00:01
Welcome back.
00:02
Thanks for joining me on this
discussion of the initial
survey and management under
the section of trauma.
00:08
Right off the bat
to let you know,
trauma is a very favorite question
of the USMLE examination.
00:13
So we’re going to spend a fair amount of
time discussing possible injury patterns.
00:19
Let’s start with a
clinical scenario.
00:21
You’re presented with a 32-year-old
man who is drinking alcohol
and sustained a front-end collision
with an incoming traffic.
00:30
Here is what his car looked
like after the fact.
00:33
What’s going on in your mind?
The question is, “Did
the passenger make it?”
I’ll give you a few seconds
to think about this.
00:45
In trauma, no matter how severe
or the mechanism of injury,
we always follow the ATLS protocol or
the Advanced Trauma Life Support System
and the priorities are easily
delineated for us using alphabets.
01:02
A for airway, B for breathing,
and C for circulation.
01:08
Let’s stop for a moment.
01:10
In the initial survey and
management, there are hard stops.
01:15
At every step along the way,
we don’t move on to the
next system if something
needs to be addressed.
01:23
For example, if the airway is not
intact, one needs to obtain a
definitive airway before moving
on to the next step in sequence.
01:34
A, again, is for airway.
01:37
In assessing airway, we are evaluating the
patency of the airway delivery conduit.
01:42
This includes the mouth, the
posterior pharynx, upper airways,
and the trachea, and several
divisions of the trachea.
01:52
What can potentially
compromise the airway?
A patient who has a Glasgow
Coma Scale of less than 8.
01:57
We’ve all reviewed the
Glasgow Coma Scale,
but the Glasgow Coma
Scale is basically an
assessment of the patient’s
neurological status.
02:06
Additionally, clear and obvious
facial trauma particularly
with active bleeding may pose a
risk for an airway compromise.
02:14
And lastly, direct laryngeal
trauma such as a hanging victim
or direct blow to the neck can
cause compromised airway.
02:23
Additional risk of airway
compromise is a burn patient.
02:30
To secure an airway, we
first bag mask the patient.
02:34
Bag masking the patient
allows us to deliver oxygen.
02:39
Remember, there is a disadvantage
of bag masking a patient.
02:42
Significant amounts of air enters the stomach
and poses a threat to vomiting patients.
02:48
We then achieve definitive airway by
performing an endotracheal intubation.
02:55
Sometimes, endotracheal
intubation is impossible.
02:59
In which case, we would
have to do an emergency
surgical cricothyroidotomy
as depicted by this image.
03:07
A needle or a knife is inserted
through the cricothyroid membrane.
03:13
Remember, cricothyroid
membranes, in neck anatomy,
is actually named from a
caudal to cranial direction.
03:22
Next, after airway has been
ascertained, we move on to breathing.
03:26
B for breathing.
03:29
In breathing, we are
evaluating whether or not
the patient is moving air
to allow ventilation.
03:35
Just because the patient has an intact airway,
meaning the conduit is not obstructed,
does not necessarily mean that the patient
is actually moving air through the conduit.
03:47
What are some reasons why
someone might not be
moving air despite
having an intact airway?
For example, a very high spinal cord
injury can render the diaphragm paralyzed.
03:58
Somebody who has significant
traumatic brain injury may
be comatose or have their
respiratory centers damaged.
04:06
Injury to the diaphragm or
the ribs can significantly
alter the patient’s
ability to move air.
04:11
When you have secured airway and
ascertained the breathing or
patient is moving air, we then
move on to C for circulation.
04:21
In circulation, we evaluate
the heart’s ability to
pump blood and oxygenate
or perfuse the tissues.
04:28
How do we evaluate circulation?
Well, quick checks
of mental status.
04:33
If the patient is oriented
and conversational,
they likely have
perfusion to the brain.
04:39
Check their pulses.
04:41
For a patient to have distal
pulses such as the radial pulse
or DP pulses or dorsalis
pedis pulses in the feet,
they have to at least have
enough of a pressure head.
04:50
And lastly, to assess whether or
not somebody has intra-abdominal
bleeding, we perform what’s
called a fast examination.
04:58
Let me pose a question to you.
05:00
What is a very quick way to
assess A, B, C all at once?
I’ll give you a second
to think about this.
05:09
It’s quite easy.
05:10
All you have to say is, “Hi sir.
Can you tell me your name?”
And if the patient is able
to tell you their name,
it suggests, number one, that
their mental status is intact.
05:22
A, the airway conduit is intact.
05:24
B, air has to be moving to the conduit and
pass the vocal cords for them to answer.
05:30
And C, they have enough
of a perfusion to the
brain to be able to
answer your question.
05:37
What if there’s a clinical change during the
survey, at any point during the survey?
I’ll give you a few seconds
to think about this.
05:48
If there’s a clinical change
during your initial assessment,
it’s always prudent to go back
to the beginning of your ABCs.
05:54
Start with airway again.
05:56
Make sure that the patient’s
conduit has now been obstructed.
05:59
Remember, sometimes if the patient
has altered mental status during the
clinical examination, the tongue may
fall back obstructing the airway.
06:07
Next, reassess breath sounds.
06:09
Listen to their breaths to
make sure the air is moving.
06:12
And lastly, re-continue on
circulation assessment.
06:17
After you’ve completed an
initial survey and your ABC,
the last two letters
are actually D and E.
06:24
D for disability and
E for exposure.
06:27
D is the section which
will be discussed later,
it is where we assign the
patient of Glasgow Coma Scale.
06:32
And E exposure is thoroughly
taking a look from head to
toe of the examination in
completely exposed patients.
06:39
Remember, in a completely exposed patient,
hypothermia can institute within minutes.
06:45
Make sure you cover the patient.
06:47
Now we can move on to
a secondary survey.
06:50
A secondary survey is a
fancy name for basically
a head to toe examination
of the patient.
06:56
We also obtain an
abbreviated history.
06:58
It’s called an ample history to
the most pertinent information
that we need to help manage
the traumatic patient.
07:05
And lastly, we like to call
for a transfer center to a
higher level of care for
definitive trauma resuscitation.
07:13
Let me pose another
question to you.
07:16
You must be wondering, “What
happened to our initial patient?”
Well, thankfully because
of your initial
assessment and management,
the patient survived.
07:26
Important clinical pearls.
07:27
The patient may have an intact airway
but may not be actually breathing.
07:32
Remember, the airway
is just the conduit.
07:34
The breathing has the mechanics of
moving air through this conduit.
07:39
In a high-yield fact, any time your
clinical scenario shows clinical change
or deterioration, make sure you go
back to the beginning of your ABCs.
07:49
Thank you very much for joining
me on this discussion of the
initial assessment and management
of traumatic patients.