NOTE

All the medical procedures and drug administration mentioned in this text should be done only under a senior doctor’s consultancy.

 

 

·        Primary survey.

·        On A (airway) we check the airway’s patency. A is also C Spine immobilization (on suspected injury). We open airway with jaw thrust or chin lift (we use jaw thrust on suspected C – spine injury), we do suction (e.g. of vomits), we place an oropharengeal airway (if the airway is endangered and also if no gag reflex) and consider a permanent airway (e.g. ET intubation). On A we also check tracheal position and also for JVD (jugular vein distension).

·        Traps on A (airway) are cribiform and face trauma and base skull fracture with ear or nose leakage of CSF, racoon eyes and Battle sign with haematoma behind the ears and also blood from the ear. In the above cases the nasal airway or the nasogastric tube may enter to the brain so its use is contraindicated!).

·        On B (breathing) we check RR (respiratory rate), chest expansion (if it is equal bilaterally, otherwise suspect e.g. flail chest), we ausculate the chest (is breathe sound bilaterally equal?), we percuss the chest (any tympany?) and take oxygen saturation (SpO2). If RR is < 10 or > 30 (in adults) and/or GCS <_ 8 we ventilate with BMV (bag mask ventilation) or intubate (we use RSI rapid sequence intubation if GCS is >3).

·        Traps on B (breathing) are vulnerable ages (on children rib fractures are rare, if they occur they indicate severe lung injury;  the elderly are vulnerable and they may also suffer from pulmonary oedema after a high fluid resuscitation (e.g. on lung contusion). 

·        On C (circulation) we check pulse (radial and carotid; Is it fast and thready?), BP, pulse pressure (SBP systolic BP – DBP diastolic BP). We obtain vascular (IV/IO) access (2 wide IV lines – grey or orange). On hypovolemia we give 500 ml NS (normal saline) or RL (Ringers - Lactated) and reassess (we may give e.g. 1 – 2 Lt fluids) and also consider early to transfuse blood (if not type available give Group O Rh negative). Fluids should be warm (39 degrees C). On children we give 20 ml/kg fluids. On no response, we repeat 20 ml/kg and if shock still remains we give 15 ml/kg packed red blood cells PRC to 10 ml/kg crystalloids or we give 10 ml/kg whole warmed blood. On hypovolaemic newborn we give10 ml/kg fluids over 5 – 10 min.

 

After IV access we also take blood for Labs (including pregnancy test on women, toxicology, coagulation and blood type and crossmatch – we ask blood units for transfusion). We also look the color and temperature of the skin (a cold clammy skin may indicate shock, however exclude low ambient temperature!), the capillary refill timer (normal is when < 2 sec, on 5 sec finger nail pressure) and LOC (level of consciousness). 

 

We also connect to a monitor, and – if indicated (e.g. heart contusion) – we take a 12 lead ECG. If there is time, we may also take ABGs to check for acidosis.

 

·        On D (disability) we check AVPU (Alert, React to voice, Reacts to pain, Unresponsive), or if there is time (and always on head trauma) we check GCS (Glasgow comma scale). We also check pupil’s size & reaction to light and also for abnormal postures of flexion (decorticate) or extension (decerebrate).

·        Traps on D (disability) are intoxicated patient, or under illicit drugs influence. On a patient with head trauma do not attribute the decreased level of consciousness on drugs or alcohol, unless you exclude head pathology (e.g. increased ICP intracranial pressure). This is also the case in general for a patient with trauma. Other traps is the lucid interval on epidural hematoma, brain’s vasoconstriction from hyperventilation and also ICP increasing with intubation (prevent it with lidocaine as premedication of RSI rapid sequence intubation, and etomidate as an anaesthetic– the last is contraindicated on hypotension – in that case stabilize the patient e.g. with fluids and perhaps with surgery).

·        ΟE (Expose, Environment) we expose the patient (from his/her clothes) and check the skin for clues (wounds, rash, belt sign etc). We also perform log roll and check the back. Next we prevent hypothermia e.g. with blankets. E is also to call Expert! 

·        Traps on E are hypothermia which complicates clotting.

·        Aids on ABCDs are ABGs, SpO2 (oxygen saturation), capnographer (CO2 detector after intubation), Foley, Levine (nasogastric tube), ECG, DPL (diagnostic peritoneal lavage) and FAST.

