– Primary Survey –
PPE: goggles, mask, gown, gloves
AIRWAY + C-SPINE:
- Talk to the patient (patent airway, conscious, in pain?)
- Ask pt to open their mouth (inspect for foreign bodies)
- Look, listen, and feel (hoarseness, cough, stridor)
- Oxygen mask
- Apply C-collar
BREATHING:
- Inspect neck + palpate trachea (edema, distended neck veins, subcutaneous emphysema)
- Expose chest: inspect, palpate, percuss, auscultate (circumferential burns, symmetrical breathing)
- Pulse oximetry
- CXR + pelvic X-ray
CIRCULATION:
- BP, pulses, capillary refill
- Insert 2 large-bore Iv cannula in ante-cubital fossa
- Draw blood for CBC, cross match, coagulation, electrolytes, chemistry, pregnancy, tox, ABGs
- Run warmed 2L crystalloids
- Examine pelvis, abdomen, limbs (for circumferential burns, swelling, fractures)
- External bleeding
- FAST
DISABILITY:
- Pupils
- GCS
EXPOSURE:
- Check temperature
- Remove clothes and fully expose the patient
- Cover the pt w\ blankets to prevent hypothermia
LOG ROLL + PR EXAM
ADJUNCTS:
- ECG
- Decompression: NGT + foley cath
– Secondary Survey –
- AMPLE history:
- Allergies
- Medications
- Past medical hx
- Last meal
- Event \ Environment:
- Time
- Location (closed vs open space)
- Cause (thermal, chemical, electrical, …)
- Associated injuries
- What first aid did the pt get?
- Complete head-to-toe physical examination
- Re-evaluation of the pt
- Specific tests (CO level > 10%)
- Definitive treatment
– Open Fracture Management –
(If at the beginning of the station the examiner says, “you’ve already done your primary and secondary surveys” -> jump straight to here!)
- Assessment: “describe what you see”
- Location, size, depth
- Soft tissue, muscle, bone
- Gustillo staging
- Active bleeding? Stop it
- Compartment syndrome? Fasciotomy
- Neurovascular examination (including; pulses, pulse oximetry, doppler US)
- Remove any obvious foreign bodies (irrigate w\ saline only if grossly contaminated)
- Cover it w\ sterile dressing
- Reduce + splint
- Reassess neurovascular status
- Know how to examine pulses and nerves in upper and lower limbs
- If persistently diminished pulses even after attempted realignment -> call vascular for arteriographic evaluation
- Analgesia
- Tetanus
- Abx:
- Grade I: cefazolin
- Grade II: cefazolin + gentamicin
- Grade III: cefazolin + gentamicin + penicillin
- X-ray
- Take to OR w\in 6 hrs: I&D + Ex Fix + leave wound open (cover w\ sterile dressing)
- Take back to OR w\in 2-7 days: permanent fixation + soft tissue coverage
- Soft tissue coverage:
- Grades I –> secondary intention
- Grades II + IIIA –> delayed primary (w\out tension) or split thickness skin graft
- Grades IIIB + IIIC -> call plastic for flap coverage
- Soft tissue coverage: