Emergency Medicine Book

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Primary Survey Circulation EvaluationAka: Emergency Circulation Management

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  1. Assess Organ perfusion
    1. Level of Consciousness
    2. Skin color
    3. Central Pulse
      1. Child or adult: Carotid pulse or femoral pulse
      2. Infant: Brachial Pulse
    4. Sites of rapid blood loss
      1. Chest Injury
      2. Abdominal Injury (especially retroperitoneal)
      3. Pelvic Injury
      4. Extremity Injury (especially femur)
  2. Pulse Present Protocol
    1. Rescue Breathing
    2. Mnemonic: IV-O2-Monitor
      1. Intravenous Access
      2. Oxygen Delivery
      3. Monitor and 12 lead EKG
    3. Consider Endotracheal Intubation
    4. Vital Signs, History and Exam
    5. Assess for suspected cause
      1. Hypotension
        1. Hemorrhagic shock
        2. Intraabdominal blood loss
        3. Closed Head Injury
          1. Patrick (2002) Am J Surg 184:555
      2. Shock
      3. Acute pulmonary edema
      4. Acute Myocardial Infarction
      5. Arrhythmia
        1. Too fast (Tachycardia)
        2. Too slow (Bradycardia)
  3. Pulse absent Protocol
    1. Perform Chest Compressions
    2. Assess Rhythm
      1. Arrhythmia requiring Immediate Defibrillation?
        1. Ventricular Fibrillation
        2. Pulseless Ventricular Tachycardia
      2. Non-shockable rhythms
        1. Pulseless Electrical Activity (PEA)
        2. Asystole
    3. Endotracheal Intubation
      1. Confirm tube placement
      2. Confirm ventilations
    4. Obtain Intravenous Access
    5. Consider potentially reversible causes
      1. Five H's
        1. Hypovolemia
        2. Hypoxia
        3. Hydrogen ion (Metabolic Acidosis)
        4. Hyperkalemia or Hypokalemia
        5. Hypothermia
      2. Five T's
        1. Tablets (Drug Overdose)
        2. Tamponade (Cardiac Tamponade)
        3. Tension Pneumothorax
        4. Thrombosis: Myocardial Infarction
        5. Thrombosis: Pulmonary Embolism
  4. Trauma Management
    1. Correct Hypovolemia: Fluid Replacement in Trauma
      1. Two large bore IVs (14 or 16 gauge)
        1. Shorter tubing provides faster IV rate
      2. Replace fluid deficit
        1. Infuse Lactated Ringers 2-3 Liters until response
        2. Consider blood transfusion
          1. Unmatched Type-specific blood may be used OR
          2. Low titer O, or Rh- O if other not available
    2. Hemorrhage Evaluation
    3. Avoid potentially harmful measures
      1. Vasopressors
      2. Steroids
      3. Sodium Bicarbonate
  5. Trauma Circulatory Pitfalls:
    1. Inadequate correction of hypovolemia
    2. Intra-abdominal or Intrathoracic injury
    3. Femur Fracture or pelvic Fracture
    4. Penetrating injuries with large vessel involved
    5. External hemorrhage

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