Trauma comes in two basic varieties: blunt
trauma and penetrating trauma.
Nonetheless, major trauma patients should
always be approached the same way: primary
survey followed by a secondary survey.
Don’t let the blood and gore distract you.
The primary survey entails a systematic assessment
using ABCDE in order to identify the true
life-threatening injuries and initiate resuscitation.
Then a detailed head-to-toe exam should occur,
which we call the secondary survey.
A. Airway assessment.
If blood, vomit or the patient’s own saliva
is blocking the airway (which often occurs
in unconscious patients), they will need suctioning
and possibly intubation.
B. Breathing.
Examine the chest through inspection, auscultation,
and palpation.
You are looking for life-threatening injuries.
Decreased breath sounds, subcutaneous emphysema,
broken ribs, and tracheal deviation, are concerning
for a tension pneumothorax, hemothorax, pulmonary
contusions, flail chest, and cardiac tamponade.
C. Circulation.
If the patient has a fast heart rate or low
blood pressure, suspect ongoing hemorrhage
or blood loss, the number one cause of preventable
death in trauma.
Bleeding is likely in one of four locations:
chest, abdomen, pelvis, or fractured long
bones.
Start IV fluids or blood transfusion through
two big intravenous lines.
D. Disability.
A basic neurologic assessment will help you
calculate a GCS or Glasgow Coma Scale.
It evaluates Eye Opening, Verbal Response,
and Motor Response that is universally understood
on a 15-point scale.
E. Exposure.
The patient should be completely undressed
to look for all injuries.
Along with the secondary survey, the major
trauma patient often requires a chest x-ray,
pelvis x-ray, and an ultrasound of the abdomen
called a FAST (focused assessment with sonography
in trauma).
This will allow identification of blood loss
from the most common sources.
If blood loss exceeds the resuscitation with
fluid and blood, the patient will spiral into
the classic trauma triad of death: acidosis,
coagulopathy, and hypothermia.
