R. Brühl-Day, Méd Vet, Dipl SA Surgery
Initial assessment
Team work is the name of the game and within a team every member has to know his or her assignment.
Blunt trauma
Car accidents. Direct impact?
Fall from a height or high rise syndrome
Kicks
Penetrating trauma
Bites
Projectiles
Stabbing
Because it may be possible not to have another chance to change an erroneous initial treatment it is important not to skip or mistakenly assess the vital signs.
In a patient with severe trauma initial assessment is made at the same time as other things are initiated to stabilize the patient. Preparedness for fluid therapy and shock treatment are started at the same time the patient is being evaluated. a detailed history of the trauma incident may provide vital clues. Time lapse since the trauma occurred is an important information that has to be asked to the owners. Many times because of nervousness the time lapse cannot be thoroughly determined, but whenever possible is a fine data and can help with some actions to be taken. Clipping the hair may facilitate visualization of bruises.
Hypoxia and hemorrhage are two of the main causes of death among traumatized patients. In every traumatized patient, in shock and with no evidence of external bleeding any accumulation of blood must be assessed
The physical evaluation must be done in an orderly fashion:
Respiratory, cardiovascular, nervous, digestive, and musculoskeletal systems
Inspection: initial overall observation of the patient
Palpation: superficial and deep.
Percussion: free fluid?, gas?
Auscultation: borborigmus?, ileus ? Decreased vesicular murmur, muffled sounds?
Other: draw blood for preliminary lab data?, bladder catheterization?, rectal palpation?
Preliminary assessment
Rectal temperature,
Heart rate and respiratory rate
Color of mucous membranes
Capillary refill time and hydration status
Pulse quality
External bleeding?
Skin integrity
Level of consciousness
Respiratory system
Adequate ventilation?
Imbalance between ventilation and perfusion?
Upper airway alterations? Is there a need for tracheotomy?
Pneumothorax? Think about thoracocentesis
Trauma or lung injuries?
Ruptured diaphragm?
Hemo, hydro or chylothorax?
Does any lesion require immediate surgery?
Cardiovascular system
Any external visible hemorrhage?
Any hypovolemic or shock signalment?
Rhythm and pulse characteristics.
Cardiac auscultation, what can we find out from that?
Venous distention?
IV catheter placement.
Draw a blood sample.
Replace any volume deficiency.
Does any lesion require immediate surgery?
Nervous system
Level of consciousness? Alert, ambulates, reflexes.
Unconscious?
Depressed, paretic, paraplegic?
Has the patient received any medication that may alter the examination?
Any perceived changes in the central or peripheral nervous system?
Does any lesion require immediate surgery?
Digestive system
Abdominal trauma can be a challenge to diagnose. It is highly important to keep in mind a suspicion for abdominal trauma every time we deal with traumatized patients.
Any signs of acute hemorrhage? Ruptured spleen? Other hemorrhage sources like kidneys, liver, mesenteric vessels?
Gl tract assessment.
Abdominal viscera exploration (i.e., urinary bladder, ureters, gall bladder, pancreas). Prepare for diagnostic peritoneal lavage (DPL) or abdominocentesis.
Possible peritonitis?
Need for immediate exploratory laparotomy?
Musculoskeletal system
Gait abnormalities or lameness
Any visible signs of open fracture or luxation?
Joint exploration
Tendon laceration or avulsion?
Ancillary diagnostics
When to order an X ray? (i.e., X-rays must be taken if possible before any centesis or DPL is performed since these procedures may introduce air into the abdominal cavity.
Plain or contrast studies?
Ultrasound?
CT scan or MRI? Do we always need such expensive studies?
Main sources for trauma In Dogs
Hit by car
Dog fights / bites
High rise syndrome
Mistreatment, kicks, punches and other type of blows
Penetrating wounds (bullets, knives, etc.)
Main sources for trauma in Cats
Fights / bites
Mistreatment, kicks, punches and other type of blows
Penetrating wounds (bullets, knives, etc.)
High rise syndrome
Hit by car
Thorax
Assess and palpate for:
Thoracic movement and respiratory pattern
Rib fractures. Do we need to alleviate pain?
Flail chest? Support bandages?
Penetrating wounds
Locate heartbeat
Abdomen
Look for pain.
Evidence for free fluid or abdominal distention.
Diagnostic peritoneal lavage more accurate (20ml/kg of warm saline or lactated Ringers).
Identify every palpable organ whenever possible.
Retroperitoneal space evaluation.
Spine and appendages
Temperature of extremities
Evaluate for fractures or luxations
Check for wounds or any evident deformity
Retroperitoneal space can be involved in spinal and / or pelvic fractures.
Nervous system
Evaluate aptitude to stand up and walk
Position of the extremities and presence of paresis / paralysis
Flaccidity or rigidity
Cranial and peripheral reflexes
Head and neck
Blood loss coming from the natural openings?
Look after injuries in the head, eyes, ears, nose and nostrils
Check for pain and range of motion of the head
Open the mouth and explore it. Look after tongue or dental lesions. Remember palate fractures in high rise syndrome.
Airway obstruction due to inspissated saliva and blood?
Exploratory surgery
When?
Patient stabilization goes first on every occasion possible, but if stabilization is not working and / or the patient not responding, do not waste time.