Step 3: Initial Survey
While the team works, the team leader performs a rapid search for
immediate life threats and corrects them if found. For example, if exsanguinating, external
bleeding is found, the team leader directs a team member to apply pressure to the site.
The leader looks for
airway, breathing, and circulatory problems (the ABCs).
Life-threatening neurologic problems are addressed. The leader obtains a SAMPLE history as this
step is finished.
Perform the initial survey for all patients. Identify and treat life threats and obtain the SAMPLE history.
The pursuit of a correct diagnosis may interfere with the immediate needs of a patient during the critical, initial period of care. Identify those problems that can be treated immediately. The ABCDE mnemonic is the easiest way to commit the steps to memory.
A stands for airway.
Patients who are awake and breathing are able to protect their airways. Look for retractions, increased work of breathing, abnormal rate of breathing, and pallor. PEDS: In small children signs of respiratory distress may be subtle. Nasal flaring or grunting may be the only indication.
If the patient is breathing but unconscious or semi-conscious:
- Open the airway with either the chin lift or jaw thrust maneuver.
Trauma: Jaw thrust maneuver Non-trauma: Chin lift maneuver
PEDS: In infants, place a folded towel (about 1 inch thick) under the shoulders.
- PEDS: In older children and adults, insert an oral airway unless it makes the patient gag. If so, insert a nasal trumpet.
- Apply oxygen per facemask at 10 to 15 L/min.
- PEDS: In infants, begin ventilation with a bag-valve-mask, taking care not to use too much pressure. In older children and adults, if a gag reflex is not present, orotracheally intubate with in-line immobilization, an endotracheal tube introducer, and cricoid pressure. Vol II—AIR SKILLS 2 BAG-VALVE-MASK, AIR SKILLS 3 OROTRACHEAL INTUBATION If the patient can be ventilated with a bag-valve-mask, endotracheal intubation may be delayed. Use cricoid pressure to make this safe. Or, in patients over 4 or 5 ft. tall, insert an esophageal-tracheal combitube or King airway. Vol II— AIR SKILLS 6 ESOPHAGEAL TRACHEAL COMBITUBE
- Confirm correct ET tube placement with an esophageal intubation detector or CO2 detector. (Vol II—AIR SKILLS 1 AIDS TO INTUBATION) Follow this with listening for breath sounds. Or, if a Combitube was used, determine if it is in the trachea or the esophagus by testing twice with an esophageal intubation detector applied to the shorter tube.
If the patient is apneic or struggling to breathe
- Open the airway with either the chin lift or jaw thrust maneuvers. PEDS: In infants, place a folded towel (about 1 inch thick) under the shoulders.
- Attempt to ventilate with a bag-valve-mask with 100% oxygen; mouth-to-pocket facemask ventilation may also be used. Insert an oral airway if tolerated; otherwise, a nasal airway may be inserted.
- If you observe good chest rise, oxygenate, hyperventilate, and complete the initial survey.
- If ventilation is unsuccessful, foreign body presence is likely.
If ventilation is unsuccessful there is a possibility of a foreign body
- Give 5 abdominal thrusts, then perform a finger sweep of the pharynx. In pregnant women and obese patients, use chest thrusts instead. PEDS: In infants and children 1 year, deliver 5 back blows and 5 chest thrusts. Do not use a finger sweep in children.
- Remove the foreign body if it is visualized.
- Re-attempt ventilation.
- If still unsuccessful, use a laryngoscope to visualize the glottis. Use a Magill forcep to grasp and remove the foreign body if it is visible.
- If the foreign body cannot be seen, presume that a tracheal foreign body is present beyond the vocal cords. If the obstruction is incomplete, continue to attempt ventilation until you can arrange rigid or flexible bronchoscopic removal.
- An 80% helium and 20% oxygen gas mixture (heliox) may be used, which will allow gas flow around the foreign body because of its decreased density and laminar flow properties. If the O2 saturation is low, supplemental O2 may be added with the use of a nasal cannula.
If the obstruction is life threatening or for complete tracheal obstruction, see Vol II—AIR SKILLS 12 TRACHEAL FOREIGN BODY REMOVAL.
Traumatic neck hematoma or tracheal disruption
- Try orotracheal intubation and attempt ventilation. (Vol II—AIR SKILLS 3 OROTRACHEAL INTUBATION) Be careful not to use too much force because a severed trachea can be pushed under the sternum.
- If unsuccessful, perform tracheotomy. (Vol II—AIR SKILLS 14 TRACHEOTOMY)
- Oxygenate, hyperventilate, and complete the initial survey if you observe good chest rise.
Epiglottitis or angioneurotic edema
- A bag-valve-mask may force some oxygen past the edema.
- An 80% helium and 20% oxygen gas mixture (heliox) may help.
- Try orotracheal intubation using an endotracheal tube introducer as a guide. (Vol II—AIR SKILLS 1 AIDS TO INTUBATION)
- If unsuccessful, use transtracheal needle ventilation. (Vol II—AIR SKILLS 16 TRANSTRACHEAL NEEDLE VENTILATION)
- While ventilating, re-attempt orotracheal intubation.
- Cricothyrotomy (Vol II—AIR SKILLS 13 CRICOTHYROTOMY) or PEDS: tracheotomy in children < 8 years, (Vol II—AIR SKILLS 15 TRACHEOTOMY IN INFANTS) may be necessary.
- Oxygenate, hyperventilate, and complete the initial survey if you observe good chest rise.
If the patient is already intubated
- Double check for correct placement by listening for breath sounds and by using an esophageal intubation detector or a CO2 detector. PEDS: In infants, use a CO2 detector to confirm correct placement. (Vol II—AIR SKILLS 1 AIDS TO INTUBATION)
- Ultimately a chest x-ray is needed to confirm correct placement.
- If a Combitube is already inserted and functioning well, there is no need to replace it. Continue the resuscitation.
Whenever possible, obtain a SAMPLE history before sedating the patient
| S | Signs and symptoms |
| A | Allergies |
| M | Medications |
| P | Past history, pregnancy |
| L | Last meal |
| E | Events, environment |
There are indications for Rapid Sequence Intubation (RSI) present:
- Depressed level of consciousness (LOC) with probable increased intracranial pressure (ICP) as in head injury, cerebral edema, intracerebral hemorrhage, subarachnoid hemorrhage, hypertensive encephalopathy, hydrocephalus, and mass formation from any cause.
- Agitated patient needing critical medical attention as in large tricyclic overdose or a head-injured patient with other possible severe injuries.
- Muscle rigidity with jaw clenching in a patient who needs intubation.
There are contraindications for RSI present:
- The patient's anatomy or the presence of a mass may result in a paralyzed patient you cannot intubate.
- The patient has a large beard, another anatomic problem, or facial trauma that may result in a paralyzed patient that you cannot ventilate with a bag-valve-mask.
- The patient may have elevated serum potassium, making the use of succinylcholine risky. Succinylcholine raises serum potassium. Chronic or acute renal failure, a crush injury or burn a few days previous, muscular dystrophy, muscle wasting, and extreme muscular exertion as in cocaine or amphetamine overdose are examples.
- A relative contraindication is the possibility of a globe injury of the eye. In such a case, the fasciculations produced by succinylcholine (that may result in loss of vitreous) can be prevented with a small dose of vecuronium 0.01 mg/kg prior to use of succinylcholine.
- If the patient is in profound shock without reflexes or muscle tone, RSI offers no advantage and is not needed.
RSI entails the use of sedation and paralysis to ease orotracheal intubation while preventing adverse responses to tracheal intubation. See Vol II—AIR SKILLS 12 TRACHEAL FOREIGN BODY REMOVALfor more discussion and optional rescue airways.
The RSI procedure should not be feared. RSI greatly facilitates orotracheal intubation because of the good relaxation it affords. RSI eliminates laryngospasm and gag reflexes. If the intubator is prepared to go to another airway if intubation fails, the risk is greatly reduced. A combitube can often be easily inserted.
