The ABC’s in ABCDE
For most of you it might be far away, but I know for a fact that for others they are glad it is finally over: trauma. Trauma is a recurring theme in G2020 and is often considered one of the most difficult themes of year 1 and 3. Trauma is also one of the topics that often recurs on the Progress Test. In this Professor Progress Test, I want to give you an overview of the basics in traumatology. After reading this I’m sure you’ll find that acute medicine might sound more traumatizing than it actually is.
I still remember having my first lecture by professor Nieboer. No laptops, no notebooks and no phones, that was the first rule. The second and third soon followed: don’t speak unless you’re spoken to, and you better not be late because you will be publicly shamed for it. And if that’s not intimidating enough, there is a chance you will be asked a random question about a life-threatening situation at any time during the lecture and if you don’t know the answer, you’ll actually feel like you just failed to save a patient’s life. Fortunately, although this sounds terrifying, these lectures have been one of, if not the most, fun and interesting lectures I have ever had during my Bachelor. And once you actually start to follow Dr. Nieboer’s advice, you’ll notice that the theory behind acute medicine is quite simple: treat first what kills first.
To make a proper assessment of what kills first, we start off by making a primary survey using the (C)ABCDE method.
C-spine – the ABCDE method starts with a C, the C of the cervical spine. Before approaching a patient, try to find out what kind of accident or situation the patient has been in. High-energy accidents can cause spine injury and the patient should be handled with extra caution to prevent worsening of potential neurological injury. Always assume cervical spine fracture unless proven otherwise.
Alarm symptoms: high-energy trauma, neck or back pain, loss of sensation
Airway – a proper oxygen supply is obviously the most important requirement of staying alive. No oxygen means no brain, no brain means no heart and no heart, well, game-over. It’s a common misconception that the heart is the central and most important organ of the body, and depending on your speciality it might be true. But in acute medicine the brain is the organ you should be worried about. A proper intervention at this level to make sure the airway is secure and open is by means of endotracheal intubation.
Alarm symptoms: absence of breathing, inability to speak or cough, wheezing, cyanosis, use of accessory breathing muscles, foreign object or blood in the oral cavity or facial trauma
Breathing – Alright, so now you know that the airways are open. But the question you should be asking now is: how well are the lungs functioning? You’ll be looking at breathing rate, breathing symmetry and overall movement of the chest and use of muscles. Shallow breathing can, for example, indicate abdominal trauma and pain. Asymmetric chest movement may indicate a (tension) pneumothorax. Proper intervention here consists of a non-rebreathing oxygen mask or a ventilator.
Alarm symptoms: breathing rate below 12 breaths/pm, breathing rate above 20 breaths/pm, cyanosis, absence of breathing, increased work for breathing, swollen and immobile half of chest (tension pneumothorax or haemothorax), chest, upper back, or upper abdominal trauma.
Circulation – Now that you know that your patient is getting enough oxygen, it is time to look at how well your oxygen transport is doing, aka the circulation. What is the heart rate? Is the heart rhythm regular? Are there any major injuries internal or external that bleed extensively? In this phase it is important to determine if the patient is in shock, and how far the shock has progressed. More on shock later. Proper interventions at this stage: IV line insertion (although this is sometimes done earlier) and damage control surgery.
Alarm symptoms: sweaty and clammy patient, paleness or blue skin, severe blood loss (20+%), slow capillary refill time, quick and shallow pulse.
Disability – In this section of the primary survey, the inner neurologist in you should be woken up. You should look at the consciousness of the patient using the GCS/EMV score. Quick tests like looking at the pupils for anisocoria (one pupil larger than the other) or checking for leakage of liquor can already determine whether there has been neurological damage. High-energy accidents can also severely impact the spine, so testing the reflexes is also a good idea.
Alarm symptoms: anisocoria, (progression to) loss of consciousness, headache, nausea, loss of control or sensation, long-lasting amnesia
Exposure – this last one might seem like the odd one out. Assessing exposure means, assessing for potential hypothermia. Proper action here is to use an emergency blanket to keep the patient warm. If the situation allows, and you don’t know it already, you should find out what happened to the patient and let him/her describe the situation.
Alarm symptoms: blue skin colour, slurred speech, shivering, drowsiness
So now that you know or are reminded of what exactly the ABCDE method is, I want to talk a bit more about the principle of shock. When a patient is in shock, blood distribution is impaired. Organs are not getting enough oxygen, and this leads to organ failure and later death. Classic signs of shock include tachypnoea (20+ breaths/pm), tachycardia (100+ bpm), hypotension, reduced urine output (<15 ml/m) and low EMV/GCS score. Shock can become irreversible. There are different types of shock, we differentiate between cardiogenic, distributive (neurogenic) and hypovolaemic shock.
Cardiogenic shock –this type of shock is characterized by a sudden insufficient pump function of the heart. This is usually caused by a severe heart attack. Treatment is difficult, fluid replacement will not work as that will only increase the preload of the heart, potentially worsening the state of shock. Treatment involves vasopressors and anti-clotting medication.
Distributive (neurogenic) shock – Distributive shock happens when massive vasodilation causes blood to pool in areas whereas it lacks in others. This is usually caused by endotoxins released by bacteria in a bacterial infection. A different type of distributive shock is neurogenic shock. This happens when the (para)sympathetic innervation of the blood vessels is malfunctioning, causing vasodilation. Treatment involves fluid replacement and treatment of the cause, for example antibiotics in a bacterial infection. Vasopressors are also widely used.
Hypovolaemic shock – Hypovolaemia happens due to haemorrhage and this is the most common type of shock. Injuries to certain organs (f.e. spleen) can cause hypovolaemic shock in less than 30 minutes. Treatment involves measures like surgery to stop the bleeding and volume replacement. Volume replacement in itself is already quite complicated, as you are replacing oxygen transporting blood with fluid. But that might be the subject of a different Professor Progress Test.
I hope you find that after reading this article, trauma is a little more clear to you, or it freshened up your memory. There is a lot more to acute medicine that are beyond the scope of this article like toxidromes, fractures, acute abdomen or emergency psychiatry. If you score badly in any of these subjects on the Progress Test and you want to change that once and for all, be sure to let us know, and maybe you’ll find everything you need to know in a future PanEssay!