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Immediate responses are likely in injured cases with blood loss of less
than 20 per cent, where bleeding will have ceased spontaneously or by
direct pressure e.g. an open fracture of tibia.
Transient responses could be found in cases of intra-abdominal or
Thoracic hemorrhage and mostly surgical intervention will be
indicated.
No responses are found in cases with active and massive bleeding in a
body cavity or in cases of non-hemorrhagic shock. Immediate surgical
intervention is required in trauma patient with blood loss of more than
40 per cent of their blood volume.
D. DYSFUNCTION OF THE CENTRAL NERVOUS SYSTEM.
During the prehospital management a rapid mini-neurological
examination of the central nervous functions is performed (AVPU).
Now a rapid assessment of motor and sensory functions should be
carried out. A detailed assessment of the injured would be conducted
during the final secondary survey.
E. EXPOSURE AND ENVIRONMENT.
The injured patient could be exposed accordingly and the environment
must be considered. Any remaining cloths should be removed and the
surrounding atmosphere must be acceptable, the rooms are warm
enough.
The result and response of the rapid primary survey of the injured
according the ABCDE sequence will be important and decisive for
any further critical decision.
Patients without life-threatening problems or that whose condition
responded well to the initial steps, are now ready and should be
submitted for further definitive management.
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X. THE SECONDARY SURVEY.
At this stage in the assessment of a traumatized patient, the treatment
of life-threatening injuries should have commenced.
The secondary survey should start with a top-to-toe physical examination
of the injured to detect and follow injuries to all body systems.
The secondary assessment utilizes the skills of inspection, palpation
and auscultation. The inspection needs total exposure of the patient,
good lighting and access to the back of the patient as well as the front.
The examination should commence at the head because about 10% of
significant head traumas are associated with trauma to the cervical
spine, which is properly examined.
In the chest, injury to the thoracic spine may be associated with fractures
of the sternum or ribs, haemopneumothorax or pulmonary contusion.
The abdomen is gently palpated to detect signs of peritonism, such as
rigidity or tenderness in the responsive patient. Careful palpation could
define the nature and extent of the injury and direct further analysis.
Auscultation is used for determining blood pressure and examining
the lungs and vascular system.
The back and the limbs are than properly examined.
Radiological studies supplement the clinical assessment and are
specific to the patient s symptoms and physical signs elicited by the
examining physician.
XI. THE HEAD.
The inspection of the head will reveal any external signs of injury.
Tender swelling over the scalp is mostly a haematoma and could be
associated with underlying skull fracture. Scalp lacerations are
obvious and could bleed profusely.
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Contusion over the mastoid (Battle s sign) indicates basilar skull
fracture. Bleeding from the external auditory meatus could mean a
fracture in the base of skull.
Leakage of cerebro-spinal fluid (CSF) should be suspected in all
patients with bloody otorrhoea. Sterile dressing should be applied and
early definitive repair is indicated.
XII. THE FACE.
Injuries to the face are managed very carefully, because the later
cosmetical result is very important for the normal appearance of the
patient. The face is properly inspected for symmetry and obvious
injuries. Contusions may indicate underlying fractures.
The face should be palpated carefully for tenderness, irregularity,
crepitus and motion to detect underlying fractures.
Accurate inspection of the eyes for papillary size and symmetry and
any abnormality. Vision and reaction to light should be also examined.
Unilateral drooping of the eye lid may indicate Horner s syndrome
and point toward blunt neck injury. Inspection of the nose to detect
any signs of bleeding from the nares with or without CSF rhinorrhoea
as a sign of dural tear. Meticulous inspection of the mouth and
oropharynx for detection of tongue lacerations or mucosal defects.
The examining doctor should look for any signs of facial nerve injury
by asking the patient to raise the brow, squint, smile and contract the
platysma.
X-rays of skull in tow directions and any further needed radiographs
would complete the examination of the head.
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XIII. THE NECK.
The assessment of the neck includes inspection, palpation and
Auscultation by complete exposure. The neck contains many
structures of vital importance to the patient s survival. In case of
presence of pain, swelling or irregularity the immobilization of the
neck is highly recommended. Accurate inspection shows asymmetry,
swelling or any other external signs of trauma. Neck swelling of any
extent should be considered as potentially life-threatening and
pressure symptoms have to be expected.
The palpation begins from up to down to detect tenderness or
irregularity and to exclude any signs of cervical spine fracture.
Auscultation of both carotid arteries to exclude the presence of bruits
as an early sign of carotid injury.
X-rays of the cervical spine, lateral and antero-posterior views
provide valuable information about the bony and anatomical position
of the neck.
Presence of cervical spine fracture make it sometimes necessary for
further investigations steps.
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C5-C6 Dislocation facture with complete plegia.
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XIV. THE CHEST.
External signs of chest trauma are mostly obvious. The examination
starts with the assessment of the ventilation. Paradoxical chest wall
motion indicates underlying flail chest. In such trauma cases one
should anticipate pulmonary contusion and the possible need for
tracheal intubation and positive pressure ventilation.