Remember the 9 Ps for RSI:
| 1. Prepare: | Equipment, meds, team, patient (basic airway management, positioning) |
| 2. Preoxygenate: | 100% O2, 3 to 5 minutes |
| 3. Premedicate: | Atropine
(0.02 mg/kg IV; PEDS minimum 0.1 mg in
children < 8 years) Lidocaine 1.5 mg/kg IV (head injury, asthma) |
| 4. Push the sedative: | Use
one: Etomidate 0.3 mg/kg IV: Use with caution in septic shock. Consider alternative sedation or supplemental corticosteroids Midazolam 0.1 mg/kg IV (adults) PEDS: 0.3 mg/kg IV: Suggested maximum single dose 10 mg; reduce dose or consider alternative in hypotension or elderly Ketamine 1 to 2 mg/kg IV (bronchodilator) Raises intracranial pressure; avoid in head injury. |
| 5. Paralyze: | Use
one: Succinylcholine 2 mg/kg IV Avoid in hyperkalemia, neuromuscular disease, or ocular trauma Vecuronium 0.1 mg/kg IV OR Rocuronium 1 mg/kg IV Wait for relaxation (45-60 sec). Do not bag unless hypoxic. |
| 6. Position airway: | Head/neck position; laryngeal manipulation, BURP, cricoid pressure as neededa |
| 7. Pass the tube: | Maintain in-line cervical immobilization in head/neck trauma |
| 8.
Patent airway assessment: |
Use esophageal intubation detector, check breath sounds, CO2 detector |
| 9.
Post-intubation plan: |
Drugs and dosages depend on medications
used during intubation Sedation: Midazolam 0.05 to 0.3 mg/kg IV. Suggested maximum single dose 10 mg; reduce dose or consider alternative in hypotension or elderly Paralysis: Vecuronium 0.1 mg/kg IV (if not used for intubation) Analgesia: Fentanyl 1 to 2 MICROgrams/kg IV
Morphine 0.05 to 0.15 mg/kg IV
Consider need for seizure prevention. |
Repeat as needed to maintain sedation, paralysis, analgesia.
If there is severe facial trauma or traumatic facial swelling with airway compromise
- Orotracheal intubation may be successful in some circumstances. Try at least once. A combitube may also work. Vol II—AIR SKILLS 3 OROTRACHEAL INTUBATION, AIR SKILLS 6 ESOPHAGEAL TRACHEAL COMBITUBE
- In many cases cricothyrotomy (Vol II—AIR SKILLS 13 CRICOTHYROTOMY) or (PEDS) transtracheal needle ventilation in children < 8 years (Vol II—AIR SKILLS 16 TRANSTRACHEAL NEEDLE VENTILATION) will be necessary.
- Oxygenate, hyperventilate, and complete the initial survey if you observe good chest rise.
B stands for breathing.
Look
for symmetrical chest rise. Feel for tracheal deviation. Feel for chest
wall crepitation that would indicate broken ribs or pneumothorax. Feel
for tenderness over the ribs and sternum. Look for chest wounds. If a
penetrating wound is found, instruct team members to place an occlusive
dressing on it. Do not explore chest wounds or remove impaled objects.
Listen over the stomach first to detect esophageal intubation quickly.
Listen for breath sounds in the mid-axillary space. Listen for heart
tones.
PEDS: Breath sounds in infants are easily transmitted from one side to
the other.
If there is a tension pneumothorax indicated by hypotension, decreased oxygen saturation, shift of the trachea away from a pneumothorax, unequal breath sounds, distended neck veins:
- Perform needle thoracostomy over the top of the third rib in the midclavicular line. (Vol II—BREATH SKILLS 5 NEEDLE THORACOSTOMY)
- Inflate the lung and keep it inflated by performing positive pressure ventilation. Attach a Heimlich flutter valve to the needle, which will allow egress of air out of the chest while preventing in-flow. This will allow the lung to expand with each breath.
- Oxygenate, hyperventilate, and complete the initial survey if you observe good chest rise.
- If the needle is ineffective, immediately insert a large chest tube (36 F in adults and PEDS: 16 to 28 F in children). (Vol II—BREATH SKILLS 1 CHEST TUBE INSERTION)Whenever inserting a chest tube in trauma, prepare for the collection of blood from the thorax. (Vol II—BREATH SKILLS 2 CHEST SUCTION AND AUTOTRANSFUSION)
Sometimes the physical findings of tension pneumothorax are subtle, especially if there are other reasons for shock and hypoxia present. When in doubt, perform a needle thoracostomy because it may be a lifesaving action.
