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

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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

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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