import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Trauma Primary Survey (MSK Focus) The trauma primary survey follows ATLS principles with CABCDE approach. Examiners expect you to understand how musculoskeletal injuries fit within the primary survey, particularly life-threatening hemorrhage from pelvic and long bone fractures, and spinal immobilization. ## Quick Reference One-Pager ## CABCDE Approach **C-ABCDE:** - **C**: Catastrophic hemorrhage control (added to traditional ABCDE) - **A**: Airway with cervical spine protection - **B**: Breathing and ventilation - **C**: Circulation with hemorrhage control - **D**: Disability (neurological status) - **E**: Exposure and Environmental control **Key Principle:** Treat life-threatening problems as you find them before moving to the next step. ## Catastrophic Hemorrhage Control **External Hemorrhage:** - Visible arterial bleeding - Traumatic amputation - Tourniquet proximal to wound **When to Apply Tourniquet:** - Uncontrollable external hemorrhage - Traumatic limb amputation - Mass casualty situations - Note time of application **Technique:** - 5cm proximal to wound - Tighten until bleeding stops - Write time on tourniquet - Maximum 2 hours before reassessment ## Airway with C-Spine Protection **C-Spine Immobilization Required If:** - Mechanism suggestive of injury - High-speed RTA - Fall from height (greater than 3m) - Axial load (diving, ejection) - Unconscious patient - Neck pain or tenderness - Neurological deficit - Distracting painful injury **Maintain Manual In-Line Stabilization** during any airway intervention **Can Patient Talk?** - If speaking normally, airway is patent **Look for Obstruction:** - Blood, vomit, debris - Facial/mandibular fractures - Swelling (burns, anaphylaxis) **Interventions:** - Jaw thrust (not head tilt in trauma) - Suction - Oropharyngeal airway - Definitive airway if needed ## Breathing **Inspect:** - Chest wall movement - Asymmetry - Open wounds - Distended neck veins (tension pneumothorax) **Palpate:** - Tracheal position - Chest wall crepitus - Tenderness **Percuss:** - Hyper-resonance (pneumothorax) - Dullness (hemothorax) **Auscultate:** - Breath sounds - Compare sides **Tension Pneumothorax:** - Respiratory distress - Tracheal deviation (away) - Absent breath sounds - Treatment: Needle decompression then chest drain **Massive Hemothorax:** - Dull percussion - Absent breath sounds - Shock - Treatment: Chest drain **Open Pneumothorax:** - Sucking chest wound - Treatment: Three-sided dressing, then chest drain ## Circulation and Hemorrhage Control **Blood Loss by Site:** | Site | Estimated Blood Loss | |------|---------------------| | Pelvis | 2-4 liters (potentially exsanguinating) | | Femur | 1-2 liters per side | | Tibia | 500mL-1L | | Humerus | 250-500mL | | Chest (hemothorax) | 2-3 liters | | Abdomen | Variable (massive possible) | **"Blood on the Floor and Four More":** Major hemorrhage sources: 1. **External** (on the floor) 2. **Chest** (hemothorax) 3. **Abdomen** (solid organ injury) 4. **Pelvis** (pelvic fracture) 5. **Long bones** (femur fractures) If hypotensive: Look for these sources! ### Pelvic Assessment **Indications:** - Mechanism suggesting pelvic injury - Clinical instability on examination - Hemodynamic instability with suspected pelvic source - High-energy trauma **Correct Position:** - Over greater trochanters (NOT over iliac crests) - Reduces pelvic volume - Tamponade effect on venous bleeding **Types:** - Commercial binder (SAM Pelvic Sling) - Sheet wrapped tightly - Apply before log roll ### Long Bone Assessment **Rapid Assessment:** - Obvious deformity - Swelling - Shortening - Rotation **Femur Fractures:** - 1-2 liters blood loss per fracture - Bilateral = massive hemorrhage potential - Traction splint (Thomas or similar) **Open Fractures:** - Photograph wound - Saline-soaked sterile dressing - Splint - Antibiotics within 1 hour - Tetanus status ## Disability **AVPU Scale:** - **A**: Alert - **V**: Responds to Voice - **P**: Responds to Pain - **U**: Unresponsive **GCS (Glasgow Coma Scale):** - Eye opening (1-4) - Verbal response (1-5) - Motor response (1-6) - Total: 3-15 **Pupils:** - Size, equality, reactivity - Unequal = herniation until proven otherwise **Rapid Assessment:** - Can move arms and legs? - Sensation to light touch? - Rectal tone (in complete assessment) **Neurogenic Shock:** - Hypotension + bradycardia - Warm, dry extremities - High spinal cord injury (T6 or above) **Spinal Shock:** - Areflexia below level of injury - May last days to weeks - Does not cause hypotension ## Exposure and Environment **Log Roll:** - Minimum 4 people - Manual in-line stabilization maintained - Inspect entire back - Palpate spine - Rectal exam if indicated **Environmental Control:** - Remove wet clothes - Warm blankets - Warm IV fluids - Avoid hypothermia (trauma triad of death) **Trauma Triad of Death:** 1. **Hypothermia** 2. **Acidosis** 3. **Coagulopathy** These are self-perpetuating and lead to physiological exhaustion. Prevention is key - damage control surgery principles. ## Secondary Survey **After Primary Survey and Resuscitation:** - Complete head-to-toe examination - AMPLE history - Detailed neurological exam - All imaging **AMPLE History:** - **A**: Allergies - **B**: Medications - **C**: Past medical history - **L**: Last meal - **E**: Events leading to injury **Each Limb:** - Look: Deformity, swelling, wounds - Feel: Tenderness, crepitus - Move: ROM (if appropriate) - Neurovascular: Pulses, sensation, motor **Document:** - All injuries - Neurovascular status - Open vs closed - Photographs of wounds ## Special Situations **High Mortality Injury:** - Massive hemorrhage potential - Associated injuries common (bladder, urethra, bowel) **Management:** - Pelvic binder (over trochanters) - Massive transfusion protocol - CT angiography - May need: External fixation, preperitoneal packing, angioembolization - Definitive fixation when stable **Crush Syndrome:** - Prolonged compression of muscle - Rhabdomyolysis on release - Hyperkalemia, myoglobinuria, AKI **Management:** - IV fluids BEFORE release (if prolonged) - Monitor potassium - Urinary alkalization - Dialysis may be required - Consider tourniquet if life-threatening **Priorities:** - Control hemorrhage (tourniquet) - Resuscitation - Care of amputated part **Amputated Part:** - Wrap in moist saline gauze - Place in plastic bag - Place bag on ice (NOT direct contact) - Label with patient details and time **Replantation Criteria:** - Sharp injury preferred - Thumb, multiple digits - Child (better outcomes) - Warm ischemia time limits ## Summary Presentation ## Examination Sequence 1. **Scene safety** and PPE 2. **C**: Control catastrophic external hemorrhage 3. **A**: Airway with C-spine immobilization 4. **B**: Breathing - chest examination 5. **C**: Circulation - access, fluids, hemorrhage source 6. **Pelvic assessment** (once only) and binder 7. **Long bone splinting** 8. **D**: Disability - GCS, pupils, limb movement 9. **E**: Exposure - log roll, environment 10. **Secondary survey** when stable ## Examiner Tips