Trauma Primary and Secondary Survey with Adjuncts

1. Trauma Primary and Secondary Survey with Adjuncts Corey R. Heitz MD

2. Objectives - At the end of this session, you will be able to: Perform a rapid initial assessment of a trauma patient (primary survey) Focus on those issues necessary for immediate management Triage care appropriately Reorder the �ABCDE� method as indicated Use adjunctive studies to assist in triage and initial management Once stabilized, perform a rapid secondary assessment Perform a head-to-toe survey with attention to life-threatening injury Maintain patient safety during this assessment Order appropriate imaging studies Perform a tertiary survey in the trauma patient prior to disposition

3. Future plans... Fellowship trained trauma surgeon General surgeon covering trauma service EM physician at a community hospital (no trauma service) EM physician at a Level I Trauma Center

4. Your future trauma role Rapid assessment Rapid stabilization Triage decisions transfer? workup?

5. The Primary Survey

6. Importance of an Organized Primary Survey Rapid identification of reversible, life-threatening issues Airway control Oxygenation status Hemorrhage control �Hidden� injuries Triage to appropriate treatment Tube thoracostomy for intrathoracic hemorrhage immediate transfer to a trauma center OR for unstable intraabdominal injuries Avoids diversion of attention to less urgent matters Signs of basilar skull fracture in a hypotensive multi-trauma patient Lack of pulses in a GSW to the head

7. The Primary Survey - ABCDE Airway Evaluate for patency, obstruction, injury Blood, crepitus, deviation, stridor �What�s your name?� Evaluate for need for protection Breathing Symmetry of chest wall motion and lung sounds, respiratory distress Hypoxia, cyanosis

8. The Primary Survey - ABCDE Circulation Peripheral and central pulses Blood pressure Massive hemorrhage mental status Disability Ability to move fingers, toes Mental status (likely evaluated earlier) Exposure Visualize all areas of potential injury Penetrating trauma: Include axilla, perineum

9. A 30 year old patient with a self-inflicted arm laceration (slight bleeding) arrives moaning and lethargic (GCS 7) with BP 63/34, HR 145, SpO2 94% on RA. What is your initial course of action? Intubate due to GCS <8 BVM due to lethargy FAST exam Rapid fluid resuscitation

10. The Primary Survey - Management Identify and treat immediate life-threats may include intubation, chest decompression, fluid resuscitation order of care is determined by underlying problem, expected course hemorrhagic shock: fluids airway control may be needed prior to transport, further care

11. A 23 year old female GSW to the head arrives by EMS. during tranport: HR 113, BP 80/60, SpO2 88% RA. What is your order of evaluation upon moving her to the ED bed? airway patency, breathing effectiveness, circulatory status including massive hemorrhage, ability to move extremities, identification of other wounds ID of other wounds (including FAST) concurrent with eval of airway patency, breathing effectiveness, circulatory status including massive hemorrhage Airway patency, breathing effectiveness, signs of basilar skull fracture, FAST exam, circulatory status including massive hemorrhage

12. Primary Survey - Order of Events Assess ABCs fully (patency, breathing, circulatory status) the apneic, pulseless patient needs to be identified immediately conditions can change rapidly Manage in order of importance to the patient�s condition For example

13. 34 year old MVA presents moaning and breathing with bleeding RUE amputation. BP 85/43 HR 135 SpO2 98%. In what order do you manage the patient? Intubation (GCs <8), eval tube placement and respiratory status, IVs with fluid resuscitation, secondary survey (look at arm) IVs with fluid resuscitation, consider intubation, further evaluate respiratory status, evaluate arm wound Evaluate arm wound and tourniquet to tamponade bleeding, place IVs and start fluid resuscitation, consider intubation, further assess respiratory status

14. Primary Survey - Order of Events Assess ABCs fully Manage in order of importance life-threatening hemorrhage (C) may come first especially if Airway appears patent and respiratory status (B) appears intact

15. 43 year old male with stab wound to the right upper chest presents hypoxic, tachypneic, hypotensive. What�s your first course of action? Intubate, reevaluation for response Fluid resuscitation, reevaluation for response Needle thoracostomy Tube thoracostomy