·        ‘TREAT FIRST WHAT KILLS FIRST’!

·        ‘TREAT AS YOU GO’!

 

·        Secondary survey is the examination from head to toes. We check pulses and also check for lacerations, edema, deformity, paleness, tenderness, crepitation, surgical (subcutaneous) emphysema, joints mobility, sensory examination, reflexes and neurological examination etc. We use X’ Rays, Doppler, CT etc.

·        The emergency needs to be transferred to the nearest APROPRIATE (trauma) medical centre/ hospital.

·        TRIAGE is based to factors such as ABCs, the available means (personnel and devices), if we have a mass destruction, the number of victims, the time and distance for definite care, the severity of the injury and the bigger chance for survival (in case of a patient with a very serious injury that is not compatible with life, or in a case of no pulse, we go on with the rest patients and ‘flag’ this patient black – or blue in some countries – i.e. expectable to die). Triage is continuing (dynamic).

·        We do not forget log roll.

 

 

·        In case we use an air filled splinter, we frequently check for compression syndrome.

·        We stabilize the patient and consider early to transfer him/her for definite therapy.

·        On bleeding avoid Tourniquet (e.g. do it on amputation with uncontrolled bleeding, but always release it periodically).

·        We check for C – spine fracture by asking the patient to open/close his/her fingers, check the sensory of upper extremity, ask the patient to elevate his/her shoulders and check the reflexes (e.g. of biceps). 

·        On the neck, blunt injuries may cause hematomas and vessels aneurysms that may compromise the airway. A clavicle fracture or a sternoclavicle dislocation may also obstruct the airway.

·        A bowel rupture may occur from the car’s belt (especially if it isn’t worn properly or if it is an old 2 points belt).

·        Pancreatic and duodenal injuries may not be obvious initially, but only with a CT.

·        On a spinal cord injury the bowel sounds may be absent. 

·        Thoracostomy tube is placed on the level of the nipples, between anterior and middle axillary line.

·        Muffled cardiac sounds may indicate cardiac tamponade.

·        Resistance on ventilations on an intubated patient may indicate tension pneumothorax.

·        We palpate the abdomen to check if it is soft and compressible and check for pain and rigidity.

·        We perform a PR (per rectum) examination and check the rectal tone, as well as a high riding prostate. After the PR examination we check the glove for blood. 

·        We check the nasogastric tube for blood mixed with gastric contents.

·        Initial X’ Rays include lateral (profile) cervical and AP of chest and pelvis.

·        Voice hoarseness may be ought to laryngeal injury or burn. Consider early intubation.

·        Crepitus/ surgical (subcutaneous) emphysema may indicate pneumothorax/ bronchial rupture or laryngeal/ tracheal injury (e.g. from sternoclavicle dislocation or sternal fracture or 1^st – 3^rd rib fracture). The last may be indicated by voice hoarseness. 

·        Early signs of shock are tachycardia (HR > 100 bpm), LOC (level of consciousness) change (confusion, distressed, irritable), increased RR respiratory rate (tachypnea, RR> 20), laboured and/or shallow breath, cold and clammy skin, decreased urine on Foley and normal or increased pulse pressure (SBP systolic BP – DBP diastolic BP).

·        Don’t forget to ask information from the place of the event (e.g car accident) and the injury mechanism.

·        Give warm fluids (39 degrees C). However do not warm blood on microwave!

·        Call early the trauma team.

·        Blood loss is from: above/ below the diaphragm, the pelvis and the extremities.

·        Head trauma is usually not a reason for hypotension/ shock. Contrary, an increased ICP (intracranial pressure) may cause Cushing triad with increased BP (!), decreased HR (heart rate) and irregular respirations.

·        Retroperitoneal blood loss may pass unnoticed. FAST and DPL (diagnostic peritoneal lavage) show peritoneal bleeding and not retroperitoneal.

·        Non haemorrhagic shock may be ought to tension pneumothorax, cardiac tamponade, cardiogenic (e.g. elderly with CHD coronary heart disease), neurogenic (here we have hypotension with bradycardia) and septic (late).

·        Don’t place IV/IO access on an extremity with a fracture.

·        Signs of responding to fluid resuscitation is primary BP and next HR, urine on Foley and LOC (level of consciousness).

·        BP decreases on category III of shock with 30 – 40% volume loss (1500 – 2000ml)!

