The successful management of severe trauma is dependent on the following six steps.
| 1 | Triage |
| 2 | Primary survey |
| 3 | Secondary survey |
| 4 | Stabilization |
| 5 | Transfer |
| 6 | Definitive care. |
The sequence of PTC is illustrated in Figure 16.1 (page 16–4):
| 1 | Start resuscitation at the same time as making the primary survey |
| 2 | Do not start the secondary survey until you have completed the primary survey |
| 3 | Do not start definitive treatment until the secondary survey is complete. |
TRIAGE
Triage means sorting and treating patients according to priority, which is usually determined by:
| :: | Medical need |
| :: | Personnel available |
| :: | Resources available. |
Patients are routinely sorted according to priority:
| 1 | In the clerking of patients |
| 2 | Setting the order of operating lists |
| 3 | In emergency rooms |
| 4 | In emergency rooms |
| 5 | In disaster areas. |
PRIMARY SURVEY
This section is covered at length in the Annex: Primary Trauma Care Manual.
Make a full primary and secondary survey of any patient who is injured, especially patients who have:
| :: | History of:
| A fall >3 metres |
| Road traffic accident: net speed >30 km/hour |
| Thrown from a vehicle or trapped in a vehicle |
| Pedestrian or cyclist hit by a car |
| Unrestrained occupant of a vehicle |
| Death of a person in the same accident or from assault |
| Injury from high or low velocity weapon | |
| :: | And/or on examination:
| Airway or respiratory distress |
| Blood pressure <100> |
| Glasgow Coma Scale <13/15> |
| Penetrating injury |
| >1 area injured. | |
The importance of ABCDE
ABCDE is a simple way of remembering the essentials of the primary survey. This is the first survey of PTC; it is also something you must return to whenever the patient’s condition becomes worse – whether this occurs 5 minutes or 5 days after the patient arrives.
A is for Airway
No oxygen can reach the tissues if the airway is obstructed; the commonest cause of obstruction is unconsciousness combined with the supine position, which causes the tongue to fall back and the pharynx to collapse. Other causes include neck trauma and foreign bodies.
B is for Breathing
Even with an open airway, no oxygen reaches the lungs unless the patient is breathing or someone provides artificial ventilation of the lungs. Breathing may stop because of severe head injury, hypoxia, mechanical or circulatory arrest.
C is for Circulation
Oxygen in the lungs cannot reach the tissues unless the heart is working; common reasons for inadequate circulation include blood loss (shock) and increased pressure on the heart from pneumothorax or haemopericardium. Shock and low blood pressure are dangerous for all patients, but especially for patients with head injury, as the blood supply to the brain will be further reduced. This causes a vicious circle in which hypoxia causes further brain swelling which, in turn, reduces the flow of blood to the brain.
D is for Disability and neurological Damage (brain and spinal cord)
Checking for neurological damage is a vital part of the primary survey. Do not make a full neurological examination at this stage. Grade the patient’s initial level of consciousness using a simple classification such as:
A Alert
V Verbal response
P Resonance to Pain
U Unresponsive.
Complete the examination within 30 seconds.
E is for Exposure
Remove the patient’s clothing and examine the whole patient, front and back, but do not allow the patient to get cold. Examining the whole patient is the only way to be sure that you have not missed other injuries.
Immediately treat any life-threatening problems, such as bleeding, pneumothorax or obstructed airway, that you find during the ABCDE primary survey. Less urgent problems, such as an arm fracture, must wait until the patient is stable; they will be picked up in the secondary survey and should be treated appropriately in the definitive care phase.
The ABCDE is easy to remember in English. If you are reading this in another language, try to find a simple way of remembering these points in the right order in your own language. In an emergency, a simple aid such as this is useful to help you remember the six phases of Primary Trauma Care Management, but it does not replace the need to think carefully about each patient.
Resuscitation skills
There are a small number of practical skills that are essential for the initial resuscitation of injured patients. The only way to learn them is by gaining practical experience under the supervision of a person who is skilled in their use. An experienced anaesthetist or trauma surgeon will also be able to help you gain practice and experience.
The skills you need include:
| :: | Making a rapid examination to diagnose and treat life-threatening injuries, including the possible need for cardiopulmonary resuscitation |
| :: | Airway skills: simple manoeuvres, artificial airway use, tracheal intubation and tracheostomy, if needed |
| :: | Reliably siting an intravenous cannula in any available vein |
| :: | Management of shock |
| :: | Patient handling: care of spinal injuries, in-line traction and log rolling |
| :: | Insertion of a chest drain. |
These techniques, and other procedures such as tracheostomy, are covered in the Annex: Primary Trauma Care Manual and on pages 16–8 to 16–13.
SECONDARY SURVEY
The purpose of the secondary survey is to make sure you examine all systems and parts of the body to ensure that nothing important is missed. During the secondary survey, you should identify all the injuries and start to think about your treatment plan. An X-ray examination, if available, is part of the secondary survey.
If there is any unexplained deterioration at any time, you must repeat the primary survey.
During the secondary survey, look in detail at:
| :: | Head, neck and spine |
| :: | Nervous system: now you can do a more extensive neurological examination |
| :: | Thorax |
| :: | Abdomen: if you suspect intra-abdominal bleeding consider diagnostic peritoneal lavage; even if this is negative, you may need to do an urgent laparotomy |
| :: | Pelvis and limb injuries |
After the secondary survey, fully document your findings, including:
| :: | Detailed history of the injury |
| :: | Previous medical history |
| :: | Medication |
| :: | Drug allergies |
| :: | Findings during examination of primary and secondary survey:
| • | Results of any special investigations | | • | Details of treatment given and the patient’s response. | |
STABILIZATION AND TRANSFER
You have examined the patient, treated life-threatening conditions and made a second examination to detect any other injuries. The management plan of the patient should now be clear.
When documentation has been completed, analgesia administered, laboratory investigations sent and any fractures immobilized, you can then decide on the best treatment option:
| :: | Transfer to the ward |
| :: | Transfer to the operating room |
| :: | Transfer to the X-ray department |
| :: | Transfer to another hospital. |
Before referring a patient:
| :: | Remember that referral is not a form of medical treatment |
| :: | Make contact with the referral centre to ensure that they can help |
| :: | Anticipate what else may go wrong on the road and be prepared for it |
| :: | Provide pain relief for the journey |
| :: | Arrange for a trained person to go with the patient. |
For more details on transfer, see pages 1–15 and 3–3.
DEFINITIVE CARE
Once the patient has been resuscitated, stabilized and transferred, the planned correction of the injury can proceed.
In order to save the patient’s life, it may be necessary to carry out an immediate surgical procedure as part of the initial primary survey and early resuscitation. The decision whether to rush the patient to the operating room needs careful consultation and good communication between the surgeon and anaesthetist.
Special patients and special situations
Be aware of special patients and special situations. Children and pregnant women, for example, have special needs and may need different treatment because their anatomy and physiology vary from that of a non-pregnant adult. Details of the differences are given in Unit 3.2: The Paediatric Patient, Unit 14.3: Paediatric Anaesthesia and the Annex: Primary Trauma Care Manual.
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