 Today, you're working in the emergency department, the paramedic from Rings. They're bringing in a 20-year-old involved in a motor vehicle accident. Welcome to the EM Ottawa Trauma Video Series. In this series, we will discuss the approach to trauma. We'll break this down into mechanism, primary survey and resuscitation, secondary survey. We'll also discuss the Canadian sea spine and the CT head rules. Let's begin. To prepare for the patient's arrival, we would like some more detail about the accident. What history about the accident do you think would be important for us? These are the factors we would like to know. The speed of the vehicles, the mechanism of the collision, whether this was head-on, t-bone, or rollover, what kind of vehicle, such as recreational vehicle, bicycles, whether there are safety restraints being used such as seat belts, airbags, and car seats for children. The damage to the cars, where and how much, and whether there was intrusion into the compartment. You also want to know whether there are other occupants who were expelled from the car or have died on scene. That usually means a bad prognosis because it reflects high impact of the collision. The patient now arrives. This is a healthy 28-year-old who is involved in a high-speed rollover collision. He did not have a seat belt on and was thrown from the car. His vital signs are as follows, blood pressure is 80 over 60, heart rate of 120, rest rate of 30, saturation is 90% of room air, and it appears untunded. Now that we know a little bit about the mechanism, we'll approach the patient with the trauma primary survey. What is the primary survey? The primary survey is your first trauma assessment. The steps in the primary survey have to be done sequentially. We do not go to the next step until the previous component is corrected. The objective of the primary survey is to identify any life-threatening injury and resuscitate the patient quickly. There are five components of the primary survey. They are airway, breathing, circulation, disability, and exposure. We will first discuss airway. In the airway assessment, we assess for the patency of the airway, meaning whether the airway is open to airflow or is it obstructed. Since the patient can have other injuries such as cervical spine injury, any airway assessment or intervention needs to be done with the cervical spine being immobilized. The neck must not move. Let us look at a cross-section of the airway. The tongue is here. The trachea is anterior to the esophagus. In a patent airway, air flows from the nasal pharynx and the oral pharynx into the trachea. Now, what can cause obstruction of the airway, especially when the patient is lying flat? Any secretions, including blood and vomit, can pull in the oral and nasal pharynx and further down the trachea causing an obstruction. Any distortion of the anatomy can cause obstruction as well. That can include fracture or swelling from expanding hematoma that leads to compression. In patients with decreased level of consciousness, their tongue can fall backwards due to poor muscle tone causing airway obstruction. How do we assess for airway patency? We listen and watch. In an alert patient, if the patient is able to talk to you, they have a patent airway now. In an alert patient, if the patient is not able to speak, or is only making gurgling noises, the airway is obstructed. Something is blocking the airflow from the oral pharynx to the trachea. In an obtained patient who is making respiratory efforts, if you hear noisy breathing, there is an airway obstruction. If the patient is not making any respiratory effort because of decreased level of consciousness, we will presume they also lost the muscular tone to keep the airway patent. As a general rule, a Glasgow coma scale of less than 8 usually signifies the need for an airway intervention. Let's go back to our patient. In our patient, he is making gurgling noises when he breathes. Therefore, he has an obstructed airway. How do we fix an airway obstruction? If the airway is obstructed due to blood to vomit, we can use suction to clear out the debris. We can also use a jaw thrust to pull the mandible and hence move the tongue more anteriorly. We need to be careful not to do a head tilt because that will move the neck. Both suction and jaw thrust are temporary measures. We can also insert an oral airway or a nasal pharyngeal airway to keep a rigid structure in the oral and nasal pharynx. However, they do not prevent blood or secretions from going into the trachea. The definitive airway management is an endotracheal intubation. It starts in the oral pharynx and goes directly into the trachea, bypassing all the structures that may cause obstruction. It also prevents aspiration into the lungs. There are other extragalodic devices such as LMA that you might have seen used in other cases in the emergency department. However, they do not protect against aspiration. If an endotracheal intubation cannot be done due to difficult anatomy, then a cricothyroidotomy is performed to gain access into the trachea through the interior neck. This is an advanced airway skill and will not be discussed here. Since our patient's GCS is low and his breathing was noisy, we decided to intubate him. After securing the airway, we can then move on to the next step of the primary survey, breathing. Please refer to that video.