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 internal hemorrhaging
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.
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.