If abdominal distension is interfering with ventilation:
Insert
a large bore orogastric tube for stomach decompression. Use a size 32 F
in adults, (PEDS) a size 10 F to 16 F in children, or a size 8 F
feeding tube in infants.
A crushing chest injury can result in severe pulmonary contusion, necessitating the use of high inflation pressure when a bag-valve-mask is used. Under these circumstances, cricoid pressure will help prevent abdominal distension.
In severe asthma, high inflation pressures may also be needed; however, the tidal volumes should be small and each breath 8 seconds apart. This is counter-intuitive, so count the rhythm out loud. Initiate continuous albuterol nebulization immediately. If improvement is not seen and the patient is in a life-threatening condition, perform RSI so that maximum relaxation and airway control can be achieved.
Other causes of severe respiratory failure include chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis. These patients may also respond to albuterol nebulization if there is a bronchospastic component to their disease.
PEDS: In infancy, diaphragmatic hernia can present with severe respiratory distress. In such cases, an orogastric tube can be lifesaving.
PEDS: Children are prone to swallow large amounts of air when distressed. Gastric distension is very common in injured children to the point that all significantly injured children should receive an orogastric tube as part of their initial resuscitation.
Fulminant pulmonary edema secondary to heart failure can result in a patient in severe respiratory distress who cannot lie down or cooperate with his or her care. Pink, frothy sputum is evident. Such patients will usually refuse positive pressure ventilation or the application of an oxygen mask because they are afraid of suffocation. If an IV can be established, initiate a nitroglycerine drip at 10 to 20 μg/min and administer furosemide IV. Titrate the dose of nitroglycerine upward as needed for effect with titration increments of 5 to 10 μg/min every 3 to 5 minutes. Close monitoring of oxygen saturation and blood pressure must be undertaken.
When the fulminant pulmonary edema patient is in mortal danger, perform nasotracheal intubation. Use topical anesthesia to make this painful procedure tolerable. Vol II—AIR SKILLS 3 OROTRACHEAL INTUBATION, AIR SKILLS 12 TRACHEAL FOREIGN BODY REMOVAL Once the patient is intubated and undergoing positive pressure ventilation, he or she can lie down in safety, greatly facilitating further care.
C stands for circulation.
While listening for heart sounds, feel for a carotid or femoral pulse. The presence of a central pulse means that at least 50% of the patient's blood volume is still in circulation. PEDS: In children < 1 year, check for a brachial pulse. Observe neck veins for distension. Observe for external bleeding. If such is seen, instruct a team member to apply pressure to the site. Check the time it takes for capillary refill (under 2 seconds under normal conditions). Estimate the pulse rate. By this time, the team will have obtained vital signs and applied an ECG monitor.
If the pulse is absent
- Apply quick look paddles. If ventricular fibrillation or ventricular tachycardia is present, shock up to 3 times in adults and (PEDS) in larger children (200 J, 200 to 300 J, 360 J).
- Begin CPR while determining resulting rhythm. If asystole is present, begin CPR and complete the initial survey. If pulseless electrical activity is present, begin CPR, start a fluid bolus, and complete the initial survey.
If the pulse is too slow
PEDS: In neonates, begin CPR if
the pulse rate is < 60 bpm. In adults with heart block and
shock,
apply an external pacer and pace at 60 bpm; complete the initial survey.
If the pulse is too fast
Often
tachycardia accompanies shock of most etiologies. Give priority to
treating the underlying problem. However, if there is a tachyarrhythmia
(such as a supraventricular tachycardia) that is causing severe
decompensation, prepare for synchronized cardioversion while completing
the initial survey. Use an initial setting of 100 J in adults and
(PEDS) older children and 0.5 to 1.0 J/kg in small children. Etomidate
at a reduced dose (0.2 mg/kg) can be used for pain control in aware
patients.
