Trauma Primary Survey; Roadside to Resus

complete the MCQ and you can add in all of your other CPD activity for those that are having fun just like me in revalidating at the moment. So if I don't return in the next episode, you'll know the outcome of that process.

So in this episode, as we mentioned, we're gonna run through the primary survey in trauma. Now the primary survey is the clinical assessment that helps us identify and treat life threatening injuries and to rapidly intervene.

Is just have a think about how we can do the best primary survey possible when it's just a couple of clinicians present. And that way, when there are more people available and more resources on scene, things can be delegated out and done in a more concurrent way.

for the last couple of years because I think there's a huge amount of potential for us all to improve how we conduct a primary survey and how that can affect our patients' care. Because ATLS taught me to rattle off the A to E looking for the main bits that we should be with our patients, and this isn't me having a dig at ATLS, more my interpretation of it, I think.

But actually there is so much more vital information that we could tease out of that 60 second assessment and I wanted to investigate how we can be slicker at it. And this really goes back to when I was doing my pre hospital sign off because yes, I'm pretty sad. I wrote down every single aspect of the primary survey that I thought was important and then recorded it.

And I had the pleasure of listening back to my voice, repeating it over and over and over again until it was absolutely nailed in my mind. And I can actually remember sharing that with somebody when They were preparing for their sign-off. I don't remember getting any feedback about that, so I take it it was a pretty poor effort that I'd done. But my point being, I think actually getting really good and really slick at the primary survey takes a significant amount of thought.

effort and effort. So I thought we could all share that process in this episode. Thinking back to practice for a second, pre hospitally with so much importance of gaining all that you can out of a clinical assessment. It really gives you the opportunity to easily appreciate how much difference a high quality primary survey can bring. And I think, maybe again, this is just me reflecting my practice, I think in hospitals

I'd started to rely upon really good accessibility to rapid scanning and this probably took away the importance I had in my mind of what the primary survey can bring in hospital. But Having refocused attention, actually, it's got a lot to offer in hospital as well. Now the other thing to say is that the accuracy of identifying life and limb threatening injuries from clinical examination isn't perfect.

In papers of the month a few months ago we looked at Walshmut's paper on clinical accuracy of London Hems and Mona's paper looking at the accuracy of identifying pelvic injuries and found with both of those papers in really good systems. The injuries are frequently missed. So this is an area that does deserve attention. So hopefully the next 30 minutes or so will be useful to us all in thinking how we can nail these assessments and deliver the best care to our patients.

Now pre hospitally, what we might consider is how we're gonna split the team if we are first on scene. So what kit are we gonna take? How are we gonna divide those tasks once we arrive? So for example One clinician might do what's called the coma, so the clothing, the oxygen, the monitoring, the access, and the other clinician might then separate off to provide that primary survey. But basically you're freeing up those people and you're allocating those taxes. Prior to arrival.

Now when it comes to in hospital we're probably gonna have more resources And we need to just strike a balance in hospital of having the key people we need there, but not overcomplicating this assessment. And for those that are there, we need to be aware of each other's roles and skill set.

And be sure that they're feeding back to that lead with really good communication skills and not having these like micro conversations within the team that no one can really hear'cause it's too quiet and we don't know if it's important.

Now there is a really good section on briefing the team within the European trauma course manual and there is quite a lot to actually consider and I guess that there are layers in there that you might add or you might remove depending on that exact scenario on that day. But in an ideal world, go and have a little read of that section in the ETC manual if you want to know a bit more about briefing the team. It's really good.

And I don't know, Simon, whether you have specific SOPs for who does the primary survey. But I totally agree. Having a little bit of a an idea in your mind as to who is going to take on what role when you arrive on scene, I think is really valuable. And I think personally I quite like if if I've sort of chosen to take the lead, if you like, for that case, I quite like being the one who does the primary survey.

Um I think that adds a lot of value and I think it means that there's not any lost communication uh and time between someone doing a primary survey and then feeding back to the other team member who's involved in cutting off the clothes at the auction and so on. So I I I quite like doing the primary survey if I'm the lead clinician. I don't know how you guys find that.

