D Disability and E Exposure

D: Disability and E: Exposure

On admission, the GCS score should be calculated ( Table 27.1 ), the pupils assessed for size and reaction to light and the patient observed to determine whether they are moving all four limbs. The core temperature must be recorded. Patients are managed with cervical spine protection (cervical collar and blocks) and protection of the thoracolumbar spine using standard log roll techniques until a spinal injury has been excluded. Early WBCT scan will rapidly identify the majority of intracranial and spinal pathology . The patient must be adequately exposed to allow a thor ough and systematic clinical examination during the second ary survey but they must be kept warm. Trauma patients are frequently hypothermic and this will further increase coagulo pathy . Every e ff ort should be made to maintain normal tem perature by minimising unnecessary exposure of the patient and by using warmed blankets and trolleys and warmed fluids during resuscitation. Log-rolling patients with severe pelvic fractures may harm the patient b y disturbing established blood clots. Log-rolling should not occur until a pelvic fracture has been - radiographically excluded. If patients need to be moved - during their primary survey , such as when moving onto the CT scanning gantry , a 20° roll with inline spinal stabilisation - should be used. Modern ‘scoop stretchers’ mean that there is - no requirement to roll any patient more than 20° until a pelvic fracture has been excluded. Formal log-rolling of the blunt trauma patient to exam - ine the back during the primary survey adds minimal useful clinical information, delays the WBCT scan and may cause harm to a patient with a pelvic fracture. It should be deferred until after the primary survey , with the exce ption of patients

(c) TABLE 27.1 Glasgow Coma Scale. Best eye response (E) Best verbal response (V) 4 Eyes opening spontaneously 5 Oriented 3 Eye opening to speech 4 Confused 2 Eye opening in response to pain 3 Inappropriate words 1 No eye opening 2 Incomprehensible sounds 1 None (d) Figure 27.2 (a–d) Severe degloving injuries to the upper and lower limbs following a high-speed road traf /f_i c accident. The initial appear

ance and severity of the injury should not detract from following the important Advanced Trauma Life Support (ATLS) sequence in evaluating and treating immediate life-threatening injuries. Bleeding and severe injuries within the chest, abdomen and pelvis must be actively excluded. Best motor response (M) 6 Obeys commands 5 Localises to pain 4 Withdraws from pain 3 Flexion in response to pain 2 Extension to pain 1 No motor response

presence of a posterior torso wound. Mechanical testing of the pelvis in the emergency room (‘springing the pelvis’) adds no useful clinical examination and will disrupt any blood clot that has formed around vic fracture. It should never be performed – a pelvic fracture should always be diagnosed radiographically . Summary box 27.4 The cABCDE of trauma care /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

c – Control of massive external haemorrhage A – Airway with cervical spine protection B – Breathing and ventilation C – Circulation and haemorrhage control: apply a pelvic binder and do not remove until a pelvic fracture is excluded D – Disability (neurological status) E – Exposure (assess for other injuries)

D: Disability and E: Exposure

On admission, the GCS score should be calculated ( Table 27.1 ), the pupils assessed for size and reaction to light and the patient observed to determine whether they are moving all four limbs. The core temperature must be recorded. Patients are managed with cervical spine protection (cervical collar and blocks) and protection of the thoracolumbar spine using standard log roll techniques until a spinal injury has been excluded. Early WBCT scan will rapidly identify the majority of intracranial and spinal pathology . The patient must be adequately exposed to allow a thor ough and systematic clinical examination during the second ary survey but they must be kept warm. Trauma patients are frequently hypothermic and this will further increase coagulo pathy . Every e ff ort should be made to maintain normal tem perature by minimising unnecessary exposure of the patient and by using warmed blankets and trolleys and warmed fluids during resuscitation. Log-rolling patients with severe pelvic fractures may harm the patient b y disturbing established blood clots. Log-rolling should not occur until a pelvic fracture has been - radiographically excluded. If patients need to be moved - during their primary survey , such as when moving onto the CT scanning gantry , a 20° roll with inline spinal stabilisation - should be used. Modern ‘scoop stretchers’ mean that there is - no requirement to roll any patient more than 20° until a pelvic fracture has been excluded. Formal log-rolling of the blunt trauma patient to exam - ine the back during the primary survey adds minimal useful clinical information, delays the WBCT scan and may cause harm to a patient with a pelvic fracture. It should be deferred until after the primary survey , with the exce ption of patients

(c) TABLE 27.1 Glasgow Coma Scale. Best eye response (E) Best verbal response (V) 4 Eyes opening spontaneously 5 Oriented 3 Eye opening to speech 4 Confused 2 Eye opening in response to pain 3 Inappropriate words 1 No eye opening 2 Incomprehensible sounds 1 None (d) Figure 27.2 (a–d) Severe degloving injuries to the upper and lower limbs following a high-speed road traf /f_i c accident. The initial appear

ance and severity of the injury should not detract from following the important Advanced Trauma Life Support (ATLS) sequence in evaluating and treating immediate life-threatening injuries. Bleeding and severe injuries within the chest, abdomen and pelvis must be actively excluded. Best motor response (M) 6 Obeys commands 5 Localises to pain 4 Withdraws from pain 3 Flexion in response to pain 2 Extension to pain 1 No motor response

presence of a posterior torso wound. Mechanical testing of the pelvis in the emergency room (‘springing the pelvis’) adds no useful clinical examination and will disrupt any blood clot that has formed around vic fracture. It should never be performed – a pelvic fracture should always be diagnosed radiographically . Summary box 27.4 The cABCDE of trauma care /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

c – Control of massive external haemorrhage A – Airway with cervical spine protection B – Breathing and ventilation C – Circulation and haemorrhage control: apply a pelvic binder and do not remove until a pelvic fracture is excluded D – Disability (neurological status) E – Exposure (assess for other injuries)