Consider cardiac tamponade
Beck's triad, although not
always present in tamponade, is worth remembering. It consists of
muffled heart sounds, distended neck veins, and hypotension.
Penetrating chest wounds, a misplaced transvenous pacemaker lead, and
medical causes such as myocarditis or a dissecting aortic aneurysm are
not uncommon causes. Cardiac ultrasound is a lifesaving tool in the ED.
If cardiac tamponade is resulting in life-threatening shock, attempt transcutaneous or transthoracic pericardiocentesis now. (Vol II—CIRC SKILLS 6 PERICARDIOCENTESIS) Otherwise, continue the initial survey.
If ventricular fibrillation ensues and surgical back-up is available in the community, perform an emergency thoracotomy. (Vol II—CIRC SKILLS 4 EMERGENCY THORACOTOMY) A pericardiotomy will enable internal cardiac massage, staple closure of the cardiac wounds, and internal defibrillation in preparation for operating room management.
If the patient is in the third trimester of pregnancy
Place a rolled blanket under the right hip to move the uterus to the
left.
Feel the abdomen and gently compress the pelvis in an AP direction
The
abdomen and pelvis are common areas of occult blood loss. A brief
palpation of these areas can help direct future efforts. Palpation or
ultrasound examination may reveal an abdominal aortic aneurysm.
If there is evidence of hypovolemic shock or septic shock with
hypotension and flat neck veins
In adults, administer a bolus of 1 to 2 L NS solution IV and complete
the initial survey.
PEDS: In children, administer a bolus of 20 mL/kg of NS solution IV and
complete the initial survey.
When IV access is difficult, there are several quick and good solutions to the problem:
- If only a small IV can be established, it can be converted to a large bore introducer using guidewire technique. (Vol II—CIRC SKILLS 1 ARTRIAL AND VENOUS CATHETER INSERTION)
- PEDS: In children under about 6 years of age, intraosseous needles can be inserted into the tibias and femurs. (Vol II—CIRC SKILLS 5 INTRAOSSEOUS NEEDLE PLACEMENT)
- In adults and (PEDS) older children in extremis, a sternal-iliac bone marrow needle can be placed in the manubrium of the sternum closely observing the 1/4 inch rule. (Vol II—CIRC SKILLS 5 INTRAOSSEOUS NEEDLE PLACEMENT)
- Saphenous vein or other large vein cannulation is greatly facilitated when guidewire technique is used. (Vol II—CIRC SKILLS 1 ARTRIAL AND VENOUS CATHETER INSERTION)
D stands for disability (neurologic deficit).
The AVPU system is a quick and reliable method of estimating LOC:
| Corresponding GCS score | ||
| A | Alert - the patient is awake | 14 to 15 |
| V | Responsive to Vocal Stimuli | 12 to 13 |
| P | Responsive to Pain only | 8 |
| U | Unresponsive | 3 to 4 |
Glasgow Coma Scale—Adult, Pediatric, Infant
| Eye Opening | |||
| Infant (<1 year) | Pediatric (>1 year) | Adult | |
| Spontaneous | Spontaneous | Spontaneous | 4 |
| Voice | Voice | Voice | 3 |
| Pain | Pain | Pain | 2 |
| None | None | None | 1 |
| Verbal Response |
|||
| Infant (<2 years) | Pediatric (>2 years) | Adult | |
| Coos, babbles | Appropriate
word/ phrase |
Oriented | 5 |
| Irritable but consolable |
Disoriented/ converses |
Confused | 4 |
| Persistent cries/ screams |
Inappropriate word |
Inappropriate | 3 |
| Moans/grunts to pain; restless |
Incomprehensible sounds |
Incomprehensible | 2 |
| None | None | None | 1 |
| Motor Response |
|||
| Infant (<1 year) | Pediatric (>1 year) | Adult | |
| Spontaneous | Obeys | Obeys | 6 |
| Localizes pain | Localizes pain | Localizes pain | 5 |
| Flexion-withdrawal | Flexion-withdrawal | Withdraws | 4 |
| Flexion/decorticate | Flexion/decorticate | Abnormal flexion (decorticate) |
3 |
| Extension/decerebrate | Extension/decerebrate | Abnormal extension (decerebrate) |
2 |
| None | None | None | 1 |
| _________ 3 to 15 |
|||
Do the DONT for patients with a depressed LOC. Give:
Dextrose
(if hypoglycemia is possible), unless the team has used a glucose
monitor to indicate that hypoglycemia is not present. PEDS: In infants,
use 10% dextrose.