Well that's even better, isn't it, for getting an oversight of what's going on and I think What this really brings about, isn't it, that it's good to have a format of how a standard job in inverted commas will go, and the same in hospital as well. I think excellence really comes, doesn't it, when you can then flex from what you're expecting to do to then seeing how it's best to adapt

And sort of deliver a bespoke episode of care for that patient, depending on the nuances that you're seeing. So that's a really woolly answer again, isn't it? Which I'm think I'm becoming quite an expert at giving. But but things aren't binary, are they? And it's good to have you know, a standard formula, but being able to adapt that for the best in that circumstance in the team there I think is is really key, isn't it

What are we gonna do when we first arrive on scene? Who's taking what kit in? What stuff is actually gonna happen? I think is fundamental and just making sure everyone's on the same page. And you know, like I said, the exact scenario will change and it you know, it's multiple factors, you know, are there gonna be other crews on scene? Have you got a trainee with you on that day who has got some specific learning objectives?

in the resource room have you got multiple specialties that you're trying to fend off at the same time to to that's probably the wrong term. I what I mean by is um is uh focus their mind. Focus their mind rather than fend off. Um but there's loads of different scenarios but you you have to have a system, don't you? And it has to take into account all of the nuances that come with the the jobs that need to be done. And I I I agree with James. I personally feel most comfortable

when I am performing that primary survey myself. However, I'm also aware that, you know, there are other trainees who work with me that need that exposure and to be able to do that process. So A as part of my my role i which might be the team leader, it might be the person providing the primary survey, it's about adapting on that day, isn't it, to find out what everyone else needs from this situation on top of what the patient needs as well, if you've got the ability to provide everything.

You know, in the pre hospital setting there is an awful lot of information that we can draw upon as we arrive on scene, you know, like reading the scene to an anticipate the mechanism of injury and the likely injury patterns we might find. Seeing the activity of other services around the patient, or looking at the level of panic or the kind of movement of bystanders, that can give us so much information about what we're about to walk into.

But you know if we're arriving as a secondary resource or we're wheeling our patient into E D, there's something else we all do as well. at the patient and we look at the monitor and we're instantly making a judgment over how sick they are and we want to start asking questions, don't we? Even before our handover has started. But you know, I think that's not necessarily inappropriate, but it's got to be done supportively and in a targeted fashion.

So I guess as an example, I sometimes open my interactions with crews after I've arrived and after we've done our introductions by saying something like, you know, do you have any major concerns that need addressing immediately?

And I'm sure you've all come across trauma team leaders when you get to hospital who might ask us is the patient stable for handover? Now we don't need to necessarily do this on every patient, but we can be guided by systems such as the five second round from the European Trauma Course.

Now what is that? This is a like a hands-off visual assessment of the patient, which aims to rule out immediate life-threatening conditions such as complete airway occlusion, massive external hemorrhage, and traumatic cardiac arrest. And the way we do that is through the use of an assessment triangle, really similar to the pediatric assessment triangle, if you're familiar with that. So what are we looking for? Well, it's social interaction, so is the patient calm, agitated, or unconscious?

And what's their respiratory effort, normal, increased, or absent? And what's their skin perfusion, pink, pale or mottled or absent? If there are any life-threatening issues raised during this five second round, then they're verbalized to the team, and then the handover isn't started, and the issues are resolved before the handover begins.

But if we're thinking about the point at which we actually get our hands on, the traditional primary survey, then we already mentioned, didn't we, ATLS drilled in that A to E approach and More recently, although I guess not really that recent, uh things have changed to the uh the s oh God, we're showing our age again, boys.

Um the the we've moved to the C A B C approach with catastrophic hemorrhage being the first thing to look for. And then at each point as you progress through your C A B C approach. We're trying to identify something that needs immediate intervention before we progress on to the next stage.

So it's probably worth talking about this C A B C approach then. So To get the primary survey show on the road, let's use a case and let's talk about a a fictional character, a 45-year-old motorcyclist who's been involved in an RTC. They've gone head on into a car crossing their path at about. forty miles an hour. Unfortunately not an uncommon case that I'm sure we've all encountered. So Simon, what would your primary survey look like on this case?

So starting with that C, catastrophic hemorrhage. So is there on this motorcyclist clear catastrophic hemorrhage that needs immediate attention? And in those with penetrating trauma, to look for hidden catastrophic hemorrhage. in the form of bleeding from axilli, groins and around the back and the butter.

Then once we've had a look for that and we're happy, we're gonna move on to airway. And as I said Traditionally, I think with things like ATLS my take home was is the airway patent yes or no skip on to B. But what we're really trying to do here is to get as much detail as we possibly can.

out of this one assessment so that we don't have to go back and duplicate things. And that means not just teasing out the bits which are relevant for that immediate decision of what interventions and care are required. but anticipating what further information we might need later on down the line to then work out what interventions might be appropriate.

