4.3 Trauma Assessment & Environmental Emergencies

Trauma Assessment & Environmental Emergencies

In trauma and environmental medicine, standardizing the clinical approach is essential to minimize morbidity and mortality. This section covers the Advanced Trauma Life Support (ATLS) primary and secondary surveys, the clinical management of heat stroke versus heat exhaustion, and the classification and treatment of minor burns.

Trauma Assessment: The Primary and Secondary Surveys

The Primary Survey (ABCDE)

The primary survey is a systematic protocol executed to identify and treat immediate life-threatening injuries in rapid succession. Resuscitation must occur simultaneously with the identification of injuries.

• A: Airway Maintenance with Restriction of Cervical Spine Motion:
  • Assess airway patency (check for airway obstruction, foreign bodies, facial fractures, vocalizations).
  • Clear secretions using suction. Perform a jaw-thrust maneuver (avoid head-tilt/chin-lift to protect the spinal cord).
  • Establish a definitive airway (endotracheal intubation) if there is airway compromise, severe inhalation injury, or a Glasgow Coma Scale (GCS) score <= 8. Maintain manual inline stabilization during intubation.
• B: Breathing and Ventilation:
  • Inspect chest expansion, auscultate breath sounds, and monitor oxygenation. Identify and immediately treat:
    • Tension Pneumothorax: Diagnosed clinically by respiratory distress, unilateral absent breath sounds, jugular venous distention, and tracheal deviation (late sign). Treat immediately with needle decompression (e.g., in the 2nd intercostal space at the midclavicular line or 4th/5th intercostal space at the anterior/mid-axillary line) followed by tube thoracostomy. Do not delay treatment for an X-ray.
    • Open Pneumothorax: Apply a three-sided sterile occlusive dressing, creating a flutter-valve effect.
    • Massive Hemothorax: Indicated by dullness to percussion and shock. Treat with a chest tube and volume resuscitation.
• C: Circulation with Hemorrhage Control:
  • Assess pulses, skin temperature, capillary refill, and blood pressure.
  • Apply direct pressure, pressure dressings, or tourniquets to control external hemorrhage.
  • Identify sources of major internal hemorrhage (chest, abdomen, pelvis, retroperitoneum, and long bones).
  • Obtain two large-bore IV lines (14G or 16G) or intraosseous (IO) access. Resuscitate with blood products (packed red blood cells, fresh frozen plasma, platelets) using a balanced ratio (1:1:1) in hemorrhagic shock rather than large volumes of crystalloids to avoid dilutional coagulopathy.
• D: Disability (Neurological Evaluation):
  • Determine GCS score, pupil size and reactivity, and check for lateralizing signs.
• E: Exposure and Environmental Control:
  • Completely undress the patient to ensure no injury is missed.
  • Prevent hypothermia immediately by using warmed IV fluids, warm blankets, and a warm resuscitation room. Hypothermia impairs coagulation and contributes to the "lethal triad" of trauma (hypothermia, acidosis, coagulopathy).

The Secondary Survey

The secondary survey is a comprehensive, head-to-toe examination. It should only begin AFTER the primary survey is completed, resuscitation is ongoing, and the patient's vital signs are stabilized.

• AMPLE History:
  • A: Allergies
  • M: Medications
  • P: Past medical history and pregnancy
  • L: Last meal (time of last oral intake)
  • E: Events and Environment surrounding the injury
• Physical Examination: Detailed examination of the head, neck, spine (log-rolling the patient while maintaining cervical spine protection), chest, abdomen, pelvis (assess pelvic stability once to prevent worsening hemorrhage), and extremities.

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Environmental Emergencies: Heat Exhaustion vs. Heat Stroke

Heat-related illnesses exist on a spectrum of severity. Distinguishing between heat exhaustion and heat stroke is crucial for survival:

• Heat Exhaustion:
  • Core body temperature is elevated but remains < 40°C (104°F).
  • Mental status remains intact (no neurological impairment).
  • Symptoms: Profuse sweating, headache, nausea, vomiting, dizziness, weakness, muscle cramps, and mild tachycardia.
  • Management: Move the patient to a cool environment. Remove excess clothing. Hydrate with oral rehydration solutions or IV normal saline. Passive cooling (fans, cool mist) is generally sufficient.
• Heat Stroke:
  • Core body temperature exceeds 40°C (104°F).
  • Characterized by central nervous system dysfunction (confusion, delirium, hallucinations, seizures, ataxia, or coma).
  • Skin: Hot and flushed; sweating may be present (exertional heat stroke) or absent (classic/non-exertional heat stroke).
  • Management: A life-threatening emergency. Immediately initiate active cooling. The target is to reduce the core temperature to < 39°C (102.2°F). Use cold-water immersion (preferred for exertional heat stroke) or evaporative cooling (spraying with tepid water and using fans). Antipyretics (e.g., paracetamol, NSAIDs) are contraindicated as they do not affect the hypothalamic thermoregulatory set point in environmental hyperthermia and can exacerbate hepatic or renal injury.

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Minor Burn Classification and Care

Burns are classified based on the depth of tissue damage:

Estimation of Burn Size (Wallace Rule of Nines)

A rapid clinical tool used in the primary assessment to estimate the TBSA of partial- and full-thickness burns: Head (9%), Anterior Torso (18%), Posterior Torso (18%), Each Arm (9%), Each Leg (18%), and Perineum/Genitalia (1%). This estimation is critical for determining transfer criteria to a burn center and calculating fluid resuscitation volumes.

Minor Burn Criteria (ABA Guidelines)

To be classified as a minor burn suitable for outpatient care, the burn must meet all the following:

• < 10% TBSA in adults aged 10-50 years (or < 5% in children < 10 and adults > 50).
• < 2% TBSA full-thickness (3rd-degree) burn.
• No involvement of critical areas: face, hands, feet, perineum, or major joints.
• No electrical or chemical burns, inhalation injury, or major trauma.

Outpatient Management of Minor Burns

1. Cooling: Cool the burn with cool tap water (not ice or ice water, which causes vasoconstriction and extends tissue damage).
2. Cleansing: Gently clean the wound with mild soap and water.
3. Blister Management: Leave intact blisters alone to protect the wound bed; only debride ruptured or tensely distended, non-viable blisters.
4. Topical Agent: Apply a thin layer of topical bacitracin or silver sulfadiazine (avoid silver sulfadiazine on the face to prevent staining, and do not use in patients with sulfa allergies).
5. Dressing: Apply a sterile, non-adherent dressing (e.g., petrolatum gauze) and wrap with elastic gauze.
6. Supportive Care: Update tetanus vaccination if it has been > 5 years. Provide oral analgesia (NSAIDs or paracetamol).