Oxygen, and Naloxone when opiate intoxication is
possible, and Thiamine for any patient in whom chronic alcoholism may
be present.
If there is a depressed LOC with lateralization
Check
for a dilated pupil and limb weakness on the opposite side. If present,
uncal herniation may be occurring. Give mannitol 1 g/kg IV. PEDS: In
children, give 0.25 to 0.5 g/kg IV. Orotracheally intubate,
hyperventilate with oxygen, and complete the initial survey.
If there is seizure activity
Administer
IV or rectal diazepam, 8 to 10 mg in adults, and (PEDS) in children,
0.2 mg/kg IV up to 10 mg. Repeat this dose if needed in 5 minutes.
Administer oxygen by mask. Orotracheally intubate if there is a
depressed gag reflex. Prepare for vomiting, aspiration, and cardiac
arrhythmias; complete the initial survey.
If the patient is posturing
Check
for decorticate (arm flexion) or decerebrate (arm and leg extension)
posturing. If present, give mannitol, 1 g/kg IV, in adults and (PEDS)
in children, 0.25 to 0.5 g/kg IV. Orotracheally intubate and
hyperventilate with oxygen. Continue on.
If there is evidence of a spinal cord lesion or injury
Look
for paralysis, sensory deficit, and priapism. A more thorough mini
neurologic exam can be done later. Although, if RSI must be done
quickly, it should be preceded by a mini neuro exam.
In brief, a mini neuro exam should consist of
Pupils and Vision
Conjugate or disconjugate gaze
Size, equality, and reactivity
Finger countingTympanic membranes
HemotympanumNeck
Midline tenderness posteriorlyExtremities
Movement and strength on command or to pain
Ankle, patellar, and brachial reflexes; clonus, Babinski reflexes
Sensation and position senseTrunk
Priaprism, saddle sensation, anal sphincter tone
Sensation level
In the past, administering high-dose methylprednisolone (30 mg/kg IV over 15 minutes) to patients with evidence of spinal cord injury had been common practice. This has been controversial and is no longer universally accepted. Check with your receiving facility or neurosurgical consultant regarding administration of high-dose methylprednisolone.6-8
E stands for exposure.
By now the patient should be completely undressed. Observe quickly for problems that need to be addressed immediately. Look for extremity deformity. If there are ominous skin changes, such as the purpura of meningococcemia, the red rash of toxic shock syndrome, and/or the bronzing of gas gangrene, order the preparation of IV antibiotics appropriate for the infection.
SAMPLE history
Before going on, be certain to obtain the SAMPLE history before the opportunity is lost.
| S | Signs and symptoms |
| A | Allergies |
| M | Medications |
| P | Past history, pregnancy |
| L | Last meal |
| E | Events, environment |
References
- Miller RD, editor. Miller’s Anesthesia, 6th ed. Philadelphia, Pa: Churchill Livingstone, 2005.
- Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med. 2007;50:653-665.
- Shirley P. Cricoid pressure for emergency airway management. Emerg Med Australas. 2006;18:99.
- Morris J, Cook TM. Rapid sequence intubation: a national survey of practice. Anaesthesia. 2001;56:1090-1097.
- Hartsilver EL, Vanner RG. Airway obstruction with cricoid pressure. Anaesthesia. 2000;55:208-211.
- Hurlbert RJ. Strategies of medical intervention in the management of acute spinal cord injury. Spine. 2006;31(11 suppl):S16-S21.
- Sayer FT, Kronvall E, Nilsson OG. Methylprednisolone treatment in acute spinal cord injury: the myth challenged through a structured analysis of published literature. Spine J. 2006;6:335-343.
- Bracken MB. Steroids for acute spinal cord injury. Cochrane Database of Systematic Reviews 2002. Issue 2. Art No: CD001046.DOI: 10.1002/14651858.CD001046.