Trauma Survey

Trauma Survey

David Ray Velez, MD

Table of Contents

Primary Survey
   – Approach
   – Components
Secondary Survey
Tertiary Survey

Primary Survey – Approach

Definition: An Initial Rapid Assessment of the Trauma Patient for Life-Threatening Injuries

All Traumas Start with an Efficient Primary & Secondary Survey

Traditional Approach: “Airway First”

  • “A-B-C-D-E”

Modern Approach: “Circulation First”

  • “x-ABC”
    • x: Exsanguination Control
    • A: Airway
    • B: Breathing
    • C: Circulation
  • “CAB” – From the American Heart Association (AHA) for CPR
    • C: Circulation
    • A: Airway
    • B: Breathing
  • “MARCH” – From the Military Tactical Combat Casualty Care (TCCC)
    • M: Massive Hemorrhage
    • A: Airway
    • R: Respiratory (Breathing)
    • C: Circulation
    • H: Hypothermia/Head Injury

In General, a “Circulation First” Approach (x-ABC) to Control Massive Hemorrhage is Preferred in Trauma as Induction/Intubation Can Cause Hemodynamic Collapse While Hemorrhage Control and Improved Circulation Can Benefit Respiratory Function

  • Generally Try to Avoid Intubation in Hemorrhagic Shock Until in the OR Ready to Source Control (Even if GCS ≤ 8)

The Traditional “Airway First” Approach (ABCDE) is Still Preferred for Traumatic Injuries Causing Airway Obstruction or Compromise

Adjusted Algorithm for Cardiac Arrest (Outside of the ED Thoracotomy Indications)

  • Adjusted Algorithm: “A-A-B-B-C-C”
    • Airway
    • Access
    • Bilateral Chest Tubes
    • Blood Products
    • Cardiac US
    • CPR (ACLS)
  • Includes Situations Such as “Unwitnessed” Blunt Trauma, Penetrating Trauma > 15 Minutes, and Facilities with No Surgical Capabilities

Primary Survey – Components

A: Airway

B: Breathing

  • Goal: Assess Pulmonary Function
  • Assessment:
    • Respiratory Rate and Rhythm
    • Chest Wall Movement
    • Lung Auscultation
    • Oxygen Saturation

C: Circulation

  • Goal: Assess Effectiveness of Cardiac Output
  • Assessment:
    • Blood Pressure
    • Heart Rate
    • Check for Pulses Throughout the Body
    • Capillary Refill
  • Always Secure Two Large Bore (16 or 18-Gauge) Peripheral IV’s
  • If Unable to Achieve IV Access: Intraosseous (IO) Cannulation
    • Peds: Proximal Tibia (Distal Femur #2)
    • Adults: Sternum (Proximal Tibia #2)
  • Consider Cordis Central Line if Anticipating Massive Transfusion

D: Disability

  • Goal: Assess Neurological Status
  • Assessment:
    • Level of Consciousness
    • Glasgow Coma Scale (GCS)
    • Pupil Response
  • Posturing:
    • Decerebrate
      • Extensor Posturing: Arms Extended, Head Arched Back, and Legs Extended
      • Cause: Brain Stem Damage, Below Level of the Red Nucleus
    • Decorticate
      • Flexor Posturing: Arms and Wrists Flexed, Fingers Clenched, and Legs Extended (MNEMONIC: “De-CORE-ticate – Arms to the Core”)
      • Cause: Disinhibition of the Red Nucleus
  • Glasgow Coma Scale (GCS)
    • The Most Prognostic Factor is Motor Function
Score Motor (6) Verbal (5) Eyes (4)
1 None None (1T: Intubated) None
2 Decerebrate Incomprehensible Open to Pain
3 Decorticate Inappropriate Open to Speech
4 Withdraws to Pain Confused Spontaneous
5 Localizes Oriented
6 Obeys Commands

MNEMONIC for GCS Motor Scoring: “Up-Down-Up-Down” with Arms

  • 6 – Normal (Follows Commands)
  • 5 – Up (Localizes to Sternal Rub)
  • 4 – Down (Withdraws to Sternal Rub)
  • 3 – Up (Decorticate)
  • 2 – Down (Decerebrate)
  • 1 – Nothing

E: Exposure

  • Goal: Achieve Complete Exposure to Completely Evaluate for Other Injuries
  • Interventions:
    • Thoroughly Expose Skin
    • Remove All Clothing/Undress
    • Cover with Warm Blankets

Secondary Survey

Definition: A Head-to-Toe Injury Inventory and Exam Performed After the Primary Survey

Includes “AMPLE” History

  • Allergies
  • Medications
  • Past Medical History
  • Last Meal & Oral Intake
  • Events Leading to Presentation

Tertiary Survey

Definition: A Repeat Head-to-Toe Injury Inventory and Exam Performed Later to Evaluate for Missed Injury

  • Also Includes a Review of Every Diagnostic Imaging Study

Timing

  • Occurs After Stabilization and the Initial Interventions are Complete
  • Typically After Extubation or On Hospital Day #2

7-13% of Trauma Patients Have Missed Injuries on the Initial Evaluation