Primary survey and resuscitation

The primary survey identifies and treats life-threatening injuries in the order in which they are most likely to kill the patient. The priorities for recognising and responding are:

• A: Airway with cervical spine control

• C: Circulation and haemorrhage control

• D: Dysfunction, refers to neurological status

• E: Exposure and environment.

A: Airway and cervical spine

It is important that the casualty has a clear airway and adequate oxygenation. The airway is assessed and managed as described in Chapter 7, with the proviso that the cervical spine is protected. A patient who can speak clearly has a clear airway, whereas the unconscious patient may require help with maintaining an open airway and breathing. Snoring, gurgling and stridor can indicate an upper airway obstruction.

A cervical spine injury should be assumed in all patients with severe trauma until it has been excluded. Jaw thrust and airway adjuncts are the preferred methods to open the airway of the unconscious trauma patient. The cervical spine is immobilised with one of two methods:

• manual in-line stabilisation. A team member holds the casualty's head and neck in the neutral position;

• semi-rigid cervical collar blocks and tape (see Figure 14.1).

Seriously injured patients are at high risk of vomiting and aspiration of gastric contents. Patients with a decreased conscious level and inability to protect their airway require early tracheal intubation which is ideally performed using a rapid-sequence induction (RSI) technique. This requires administration of an intravenous sedative, a fast-onset, short-acting muscle relaxant (suxamethonium) and the application of cricoid pressure. Once the patient is fully sedated and relaxed the trachea is intubated. This requires specialist training (Clancy & Nolan 2002). The head is held using manual in-line stabilisation during tracheal intubation to ensure the cervical spine is not moved. This is preferable to using head blocks and a cervical collar, which can make access and mouth opening difficult.

B: Breathing

All patients must initially be given oxygen at the highest concentration possible. A fully conscious patient who is breathing normally requires a facemask with reservoir and high-flow oxygen (10-15l/min). A patient who is not breathing will require assistance with breathing using a bag-valve-mask device.

Fig. 14.1 Immobilisation of the cervical spine using collar blocks and straps.

Chest injuries will cause difficulty in breathing and the patient may have a fast or slow respiratory rate and also be hypoxic. The need for oxygen to maintain a normal oxygen saturation also indicates there is a problem. The team leader should look for and treat life-threatening chest injuries in the primary survey. These can be diagnosed clinically and excluded in the primary survey (see Table 14.2). The recognition of and response to these injuries require specialist training.

C: Circulation

'Shock' is defined as inadequate organ perfusion and tissue oxygenation. The recognition of hypovolaemic shock is based on clinical findings: hypotension, tachycardia, tachypnoea, altered conscious level as well as hypothermia, pallor, cool extremities, decreased capillary refill and decreased urine production.

A low blood pressure (hypotension) is assumed to be due to bleeding (haemorrhage) in the injured patient unless proven otherwise. The amount of blood loss after trauma is often poorly assessed and in blunt trauma is usually underestimated. Often large volumes of blood may be hidden in the abdominal and chest cavity. A femoral fracture can be associated with a 2 litre blood loss. This is a large proportion of the blood volume if one considers that the total blood volume of a 70 kg male is 5 litres. Bleeding must therefore be identified and stopped to prevent hypovolaemic shock. Hypovolaemic shock in the adult can be categorised into four stages (I, II, III, IV) based on the amount of blood loss (see Table 14.3).

Capillary refill is measured by pressing a distal digit at heart level for five seconds. A normal capillary return time is less than two seconds. This can be affected by cold weather so it must be interpreted with other signs and symptoms.

The response to hypovolaemic shock is to stop the bleeding and correct the blood volume. Wound bleeding can be stopped by applying direct pressure. Internal blood loss may require rapid transfer to an operating theatre for surgical control of blood loss. Blood volume is restored using intravenous fluids and blood.

Table 14.2 Chest injuries identified and treated in the primary survey.

Injury

Recognition

Response

Tension pneumothorax

Open pneumothorax

Massive haemothorax

Flail chest

Cardiac tamponade m en CO

Decreased air entry, decreased expansion and hyperresonance to percussion on the side of injury Trachea deviated away from injured side

There is a hole in the casualty's chest wall, which sucks on inspiration: 'sucking chest wound'

There is bleeding in the chest. The affected side will have decreased expansion and air entry and will be dull to percussion. A large volume of blood can be lost in the chest so the patient may be shocked

This occurs when there are a large number of rib fractures. A portion of the chest wall (flail segment) moves freely. This limits expansion of the lungs on inspiration. The flail segment will not move on chest expansion. The extent of the rib fractures also indicates that the chest has been struck with a large force so there is usually an underlying lung injury (lung contusion)

Bleeding around the heart may prevent it pumping effectively. It can occur after blunt or penetrating trauma. The patient will be shocked (low blood pressure) and there may be a wound (between the nipples or shoulder blades). There may be muffled heart sounds and distended neck veins

