Question Of The Day #61

This patient arrives to the hospital after penetrating trauma to the right chest.  His initial examination reveals hypotension, tachycardia, tachypnea, and a low oxygen saturation.

All medical and trauma patients that arrive to the Emergency Department, especially those who are ill-appearing or with abnormal vital signs, should undergo the “ABCs”.  This is also known as the primary survey.  The primary survey aims to create a step-wise initial approach to patients where all life-threatening conditions are identified and treated early in the encounter with the patient.  The primary survey should be conducted prior to taking a full history.  In trauma patients, the primary survey is extended to include the “ABCDEFs”.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam.  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. 

Airway assessment involves checking for airway patency (clear voice, stridor, blood or vomitus in mouth, etc.) and applying cervical spine immobilization if needed.  Endotracheal intubation or a surgical airway may need to be placed during this step.  Breathing assessment involves auscultation of the lungs, checking the oxygen saturation, and providing supplemental oxygen to the patient if needed.  Abnormalities in the breathing exam (absent unilateral lung sounds, tracheal deviation, etc.) may prompt the placement of a chest tube or needle decompression.  It is during the breathing step that a pneumothorax, tension pneumothorax, or hemothorax is identified and treated.  Circulation assessment involves checking the heart rate and blood pressure, palpating all peripheral pulses, establishing IV access, and administering IV fluids or blood products.  It is during the circulation step that hemorrhage and shock is identified and controlled (pressure dressing applied to bleeding extremity wound, tourniquet applied to slow bleeding at amputated limb, etc.).  Disability assessment involves checking the patient’s neurologic status.  This involves calculating a GCS (Glasgow Coma Score), measuring the patient’s glucose level, and performing a focused neurologic exam.  Exposure involves removing all the patient’s clothes which may be obstructing view of other injuries.  This step involves rolling the patient to the lateral decubitus position to check the back and perineal areas for trauma.  The last step of the primary survey in trauma is the FAST exam (Focused Assessment with Sonography in Trauma).  The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas. 

The question stem provides information regarding the airway of the patient, which is stated to be patent.  The next step in the “ABCDEFs” should be evaluation of the ‘Breathing’.  Administration of packed red blood cells (Choice A) is considered part of the “Circulation” assessment.  Removing the patient’s clothes to evaluate for occult injuries (Choice C) is important, but the “Breathing” assessment should be performed prior to the patient’s “Exposure” step.  Performing a FAST exam (Choice D) is also an important part of the primary survey, but it should be performed after the “Breathing” step is completed.  Auscultation of both lungs (Choice B) is the best next step, as this is part of the “Breathing” step after the “Airway” assessment.  During this step, the patient should be given supplemental oxygen and evaluated for abnormal or absent unilateral lung sounds.  This is important as this patient is at risk for a large pneumothorax, tension pneumothorax, or hemothorax after his penetrating trauma.