Inevitably, at some point of your surgical rotation, your seniors will ask you, 'So doc, what would you want to do for this patient?'.
The simple question that expands into detailed Resuscitation.
Primary survey and resuscitation: life-threatening conditions are identified rapidly & managed in sequence by priority
A team can manage priorities in parallel.
Brief history: age, gender, mechanism of injury (what led to the injury)
Airway with cervical spine control
Upper airway (above vocal cords) managed adjunctively with chin lift/jaw thrust, suctioning, oral airway, nasopharyngeal airway, and laryngeal mask airway. The most common cause of airway obstruction in the unconscious patient is the tongue.
Lower airway managed definitively with a cuffed tube in the trachea (orotracheal intubation, nasotracheal intubation, or surgical airway—cricothyroidotomy)
Assume cervical spine injury in patients sustaining any blunt injury or penetrating injury above the chest.
Intubation is indicated for airway protection (GCS < 9; severe maxillofacial fractures; laryngeal or tracheal injury; evolving airway loss with neck hematoma or inhalation injury) and as a conduit for ventilation (apnea, respiratory distress--tachypnea >30, hypoxia/hypercarbia).
Breathing
Ensure adequate oxygenation (pulse oximetry) & ventilation.
Provide supplemental oxygen.
Assess breath sounds, chest percussion, chest wall excursion, and jugular venous distention.
Re-expand alveolar volume:
Tension pneumothorax (pneumothorax with hypotension) with needle decompression (second intercostal space, mid-clavicular line), followed by 32-36 French anterior chest tube
Simple pneumothorax with 32-36 French anterior chest tube
Open pneumothorax with occlusive chest wall dressing and 36 French anterior chest tube
Massive hemothorax with 36 French posterior chest tubes en route to operating room
Simple hemothorax with 36 French posterior chest tube
Flail chest/severe pulmonary contusion with intubation and mechanical ventilation
Circulation: Hemorrhagic shock is the most common form of shock in trauma.
Assess for and stop external hemorrhage.
Direct manual pressure.
For traumatic amputation/severe mangled extremity, application of a tourniquet
Assess for tissue perfusion.
Cardiovascular: blood pressure, pulse, pulse pressure
Pulmonary: oxygen saturation via pulse oximetry, respiratory rate
Skin: color, temperature, capillary refill
CNS: mental status
Renal: urine output (normal 0.5 cc/kg/hr in adults, 1.0 cc/kg/hr in children, 2.0 cc/kg/hr in neonates)
Gain vascular access.
Two < 16-gauge peripheral intravenous catheters
>9 French central (subclavian, femoral, or internal jugular) introducer catheters
Intraosseous catheter
Saphenous vein cutdown
Administer initial volume.
2 L lactated Ringer’s
If penetrating torso trauma, controlled resuscitation with minimal fluids until bleeding is controlled
Assess for response.
Responder: bleeding < 20%
Transient responder: bleeding 20-40%, needs blood
Non-responder: >40%, needs blood and intervention to stop internal bleeding
Consider and intervene to stop hidden sources of bleeding.
Chest: chest tube
Abdomen
Pelvis: pelvic binder
Long bone fracture: reduce and splint
Posterior scalp laceration: whipstitch closure
Maxillofacial trauma with swallowed blood: anterior/posterior nasal packing
Blood left at the scene
Consider non-hemorrhagic sources of shock
Tension pneumothorax
Cardiac tamponade
Neurogenic shock (relative hypovolemia due to vasodilatation)
No role for vasopressor agents in the initial management of traumatic shock
Disability
Brief neurologic exam
Level of consciousness: Glasgow Coma Scale
Pupil symmetry and reaction to light
Lateralizing signs
Maintain airway, breathing, and circulation to prevent secondary brain injury.
Temporize for evidence of increased intracranial pressure.
Elevate head of bed.
Mild hyperventilation to paCO2 = 35
Mannitol (1 gm/kg)
Neurosurgical consultation
Exposure/environmental
Assess temperature.
Remove all clothing to facilitate access and examination.
Maintain normothermia/prevent hypothermia: warm room, warm fluids, warm blankets.
Adjuncts to primary survey and resuscitation
Foley placement to monitor urinary output; withhold for evidence of urethral injury (blood at the urethral meatus, perineal hematoma, high-riding prostate)
Gastric tube placement to prevent gastric dilatation; no nasal placement in setting of facial fractures
Hemodynamic monitoring for blood pressure, heart rate, and cardiac rhythm
Respiratory monitoring with pulse oximetry, capnography, and respiratory rate monitoring
Arterial blood gas (pH, base deficit) and lactate monitoring
CBC, electrolytes, glucose, creatinine (relevant for contrast administration), INR (relevant to detect antecedent anticoagulation), type and screen vs. crossmatch
*NB, learn to recognize the stages of Shock!*
