ACUTE MAYOR TRAUMA ALGORITHM- PRIMARY SURVEY

• Approach the patient from the side confirming that its safe to approach- shout for help.

1. AIRWAY + C-SPINE:

• Stand behind patient with your hands stabilizing the head (fingers apart so that they don’t cover the ears).
• Confirm who is your assistant and ask them to get you a c-spine head brace
• Inspection: airway obstruction- foreign bodies, facial, mandibular, tracheal, laryngeal fractures
• Put your cheek to their mouth and feel for any air movement.
• Interventions: if not breathing do a jaw thrust (will need both hands)
• Suction: to clear the airway of FB.
• Establish a definitive airway: orotracheal or nasotracheal intubation, jet insufflation, surgical cricothyroidotomy.
• Ask assistant for high flow oxygen: 15 litres/min through non- rebreathing (Hudson) mask (provides ~ 85% oxygen).

Indications for definitive airway:
Unconscious (GCS ≤ 8)
Severe maxillofacial fractures
Risk of aspiration (bleeding, vomiting)
Risk of obstruction

2. BREATHING + VENTILATION:

• Inspection: chest wall movement (symmetrical), chest injuries
• Palpation: bony deformities, fractured ribs, wounds
• Interventions: pulse oximeter
• Needle decompression (2^nd intercostal space MCL)
• Chest drain (5^th intercostal space mid axillary line)
• Seal open pneumothorax

Breathing problems identified in 1° survey:
Tension pneumothorax
Flail chest with pulmonary contusion
Massive hemothorax
Open pneumothorax


3. CIRCULATION + HAEMORRHAGE CONTROL:

• Level of consciouness, skin colour, pulse
• Inspection: colour (well perfused or pale), obvious haemorrhage
• Palpation: feel hands (warm or cold), capillary refill time
• Identify external bleeding- strongly palpate chest, abdomen, pelvis, long bones for haemorrhage
• Presence of pulses: carotid (SBP≥ 60 mmHg), femoral (SBP≥ 70 mmHg) and radial (SBP≥ 80 mmHg)
• Interventions: IV access- 2 litres Hartmanns for adult- BBC2- brown cannulae in both arms wherever you can get them. Take blood when put cannulae in for FBC, glucose. Blood transfusion
• Surgical intervention for internal bleeding
• Venous cutdown
• Chest drain: for massive hemothorax
• Pericardiocentesis: for cardiac tamponade
• Blood pressure, ECG

Injuries that acutely impair circulatory status:
External/internal bleeding with hypovolemic shock
Massive hemothorax
Cardiac tamponade


4. DISABILITY + DIABETES:

• GCS, AVPU for medical school
• Pupils: size, equality and reaction
• Blood glucose: pinprick for portable blood glucose monitor
• Interventions: burr holes (for trans-tentorial herniation), IV mannitol

5. EXPOSURE + ENVIRONMENT:

• Completely undressed the patient- prevent hypothermia- injured patients may arrive in hypothermic condition
• Log-roll and warmed crystalloid fluid

6. ADJUNCTS TO PRIMARY SURVEY:

• AP Chest and AP pelvic radiographs
• Urinary Catheter
• Gastric Catheter
• ABG
• DPL (Diagnostic peritoneal lavage) and FAST (Abdominal ultrasonography)
• Analgesia: morphine 10mg in 10ml after you have completed A-C