02.01 Trauma Survey

So, this kind of says it all. The trauma survey, when done properly, can spot any and all life-threatening injuries. As soon as we figure out what is happening to our patient, we can treat them. You will find that in Emergency Medicine, we use a whole lot of mnemonics. As providers who can treat anything that comes through our doors, it helps to have any little hint to remember things. 

The easiest way to remember the steps of the trauma survey is by using the A to I mnemonic. The initial survey is broken down into a primary and secondary survey.

Now the primary survey consists of A, airway; B, breathing; C, circulation; D Disability, and E, expose and environmental control.

The secondary survey continues to just follow the alphabet. F, full set of vitals and family presence, G, get resuscitation adjuncts and give comfort measures, H, History and head-to-toe assessment, and I, inspect posterior surfaces. See… easy. Just remember A through I and it will guide you through those first few minutes after your patient hits the door.

Important to note, its best not to do the secondary survey before the primary survey. We don't need to know if the patients toe is broken if he isn't breathing. 

So….first things first…. Does our patient have an airway? 

Can your patient can talk? This is also a way to good way to gauge their level of alertness. We use the mnemonic AVPU, which stands for Alert, Verbal, Pain and Unresponsive. What does this mean? Well, if your guy comes in and says, “Hi there, fine hospital you have here. I’d like you to fix me up and discharge me as soon as you can.”, then guess what. He is alert. And you know what...he also has an airway. If the patient is talking, whether they make sense or not, then they usually have a patent airway. You can also assume, if they can talk, they can breathe, but we will get into that.

Verbal means the patient comes in with his eyes closed. You say his name and he opens his eyes. See….he responded to verbal stimuli.

Pain means just that. Same guy comes in, eyes closed….you shout and get no response. So you decide to use painful stimuli. This could be a sternal rub, a trapezius pinch, maybe even the insertion of an angiocath. If any of these things gets the patient to respond in any way, then he is responsive to painful stimuli.

And unresponsive is just that….you got nothing.

In any true trauma patient, as we are quickly assessing the airway, we want to always maintain stabilization of his C-spine. If they come in with a C-collar on….like the one above….then great. C-spine stabilized. If not, then we need to apply manual stabilization until we can secure it with the collar. See the guys hands in the pic… That’s pretty good but i have always found if you bring your hands down a little lower, even anchor them to the shoulders and hold the head in your forearms, you get a little more stabilization. I want you guys to understand….we maintain C-spine stabilization throughout airway because it’s very common to move the neck and head when assessing an airway. We need to make sure that the c-spine stays in alignment while also making sure our guy can breathe.

So, we have an airway, and our guy is breathing…somehow. Now time to assess circulation. We know that blood outside the body is a bad thing. Remember that and you will do great in trauma. We need to control life-threatening hemorrhage. Traumas are the time when we use a protocol that many hospitals are instituting... the massive transfusion protocol. This is where the blood bank sends up a large amount of blood, platelets, and possibly some other blood products in one big cooler.

Now our patient is leaking...but here is the question of the day. Does he have a pulse? We assess this by palpating a central pulse...this means carotid, or femoral., not peripheral.

Our guy has no pulse…...well this is no different from any other instance in which a patient doesn't have a pulse… come on, say it with me. START CPR! And we will do CPR until we get the return of spontaneous circulation, or ROSC, or the doc calls it. We don’t stop compressions unless we are doing a pulse check or defibrillating.

If our guy has a pulse, we would continue with our assessment. We’re looking for any bleeding throughout the body, assessing the skin… color, temperature, and we do that by actually touching our guy, or…palpating.

So, we have A, B, and C, let’s move on to D

Disability… now I’m not talking about like a physical disability like if your patient is deaf or only has one leg. We are talking about neurological disability. This is where we want to assess and document mental status. In the trauma bay, we use the Glasgow Coma Scale to assess level of consciousness. There is a great lesson on GCS in our med surg, head to toe assessment, neuro assessment lesson. You really should go check it out if you need a refresher on GCS.