16. Primary Survey - Order of Events Signs of tension pneumothorax hypotension, hypoxia, diminished breath sounds, distended neck veins, tracheal deviation Treatment is decompression (B) Intubation (A) will be harmful positive pressure ventilation results in increased intrathoracic pressure This person�s hypotension may not be due to hemorrhage (C) fluid resuscitation will occur, but is not the most important step

19. What�s not performed concurrently? Secondary survey Must complete primary survey prior to moving to secondary survey

20. 35 year old MVA presents with BP 89/56, HR 134, SpO2 94% NRB. He cannot move his hands or LEs and has a reported hemostatic (dressed) open fracture to the RLE. His airway is patent and he is breathing, although his breath sounds may be diminished on the left.Two large bore IVs are in place. What is your order of action? Initiate fluids, perform c-spine lateral films and attempt c-spine clearance, FAST exam Initiate fluids, maintain in-line cervical spine protection, FAST exam, CXR and pelvis X-rays Initiate fluids, maintain spinal protection, CXR, pelvis, and RLE xrays, FAST exam Logroll patient to look for spinal stepoffs, look in ears for signs of skull fracture, undress RLE wound, transport for CT of head/neck/chest/abdomen/pelvis/RLE/toes

21. Primary Survey - Adjuncts Use adjuncts to help triage the patient�s management Options FAST exam CXR, pelvis xrays EKG

22. Primary Survey - Not Adjuncts CT scans of any sort Cervical spine plain films Extremity films

23. 35 year old MVA presents with BP 89/56, HR 134, SpO2 94% NRB. He cannot move his hands or LEs and has a previously bleeding reported hemostatic (dressed) open fracture to the RLE. His airway is patent and he is breathing, although his breath sounds may be diminished on the left.Two large bore IVs are in place. FAST exam shows is shown below. What do you do now? Fluid resuscitation, transport to CT Fluid resuscitation, CXR, pelvis and RLE xrays while reassessing for response to fluids Fluid resuscitation, chest and pelvis xrays, immediate transport to OR Fluid resuscitation, CXR, pelvis, RLE xrays followed by CT head, C-spine, etc

24. 35 year old MVA presents with BP 89/56, HR 134, SpO2 94% NRB. He cannot move his hands or LEs and has a previously bleeding, now reported hemostatic (dressed) open fracture to the RLE. His airway is patent and he is breathing, although his breath sounds may be diminished on the left.Two large bore IVs are in place. FAST exam shows is shown below. What do you do now?

25. Primary Survey - Adjuncts Used in triage decisions unstable patients do not go to the CT scanner use FAST exam, CXR, pelvis xray to determine how to proceed positive FAST: OR negative FAST: look at chest, pelvis manage appropriately (chest tube, OR for packing/IR for embolization, fluids and pressors for probable spinal injury)

28. Awake and yelling 18 year old male, GSW to the right upper arm and RLE. BP 123/76, HR 115, SpO2 97%. IV access has been established. What�s your initial evaluation? Disrobe patient, check axilla, perineum, back, chest, buttocks for more wounds RLE, RUE xrays to look for bony injury, bullet fragments FAST exam check blood pressures in both arms

29. A 35 year old male presents after an MVA with multiple injuries. He arrested 4 min prior to arrival and has not been intubated. What�s your course of action? Intubate, bilateral needle decompression, large bore IVs/Cordis with volume resuscitation while performing CPR Thoracotomy: cross clamp aorta FAST exam to look for cardiac function; if absent, cease efforts Intubate, bilateral tube thoracostomies (with or without tube placement), large bore IVs/Cordis with fluid resuscitation

30. Blunt Trauma Arrest My training: manage immediate, treatable life-threats, reassess airway: intubate breathing: bilateral thoracostomies (not needles) circulation: immediate volume resuscitation while awaiting response, FAST (esp. looking at pericardium) then decide if you�re done

31. The case for immediate cardiac US Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med. 2001;8:616-621. not trauma patients 169 patients, 136 w/ cardiac standstill 20 survived to leave the ED none with cardiac standstill (regardless of electrical activity) convenience sample mean age 72 in standstill, 68 in those w/ activity (71 overall, range 32-97)

32. The case for immediate cardiac US Schuster KM, Lofthouse R, Moore C, Lui F, Kaplan LJ, Davis KA. Pulseless electrical activity, focused abdominal sonography for trauma, and cardiac contractile activity as predictors of survival after trauma. J Trauma. 2009;67:1154-1157. retrospective, included all traumas w/o pulse or BP 28 patients, average age 49 12/28 had contractile activity, 5 survived ED 0 of those w/o conractile activity survived longer resusc time in those with contractile activity (10 vs 5 min)

33. Final Thoughts on Blunt Arrest There may be a role for US to evaluate for cardiac activity I still favor rapidly attempting resuscitation intubate bilateral thoracostomies volume resuscitation US at this point?

34. Primary Survey - Summary Manage obvious life-threats before potential life-threats Stop the bleeding Airway management may be indicated for AMS, but not necessarily immediately Obtain complete vital signs, IV access - until then, the primary survey is not complete Use bedside tests only: US and chest, pelvis films to triage, direct management C-spine and extremity films are not included in the primary survey Unstable patients do not go to the donut of death Get em nekked! (check for missed/hidden wounds)

36. Secondary Survey Occurs only after primary survey and initial resuscitation Goal is identification of other important injuries or risk for those injuries Thorough evaluation, along with H/P

37. Secondary Survey - History Allergies Medications Past medical history Last meal Events Where do you hurt? What do you remember? What happened prior to the accident? Drinking or drug use? LMP

38. Secondary - History Goal is to determine not only potential sites of injury but also medical issues chest pain prior to the accident? LOC before accident? meds or drugs taken today?

39. Secondary Survey - Physical Exam head to toe survey must know what you are looking for includes logroll, palpation of spine potential for spinal clearance at this time continuous reevaluation and monitoring of patient any instability, go back to your ABCs

40. Secondary Survey - Head and Face Scalp lacerations cephalohematoma skull fracture Ears lacerations CSF otorrhea blood from ear canal blood behind TMs Face lacerations numbness stepoffs pain malocclusion dental injuries nasal injuries (septal hematoma) eyes

41. Secondary Survey - Eyes

42. Secondary Survey - Eyes

43. Assault with injuries only to the head, stable vital signs. Head exam normal, some facial contusions, and you notice missing teeth. What study do you need to order?

45. Secondary Survey - Neck tracheal deviation bruits crepitus swelling lacerations seat belt stripe bony tenderness, stepoffs can you clear the c-spine?

46. Secondary Survey - Neck Adjuncts assume you cannot clinically clear the cervical spine what is your choice of imaging? CT vs xray NEXUS: 35 of 1500 injuries missed by adequate plain films (3 unstable injuries) Bailitz, 2009 J Trauma 50 clinically significant missed injuries in 1500 patients CT 100% sensitive, xray 62%

47. Secondary Survey - Chest reevaluate breath sounds chest wall motion crepitance areas of tenderness contusion previously missed penetrating injuries take another look at your chest xray

48. Secondary Survey - Chest Xray evaluate ribs mediastinum apices small effusion (hemothorax)

50. Your MVA patient is stable with no large pneumo- or hemothorax on supine chest xray. How sensitive is that xray for pneumothorax? excellent (almost 100%) at most 75% at most 50% horrible (25%)

51. Adjuncts to the secondary survey: E-FAST �extended� FAST exam (E-FAST) thoracic ultrasound added to the FAST exam 86 to 98% sensitive, 98-100% specific (LR- 0.05)

52. E-FAST performed longitudinally, midclavicular, near the apex looking for lung sliding, comet tails

53. E-FAST performed longitudinally, midclavicular, near the apex looking for lung sliding, comet tails

54. Secondary Survey Adjuncts - When to CT the chest indications for CT of the chest abnormalities on CXR external signs of injury how much better than CXR is CT? Trupka 1997 J Trauma: 65% of 103 patients had new findings on CT 41% resulted in a change in management Barrios 2009 Am Surg: 25% of 143 patients with normal CXR had findings on CT (6% change in management) 81% of 57 with abnormal CXR had CT findings (37% change in management)

55. Secondary Survey - Abdomen tenderness distension contusion penetrating trauma don�t forget perineum, rectum, vagina, urethra

56. 18 year old female assault with abdominal pain. FAST exam is negative. How sensitive is the FAST exam for intraabdominal trauma? 20% 40% 60% 80% almost 100%

