Initial Assessment of Trauma Patients

Initial Assessment: Overview & Principles - Trauma Triage Time

• Guided by ATLS® (Advanced Trauma Life Support) principles for systematic, rapid evaluation.
• Golden Hour: First 60 minutes post-injury are critical; emphasizes urgency for definitive care.
• Triage: Prioritizes patients based on injury severity, physiological stability, and survival likelihood.
  • Aim: Rapidly identify those needing immediate life-saving interventions.
• Initial approach involves a swift primary survey (ABCDE) with concurrent resuscitation.

⭐ The "trimodal death distribution" in trauma highlights three peaks: immediate (seconds to minutes), early (minutes to hours - the "Golden Hour"), and late (days to weeks).

Primary Survey (A,B): Airway & Breathing - Gasping for Action

A: Airway & C-Spine Control

• Assess: Patency (verbal response?), obstruction signs (stridor, gurgling, hoarseness). Assume C-spine injury: Manual In-Line Stabilization (MILS).
• Intervene:
  • Basic: Jaw thrust (preferred in trauma), chin lift. Oropharyngeal Airway (OPA) if no gag; Nasopharyngeal Airway (NPA) if no suspected basal skull fracture.
  • Advanced (Definitive Airway): Endotracheal Intubation (ETI) for GCS < 8, apnea, impending airway obstruction, or inability to protect airway.
    • 📌 LEMON for difficult airway: Look, Evaluate 3-3-2, Mallampati, Obstruction, Neck mobility.
  • Surgical: Cricothyroidotomy if ETI fails or is contraindicated.

B: Breathing & Ventilation

• Assess: Expose chest. Respiratory Rate (RR), effort, SpO2. Inspect for chest wall movement, wounds, cyanosis. Auscultate for bilateral air entry. Palpate for crepitus, tenderness.
• Intervene: High-flow oxygen (10-15 L/min via non-rebreather mask) for all.
• Manage Life Threats:
  • Tension Pneumothorax: Clinical diagnosis. Needle decompression (2nd ICS MCL or 5th ICS AAL) → chest tube.
  • Open Pneumothorax ("sucking chest wound"): Three-sided occlusive dressing → chest tube.
  • Massive Hemothorax: Chest tube insertion. >1500mL initial drainage or >200mL/hr for 2-4 hrs indicates urgent thoracotomy.
  • Flail Chest: Analgesia, oxygen. Positive Pressure Ventilation (PPV) if respiratory failure.

⭐ Unexplained shock combined with unilateral decreased/absent breath sounds and tracheal deviation away from the affected side strongly suggests a Tension Pneumothorax. This requires immediate needle decompression without waiting for radiological confirmation.

Primary Survey (C): Circulation & Hemorrhage - Bleeding Edge Battles

• Assess for Shock: Tachycardia, hypotension (late), ↓peripheral pulses, cool/clammy skin, Capillary Refill Time (CRT) >2s, altered Level of Consciousness (LOC). Urine output goal: >0.5 ml/kg/hr.
• Control Hemorrhage:
  • External: Direct pressure, tourniquet (for extremity), hemostatic agents.
  • Internal: Pelvic binder (if suspected pelvic fracture), rapid transport for definitive surgical care.
• IV Access & Fluids:
  • Two large-bore IV cannulas (14-16G). Intraosseous (IO) access if IV attempts fail.
  • Initial: Warm crystalloids (Normal Saline/Ringer's Lactate) 1L bolus for adults; 20 ml/kg for pediatrics. Reassess response.
  • Blood Products: Early consideration for Packed Red Blood Cells (PRBCs), Fresh Frozen Plasma (FFP), Platelets in a 1:1:1 ratio (Massive Transfusion Protocol - MTP).
  • Tranexamic Acid (TXA): 1g IV over 10 min within 3 hours of injury, followed by 1g IV over 8 hours if significant bleeding.

⭐ Permissive hypotension (target Systolic Blood Pressure SBP 80-90 mmHg, Mean Arterial Pressure MAP >65 mmHg) is crucial in penetrating trauma without Traumatic Brain Injury (TBI), until definitive hemorrhage control is achieved.

Primary Survey (D,E) & Adjuncts - Nerve & Naked Truths

• D: Disability (Neurologic Status)
  • GCS: 📌 EVM (Eyes 4, Verbal 5, Motor 6). Score ≤ 8 → Intubate.
  • Pupils: Assess size, equality, reactivity (PERRLA).
  • Gross motor & sensory deficits (e.g., limb movement, response to pain).
• E: Exposure & Environment
  • Completely undress patient ("Naked Truth") to examine head-to-toe.
  • Prevent hypothermia: Target core temperature > 35°C. Use warm blankets, warmed IV fluids.
  • Log roll (maintaining C-spine precautions) for spine/back assessment.
• Adjuncts to Primary Survey & Resuscitation
  • Monitoring: ECG, SpO2, NIBP/Arterial line, ETCO2 (if intubated), Core Temperature.
  • FAST scan (Focused Assessment with Sonography for Trauma).
  • X-rays: AP Chest, AP Pelvis. (Consider C-spine X-ray if CT unavailable & suspicion high).
  • Labs: ABG, CBC, Coagulation profile (PT/INR, aPTT), Type & Screen/Crossmatch, Lactate, Glucose.
  • Urinary catheter (check for contraindications: blood at meatus, perineal hematoma).
  • Gastric tube (NG/OG - check for contraindications: mid-face fractures for NG).

⭐ Hypotension (SBP < 90 mmHg) in an adult trauma patient is assumed to be of hemorrhagic origin until proven otherwise.

High‑Yield Points - ⚡ Biggest Takeaways

• The ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) is fundamental in trauma assessment.
• Always suspect and immobilize the cervical spine until injury is ruled out.
• Rapid hemorrhage control and early balanced resuscitation with blood products are critical.
• Glasgow Coma Scale (GCS) is key for assessing neurological status (Disability).
• A concise AMPLE history (Allergies, Medications, Past illnesses, Last meal, Events) is vital.
• Aggressively prevent/treat the lethal triad: hypothermia, acidosis, coagulopathy.
• Employ Damage Control Resuscitation (DCR) for patients with massive hemorrhage.