If there is one thing I can tell you about GCS...and I say this because I have seen it documented many times. A patient can not...I repeat, a patient cannot have a GCS of zero! The lowest possible GCS score is 3. A score of 3 means there is no verbal response, no eye opening and no motor function. Nada, nothing...and still it’s a score of 3. Technically the screen you are watching this on has a GCS of 3. So please, never….ever document a GCS of zero.  Ok, I’m done ranting on that.

So a very common trauma presentation is that of a head injury. Kind of like the one in the picture above. For the record, that is a pic of a subdural hematoma with a midline shift. Not a good day for our guy there. So, if we suspect, or have confirmed a head injury or a head bleed of any sort, we want to be very aware of the patient's position in the bed. We want to either keep them supine, or raise up the head of the bed about 30-40 degrees. Not too high. Watch closely for signs on increasing ICP (again, check the neuro assessment lessons).

It’s now time to get the rest of the patients clothes off. In most traumas, we all grab our trauma shears and start cutting. Usually we get off the shirt and the pant legs right away. Once we have gotten to this point of the assessment, we need to remove everything. Get the patient naked. We also want to make sure that as we are removing the clothes, we take them out from underneath the patient. Pulling out the clothes from under the patient can actually give us an idea of any possible bleeding on the posterior surface as we probably haven't rolled the patient yet.

So now we have a naked patient in a cold ER. Let’s get them warm. We can user blankets, raise the temperature in the room, give warm IV fluids, use warm air circulators like a Bair Hugger, or, if you have them, radiant heat lamps. I have found in my practice, that one of the most coveted items in any ER is the blanket warmer. Do your best to always make sure it's stocked.

With the primary survey done, we move right into our secondary survey, which starts with a full set of vital signs. When it comes to blood pressure, I know we all like to throw on the automatic cuff and set it to just do continuous readings. Both the American college of surgeons (the guys who kind of regulate trauma care) and the Emergency Nurses Association recommend that the first blood pressure we get is done manually. The manual gives us a baseline and allows us to compare with the automatic. If the readings are very different, continue to get manual pressures until you can fix the problem with your monitor.

While we’re doing that, consider bringing the family in to the trauma bay. Studies continue to show that family presence helps loved ones accept what is happening to the patient. Having them witness the work we are doing helps them to grasp the severity of the situation. The tough part of this is making sure that there is a staff member with the family members in the room. This could be a nurse, PA, resident. But the best people for this are usually social workers or members of the chaplaincy. They are trained to deal with families in traumatic situations a little more than we are and as they are not directly hands on with the patient, they are perfectly situated to help with the family.

OK - now we need to get resuscitation adjuncts. Well what does that mean? This is basically things that will help us to really understand how sick our patient is. It’s one thing to see the external injuries, but we also need to know what’s going on inside. One way to remember some of these things, is the mnemonic LMNOP:

L - Labs. All the basics. We also want an alcohol level and a tox screen. We would also draw either an arterial or venous blood gas to get a lactate level and base deficit.

M- Monitor...simple enough. Keep ‘em on the cardiac monitor and watch for any arrhythmias.

N - Naso or oro-gastric tube and indwelling urinary catheter. Attach the NG or OG tube to suction to prevent aspiration. Insert an indwelling urinary catheter to monitor the patient's urinary output.

O - Oxygenation and ventilation: He is getting something. Lets monitor his oxygenation with the pulsox, at the least, and if you have it, capnography.

and P - Pain management: I think this should go without saying, but if a person is broken in some way, it’s going to hurt. Do not be afraid to medicate them.

History and head to toe assessment: There is a reason this is letter H, and it's not because it works in the alphabet. We can take care of our patient without this information. It helps of course, but it is not absolute for the care….look how much we have done to this point! If we can get this info, great. If not….move on.

