The
management of severe multiple injury requires clear recognition
of management priorities and the goal of the initial assessment
is to determine those injuries that threaten the patient’s
life. If performed correctly, this first survey (the “primary
survey”) should identify such
life-threatening injuries such as:
| :: |
Airway
obstruction |
| :: |
Chest
injuries with breathing difficulties |
| :: |
Severe
external or internal haemorrhage |
| :: |
Abdominal
injuries. |
If
there is more than one injured patient, treat patients in
order of priority (triage). Successful triage requires rapid
assessment and clear thinking.
THE PRIMARY SURVEY
First, carry out the ABCDE survey:
| :: |
Airway |
| :: |
Breathing |
| :: |
Circulation |
| :: |
Disability |
| :: |
Exposure. |
The
ABCDE survey is sometimes referred to as the “primary
survey”.
Its primary function is to diagnose and treat life threatening injuries which,
if left undiagnosed and untreated, could lead to death:
| :: |
Airway
obstruction |
| :: |
Chest
injuries with breathing difficulties |
| :: |
Severe
external or internal haemorrhage |
| :: |
Abdominal
injuries. |
When
more than one life threatening state exists, simultaneous
treatment of injuries is essential and requires effective
teamwork.
Airway
Assess the airway. Can the patient talk and breathe freely? If obstructed,
consider the following steps.
| :: |
Chin
lift/jaw thrust (tongue is attached to the jaw) |
| :: |
Suction
(if available) |
| :: |
Guedel
airway/nasopharyngeal airway |
| :: |
Intubation;
keep the neck immobilized in neutral position. |
Breathing
Assess airway patency and breathing adequacy by clinical observation.
If inadequate, consider:
| :: |
Artificial
ventilation |
| :: |
Decompression
and drainage of tension pneumothorax/haemothorax |
| :: |
Closure
of open chest injury. |
Reassess
the ABCs if the patient is unstable.
Circulation
Assess the patient’s circulation as you recheck the oxygen supply, airway
patency and breathing adequacy. If inadequate, you may need to:
| :: |
Stop
external haemorrhage |
| :: |
Establish
2 large-bore IV lines (14 or 16 G) if possible |
| :: |
Administer
fluids, if available. |
Give oxygen, if available.
Disability
Make a rapid neurological assessment (is the patient awake, vocally responsive
to pain or unconscious?) There is no time to do the Glasgow Coma Scale (page
PCTM –23) so use the following clear, quick system at this stage:
A Awake
V Verbal response
P Painful response
U Unresponsive
Exposure
Undress the patient and look for injury. If you suspect a neck or spinal
injury, in-line immobilization is important.
Take care when moving the patient, especially if he or she is unconscious.
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