The chest wall should be gently palpated for tenderness and\or
crepitus and if present, rib fracture suspected.
Breath sounds and chest wall expansion both sides should be
compared. If breath sounds are absent or significantly diminished on
one side, pneumothorax and \ or haemothorax should be suspected.
Percussion of chest wall may help distinguish between pneumothorax
(hyper-resonant) and haemothorax (dull percussion note).
Tension pneumothorax is treated by needle decompression and tube
thoracostomy based strictly on clinical suspicion. Because collapse of
the lung and bleeding into the pleural space often coexist, lateral tube
placement is the approach of choice in the injured patient. The tube is
inserted at the nipple level between the anterior and midaxillary lines.
Bleeding in the pleural space is analogous to external bleeding, so
that volume replacement must be just as vigorous for haemothorax as
for any other bleeding elsewhere. Rib fractures with laceration of
inter-costal vessels account for the majority of significant
haemothoraces.
Bleeding from the pulmonary parenchyma usually ceases spontaneously,
because pulmonary vascular pressure is comparatively low.
The mediastinum warrants meticulous examination in all trauma cases
including inspection and palpation.
X-rays of chest in upright position (if possible) in one and \ or both
directions are very useful.
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Pneumothorax right chest cavity.
XV. THE ABDOMEN.
The abdomen is first carefully inspected for external signs of injury.
Contusions across the abdomen could have underlying injuries. The
examining physician should search for evidence of intra-abdominal or
retroperitoneal haemorrhage. Percussion of the abdomen could help
distinguish intra-abdominal air or gas (tympanitic) from fluid (dull
percussion) and also for detection of intra-abdominal tenderness.
Percussion tenderness could mean underlying peritoneal irritation and
has the same significance as rebound tenderness. Injury limited to the
retroperitoneal space may be occult or result in massive haemorrhage.
Signs of retroperitoneal trauma are usually indirect. Haematuria is the
most common and indicates genitourinary injury.
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The rectal examination is a vital part of the abdominal examination,
especially if there is local trauma of the rectal region. It should be
performed prior to insertion of urinary catheter. Specific findings on
rectal examination are assessment of rectal tone, presence of blood
and confirmation of prostatic texture and location. Local trauma of
rectal region may be related to major pelvic fracture or penetrating
trauma.
Blood in the rectum should alert the examining doctor to the possibility
of injury to the rectum or more proximal bowel.
Anoscopy or proctosigmoidoscopy may disclose the cause of
bleeding. Intra-venous pyelography (IVP) is a diagnostic choice for
suspected urinary tract injury.
Computed tomography CT is nowadays superior to IVP and has the
added benefit of demonstrating other retroperitoneal abnormalities. In
women pelvic examination is also essential and vaginal bleeding
should not be dismissed.
The superior surface and the back of the patient must be also examined.
The back should be inspected and palpated for signs of injury.
Injuries to the pelvis are commonly following motor vehicle crashes,
motorcycle crashes, pedestrian impacts and falls.
Such injuries could be severe and associated with massive bleeding.
Laceration of the perineum indicates usually an open pelvic fracture.
Diagnostic techniques of the injured abdomen include abdominal
ultrasonography, peritoneal lavage, CT scan and angiography.
Diagnostic laparoscopy is recently advocated with limited indications.
XVI. PELVIS.
The examination of the pelvis and exclusion of any pelvic trauma is
very important for the trauma patient. The pelvis is gently compressed
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and distracted manually to check for pain and stability. Any external
signs of injury or blood may indicate underlying injury. An AP-X-ray
of the pelvis should be obtained.
Multiple fractures in the pelvis of a patient with
Complex abdominal trauma.
XVII. SPINAL INJURY.
In spinal injuries with unstable fractures, further neurological damage
can be caused by moving the patient inappropriately. Therefore one
must be very careful during dealing and examining the spine after
trauma to avoid any further additional damage.
Full examination should require the patient to be log rolled with the
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help of sufficient personnel. One should examine the back and
perineum accurately including rectal examination if not done before.
The transport of these patients require the same care as for a log roll.
XVIII. EXTREMITIES.
Injuries of the extremities cause considerable high morbidity.
Musculoskeletal injuries account about 50 % of injuries following
blunt traumas. The common usual signs of extremity injury are
tenderness, swelling, deformity, contusion, laceration, abnormal or
absent sensation, pain with motion and abnormal positioning of the
extremity.
When examining trauma patient each extremity should be well
inspected and palpated for abnormality and/ or tenderness and
compared with the opposite side. Pulses should be assessed
proximally and distally to the injury. Obvious fractures must be early
enough immobilized, protected from further injury and stabilized
early by the appropriate method.
If crush, comminution or signs of compression occur, one should
suspect compartment syndrome.
Radiological evaluation of the injured part of the extremity is almost
always indicated after the clinical assessment. It is essential to survey
the extremity from the proximal joint through the joint distal to the
injury and to take views best suited to the type of injury.
According the mechanism of trauma associated musculoskeletal
injuries are possible.
X-ray should include joints above and below a long bone fracture.
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