Basic algorithm and primary survey
The examination of critically ill or injured patients differs cardinally from a routine outpatient appointment. The physician follows a strict algorithm without wasting time on complaints:
- Assessment of vital functions. Comprehensive and simultaneous check of neurological status, pulmonary, and cardiac function.
- Management of abnormalities. Immediate resuscitation measures to restore life support.
- Targeted examination. Performed to establish a precise diagnosis only after the patient's condition is stabilized.
During the primary survey, the clinician rapidly records the level of consciousness (responsiveness, ability to follow commands), airway patency, respiratory rate and rhythm, pulse parameters, and blood pressure. Muscle tone and the presence of specific signs, such as cerebrospinal fluid leakage or bleeding from the nose and ears, which indicate a skull base fracture, are assessed.
Assessment of CNS and pupillary function
Central nervous system disorders most commonly arise from traumatic brain injury (TBI), massive blood loss, or gas exchange abnormalities. Severe central nervous system depression manifests as coma.
In coma, the patient does not make contact and does not respond to pain (protective reflexes are absent). The neurological status is characterized by the absence of corneal and ciliary reflexes, moderately dilated pupils, and sluggish light reaction. Deepening coma is always accompanied by tachycardia and tachypnea.
Pupillary status serves as a critical marker:
- Anisocoria (unequal pupil size) in TBI indicates cerebral hemisphere damage due to hemorrhage or compression.
- Fixed, dilated pupils combined with absent light reaction, respiratory, and circulatory arrest are signs of biological death.
Respiratory disorders
Breathing problems require immediate resolution. The pattern of abnormalities helps determine their pathophysiology:
- Rapid and shallow (splinting) — typical of pain caused by rib bruises or fractures; leads to decreased ventilation and hypoxia.
- Deep and rapid — the body's reaction to a drop in circulating blood volume (CBV).
- Stridorous (noisy exhalation) — a sign of partial airway obstruction.
- Apnea with cyanosis — severe hypoxia; complete airway occlusion rapidly leads to cardiac arrest.
Paradoxical breathing syndrome represents a special danger. It occurs in flail chest with multiple rib fractures when the chest wall loses its rigidity. The flail segment indents on inspiration and balloons out on expiration. This causes severe strain on accessory muscles and their rapid fatigue, leading to acute respiratory failure (ARF).
Physical methods are used for rapid diagnosis of the pleural cavity condition:
| Abnormal | Percussion note | Auscultation |
|---|---|---|
| Pneumothorax | Hyperresonant | Absence of breath sounds |
| Hemothorax | Dullness (diminished resonance) | Absence of breath sounds |
Circulatory status
Critical circulatory disturbance in trauma is caused by pain factors, shock (traumatic or hemorrhagic), and blood loss. The more pronounced the symptoms, the more severe the degree of shock.
The clinical presentation in major disorders includes skin pallor, cold clammy sweat, and extremity hypothermia. Acrocyanosis develops (bluish discoloration of the lips, tip of the nose, auricles, fingers). Blood pressure drops, and the pulse becomes rapid and thready.
A more detailed assessment is performed in a hospital setting. Physicians need to measure central venous pressure (CVP), determine circulating blood volume, check laboratory hemoglobin and hematocrit values, and establish hourly urine output monitoring.
Briefly: answers to topical questions
Which scale is used to objectively assess the level of consciousness impairment in victims with traumatic brain injury?
The level of consciousness impairment in victims is objectively assessed using the Glasgow Coma Scale (GCS). The following tools are used for a comprehensive neurological status assessment:
- Glasgow Coma Scale — assesses the sum of scores of three parameters (from 3 to 15 points).
- FOUR score (Full Outline of UnResponsiveness) — used to assess the level of consciousness in adults and children.
- Modified Glasgow Coma Scale — used in pediatric practice.
- Trauma Score (TS) (Trauma Score) — uses Glasgow scale responses to determine the overall severity of traumatic disease.
What types of shock develop in severe trauma and what are their pathogenetic differences?
In severe trauma, sources indicate traumatic, hemorrhagic, and toxic/toxic-infectious shock. Fundamental pathogenetic changes in shock are uniform and associated with tissue hypoxia. The leading disorder regardless of the cause is hypovolemia, which leads to tissue hypoxia and metabolic disorders.
The differences are related to the shock-inducing factor: in traumatic shock, pain is managed; in hemorrhagic shock, bleeding is stopped; in toxic shock, detoxification therapy is performed.
Which ultrasound protocols are used for the rapid diagnosis of free fluid in body cavities during polytrauma?
FAST and eFAST protocols are used for the rapid diagnosis of free fluid and injuries in polytrauma.
The FAST protocol includes:
- Ultrasound for free fluid in the abdominal cavity;
- Ultrasound of the pleural cavity;
- Ultrasound of the retroperitoneal space;
- Echocardiography.
The source also indicates a comprehensive ultrasound of the pelvic organs. If hemopneumothorax is detected by eFAST, whole-body CT is performed after pleural cavity drainage. For whole-body CT in children, eFAST is performed prior to CT.
Class and exam questions
Why is taking a medical history delayed in severe trauma?
Due to the threat to life and acute time constraints. The main task is to immediately assess and restore vital functions (respiration, circulation, CNS).
What does anisocoria indicate in a trauma patient?
Unequal pupil diameter is a sign of severe traumatic brain injury, indicating damage to the cerebral hemispheres due to hemorrhage and compression.
What is the danger of paradoxical breathing?
A flail chest segment disrupts the mechanics of inspiration and expiration. This leads to rapid exhaustion of respiratory muscles and the development of acute respiratory failure.
What else to study on this topic
- Pathophysiology of traumatic and hemorrhagic shock
- Mechanisms of development of acute respiratory failure in trauma
- Laboratory markers for assessing blood loss (hemoglobin, hematocrit)
- Measurement technique and clinical significance of central venous pressure (CVP)
- Differential diagnosis of pneumothorax and hemothorax
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