When available, a history obtained from a patient, witnesses, or prehospital provider may provide important information regarding circumstances of the injury (single-car accident, a fall, exposure, smoke inhalation), preexisting medical conditions (depression, cardiac disease, pregnancy), or medications (steroids, b blockers) that may suggest certain patterns of injury or the physiologic response to injury.
A primary survey is undertaken quickly with the goal of identifying and treating life-threatening conditions. Specific lethal problems (discussed in further detail below) that should be identified immediately are airway obstruction, tension pneumothorax, massive hemorrhage, open pneumothorax, flail chest, and cardiac tamponade. During the primary survey, the following are quickly assessed:
a. Airway maintenance with C-spine control b. Breathing/ventilation c. Circulation with hemorrhage control d. Neurologic disability e. Exposure, where the patient is completely undressed
Some specific points are emphasized regarding the various components of the trauma evaluation. Airway with C-Spine Control
Rapid assessment for airway patency includes inspecting for foreign bodies or maxillofacial fractures that may result in airway obstruction. The chin-lift or jaw-thrust maneuver or the insertion of an oral or nasal airway is a first response for the patient making inadequate respiratory effort. A two-person technique is suggested, where one devotes undivided attention to maintaining in-line immobilization and preventing excessive movement of the cervical spine. Comatose patients (Glasgow Coma Scale score 3-8; see "Disability" below) should be intubated tracheally to protect the airway and to prevent the secondary brain injury that occurs with hypoxemia. Log rolling and pharyngeal suction may be necessary to prevent aspiration if the patient vomits. A team approach, where surgeons and emergency medicine physicians work together, is utilized for patients whose anatomy or severe maxillofacial injury precludes endotracheal intubation. In such cases, a surgical airway by means of cricothyroidotomy may be necessary. Agitated trauma patients suffering from head injury, hypoxia, or drug- or alcohol-induced delirium may present a danger to themselves. In these circumstances, paralyzing agents such as succinylcholine or vecuronium, along with a small dose of diazepam or midazolam, may be necessary to enable safe airway management. See Chap 15 for details, dosages, and techniques.
The issue of C-spine clearance is one that has received much attention in the recent past. Ultimately, "clearance" of a C-spine is both a radiologic and a clinical undertaking. This implies that patients who do not demonstrate evidence of bony fractures or subluxation on x-ray may still have significant injuries that are not appreciated if they cannot cooperate with a thorough physical examination. On the other hand, precious time should not be expended on multiple views in patients who have critical head, thoracic, and abdominal injuries that may require rapid intervention. In these patients, after a cross-table lateral view of the C-spine, the cervical collar should be left in place until the patient ultimately can cooperate with the clinical examination or undergo more sophisticated studies (e.g., CT scans or MRI of the spine).
Finally, the practice of obtaining multiple C-spine x-rays in awake, alert patients with normal examinations (no pain or tenderness with the neck in neutral position and rotated in all four directions) is excessive. A prospective study undertaken at a large level I trauma center evaluated nearly 2000 patients admitted with blunt trauma. 8 Five-hundred and forty-nine of these patients were alert, oriented, and clinically nonintoxicated and had a normal neck examination. These patients subsequently underwent anteroposterior, lateral, and odontoid views of the cervical spine at a minimum. Additional films were necessary for clearance in 59 percent of patients. The total resources used on these 549 patients were 2272 spine films, 78 CT scans, 1 MRI, and 17 additional hospital days just to clear the C-spine. There was not a single injury identified in this group of patients, suggesting that clinical examination alone is reliable to assess the neck in blunt trauma patients who are alert, nonintoxicated, and have no neck symptoms.
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