The successful management of severe trauma is dependent on the following six steps.

The sequence of PTC is illustrated in Figure 16.1 (page 16–4):

TRIAGE

Triage means sorting and treating patients according to priority, which is usually determined by:

Patients are routinely sorted according to priority:

PRIMARY SURVEY
This section is covered at length in the Annex: Primary Trauma Care Manual.

Make a full primary and secondary survey of any patient who is injured, especially patients who have:

The importance of ABCDE

ABCDE is a simple way of remembering the essentials of the primary survey. This is the first survey of PTC; it is also something you must return to whenever the patient’s condition becomes worse – whether this occurs 5 minutes or 5 days after the patient arrives.

A is for Airway

No oxygen can reach the tissues if the airway is obstructed; the commonest cause of obstruction is unconsciousness combined with the supine position, which causes the tongue to fall back and the pharynx to collapse. Other causes include neck trauma and foreign bodies.

B is for Breathing

Even with an open airway, no oxygen reaches the lungs unless the patient is breathing or someone provides artificial ventilation of the lungs. Breathing may stop because of severe head injury, hypoxia, mechanical or circulatory arrest.

C is for Circulation

Oxygen in the lungs cannot reach the tissues unless the heart is working; common reasons for inadequate circulation include blood loss (shock) and increased pressure on the heart from pneumothorax or haemopericardium. Shock and low blood pressure are dangerous for all patients, but especially for patients with head injury, as the blood supply to the brain will be further reduced. This causes a vicious circle in which hypoxia causes further brain swelling which, in turn, reduces the flow of blood to the brain.

D is for Disability and neurological Damage (brain and spinal cord)

Checking for neurological damage is a vital part of the primary survey. Do not make a full neurological examination at this stage. Grade the patient’s initial level of consciousness using a simple classification such as:

A Alert
V Verbal response
P Resonance to Pain
U Unresponsive.

Complete the examination within 30 seconds.

E is for Exposure

Remove the patient’s clothing and examine the whole patient, front and back, but do not allow the patient to get cold. Examining the whole patient is the only way to be sure that you have not missed other injuries.

Immediately treat any life-threatening problems, such as bleeding, pneumothorax or obstructed airway, that you find during the ABCDE primary survey. Less urgent problems, such as an arm fracture, must wait until the patient is stable; they will be picked up in the secondary survey and should be treated appropriately in the definitive care phase.

The ABCDE is easy to remember in English. If you are reading this in another language, try to find a simple way of remembering these points in the right order in your own language. In an emergency, a simple aid such as this is useful to help you remember the six phases of Primary Trauma Care Management, but it does not replace the need to think carefully about each patient.

Resuscitation skills

There are a small number of practical skills that are essential for the initial resuscitation of injured patients. The only way to learn them is by gaining practical experience under the supervision of a person who is skilled in their use. An experienced anaesthetist or trauma surgeon will also be able to help you gain practice and experience.

The skills you need include:

These techniques, and other procedures such as tracheostomy, are covered in the Annex: Primary Trauma Care Manual and on pages 16–8 to 16–13.

SECONDARY SURVEY

The purpose of the secondary survey is to make sure you examine all systems and parts of the body to ensure that nothing important is missed. During the secondary survey, you should identify all the injuries and start to think about your treatment plan. An X-ray examination, if available, is part of the secondary survey.

If there is any unexplained deterioration at any time, you must repeat the primary survey.

During the secondary survey, look in detail at:

After the secondary survey, fully document your findings, including:

STABILIZATION AND TRANSFER

You have examined the patient, treated life-threatening conditions and made a second examination to detect any other injuries. The management plan of the patient should now be clear.

When documentation has been completed, analgesia administered, laboratory investigations sent and any fractures immobilized, you can then decide on the best treatment option:

Before referring a patient:

For more details on transfer, see pages 1–15 and 3–3.

DEFINITIVE CARE

Once the patient has been resuscitated, stabilized and transferred, the planned correction of the injury can proceed.

In order to save the patient’s life, it may be necessary to carry out an immediate surgical procedure as part of the initial primary survey and early resuscitation. The decision whether to rush the patient to the operating room needs careful consultation and good communication between the surgeon and anaesthetist.

Special patients and special situations

Be aware of special patients and special situations. Children and pregnant women, for example, have special needs and may need different treatment because their anatomy and physiology vary from that of a non-pregnant adult. Details of the differences are given in Unit 3.2: The Paediatric Patient, Unit 14.3: Paediatric Anaesthesia and the Annex: Primary Trauma Care Manual.