I think I've refused a lot of words there, but hopefully that made some sort of sense. So anyway, is the airway patent? That is a really important question. Are they talking? Is their voice clear and does it sound any different to normal? But then also things like what position is that airway in? Is it optimized and can we correct it to get it into a better position and into optimal patency without affecting their neck if we're worried about that?

What's their mouth opening like? Is their jaw injured? Can they protract their mandible? Is their tongue bitten? And is it bleeding? Or is there any evidence of swelling? Are there any other secretions in the mouth? Any evidence of vomiting, especially if they've had a head injury? And if they've got fluid that's in their mouth, is it pulling and accumulating and is it posing a risk to the airway or can it passively drain in the position that the patient's in?

Now this is only going to take a few seconds. And as we've said, if it's patent, that's fantastic. But it's doing things like making that airway assessment. for in case this patient with their really significant mechanism of injury is going to go on to need an anesthetic. You've got all of that information now to have made a good assessment on how their airway looks. And the sort of plans that you might then consider taking if they're going to need an anesthetic.

Now some will also group into airway management sea spike control as well, but you need to be mindful that this doesn't slow down identifying other life-threatening issues. So it might be wise to come back to that at a later point in the primary service.

So on to B and you'll already have started this when you first got eyes on the patient. So what's the breathing pattern like? Looking at both the rate, tidal volumes and phases of respiration. What does the saturation show? Is the rise and fall of both sides of the chest symmetrical?

Placing your hands on the chest, feeling down from clavicle, down every rib on one side, and then onto the other side to see if you can identify any fracture at any point. Then placing your hands onto both sides of the chest, feeling for surgical emphysema up to the axillium. Now depending on the level of background noise you can have a listen to both sides of the chest for air entry as well.

More likely to be useful in hospital, and you might also want to assess the trachea for deviation. But remember that, in the context of attention pneumothorax, this will only be present in around a quarter of cases. Then on to circulation. Are they sweaty, diaphragmatic? Can you feel a pulse? Where is it? Is it symmetrical on both sides? For example, can you feel bilateral radio pulses? What's the rate and what's the volume?

What's the blood pressure if you've got it and what's the central cap refill? You've already looked at this in catastrophic hemorrhage, but is there any significant external bleeding that requires immediate attention? Examine the areas for significant blood loss, so the chest, the abdomen, and the pelvis, along with the long bones.

Now with the pelvis, have a feel around the rim. Is there any bruising in the perineum? Are the legs lying symmetrically or asymmetrically? Hold gently onto the crest and can you bring the pelvis together? If so, you need to hold that to position.

bind it at that point to save any further movement. Now if they're GCS 15 and the pelvis is not clearly deformed, can they straight leg raise on the left and the right and to what extent? Because we know that that is a good sign that there isn't a ring. Coming on to D, what's the GCS? Making sure you pay particular attention to the motor score and you've applied a stimulus above a potential spinal injury, as in superorbital pressure, if they haven't responded at all.

What are the pupils doing? What's the size? Do they react? Can they move each limb to a command? And if not, if they're unconscious, have you seen each limb move? And if they are conscious enough, Have they got a sensory level by running your hands from the neck, down the arms, down the chest, down the abdomen, and down the legs?

Then finally onto E, obviously ensuring you've got adequate removal of the clothes, looking for any other major injuries that you've missed. It's easy to miss bleeding from things like wounds on the back of the head. Sweep both of your hands with clean gloves down the back looking for bleeding and with suspected penetrating trauma you need to do a log roll looking at the back on both sides and as we've said in those exili groins.

So rather than doing each side of the chest uh as a sort of a separate entity, I would tend to put both of my hands almost kind of encircling the the front of the chest. starting up near the clavicles and giving the whole kind of chest a bit of a squeeze and then moving down the chest probably another couple of times um to feel and cover off all of the ribs, seeing if there's any pain described or see if the patient grimaces at all.

If there was then any pain described or any grimacing, I would then potentially go back and sort of individually explore the areas that were described. So I I would do that as a as a one-er, I suppose, on the chest.

And if we're looking at it just visually, we're not always gonna see a deformity or swelling around the area. I personally would get in there and I would have a feel kind of along the length with both of my hands on the femurs and the humeruses and potentially the radius ulna and the Tibfib as well. and just feel for the stability of the bone uh under my hands. I mean, clearly if you find crepitus and instability, that is going to elicit a lot of pain for the patient.