Our first source if info is going to be EMS. Hopefully, they will provide you with a quick rundown of the patient in the form of the MIST. Mechanism of injury, Injuries they have identified, Signs and symptoms they were exhibiting in the field, and Treatments they provided. When EMS is giving this report, the room should be silent to everyone can hear and process the information.

So now we need some more info about our patient. If they are awake and alert….great! we can ask them directly. Hopefully we have assessed there orientation level prior to this because if you ask about events leading up to the injury and he says he was breakdancing on the moon with the Pope, i think it’s safe to assume he is a bit confused. In this situation, or if they cant respond, we need to try and find a friend or family member to give us some info. To get a quick verbal history, we use SAMPLE:

Symptoms they were having

Allergies (to meds or otherwise)

Medications they are currently taking

Past pertinent medical history

Last Oral intake

Events leading up to the injury. We ask this, not only to get an idea of how they got themselves in this situation, but if there was something medical leading up to it. If they fell and broke their arm because they tripped...that's simple enough. If they became dizzy, passed out, and fell so hard they dislocated their shoulder, this we need to investigate a little more.

Then we will perform our head-to-toe assessment. I'm not going to go through the full assessment here as there are some amazing assessment lessons throughout NRSNG.com. I will however say this. It is very important in trauma to avoid tunnel vision. What i mean here is that it's easy to focus on the traumatic upper extremity amputation at the shoulder, but don't put all your focus here and ignore the open posterior head wound that is slowly saturating the sheets below his head with bright red blood.

OK we’re on to the last step of the trauma survey. We have checked them from head to to on the front, but now we need to see their back. Maintaining c-spine stabilization if necessary, we roll the patient on their side and inspect their entire posterior from head to toe. 

One of the parts of this inspection, performed by one of the physicians on hand, is a quick rectal exam, lovingly known in some circles as the trauma handshake. The rectal exam in this instance is looking for two very specific thing: Blood, and rectal tone.  Blood is a sign of….well...bleeding. A decreased rectal tone is a sign of spinal injury or neurologic injury and requires further investigation. 

And our initial survey is done. At this point we will reassess all our previous interventions and continue to trend vital signs and address any changes.

So I threw this picture in here guys because i thought it shows what we have been talking about pretty well. It looks to me like they are on their secondary survey and they are inspecting the posterior. I want you to notice a few things here. Clearly there are a lot of things going on at once, but everyone is working together. The team is working as one unit to care for the patient. We have the doc at the head of the bed maintaining c-spine stabilization and the patient has a collar on. We can see that probably all of his clothes have been removed and nicely placed on the floor next to the bed. Monitors are attached, fluids are hanging. I would guess we have 3 nurses in the room: one is facing us, one to the left is probably at the crash cart, and the third is near the wall… I'm going to say she is the recorder (which is one of the most important jobs in the room). All in all, I just like this picture. 

Remember guys, trauma is based on these three principles. Critical thinking, Evidence based practice, And Prioritization. Everything we do is based on these concepts.

So, a few key things to remember:

The initial trauma survey uses the A to I mnemonic to provide a systemic flow for evaluation.

The primary survey involves airway, breathing, circulation, disability and exposure

The secondary survey includes getting as full set of vitals and family presence, getting resuscitation adjuncts and giving comfort measures, performing the head-to-toe assessment and getting a history, and inspecting the posterior surface. 

Teamwork is key in a trauma activation. A good trauma team works seamlessly. Each member knows their tasks and the tasks of everyone else in the room and can anticipate the movements of their colleagues. When you see a great trauma team at work, its like watching a ballet. 

And finally, don't get tunnel vision. It's very common for new nurses to focus on one thing. Like if your guy comes in with a knife stuck in his chest, everyone starts focusing on the knife. Don't forget to see if his airway is patent and he is breathing before you worry about the knife. Make sure you always keep the flow of assessment in mind and you will be fine.

So….thanks for joining me in  on our intro to trauma. There is a lot more to come here on NRSNG so i hope you will all tune in again.  And as always… Happy nursing!