Needle thoracocentesis. A large-bore needle is placed in the second intercostal space, midclavicular line to relieve the tension. A chest drain is then inserted

The hole should be covered with a square waterproof dressing that is taped down on three sides. This stops air being sucked in but allows air to escape through the hole. A chest drain is then inserted

Chest drain inserted on injured side. If there is a large amount of blood loss the patient requires immediate surgery to stop the bleeding

Oxygen, analgesia to make breathing less painful. Tracheal intubation and controlled ventilation if there is severe lung contusion

Pericardiocentesis. A drain is inserted into the pericardial space and any blood around the heart removed. Effective treatment may require an urgent thoracotomy in the emergency room (Rhee et al. 2000)

Table 14.3 Categories of hypovolaemic shock.

I

II

III

IV

Blood loss

<0.75

0.75-1.5

1.5-2.0

>2.0

(litres)

Percentage

<15

15-30

30-40

>40

blood loss

(%)

Heart rate

<100

>100

>120

>140 or low

Systolic BP

Normal

Normal

Decreased

Decreased ++

Diastolic BP

Normal

Raised

Decreased

Decreased ++

Pulse

Normal

Decreased

Decreased

Decreased

pressure

Capillary

Normal

Delayed

Delayed

Delayed

refill

Skin

Normal

Pale

Very pale

Very pale/

colour

cold

Respiratory

14-20

20-30

30-40

>35 or low

rate

Mental

Normal/

Anxious

Anxious/

Confused/

state

anxious

confused

drowsy

Fluid

None/

Crystalloid/

Blood

Blood

choice

crystalloid

colloid

Pulse pressure = systolic BP - diastolic BP

Pulse pressure = systolic BP - diastolic BP

Intravenous access must be established early during the resuscitation. Two large-bore cannulae (14 gauge) should be inserted. At this time blood should be taken for the following investigations:

• full blood count

• urea and electrolytes

• coagulation study

• cross-matching

• consider a pregnancy test in females of child-bearing age

• arterial blood gases.

It is pointless giving large amounts of intravenous fluids to a patient who is actively bleeding if no effort is made to stop the blood loss. The role of fluid resuscitation at this stage is to keep the patient alive until there is definitive control of bleeding. As mentioned previously, this requires direct pressure, splinting of fractures or immediate surgery. Failure to stop bleeding results in excessive fluid administration. This can cause increased blood loss as clots may be disrupted at the injury site due to increased blood pressure and dilution of clotting factors and platelets (Revell et al. 2003).

The choice of resuscitation fluids is controversial (Nolan 2001). Fluids that could be used include crystalloids (Hartmann's or 0.9% normal saline) and colloids such as gelatins (Gelofusin, Haemaccel), dextrans or starches. Current evidence indicates that there is no real advantage in using the more expensive colloids over cheaper crystalloids for initial fluid management in trauma patients. The volume given should be based on the response in terms of improvements in blood pressure, pulse and conscious level.

The amount and urgency of blood transfusion will depend on the degree of hypovolaemia. In multiple injuries it may be necessary to order 6-10 units of blood. If blood is required immediately, the blood bank will supply group O blood, which has not been grouped or cross-matched to the patient. If it is possible to wait 10-15 minutes, the blood bank can supply group-confirmed blood. This is the same blood group as the patient but has not been cross-matched with the patient's blood. Fully grouped and cross-matched blood takes much longer to process.

All fluids and blood products should be warmed before infusion. Critically ill patients tolerate lower haemoglobin concentrations than previously thought. During resuscitation a haemoglobin concentration of between 7 and 9g/dl (normal range approximately 12-16g/dl) is likely to be adequate, with the possible exception of those patients with acute myocardial infarction and unstable angina (Hebert et al. 1999).

If cardiac arrest occurs resuscitation should follow ALS guidelines as described in Chapter 6. Special attention should be paid to stopping blood loss and restoring the circulating volume. If cardiac arrest is associated with a penetrating chest wound an emergency thoracotomy at the scene may be life saving (Rhee et al. 2000). Cardiac arrest associated with trauma has a poor prognosis (Hopson et al. 2003).

Table 14.4 Glasgow Coma Scale.

Eyes

Open spontaneously 4

Open to speech 3

Open to pain 2

None 1 Verbal

Orientated 5

Confused 4

Inappropriate words 3

Incomprehensible sounds 2

None 1 Motor

Obeys commands 6

Localises pain 5

Withdraws from pain 4

Flexion to pain 3

Extension to pain 2

None 1

D: Disability

Disability refers to the casualty's neurological status. The following need to be assessed.