·        Traps to early tachycardia as sign of shock are athletes (normal bradycardia), drugs (β’ blockers – cause bradycardia, NSAIDs – cause fluid retention and also interfere with coagulation), elderly, pregnant and patients with pacemakers.

·        Don’t forget to ask the patients AMPLE: Allergy, Medication, Past medical history, Last meal and Environment/events.

·        Airway may be obstructed from laryngeal or tracheal injury e.g. from clavicle fracture or sternoclavicle dislocation or 1^st  – 3^rd  rib fractures. Suspect this injure from voice hoarseness and surgical (subcutaneous) emphysema. 

·        On an open pneumothorax cover the injury on 3 sides (1 side needs to be uncovered) and also place a thoracic tube.

·        On flail chest from multiple rib fracture we may have paradoxal breathing with 1 half of the chest going up and the other (the contralateral) going down during inspiration. This is also accompanied with lung injury. Give pain killers, but on the elderly avoid too many fluids because they may cause pulmonary edema.

·        Do not place a Foley in case there is blood in the urethral meatus, or on the PR (per rectum) examination you palpate a high riding prostate, or if you see scrotal hematoma, or if there are vagina’s lacerations, or perineal hematoma or pelvic fracture. Exclude first urethral injury with a reversed urethrovesicography.

·        On a massive hemothorax (haemorrhage >_ 1500 ml) the jugular veins may be flat. Consider self transfusion and also operation if blood is > 1500 ml or > 200 ml/h.

·        Exclude cardiac tamponade on a patient with a penetrating trauma between the nipples or between the scapulae or a parasternal penetrating trauma.

·        Emergency thoracotomy is indicated if the surgeon is experienced (and the OR available), the wound is penetrating and the patient has PEA (pulseless electrical activity).

·        On a pneumothorax place a chest tube before you transfer the patient. This is especially important for transportation with a chopper or airplane.

·        On tracheobroncheal tree injury you see on chest tube too much air and also the lung does not expand. Call early a chest surgeon. 

·        Diaphragm rapture may occur from a blunt or a penetrating injury. We can suspect a left diaphragmatic rupture on X’ Ray with contrast media (we also check the nasogastric tube displacement on the X’ Ray) or if we perform DPL and we notice abdominal fluids in the chest tube.

·        Traumatic asphyxia is be caused from inferior vena cava pressure and results to petechial rash on upper extremities and face and also may cause brain oedema. 

·        Aortic rapture may be diagnosed by helical CT or aortography or transesophagal ultrasound. The last is indicated to the unstable patients.

·        Do not transfer an unstable patient for image exams such as a CT. Stabilize first.

·        Do not transfer an unstabilized patient. Stabilize first. However, in case stabilization can’t be achieved, then transfer for definite care.

·        Don’t delay to transfer a patient by waiting Lab exams.

·        Before transportation update (by phone and also with medical files) the receiving doctor. 

·        Oesophagal rapture may occur from severe epigastral blunt trauma. It may cause pain, shock, pneumothorax without obvious injury, air into the mediastinum on the X’ Ray and gastric contents into the chest tube.

·        Suspect aortic rupture if the CXR (chest X’ Ray) shows mediastinal wideness (> 8 cm), right tracheal deviation, indistinct aortic knuckle, pleural hematoma or hematoma of the lung’s apex (apical cupping), 1^st – 2^nd rib or scapula fractures, small hemothorax without rib fractures, depression of the left main stem bronchus, widening of the paraspinal space, widening of the right paratracheal strip, right oesophageal deviation and disappearance of the space between aorta and pulmonary artery, NG (nasogastric) tube deviation and also obliteration of the space between the aorta and the pulmonary artery. However, CXR (chest X’ Ray) is normal in 2 – 7% of the patients with aortic injury!

·        Retroperitoneal space includes the aorta, the kidneys, the duodenum and the extraperitoneal part of the rectum.

·        Knife injuries may cause rupture of the diaphragm.

·        A gluteus wound may cause extraperitoneal injury.

·        A gun injury usually needs laparotomy.

·        If you decide for DPL (diagnostic peritoneal lavage), place a nasogastric tube and a Foley.

·        A nasogastric tube is used to decompress the stomach (useful especially on children, pregnant and patients with diaphragmatic hernia). On the aspirated content check for blood.

·        Perform an IV pyelography if you suspect a Kidney injury.

