Moving on to C.
Circulatory insufficiency is very common in trauma.
Obviously, trauma is associated with bleeding.
So we very often see patients who have significant blood loss
and circulatory compromise as a result of that.
The things you wanna look for
when you're thinking about a patient circulation
is just their overall appearance.
Are they pink and perky?
or are they pale, or cyanotic, or altered?
These are things that should help you
get sort of an overall global sense
of the adequacy of their perfusion.
You can also look at things like capillary refill,
you wanna look for signs of external bleeding,
because a patient who has a wound
that’s actively hemorrhaging,
you're clearly gonna wanna control that bleeding
before you do much of anything else.
We also wanna feel their peripheral pulses.
And the peripheral pulses are really important
because they give you a quick sense
of the patient's blood pressure,
which is really the bottom line
on the adequacy of their perfusion.
So a patient who has a nice,
bounding, easily palpable dorsalis pedis pulse,
has a systolic blood pressure of 90 or more.
So that’s a pretty quick way
if you feel those dorsalis pedis pulses
and you're satisfied that they’re palpable and normal,
that is a pretty quick way to say, "Yeah.
“You know what?
My patient's circulatory status is probably adequate
at least right at this moment.”
Moving farther proximally,
radio pulses indicate a systolic of at least 80.
Femorals can indicate a systolic of at least 70.
And you don't lose your carotid pulse
until your systolic goes below 60.
getting a feel for which pulses are present,
and which pulses are absent,
can give you a pretty accurate sense
of what your patient's blood pressure is
and whether or not their perfusion is adequate.
once you get your patient hooked up to the monitor,
you wanna know what their heart rate is,
and you wanna know what their blood pressure is
because these are our circulatory vital signs
and they're gonna be used to guide our resuscitation
and help us decide whether or not
our resuscitative efforts are effective.
So our big circulatory life threat,
like I already mentioned,
is gonna be hemorrhagic shock.
Trauma is strongly associated with blood loss
and this is by far the most common cause of death
among traumatically injured patients.
However, we wanna consider other causes of shock as well,
specifically tension pneumothorax and cardiac tamponade.
Both of these are forms of obstructive shock,
where the injury
prevents normal blood flow back to the heart
from the venous circulation
and impairs cardiac output that way.
Again, we're gonna talk about both of these disease entities
in some detail in future lectures,
but you should be aware that not all shock and trauma
is gonna be related to hemorrhage.
There are these other disease processes that can lead to shock.
While we’re managing circulation,
I already alluded to this before,
but clearly if a patient has blood spurting out of a wound,
you're gonna wanna apply some direct pressure to that
to get that bleeding under control.
This is gonna be one of our immediate maneuvers that we do,
during the primary survey to stabilize the patient.
we wanna make sure that our patient has adequate IV access.
This means two large-bore peripheral IV’s.
So you don't want just one, you want two,
'cause you wanna backup in case
yours falls out or infiltrates.
You wanna make sure there are large bore,
so that you can get a lot of fluid through them if you need to.
If you can’t get large bore peripheral access,
you have other alternatives.
You can place an intraosseous line,
or you can place a trauma line,
which is a specialized central venous catheter
that’s very large in diameter
and allows large volume resuscitation.
When you do initiate fluid,
you're always gonna start with isotonic crystalloid.
normal saline or lactated ringers for most patients.
Now every now and then,
if you know upfront there was a large amount of blood loss,
either because the patient
is actively losing blood right in front of you
or because the paramedics report
that there was a lot of blood at the scene,
you might consider going straight to blood transfusion,
but generally, we're gonna start off with isotonic crystalloid
and only move on to blood,
if we don't got a satisfactory response from crystalloid.
Again, we're also gonna be looking for a specific injury patterns,
and we’re gonna be providing treatments
based on those underlying injuries.
We're gonna talk about tension pneumothorax
and cardiac tamponade in future lectures.
So don't worry too much about that right now.
But understand that certain disease processes
have specific treatments that you need.
You're not just gonna treat all hypertension or shock with fluid.
Moving on toward disability assessment.
So once we’ve covered A, B and C,
the next thing we wanna think about
is our patient’s neurologic status.
So we always wanna formally assess their level of consciousness.
The Glasgow Coma Scale is what’s used most commonly for this
and we're gonna talk about that in some detail
in our head injury lecture.
However, you can also use the abbreviated AVPU scale.
Which stands for alert, verbal, pain, or unresponsive.
