This is a hands-on activity. You should use all of your senses - look, listen, and feel for injuries. This starts with determining the nature of the injury by obtaining a very brief history and checking the patient’s overall appearance, level of consciousness, and their position (lateral, sternal, any limb or spine flexion). You should then move on to assess for any major injuries that may kill the patient in the short-term. These include catastrophic hemorrhage, open thorax, major airway issues, and others, and if present their treatment should be your top priority. Once these are complete and any necessary interventions have been performed you can move to the Primary Survey, also known as the ABCDs - Airway, Breathing, Circulation, and Disability.
If the patient’s condition allows, place him/her on a warm, padded surface for their evaluation. Try to avoid leaving them on a cold table, as trauma patients are likely already hypothermic and may have compromised thermoregulation.
The goal is to assess for a patent airway, and if compromised, secure it by clearing any obstruction or by intubating the patient. Thankfully significant airway compromise is relatively rare in dogs and cats following trauma; some notable points are as follows:
- Is there any crying, vocalisation, or whining? This indicates that the airway is patent.
- Look, listen, and feel for air moving in and out of the patient. Is it moving appropriately? If you are unsure, or if the patient is very hairy, then palpating the thorax and feeling in front of the airway is helpful.
- Check for obstructions and clear them if possible. Do not put anything into the mouth unless you can clearly visualise the airway, otherwise you risk pushing any obstruction further down.
- If fluid or foam is present, then bulb syringes, swabs, cotton applicators/Q-Tips, or suction can be used to remove it.
- If there is swelling present then intubation or tracheotomy may be required; emergency tracheotomy is however rarely indicated.
- Signs of a compromised airway include gagging/gasping, labored breathing, pawing at the mouth, drooling, abdominal breathing, extended head/neck with abducted legs (“Sphinx position”), restlessness, or central cyanosis (although this may be a delayed development so not a reliable indicator).
- Check for signs of breathing? What are the rate and quality of breaths? Are the rate and quality appropriate and sufficient to sustain life? Are the breaths deep or shallow? Fast or slow? What is the effort (inspiratory, expiratory, or neither)? Is there any struggling?
- Is the thorax compromised in any way (penetrating wounds, thoracic or abdominal wall rupture, diaphragm rupture, tension pneumothorax)? If so, cover any open wounds with plastic dressing, commercial vented chest seals, or cling film with cohesive bandage on top.
- Are there any penetrating objects in the thorax? If so, secure them in place with bandage or dressing unless they are interfering with CPR.
- Are there any penetrating wounds? Check for both exit and entry points.
- If needed or possible, place the patient in sternal position to allow expansion of both sides of the thorax. Avoid dorsal recumbency where possible.
- Although relatively rare in dogs and cats, it is nevertheless important to check the whole body for any massive or life-threatening external haemorrhage. Assess and control this before moving further.
- Assess physical perfusion parameters. These include heart rate, pulse rate, peripheral pulse quality, mucous membrane colour and capillary refill time; mentation, extremity temperature and rectal temperature are also useful if less sensitive. Secondary measures such as blood pressure and blood lactate level may be helpful.
- Address shock induced hypothermia. Prevent further heat loss and as far as practicable implement passive external rewarming. Cover the patient with insulating blankets (fleece, bubble wrap, foil emergency blankets), and place them somewhere warm, dry, and insulated.
Disability / Neurological Deficits
- Assess level of consciousness. One helpful tool for this is the AVPU Scale, which uses a grading system to assess a patient’s responsiveness. A conscious and responsive patient would receive a grade of A, while a completely unresponsive patient would receive a U; note that the AVPU Scale remains to be more thoroughly investigated in human medicine and even more so in veterinary patients. For patients with more severely altered mentation (P or U), the modified Glasgow Coma Scale can also be used for a more complete assessment and to track changes in condition.
- A) Alert: Spontaneously awake, normal body function
- V) Voice: Responsive to voice commands or stimulation.
- P) Pain: Responsive to painful stimuli.
- U) Unresponsive: Not responsive to any stimuli.
- Assess pupils. Are they equal, round, responsive to light? Is the pupillary light reflex synchronous? Any miosis or mydriasis?
- Address increases in intracranial pressure (ICP) (Head Trauma) for which the Cushing’s Response is a delayed but reliable indicator: an increase in blood pressure and a reflex decrease in heart rate to compensate for raised intracranial pressure (see podcast episode on traumatic brain injury)
- Assess for spinal cord injury and use spinal cord precautions if necessary.
- Check for obvious injuries to the back and spinal cord. Is there any pain or tenderness along the vertebral column? Is there any history of any falls from a height (>4m) or road traffic accident?
- Weakness or paralysis of one or more limbs, or lack of recognition of stimulus or painful stimuli are indicators of spinal cord injury.
- Check for distraction injuries from trauma such as tail pull or hanging/strangling.
- Injury to segments C3-C5 can cause respiratory compromise.
How you utilise your team during this time will depend on your staffing level and their training. If it is a single nurse and yourself then you will likely both be occupied during the initial exam and stabilisation period. However, if you have a larger team present, they can help you run diagnostics and collect monitoring equipment.
For any trauma patient, a baseline packed cell volume (PCV)/plasma total solids (TS), lactate, blood glucose, and basic biochemistry (urea, creatinine, ALT), can help assess the severity of trauma and allow you to monitor patient progress. Depending on the mechanism of injury, you may also want to check coagulation times and platelet count (including via peripheral blood smear examination) and perform blood typing.
If you have an ultrasound machine, then performing an abdominal (AFAST) and thoracic (TFAST) focused assessment with sonography for trauma (FAST) can be incredibly helpful, and use of an abdominal fluid scoring system for monitoring purposes has been described. Although much debated, survey radiography may have a role in the trauma patient as long as it is done safely, with minimal stress to the patient and at the appropriate time. If your facility has access to CT, it can be helpful with diagnosing injuries in patients with polytrauma, and can be performed in suitable cases with little or no sedation. There is much debate in human medicine around the appropriate use, some would say excessive use, of CT for screening in trauma patients but that is not for this post!