·        DPL (diagnostic peritoneal lavage) has high sensitivity, but low specialty. FAST has high sensitivity and intermediate specialty. CT has high sensitivity and specialty, but is not indicated for unstable patients. Stabilize the pts first e.g. with fluids and perhaps with surgery.

·        On suspected pelvis fracture, the pelvic stability should be checked only once (for ‘open book’) from the surgeon that will operate the patient. Check also for different leg length or internal rotation. Consider placing a PAST antishock trousers on unstable patients. Consult early an orthopaedist. If PAST is unavailable, you can stabilize the pelvis with a sheet. In case the FAST or DPL are positive for intraperitoneal blood, the patient needs laparotomy. In case they are negative, stabilize the pelvis or perform angiography and embolize the leaking vessel.

·        On pregnant > 24 weeks do not forget to turn 15 – 30 degrees on the left side. Put a pillow on the right side. In case of an immobilized on long board patient, you can place a wedge below the stretcher, in order to achieve a 30 degrees decline to the left.

·        Do not forget tetanus immunization on trauma, wounds, burns, stings, frostbites, animal or human bites and electrocution. 

·        On burns, urine output is the most important sign to check for response to the fluids.

·        Normal ICP (intracranial pressure) is about 10 mmHg.

·        III cranial nerve compression causes ipsilateral pupil dilation.

·        Mean BP = (SBP + 2 DBP)/ 3

·        Increased ICP is indicated by Cushing triad (see above) and ipsilateral pupil dilation.

·        On a head trauma with GCS < 14 perform a CT.

·        On an extremity ischemia (e.g. from compression syndrome) first sign is pain, then absence of pain, then numbness, then paleness, then paralysis and finally loss of pulses. So loss of pulses is last sign on a limb ischemia! A compression syndrome may be masked by absence of pain e.g. from spinal cord injury or on an intubated or sedated patient. Exclude it also on immobilized (e.g. with splinters or with plaster) limbs or burns. Measure intracompartment pressure. Perform incision if you suspect it. Avoid giving excess fluids, because they may cause limb oedema.

·        Check if the patient takes drugs that may interfere with coagulation such as NSAIDs, antiplatelets such as aspirin, warfarin and other anticoagulation therapy and also SSRIs antidepressants. 

·        On a head trauma don't give D5W (5% dextrose) fluids. Check sodium levels (hyponatraemia may cause brain oedema) and glucose. On impending herniation you may tray controlled hyperventilation for a short time, to decrease CO2 (e.g. to PaCO2 25 - 30 mmHg). Don't give mannitol or Lasix on hypotension, but stabilize first the patient (e.g. with fluids). Consult a neurosergeon for invasive ICP monitoring and perhaps for burr holes.

·        On head trauma exclude spinal (and especially C spine) trauma. Always immobilize the neck.

·        Palpate the spine for bone ‘step’, tenderness or pain.

·        Drugs, alcohol and other injuries may mask spinal or head injuries.

·        A profile (lateral) cervical X’ Ray should show the base of skull and the T1 vertebra.

·        10% of patients with C – spine fracture have also a second fracture.

·        Remove the long board on the ER/ ED (emergency room/ department), in order to avoid compression sores.

·        Spinal ‘shock’ is not really a shock, but the absence of reflexes after a spinal cord injury, soon after the injury. However it may not be permanent. 

·        Decreased rectal tone may indicate a complete or not complete spinal cord injury.

·        A spinal cord injury may complicate the examination of the abdomen (e.g. the bowel sounds may be absent and the abdomen may appear shoft). Also the absence of pain may mask a compression syndrome!

·        Rule out a hypovolemic shock before attributing shock to be neurogenic.

·        Neurogenic shock is characterized by hypotension, but with bradycardia and warm skin. Give warm fluids and consider atropine for bradycardia and vasoconstrictive drugs for hypotension. Check urine output. Perhaps you may put a CVP line to avoid administering excess fluids.

·        Before and after the immobilization of a fracture check the limb’s pulses. 

·        On decreased pulses of a limb perform a Doppler and/or angiography.

·        If the patient is on a long board and suddenly aspiration occurs, then turn the board to the one side, with the patient on a lateral position and perform suctioning (if available).

·        The first thing we do when we reach the injured patient is to immobilize his/her head with our hand (before even we talk to the patient, because he/she may turn his/her head to look us!).