Meaning, your patient is alert and normal,
they respond only to verbal stimuli,
they respond only to painful stimuli,
or they’re completely unresponsive.
And as you can imagine,
patients who only respond to pain or don't respond at all
are clearly very ill
and you should be very concerned about them.
While we’re doing our neurologic survey,
we always wanna look at the pupils.
Pupillary function gives us a sense
of whether the patient has a focal neurologic lesion or not.
We wanna look four extremity movement
to make sure that there's not any evidence of neurologic focality
that might suggest a brain or a spinal cord injury.
We wanna look for external signs of head or neck trauma,
that may point us in the direction
of a significant head her neck injury.
if our patient is in any way shape or form altered,
we wanna check their glucose.
trauma doesn't make you hypoglycemic,
trauma is always precipitated by some event, right?
And it’s not uncommon that people
with medical illnesses will sustain trauma.
So if your patient became hypoglycemic
that made them confused
and then they crashed their car.
You know, clearly they're gonna have both the medical problem
that precipitated the event
as well as the traumatic injury for you to deal with.
So you wanna make sure
that you're considering the big picture for your patient.
Checking their glucose,
and checking other — for other signs of medical illness
that might have contributed to the current event today.
There are a number of neurologic life threats
that we’re looking for on our primary survey.
And we’re gonna talk in more detail about these
in future lectures.
But these include any type of penetrating cranial injury,
diffuse axonal injury
and also high spinal cord injury,
like C-Spine injuries.
In the realm of intracranial hemorrhage,
we have a variety of different disease entities to think about.
We’ve got our subdural hematomas or epidural hematomas
our traumatic subarachnoids
and then lastly,
intraparenchymal and intraventricular bleeding.
All of these are managed differently
and we’re gonna talk about them in detail in the future lecture.
So what are we gonna do initially
in our primary survey for patients
who show signs of significant neurologic impairment?
Well first and foremost,
if their GCS is below eight,
we wanna go ahead and intubate.
Patients who are significantly comatose
are not gonna be able to maintain their own airways.
So it's very, very important
that we manage the airway
and make sure that the patient maintains a stable airway
for the duration of their care.
We’re also of course gonna optimize their oxygenation
and their perfusion.
So we're gonna be giving them supplemental oxygen.
If they’re intubated,
we're gonna be placing them on a ventilator
and we're gonna give fluids, blood, etcetera
to ensure that they have adequate systemic perfusion.
We do wanna obtain emergent cranial imaging
for any patient who has a significant neurologic disability
on our evaluation,
and the test of choice is really none contrast head CT.
But obviously, we’re not gonna initiate that
until the patient is stable from an ABC perspective.
there are specific disease entities that we’re looking for
and how we manage those is gonna to vary
depending on our CT findings.
So we’re gonna talk in more detail
about how we would approach
each one of these injury types as we move forward.
Lastly, after we've covered A,B,C and D,
we wanna think about exposing the patient.
This is really, really important.
You've got to take all their clothes off,
you’ve got to get all the coverings off.
You don't wanna miss any injuries,
and I can't tell you how many times in my own practice
I've seen injuries that are missed,
because people don’t undress their patients.
So get the clothes off,
get the sheets off,
get a good look head to toe
at the patient’s entire skin.
While you're doing that however,
you wanna avoid hypothermia.
So hypothermia causes coagulopathy
and exacerbates bleeding and trauma.
So you wanna expose your patient and look at them.
But once you've done that,
get them covered up again,
make sure you keep the room warm,
make sure you use warm blankets,
because trauma patients
can actually become hypothermic very quickly.
Lastly, you’re gonna complete a head to toe exam.
So you wanna make sure that you look
not only at the obvious stuff,
but in the all the nooks and crannies.
You wanna look up in the axillae,
in the perineum.
You wanna roll the patient over to examine the back
obviously, while maintaining C-Spine immobilization.
And you wanna also make sure
you get a look at the back of the head and the neck
which is especially important
in patient’s wearing cervical collars.
We often miss those if we don't remove the collar
to examine the patient.
So take home points from this lecture,
you’ve got to do a primary survey in all of your trauma patients,
you’ve got to do it the same way every single time,
so that you don't miss things,
you got to be super systematic about this.
You wanna make sure that you look for specific life threats
in the A, B, C and D domains.
And you wanna treat those as you identify them.
You wanna know the differential of consequence
for A, B, C and D
so that you know what you're looking for
when you are doing your primary survey.
And if you follow these steps,
you're gonna have a successful trauma resuscitation
for all of your patients.