So you’re in the ER and the doctors and
nurse and therapists are all together
and you’re waiting for
the trauma to come in.
You’ve heard over the radio, a
five-year-old in an MVA roll-over,
non-responsive, coming in via
ambulance, that’s all you know.
The EMTs are typically going
to bring the child in,
they’re going to give you a quick
report at what they saw at the scene.
And you listen carefully.
Roles have already been assigned and
your role was to do your primary survey.
So here’s how we’re going to
through the primary survey.
First, you need to do A, airway.
Airway and cervical spine
control come together
because if you’re trying to
manipulate that airway,
say to open an obstructive airway
and you tip the head back, you could
cause more cervical spine damage.
So we don’t want to do that.
The patient’s in a firm
collar, they should be.
And if not, you’re going
to place them in one
and then you’re going to adjust the
airway by gently doing a jaw thrust.
Then you’re going to inspect the airway
and see if there’s any
problems with the airway.
If the airway is patent, we can move on.
Next is breathing.
If the patient is not breathing,
this is the point at which you would
start breathing for the patient.
If the patient is spontaneously breathing,
you’re going to assess the lung fields and
see whether the air is entering well.
We may at this point do more
interventions if there’s no breathing.
So let’s go through those.
First, when do we intubate?
You need to intubate when you are
unable to effectively bag ventilate
a patient who is not breathing.
You need to intubate if the Glasgow coma
scale is less than or equal to eight.
You need to intubate when the patient
has impending brain herniation
because you may want to hyperventilate
as a way of prophylaxing against that.
You need to intubate if a patient
is in respiratory distress.
You should intubate if a patient
is in uncompensated shock.
In other words, the patient
hasn’t adjusted to the shock
and the heart rate is very high.
And we need to intubate when
there is no laryngeal reflex.
When they can’t protect their own
airway, they need a stable airway.
So let’s say that patient
needed to be intubated
and you have successfully
intubated the patient.
That takes some skill and practice
and that’s perhaps another
lecture for another time.
But you get that tube in, nice job, the
patient is now being ventilated adequately.
Now and only now can you
move on to circulation.
Circulation is generally done
by auscultating the heart
and checking the cap refill
and the femoral pulses.
Those should all be there.
If they’re not, you may have a problem with
hemorrhage, either external or internal.
You want to control the hemorrhage next
before you move on to some other problem.
So we’re going to control
any external hemorrhaging,
we’re going to assess for
and if there is a good
pulse, you can move on.
Next is disability,
decontamination and dextrose.
So let's go through those D's.
Disability is generally understanding
whether the patient has
a problem in terms of
their mental capacity.
We can use the mnemonic
AVPU to help us decide
whether a patient has a disability and
we’ll talk about that in a second.
Decontamination is if there’s
some kind of toxin on their skin
or they’ve been burned or you
want to get the clothes off
and typically at this point, we
will make them completely naked
and roll them and expose
them in the next step.
Also, for kids especially, we add dextrose.
We add dextrose for
kids because, remember,
children have less liver
capacity to store glycogen.
And infants and children are at
increased risk for hypoglycemia.
Another example would be a
child who is found down
and they may have taken
grandma’s Glucophage tablet,
which can cause a glucose
of less than even 10,
you wouldn’t be at this point when you
would figure out,
“Oh, goodness, their
dextrose is low.”
Next is exposure.
We’re going to cut off the clothes
and we’re going to do a team-oriented
log-roll altogether, coordinated.
One, two, three, roll.
And you’re going to look at the
front, back, sides and the groin.
Everywhere you can see, lay an eye on every
square inch of skin on this patient.
You may be surprised at what you see.
There may be a lesion on the back,
which will tell you, “Oops, the
patient was shot with a gun.”
Or you may find burn marks or you
may find evidence of child abuse.
You don’t know what
you’re going to find.
You have to look.
Next is F.
We’ve pretty much finished
the primary survey,
but it’s important to know when
the patient last drank or ate
because that may affect our decision as
to when we can move on with anesthesia
and go into the operating room.
And then lastly is G,
which is general health.
Understand the baseline
health of the child.
If the patient has, say cerebral palsy or
some underlying condition like spina bifida,
it’s important to understand that and what
that patient’s normal expectations are.
If the patient has spina bifida and
doesn’t normally move their legs,
that’s obviously important for you to know
when you’re assessing their leg function.