Um so I'm not looking to really rag them around, but um I think it's important um that you do look for instability in Crepitus'cause that is going to clearly sort of identify a clinical fracture for you, certainly pre hospitally.

you know, pathology develops over time so it may become more obvious later on. So, you know, you could potentially reassess or things might be obvious when they arrive in hospital or things like that. But I guess from that perspective, you know, your first thing needs to be to have a good look around at that abdomen to see if there is any bruising, any abrasions, any sort of skin signs based on the mechanism that that patient.

has got and then obviously you can gently palpate the abdomen itself just to see if there's any tenderness there. But we need to be aware, hands up, that is not a good way of determining whether a patient has got an intominal injury using our fingertips. So there are other things that will probably need to happen and it's more based on that mechanism but

That doesn't mean we should skip it because we could have a very obvious injury there that is actually very clearly identifiable as being a problem early on as well. So needs to be in the in the makeup definitely.

And, you know, in the UK maybe we don't have such extremes of weather, but certainly some listeners may be faced with really extreme cold temperatures. What are we doing about kind of managing the the balance between exposing these patients for their assessment versus the protection against the elements, but also some dignity whilst we're undertaking the assessment?

So, if for example this patient is on a scoop, they've got a stretcher next to them, they've got a patent airway, they seem to be ventilating well. and they've got good signs of perfusion, realistically what you're gonna do is pop them onto that stretcher, get them into a truck and then fully expose them and complete a very detailed primary survey.

And then it's not so harmful, is it, to fully expose the patient. But I think it is really nuanced again, isn't it, to the situation and to the risks and benefits of immediate exposure.

And you have to carry out, I think, an abbreviated patient assessment and trauma survey until you identify an intervention that needs to be undertaken and that's not gonna be in the car. And so it might be that you choose to to pull this patient out of the car in w whatever fashion you're gonna extricate them.

taking them into the ambulance because in this case that I'm thinking of there was a lot of bystanders and so again for dignity and for warmth it was more appropriate to take this patient immediately into the back of the ambulance. to then undertake a full primary survey after that slightly abbreviated one uh in the car where it was more challenging to get to the

Okay, great. So that's a lot of information that we've now gathered from the scene and from our primary survey. So now you've got all that information and you've collated it all together in your mind, how are you now going to share it and who are you going to share it with?

Then actually running through and saying, you know, the airway is patent, there seems to be good mouth opening, I can't see anything in the mouth, there's no blood, no vomit, then actually that's a really distracting thing to do. And again, maybe relaying all the bits of B, C, D, and E.

It's just gonna be too much noise, but there are occasions I think especially when maybe there's been some initial under triage of the injuries of that patient, that actually explaining what you're finding to a team that there isn't a lot of concurrent activity can very quickly Get the team onto the same page. So there is a degree of information sharing that goes on as you go through it, but yeah, really nuanced.

What absolutely has to be there is a summary of those key findings at the end of the primary survey. So for example, A is patent, B's revealed that they've got a complex left-sided chest injury, multiple rib fractures, surgical emphysema, a presumed underlying pneumothorax, and they're hypoxic on the oxygen that they're on already. C, we've got no evidence of shock. D has got decreased GCS, he's agitated and got a motor score of four, and E has revealed no further injuries.

Now in hospital, there's then that communication that you're going to give back. So as a team leader, you've just received all that from Simon. And then as a trauma team leader you're gonna then summarise the case and findings. Well that's personally what I do. Along with my plan in a really succinct overview that shares

that mental model of that team leader and acts as a sort of final safety check to close this episode off. And that's predominantly in my case in case I've missed anything. So for example, I might say, you know, right team, if everyone can listen in while I summarise what's going on. We've got this forty five year old motorcyclist who was injured an hour ago in an RTC. He's hemodynamically stable but has a reduced GCS and what appears to be a left sided chest injury.

The priorities right now, team, are that we need to get some IV access and some bloods, and we need to give a grammar TXA in the next 10 minutes. We need to perform an RSI for neuroprotection, but we need to be super cautious that that positive pressure ventilation in the presence of a chest injury might mean we will need to treat a tension pneumothorax, so we need to be prepared for that.

And in the next hour, we need to have all of those other jobs done, but we also want to be back from CT and we will need someone to request that imaging. And then you check, you know, that everyone's happy with that plan. If they are, then okay, great. And then you delegate those tasks to individuals. So nurse one, can you get the IV access bloods and TXA? Anesthetic team, thanks for being here. Could you get set up for the RSI?