·        The patient who holds the head guides the other EMT (Emergency Medical Team) during log role.

·        A joint X’ Ray should also show the joint that are above and below it.

·        On a patient with an immobilized (e.g. on splinter or cast) limb that arrives in the ER/ED (emergency room/ department), we remove/ open it and check the pulses of the limbs.

·        If on a pneumothorax the chest tube doesn’t work, we put a new tube on a different place.

·        We palpate the ribs for fractures.

·        On abdominal examination we palpate for involuntary muscle contraction/ rigidity and percuss for tympany or decreased resonance.

·        We remove skin dust with a brush, not with water.

·        Rabdomyolysis is treated with fluids, diuresis, mannitol and bicarbonate.

·        On frostbites reheat with water at 40 degrees C. don’t rub. Use warm blankets and don’t forget Td (tetanus immunization).

·        On a suspected inhalation burn intubate early. Suspect it from face/ neck burns, burned eyebrow or nasal hair, dyspnea, stridor, HbCO (carboxyhemoglobin) > 10%, black sputum, voice hoarseness, neck oedema.

·        A chest burn compromising breathing needs escharotomy. 

·        On hypothermia check also electrolytes.

·        On children stabilize on long board on ‘sniffing position’.

·        A child with shock will develop hypotension when it loses > 45% of blood volume.

·        Intubate early a child with head trauma.

·        A child may have a spinal cord injury without X’ Ray changes. Perform CT/ MRI.

·        Haemorrhage on liver or spleen may be self tamponaded on a child and thus operation may be avoided.

·        DPL (diagnostic peritoneal lavage) is unreliable on children.

·        Children may have severe lung contusion without rib fractures. However, rib fractures on children indicate severe internal injuries.

·        Place an ET (endotracheal) tube without cuff on a < 8 years old child.

·        On the elderly consider early intubation.

·        Artificial dentures on the elderly shouldn’t be removed (they ‘hold’ the airway during BMV), unless they are dislocated.

·        Elderly may have cervical arthropathy. This may complicate ET (endotracheal) intubation.

·        Elderly taking drugs (such as β’ blockers) or with a pacemaker may not show tachycardia on shock.

·        Elderly with hypertension may have shock with lower limits of BP.

·        Elderly with osteoporosis may suffer from hip or brachial or Coles (radial) fractures.

·        Perform a pregnancy test in all women of reproductive age.

·        A pregnant with abdominal pain may have abruption of the placenta, vaginal or uterus rupture.

·        Trauma on a pregnant may induce labor.

·        Normal hypervolaemia on pregnant may initially mask shock, on hypovolaemia (trauma, dehydration).

·        Perform an ultrasound and a NST (non stress test) cardiotocography on all pregnant.

·        Exclude abuse especially on children and elderly, women and pregnant.

·        When transferring an intubated patient be careful for ET (endotracheal tube) dislocation.

·        Transfer the patient to the nearest and more appropriate hospital.

 

 

 

APPENDIX: SIGNS OF HYPOVOLAEMIC SHOCK

Signs of hypovolaemic shock (haemorrhage - external or internal blood loss; or severe dehydration e.g. on severe diarrhea or vomiting) include: tachycardia (if not on β' blockers or pacemaker!), fast thready pulse, narrowed pulse pressure (Systolic BP - diastolic BP), weak peripheral pulses, tachypnea, decreased level of concioussness (LOC), decreased urine output (adults < 0.5 ml/kg/h, children 1ml/kg/h, infants 2 ml/kg/h), decreased capillary refill time (>2 sec), hypotension (late, with > 30% volume loss on adults and > 40% on children), cool pale skin, diaphoresis (not on dehydration); also decreased skin turgor (unreliable on the elderly) and dry mucus membranes (e.g. dry tongue) on dehydration.

NOTE

Some information in this text is empirical and its reliability can't be ascertained. It is suggested to search official medical articles, books and guidelines in order to ascertain the medical information of this text.

All the medical procedures and drug administration mentioned in this text should be done only under a senior doctor's consultancy.

 

BIBLIOGRAPHY FOR EMERGENCY & ACUTE MEDICINE

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Physicians, 4th edition (revised), 2006.

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16) ACLS (Advanced Cardiac Life Support), American College of Emergency Physicians, Study Guide, 2^nd edition, Jones and Bartlett Publishers, 2007.