57. FAST exam for blunt abdominal trauma Miller 2003 J Trauma 372 patients with suspected blunt abdominal injury all had FAST, followed one hour later by CT 313 true negatives, 22 false negative, 8 false positives sensitivity 42% (PPV 67%, LR- 0.85) 19 true-negative FASTs went on to laparotomy for injuries w/o hemoperitoneum 11 patients had retroperitoneal injuries

58. Secondary Survey - Spine cervical spine we discussed logroll for thoracolumbar spine palpation stepoffs, tenderness while you�re there, look at the back lacerations, contusions, penetrating wounds missed previously The Valley Handshake (i.e., the rectal exam)

59. Utility of a Rectal Exam in Trauma What are we looking for? decreased tone blood high-riding prostrate Esposito 2005 J Trauma DRE vs �other clinical indicators� (OCIs) no difference in negative and positive predictive value OCIs much more associated with index injuries conclusion: DRE rarely provides information that changes management

60. Extremities and Neuro pulses sites of tenderness contusions deformities lacerations range of motion at joints neurologic function pelvis 3 axes if there�s any instability, stop examining

61. You are evaluating a patient with a single gunshot to the RLE with intact pulses. What test do you want to perform to decide if he is safe for discharge? Arteriography Arterial Duplex Ultrasonograpy Ankle Brachial Index Equal pulses are good enough for me

62. Role of ABIs Sadjadi J, Cureton EL, Dozier KC, Kwan RO, Victorino GP. Expedited treatment of lower extremity gunshot wounds. J Am Coll Surg. 2009;209:740-745. retrospective, 182 patients then 90 prospective ABI <0.9 = CT angiography, ABI >0.9 = safe for d/c 100% PPV, 98% NPV no patient developed bleeding, ischemia, or limb loss Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004;56:1261-1265. 38 patients, 11 w/ ABI <0.9, 27 >0.9 all patients with abnormal had injury, no patients with normal had injuries �gold standard� was serial exams, duplex ultrasonography

63. tertiary survey What is the tertiary survey? final reassessment prior to disposition your last chance to detect missed injuries Biffl WL, Harrington DT, Cioffi WG. Implementation of a tertiary trauma survey decreases missed injuries. J Trauma. 2003;54:38-43; discussion 43-4. 2.4% missed injuries pre, 1.5% post missed being defined as �at time of admission� mostly musculoskeletal some studies show up to 10% of patients have initially missed injuries

64. Summary - Secondary Survey Thorough evaluation of all areas of potential injury If patient develops instability, return to the primary survey Use imaging studies to define further injuries based on exam Perform a tertiary survey on all trauma patients especially those being discharged home

65. References Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med. 2001;8:616-621. Schuster KM, Lofthouse R, Moore C, Lui F, Kaplan LJ, Davis KA. Pulseless electrical activity, focused abdominal sonography for trauma, and cardiac contractile activity as predictors of survival after trauma. J Trauma. 2009;67:1154-1157. Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Annals of Emergency Medicine. 1998;32:461-469. Bailitz J, Starr F, Beecroft M, et al. CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison. J Trauma. 2009;66:1605-1609. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Academic Emergency Medicine. 2010;17:11-17. Trupka A, Waydhas C, Hallfeldt KK, Nast-Kolb D, Pfeifer KJ, Schweiberer L. Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study. J Trauma. 1997;43:405-11; discussion 411-2.

66. References Barrios C, Malinoski D, Dolich M, Lekawa M, Hoyt D, Cinat M. Utility of thoracic computed tomography after blunt trauma: when is chest radiograph enough? Am Surg. 2009;75:966-969. Miller MT, Pasquale MD, Bromberg WJ, Wasser TE, Cox J. Not so FAST. J Trauma. 2003;54:52-9; discussion 59-60. Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma. 2005;59:1314-1319. Sadjadi J, Cureton EL, Dozier KC, Kwan RO, Victorino GP. Expedited treatment of lower extremity gunshot wounds. J Am Coll Surg. 2009;209:740-745. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004;56:1261-1265. Biffl WL, Harrington DT, Cioffi WG. Implementation of a tertiary trauma survey decreases missed injuries. J Trauma. 2003;54:38-43; discussion 43-4.