• Conscious level is assessed quickly using the AVPU method (see below). The Glasgow Coma Scale (GCS) score is the preferred method for assessing conscious level (see Table 14.4). A scoring chart should be available on the resuscitation room wall. The best score is recorded. Some patients who appear deeply unconscious may respond to a painful stimulus. The lowest score that can be achieved is 3. Patients with a GCS score less than 8 are in a coma and will usually require tracheal intubation. Common causes of a low GCS score in the trauma casualty are hypovolaemia, hypoxia, head injury and drugs or alcohol.

• Pupillary reflexes - both pupils need to be assessed simultaneously. They should be equal in size. Both pupils should react when a light is shone on one eye (direct and consensual light reflex present).

• Lateralising signs - the patient should move both sides of their body.

AVPU for assessing conscious level:

A - Alert. The casualty is awake and fully orientated.

V - Vocalising. The casualty is awake and confused.

P - Pain. The casualty only responds to a painful stimulus, such as pressure on the nail bed or supra-orbital ridge. U - Unresponsive. There is no response to painful stimuli.

If a head injury is suspected, the casualty's ABCs need to be optimised as described above to prevent further brain damage. This requires tracheal intubation with sedation and controlled ventilation if the GCS score is 8 or less. Further care needs to be discussed with a neurosurgeon. The response will include a CT scan and possible transfer to a neurosurgical centre for further management. Hypoxia and hypotension must be avoided to improve outcome in severe head injury (Chestnut et al. 1993). Current national guidelines for management of head injury should be followed (Scottish Intercollegiate Guidelines Network (SIGN) 2000).

Large numbers of casualties present with minor head injuries and concussion. Departments usually have guidelines to deal with these with regards to investigations (X-rays, CT scans) and admission or discharge. Those discharged after head injuries need to be supervised by a responsible adult and advised to return to the department if symptoms (including headache, blurred vision, nausea, vomiting) worsen. A head injury advice sheet with emergency contact details should be provided. Neurological status can change over time. Assessments need to be taken and recorded at regular intervals and recorded on a 'Neurological Observation' chart.

E: Exposure and environment

The casualty must be adequately exposed to allow a full head-to-toe assessment, requiring the removal of their clothes. Specially designed cutters are available to assist in this. Patient dignity must be maintained at all times. Efforts should be made to prevent hypothermia although a mild degree of hypothermia may be beneficial in head injury patients (Bernard & Buist 2003). It is therefore important not to over warm patients. The patient's temperature should be measured regularly and controlled appropriately.

Monitoring

Monitoring of the patient is required during resuscitation. The most important monitors are the members of the resuscitation team who look, listen and interact with the patient. The use of monitoring equipment allows earlier detection and measurement of physiological variables such as pulse, heart rate and blood pressure. A monitor will not tell you that the patient is bleeding or has a tension pneumothorax. It will merely alert you to any changes in physiological variables that occur with these conditions. The minimum monitoring required for the seriously injured patient includes:

• pulse rate and oxygen saturation using a pulse oximeter;

• blood pressure using an automated cuff;

• electrocardiogram (ECG) will give you the heart rate and rhythm;

• respiratory rate;

• capnography to measure end-tidal carbon dioxide concentration in the intubated ventilated patient;

• temperature monitoring - tympanic temperature probes are most commonly used to measure temperature intermittently. An oesophageal probe is best for continuous monitoring in the intubated and ventilated patient.

The record keeper should enter these details on the trauma observation chart. For an example of a trauma chart see: www.emergency-nurse.com/tchart/.

History of events

It is important that the cause of the injury is known and the exact sequence of events gives an idea of what type of injuries to expect. The mnemonic AMPLE offers a useful way of remembering the important areas of the history.

It is important to ensure that all the information required is obtained before paramedics or relatives leave the emergency department. It is also vital to correctly identify the casualty and affix name bands.

Adjuncts to the primary survey

To complete the primary survey of the seriously injured casualty, the following must also be considered.

• X-rays - chest and pelvic X-rays are a mandatory part of the primary survey in the seriously injured casualty. These can be taken whilst resuscitation is ongoing. Imaging for spinal fractures can wait until the patient is stabilised as long as precautions are taken to immobilise the spine. Time should not be wasted obtaining cervical spine images if this will delay treatment for life-threatening injuries.

• Nasogastric tube insertion - if the patient has a base-of-skull fracture the nasal route should be avoided.

• Urinary catheter insertion - expert help is needed if there is a pelvic fracture or evidence of urethral injury.

• Analgesia is an important part of initial treatment. Small doses of intravenous morphine can be titrated to relieve pain. Reducing fractures also reduces pain.

• There is a high risk of pressure sores developing if an injured casualty is immobilised on a long spine board. It is therefore good practice to remove the board as early as possible (Porter & Allison 2003). This requires log rolling the patient (see below).

• Further management of the seriously injured casualty often requires the involvement of a number of specialists (e.g. orthopaedic surgeons, neurosurgeons, radiologists, inten-sivists). It is important to contact them early if their services are likely to be required.

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