Primary survey

Life threatening chest injuries need to be recognised and addressed early during the primary survey of major trauma patients. It is vital to actively search these conditions out as they may not be apparent on initial presentation. Life threatening injuries evolve over time, therefore it is important to emphasize the need for constant reassessment.
Use a systematic approach based on the ABCDE survey to assess and treat an acutely injured patient. The goal is to manage any life-threatening conditions and identify any emergent concerns.
Clothing should be cut off as soon as is possible in order to gain a thorough view of the patient.

Airway with cervical spine protection
 


Assess for airway stability and rapidly assess for major injuries affecting airway patency.
Consider securing the airway with early intubation if there are any signs of:

  • Pending airway obstruction: stridor, hoarse voice.
  • Decreased level of consciousness.
  • Unprotected airway.
  • Uncooperative/combative patient leading to distress and further risk of injury.
If the patient is already intubated, document the size and position of the endotracheal tube, including lip level, cuff pressure and any intubation difficulty (or Mallampati grade).
Note ETCO2 trace.
Maintain full spinal precautions if indicated - suspect spinal injuries in all poly-trauma patients. Ensure a cervical collar and in-line immobilisation is maintained throughout patient care.
For further detail please refer to the Primary Survey section of the Early Trauma Care guideline.


Breathing and Ventilation

Identify life threats:

  • Tension pneumothorax
  • Massive haemothorax
  • Open pneumothorax
  • Flail chest & Pulmonary contusions
  • Tracheobronchial injury

Assess the chest - expose:

  • Note respiratory rate / effort / Sp02.
  • Look for open / penetrating wounds / tracheal deviation / plethoric facies.
  • Observe any bruising / deformity / abnormal chest movements: Intercostal & / or supraclavicular in-drawing.
  • Palpate – hyporesonance (fluid), hyperesonance (air), tenderness, crepitus, surgical emphysema.
  • Auscultate chest for bilateral air entry, additional noises.
Rapid, shallow ventilation occurs in chest injury as well as developing hypoxia. All patients with chest injuries have a high oxygen demand and therefore supplemental oxygen should be supplied until injury is ruled out. Make sure to check the back also as life threatening wounds may be otherwise undetected. Immediately after detection of any life threatening injuries, interventions need to occur in order to prevent further deterioration.

Detecting life threatening injuries:

  • Hyperesonance, tachypnoea, decreased or absent air entry to affected side, decreased chest movement, tracheal deviation (late sign) => Tension pneumothorax –> Finger thoracostomy followed by insertion of intercostal catheter.
  • Dullness to percuss, decreased or absent air entry => Massive Haemothorax ->Chest Tube Insertion
  • Open ‘sucking wound”, decreased air entry=> Open pneumothorax - > 3 sided occlusive dressing, intercostal catheter insertion.
  • Paradoxical chest movement =>Flail Chest & Pulmonary Contusions - >Adequate analgesia / oxygenation / consider early intubation and ventilation.
A mobile chest x-ray should be performed in the resuscitation bay at the earliest opportunity (and performed with a pelvic x-ray as adjuncts to the primary survey).


Circulation with haemorrhage control

Assess circulation and perfusion

  • Pulse – Quality/ rate/ regularity – carotid, femoral or radial?
  • Skin – colour / cap refill time / temperature.
    BP.
  • JVP – raised/ flattened.
  • Look for plethoric facies.
  • Perform FAST scan looking specifically for evidence of pericardial tamponade or pneumothorax.

Management:  

  • Obtain IV access – x 2 large bore, take bloods.
  • IO access if unable to gain peripheral access.
  • Fluid replacement: early administration of blood products if available, alternatively isotonic crystalloid solution e.g. 0.9% Saline 20ml/kg.
  • Continuous cardiac monitoring.
  • Control bleeding if compressible source.
FAST: In the hypotensive patient, FAST should be performed as part of the primary survey.  FAST is more accurate than physical examination for detecting the presence of pericardial or intraperitoneal bleeding.
For hemodynamically normal patients, FAST can be performed as an adjunct to the primary survey.


Disability: Neurological status


Assess level of consciousness, as a measure of end-organ oxygenation and perfusion.
  • GCS, Pupils, BSL.


Exposure and environmental control



By the end of the primary survey the patient should have been fully exposed so as to ensure no injuries posing an immediate life threat are missed.
Trauma patients are prone to hypothermia, so upon completion of the primary survey measures to prevent this should be taken. Application of external warming devices such as Bair Huggers / warmed blankets are encouraged if the patient is even mildly hypothermic.
Consideration must be given to the patient’s age, gender and culture when exposing them for a trauma examination. Exposure may need to be done sequentially, uncovering one body region at a time to maintain patient dignity.

Investigations

  • Baseline portable chest and pelvis x-rays.
  • FBC, U&E’s, troponin, ABG, X-Match, Coagulation studies.
  • 12-lead ECG.

Analgesia

  • Titrated IV narcotic analgesia is the initial approach to pain management in trauma.
  • Ongoing pain from chest trauma decreases coughing, leads to shallow hyperventilation, reduced FRC and retention of sputum. This is of particular concern for the elderly trauma patient who is more prone to developing pneumonia leading to increased morbidity and mortality. Effective pain management may be achieved with the use of paracetamol, non-steroidal anti-inflammatory drugs, tramadol, opioid analgesia as well as consideration of intercostal nerve blocks, likely managed in the MTS.