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begin until the primary survey (ABCDEs) is completed, resuscitative efforts are well established, and the patient is demonstrating normalization of vital functions
History Physical examination: Head-to-toe Complete neuro exam Special diagnostic tests Reevaluation
HISTORY
PHYSICAL EXAMINATION
Head Neck Chest Abdomen Limbs Spine
Head
Scalp lacerations cephalohematoma skull fracture
Ears lacerations CSF otorrhea blood from ear canal blood behind TMs
GCS
Face
lacerations numbness stepoffs pain malocclusion dental injuries nasal injuries (septal hematoma)
Eyes:
-foreign body, -subconjunctival haemmorhage, -hyphaema, -irregular iris, -penetrating injury, -contact lenses.
extradural haematoma
high density of the haematoma. Slight
extradural haematoma
gas within the haematoma - this indicates a
basal skull fracture Note also the dilated lateral ventricle on the opposite side
subdural haematomas
subdural haematomas
Haemorrhagic contusion
There is a focal area of haemorrhagic
contusion in the right frontal lobe, with surrounding low density due to infarction or oedema. This is a frequent location for a contre-coup injury following a blow to the back of the head.
haemorrhage in a typical location at the grey-white matter interface (arrow). As is often the case, there were multiple such lesions on other slices.
of conciousness, focal neurological signs, fits or any other neurological symptom and signs Coma continuing after resuscitation (GCS < 8) Deterioration in the level of conciousness Confusion or other neurological disturbances persisting for more 6-8 hours even if there is no skull Suspected fracture of the base of skull (CSF rhinorrhea or otorrhea, bilateral orbital
Neck
tracheal bruits crepitus swelling lacerations seat belt stripe bony
deviation
tenderness,
Protection of the spine Any injury above the clavicle -Unconscious polytrauma -Neck pain -Localizing signs
Chest
Chest wall: bruising, lacerations, penetrating injury, tenderness, flail segment.
reevaluate breath sounds chest wall motion crepitance areas of tenderness contusion previously missed penetrating
Chest X-Ray
evaluate ribs mediastinum apices small effusion
(hemothorax
Tension Pneumothorax
Commonly due to positive-pressure
ventilation in patients with visceral pleural injury absence of breath sounds, deviated trachea
Abdomen
Inspect for bruising, movement and wounds Palpate the abdomen Auscultate for bowel sound Squeeze the pelvis for tenderness Check the perineum and genitalia Perform rectal examination
Associated Conditions
Liver Laceration Splenic Rupture Renal Injury Hollow viscus (bowel perforation) or Lumbar
Spine Injury
Seat Belt Deceleration injury
Rectum or other bowel injury Gastrointestinal Bleeding Pelvic Fracture Urethral Injury Vaginal Injury Bladder rupture
FAST Scan
Focused assessment using sonography in
trauma
Four Quadrants : 1)Subxiphoid : Pericardium 2)RUQ : Morrisons pouch (potential space between the liver and kidney) 3)LUQ : Splenorenal recess and between the spleen and diaphragm 4)Pelvis : Pouch of Douglas
Assessment
CT Abdomen or CT Pelvis, as indicated
in-situ and gunshot wounds traversing the abdominal cavity Any penetrating injury to the abdomen with haemodynamic instability or peritoneal irritation Obvious/strongly suspected Intra-Abd Injury with shock or difficulty to stabilize haemodynamics Obvious signs of peritoneal irritation Rectal exam reveals fresh blood X-ray evidence of pneumoperitoneum or
Pelvis
Pain on palpation Symphysis width Leg length unequal Instability X-rays as needed
Pitfalls
Pelvic fractures Pelvic organ
trauma
Check for blood at the urethral meatus Any scrotal hematoma PR : high riding prostate?
Limbs
pulses sites of tenderness contusions deformities lacerations range of motion at joints neurologic function Pelvis stability
Compartment syndrome
Pain Pressure (pain on palpation) Paresthesia Paresis (late sign) Pallor (late sign) Pulseless (last sign to occur)
Spine
Spinal injuries can be partial or complete Test for sensory and motor deficits If there is evidence of spinal injury the
patient should not be moved X-ray of the affected site is required If there is no neurological deficit, the patient can be log rolled and the whole of the back examined
lacerations, contusions, penetrating wounds
missed previously
Spinal cord injury should be suspected and cervical immobilization maintained from the time of injury in the following : Unconcious trauma patient
Survivors of high velocity
accident Presence of associated injuries Significant head or facial trauma Scapular contusion Seat belt injuries Injury to feet/ankle from a fall from height