Nurse two, could you get a chest drain kit ready? And Simon, thank you so much for your amazing primary survey. But now can you get over to C T and let them know what we've got so we can actually find out for sure what those definitive injuries are.

that the person who's undertaken the primary survey is the trauma team leader or is the clinical lead, as we talked about earlier on. So I would absolutely, if I'd undertaken that assessment, do exactly what you've just talked about and I would assimilate those findings, get everybody for a heads in'cause I think that sharing of the mental model and of the sort of the projection about where you see this job going is really, really vital.

That's one way you can present that information. The other way would be to go through it in a stepwise, you know, airway is patent, breathing we've got a left sided chest wall, circulation seems fine. Have you got any preference in the way that you deliver it when you're assimilating that information, when you're pulling it all together?

with the time frames. I really like that. You know, we're gonna do this immediately, then in ten minutes we need to have done this and in one hour we need to have done this. I mean hopefully not a one hour schedule for uh pre hospital but uh you never know. Um But yeah, that summary I think is really nice and sharing your ideas and your mental model with the team, absolutely fantastic.

So I guess the final thing to touch on before we kind of wrap this uh this episode up is the secondary survey. And I know we said this was all about the primary survey, so hopefully this bit won't be too long. But uh it's worth clarifying, I think, at this point, what is the difference between the primary and the secondary survey? Well, you know, while the primary survey is that kind of fast, structured approach, looking to identify those gross life threatening concerns.

The secondary survey is a much more systematic and detailed examination of all of the different body regions, and it's aiming to identify all of the subsequent injuries. I guess it's historically referred to as a top to toe assessment. So in a stable trauma patient, I guess, this doesn't pose too many problems, and often the secondary survey will follow on shortly after the primary survey, and

You know, particularly in the conscious patient, it might be that there's only one clinician undertaking the secondary survey. You know, there's no time pressure, uh and the patient can interact with them, answer their questions and follow their commands. So it enables that nice.

detailed examination. But in the unstable patient things are a bit more challenging,'cause it's much more likely that the secondary survey is going to be done in parallel by multiple team members who then feed their findings back to the T T L or the lead clinician. And it's often done in a staggered approach with sort of targeted assessments being undertaken in little brief windows between some of those emergency procedures.

But I guess it's worth saying as well that it's not just a hands on assessment, but a Certainly in hospital the secondary survey will also involve investigations such as imaging and blood results like clotting and blood gases and usenes and so on, along with monitoring any trends in the vital signs that you see over a period of time.

So I'd be interested, I guess, to hear the sort of in hospital perspective from Rob and Simon, but for my pre hospital colleagues, I guess I need to be pretty clear about secondary surveys because In my opinion, in the pre-hospital setting, if you've got an unstable trauma patient, you should not be undertaking a secondary survey at any point.

Our priority in those patients is to treat the life-threatening concerns and transfer the patient to definitive care without delay. And I have to say I fundamentally disagree with the JRCalc guidelines on this because they say that the critical patient

should have a secondary survey completed during transport. They acknowledge it might not be done in some patients, but the statement is there nevertheless, and that does not sit well with me at all because firstly our focus should be on this critical patient and their physiology and keeping our interventions and keeping on top of trends, not working out which finger is dislocated.

And then secondly, we should be sat down and strapped in whilst the vehicle's in motion for as much of the journey as possible. We shouldn't be getting up to undertake a secondary survey that isn't going to impact upon the care that we deliver in the pre hospital setting. So

when they get back, there's inherently a lag of about anywhere between, you know, fifteen, forty five minutes for them to get that report back. That's personally where I like to go doing my secondary survey because that for me is a time when I can be focused on the patient.

without having to worry about the system wide issues that come along with trying to get their important stuff organised. So yeah, I mean I don't think the back of a truck is the place to perform that. But As I say, if there's an injury that you've identified or that you've come across, some basic first aid for that on the way is absolutely fine as well.

is able to elicit a whole load of information that can really feed into the best care and the best outcomes for our patient. And as we've demonstrated throughout the episode, there are a number of different ways in which we might go about that primary survey comparing clinician to clinician. But what we need to do is ensure that whatever system that we're personally going to use going through that primary survey is that we pick up and look for all of those keys.

where you can forget the sounds of our voices, but we'll be back with a bang with Papers of the Month and with another roadside Teresa for you in September. So take care of yourselves and we will speak to you soon.