
• Oropharyngeal / nasopharyngeal airway
• Definitive airway
(Cuffed, Secured endotracheal tube)
• Surgical airway
15
Primary Survey
Breathing and ventilation –
assess and ensure adequate
oxygenation and ventilation
Breathing and Ventilation
Assess
• Jugular venous distension
• Position of trachea
• Respiratory rate
• Percussion findings of chest
• Air entry
• Oxygen saturation
Breathing and ventilation
Recognise and treat early –
• Tension pneumothorax
• Flail chest with pulmonary contusion
• Massive haemothorax
• Open pneumothorax
Immediate Chest decompression with
Oxygen delivery
Circulation with haemorrhage control
After excluding tension pneumothorax,
cause of hypotension is hypovolemia until
proved otherwise
Circulation with haemorrhage control
Look for blood loss
– External bleeding
– Internal bleeding
• Chest
• Abdomen / Retroperitoneum
• Pelvis
• Long bones
One on floor four more
Circulation with haemorrhage control
Assess for organ perfusion
● Level of consciousness
● Skin color and temperature
● Pulse rate and character
Primary Survey
Circulatory Management
● Control hemorrhage
● Restore volume
● Reassess patient
Pitfalls
● Elderly
● Children
● Athletes
● Medications
D- Disability : Neurologic status
Rapid neurological examination is done for -
- Level of consciousness (GCS)
- Pupillary size and reaction
- Localizing signs
Primary survey - E
• Expose the patient
• Prevent hypothermia
• Cover with warm blanket
Patient’s body temperature is more
important than comfort of
healthcare providers
Assessment and Resuscitation
is
done
simultaneously
Adjuncts to Primary Survey
PRIMARY SURVEY
ABGs
Urinary / gastric cathetersunless contraindicated
Urinaryoutput
ECG Vital signs
Pulseoximeterand CO2
Adjuncts to Primary Survey
Diagnostic Tools
Adjuncts to Primary Survey
Diagnostic Tools
• FAST
• DPL
Parameters of improvement
Normalization of
• Pulse rate
• Blood pressure
• Ventilatory rate
• Arterial blood gases (ABG)
• Body temperature
• Urinary output
Transfer
• Consider transfer after stabilization
Transfer protocol
Inform the receiving doctor about
• Patient’s history including mechanism
• Physical findings
• Treatment instituted
• Patient’s response to therapy
• Diagnostics tests performed and result
• Need for transport
• Method of transportation
• Anticipated time of arrival
Continue ABCDEs with continuous monitoring
Questions
Take home message
33
Take home message
• We should have competent and co-ordinated team for trauma care
• Correct and sequential ATLS approach is needed• Primary survey includes simultaneous assessment
and treatment of trauma patient • Priorities of resuscitation remain same in various
population of trauma patients• Proper transfer protocol should be followed