| Primary Survey and Resuscitation | |
|---|---|
| Airway/cervical spine | Open: jaw thrust/spinal stabilization |
| Clear: suction/remove particulate matter | |
| Support: oropharyngeal/nasopharyngeal airway | |
| Establish: orotracheal/nasotracheal intubationa | |
| Maintain: primary/secondary confirmationb | |
| Bypass: needle/surgical cricothyroidotomy | |
| Breathing/chest wall | Ventilation: chest rise/air entry/effort/rate |
| Oxygenation: central color/pulse oximetry | |
| Support: distress—NRB/failure—BVMc | |
| Chest wall: ensure integrity/expand lungs Tension pneumothorax: needle, chest tubed Open pneumothorax: occlude, chest tube Massive hemothorax: volume, chest tube |
|
| Circulation/external bleeding | Stop bleeding: direct pressure, avoid clamps |
| Shock evaluation: pulse, skin CRT, LOCe | |
| Blood pressure: avoid over/undercorrection Infant/child: low normal = 70 + (age × 2) mmHg Adolescent: low normal = 90 mmHg |
|
| Volume resuscitation: Ringer';s lactate → packed cells Infant/child: 20 mL/kg RL, repeat x 1-2 → 10 mL/PRBC Adolescent: 1-2l, repeat 1-2 × → 1-2 U PRBC |
|
| Disability/mental status | Pupils: symmetry, reaction |
| LOC: GCS Track and trend as a vital sign Significant change = 2 points Intubate for coma = GCS ≤8 |
|
| Motor: strength, symmetry | |
| Abnormality or deterioration: call neurosurgeon Mild TBI (GCS 14-15): observe, consider CT for history of LOC Moderate TBI (GCS 9-13): admit, obtain CT, repeat CT 12-24 hr Severe TBI (GCS 3-8): intubate, ventilate, obtain CT, repeat CT 12-24 hr |
|
| Exposure and environment | Remove clothing |
| Logroll: requires four people | |
| Screening examination: front and back | |
| Avoid hypothermia: keep patient warm | |
| Adjuncts | |
| Foley catheter unless contraindicatedf | |
| Gastric tube unless contraindicatedg | |
| Secondary Survey and Reevaluation | |
| History and physical: SAMPLE history, complete examination | |
| Imaging studies: plain radiographsh, special studiesi | |
a. RSI
technique: etomidate then succinylcholine.
b. Primary: chest rise,
air entry; secondary: exhaled CO2 detector, esophageal detector device; watch
for DOPE: Dislodgement, Obstruction, Pneumothorax, Equipment failure.
c. NRB = nonrebreather
mask; BVM = bag valve mask.
d. Do not wait for confirmatory
chest x-ray.
e. CRT = capillary refill
time, LOC = level of consciousness; consider obstructive and neurogenic as
well as hypovolemic shock: exclude tension pneumothorax, cardiac tamponade,
spinal shock.
f. Meatal blood, scrotal
hematoma, high riding prostate.
g. Cerebrospinal fluid (CSF) oto/rhinorrhea,
basilar skull fracture, midface instability.
h. Chest, pelvis, lateral cervical spine;
others as indicated.
i. FAST, computer tomography (CT) scan as indicated.
Source: Adapted with permission from the American College of Surgeons Committee on Trauma, Advanced Trauma Life Support® for Doctors Student Course Manual.