Now, we’re gonna talk about the overall approach to the traumatically injured patient.
Management of trauma always begins with the primary survey.
The primary survey is a standardized way
of performing your initial assessment of all trauma patients.
And it should be done exactly the same way
every single time in every single case, so you don’t miss anything.
There are two major goals of the primary survey.
One is to identify life threats quickly,
and two, is to provide stabilization when life threats are identified.
It’s very important to remember that the primary survey isn’t just about diagnosis.
It involve simultaneous assessment and treatment of the patient
to insure that they remain stable and that life threats are quickly addressed.
The primary survey follows the same order every time.
It begins with airway, followed by breathing, circulation, disability
and lastly exposure of the patient and assessment of the environment.
So when we talk about assessing the airway.
The first thing to do is simply speak to the patient.
Ask them their names, get them to tell you what happened to them.
Any patient who’s able to talk by definition has a patent airway
and that’s clearly a good sign.
However, remember just because you have a patent airway right now,
it doesn’t mean you’re gonna have a patent airway 15 or 30 minutes from now.
So you wanna not only identify current airway obstruction,
but also risks for potential future airway obstruction.
What if the patient's not actually talking to you?
Well, the question you should ask yourself is why?
If the patient is unconscious or unresponsive then that suggest a head injury.
And if they have a significantly depress GSC
you probably wanna go ahead
and provide definitive airway management in the form of intubation.
If the patient is conscious but they're unable to phonate.
They're trying to speak but...
this is a sign of significant airway injury.
And you wanna make sure that you address that quickly.
This is a situation where you’re gonna want to emergently intubate the patient
or otherwise manage the airway if intubation is impossible.
So what are the kinds of things we’re looking for in terms of airway life threats?
Well, for patients who have a currently patent airway
but you wanna know whether they’re gonna lose their airway in the future.
Things you wanna look for are swelling.
So any kind of hematoma in the face and neck.
Any kind of edema in the face or neck.
These can compress the airway.
You wanna look for bleeding, in particular nasopharyngeal bleeding
that’s going from the pharynx back into the oral cavity can cause aspirations.
We wanna be aware of that and address it.
And then last we wanna palpate for crepitus
and we do that by feeling for that crispy crunchy feeling in the neck and upper chest.
This suggest some kind of injury to the airway structures either the larynx or the trachea
which again would mandate definitive airway managements.
While we’re thinking about the airway,
we always wanna think about the cervical spine.
So the cervical spine should be immobilized in trauma patients
in case they do have an injury.
And any time a patient has a high C-spine injury,
they can actually lose their respiratory drive.
There’s a rhyme C3, 4, 5 keeps the diaphragm alive.
So patients who have injuries in those regions of the spinal cord
might have impaired respiration not because of an airway problem
but because of difficulty breathing from diaphragmatic paralysis.
Lastly, we just wanna think about burns.
We have a whole separate lecture about burns
and we’ll talk about the burned airway there.
But for patients who do have any kind of burn as part of their trauma.
You wanna just remember that thermal injury can cause airway edema
and inhalational injury can cause damage to the lungs
which in turn can make the person hypoxic.
So these are all things that you wanna think about
for the airway of an injured patient.
Whenever you do identify airway compromise,
either currently or you think it’s gonna eminently develop,
you wanna go ahead and intubate your patient.
However, in trauma, there is often distortion of the normal anatomy.
If the patient has swelling or bleeding or facial fractures, those kinds of things.
The airway might be very technically challenging.
And to further add to our technical challenges,
we have to maintain spinal immobilization.
We can’t just crank the patient’s neck in any direction
because we don’t know whether or not they have an underlying injury.
So you need to be really proficient with airway management,
if you are gonna tackle a trauma airway.
And if this isn’t something you have a lot of experience with,
you’d probably wanna get back up from an anesthesiologist,
although for emergency physicians of course,
we would expect this is something you would be able to handle.
Always bear in mind,
that if you’re unable to intubate successfully in a noninvasive way
you need to think about the possibility of a surgical airway.
So surgical cricothyrotomy would be the procedure we would use
for the patients who have severe facial or neck injuries that preclude intubation.
And again, if you’re gonna be managing trauma airways,
this is a procedure that you need to master.
Now, we’re gonna move on to breathing.
And I’ll tell you in my 15 years of practice experience,
I can tell you that traumatic injuries to the airway are actually relatively rare.
I’ve only seen a handful in all my years of practice.
Whereas pulmonary injuries, chest injuries that lead to respiratory compromise.
These are very common,
and these are something that you see regularly in the Emergency Department.
So airways are incredibly important.
And airway injuries are really life threatening
but breathing is where you’re gonna find more pathology
and more often need to intervene.
When you’re assessing a patient’s breathing in trauma,
one of the first things you wanna do is listen to their breath sounds bilaterally.
And what you’re listening for
are the presence of equal bilateral breath sounds on both sides of the chest.
You also wanna look and just get an overall feel for their respiratory effort.
You know, of course you’re gonna note their respiratory rate
and you’re probably gonna pay attention
to specifically what they’re doing when they’re breathing.
But at the beginning, if you just get a visceral sense
of whether they're kinda chilling, breathing comfortably
or if they’re working really hard to breath.
They’re using additional muscles and they’re having a pull air in,
that should give you a sense of the severity of their respiratory compromise.
You of course wanna count the respiratory rate.
Again, this is a vital sign that is often documented incorrectly.
And when that you really wanna double check yourself.
And you should always be concerned about a patient with significant tachypnea,
because that somebody who can tire out and really got themselves into trouble shortly.
And then lastly, your respiratory vital sign is your oxygen saturation.
The whole purpose of the lungs is to get oxygen into the blood.
So you need to know if they are fulfilling that purpose effectively or not.
While we are assessing breathing,
we wanna be looking for evidence of pulmonary life threats.
And there are four major ones we wanna think about.
Tension pneumothorax is by far the most common and most serious in the trauma setting.
But you can also see open pneumothoraces,
flail chest which is always associated with underlying pulmonary contusion
and then massive hemothorax.
Whenever you suspect that the patient has a compromise of their breathing,
we always wanna initiate supplemental oxygen.
You should give them whatever flow they need to keep their oxygen saturation normal.
Which is typically gonna be above 95% for somebody with healthy lungs.
You also wanna initiate emergency treatment
for any patient in whom you identify a life threatening pulmonary injury.
Now, we have a whole other lecture on chest trauma,
and I’m not gonna get into each of this too much right now.
But there are immediate interventions for each one of these injuries
that you can perform during the primary survey to stabilize your patient.
Once your patient is stable
and you’re satisfied you don’t have an immediate life threat in the pulmonary domain,
we wanna get a chest x-ray to evaluate their lungs
and get a sense of what’s going on with them from a pulmonary injury stand point.
But we don’t wanna be getting chest x-rays
until we’re satisfied that the patient is stable.