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Advanced Trauma Life Support.
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General Approach to Traumatic Patient
Trauma
• physiological wound caused by an external source. It can also be described as "a physical wound or injury, such as a fracture or blow".
• E.g. MVA accidents, falls, industrial accidents, burns, knifings, and shootings.
• Leading cause of death in productive young man
Concepts of ATLS
• Treat the greatest threat to life first• The lack of a definitive diagnosis should never
impede the application of an indicated treatment
• A detailed history is not essential to begin the evaluation
• “ABCDE” approach
Primary Survey
• Patients are assessed and treatment priorities established based on their injuries, vital signs, and injury mechanisms
• ABCDEs of trauma care– A Airway and c-spine protection– B Breathing and ventilation– C Circulation with hemorrhage control– D Disability/Neurologic status– E Exposure/Environmental control
A- Airway
• Airway should be assessed for patency– Is the patient able to communicate verbally?– Inspect for any foreign bodies– Examine for stridor, hoarseness, gurgling, pooled
secrecretions or blood
• Assume c-spine injury in patients with multisystem trauma– C-spine clearance is both clinical and radiographic– C-collar should remain in place until patient can cooperate
with clinical exam
Difficult Airway
Airway Interventions
• Supplemental oxygen• Suction • Chin lift/jaw thrust • Oral/nasal airways• Definitive airways– RSI for agitated patients with c-spine
immobilization– ETI for comatose patients (GCS<8)
B- Breathing
• Airway patency alone does not ensure adequate ventilation
• Inspect, palpate, and auscultate – Deviated trachea, crepitus, flail chest, sucking
chest wound, absence of breath sounds• CXR to evaluate lung fields
Flail Chest
Subcutaneous Emphysema
Breathing Interventions
• Ventilate with 100% oxygen• Needle decompression if tension
pneumothorax suspected• Chest tubes for pneumothorax / hemothorax• Occlusive dressing to sucking chest wound• If intubated, evaluate ETT position
Chest Tube for GSW
C- Circulation
• Hemorrhagic shock should be assumed in any hypotensive trauma patient
• Rapid assessment of hemodynamic status– Level of consciousness– Skin color– Pulses in four extremities– Blood pressure and pulse pressure
Circulation Interventions
• Cardiac monitor• Apply pressure to sites of external hemorrhage• Establish IV access– 2 large bore IVs– Central lines if indicated
• Cardiac tamponade decompression if indicated• Volume resuscitation– Have blood ready if needed– Level One infusers available – Foley catheter to monitor resuscitation
D- Disability
• Abbreviated neurological exam – Level of consciousness– Pupil size and reactivity– Motor function– GCS • Utilized to determine severity of injury• Guide for urgency of head CT and ICP monitoring
Disability Interventions
• Spinal cord injury– High dose steroids if within 8 hours
• ICP monitor- Neurosurgical consultation• Elevated ICP– Head of bed elevated– Mannitol– Hyperventilation– Emergent decompression
E- Exposure
• Complete disrobing of patient• Logroll to inspect back• Rectal temperature• Warm blankets/external warming device to
prevent hypothermia
Always Inspect the Back
Secondary Survey
• AMPLE history– Allergies, medications, PMH, last meal, events
• Physical exam from head to toe, including rectal exam
• Frequent reassessment of vitals• Diagnostic studies at this time simultaneously– X-rays, lab work, CT orders if indicated– FAST exam
20
Physical Exam
Battle Sign
Raccoon's Eyes
Cullen’s Sign
Grey-Turner’s Sign
Seatbelt Sign
22
Adjuncts to Secondary Survey Radiology– Standard emergent films
C-spine, CXR, Pelvis– Focused Abdominal Sonography in Trauma (FAST)– Additional films
Cat scan imagingAngiography
Foley Catheter– Blood at urethral meatus = No Foley catheter
Pain Control Tetanus Status Antibiotics for open fractures
23
Classic Radiographic Findings Epidural
Hematoma– Middle Meningeal
Artery
Subdural Hematoma– Bridging Veins
24
Classic Radiographic FindingsDiaphragmatic rupture w/ spleen
herniation
25
Classic Radiographic Findings
Widened Mediastinum – Aortic Injury
Abdominal Trauma
• Common source of traumatic injury• Mechanism is important – Bike accident over the handlebars – Car with steering wheel trauma
• High suspicion with tachycardia, hypotension, and abdominal tenderness
• Can be asymptomatic early on• FAST exam can be early screening tool
Abdominal Trauma
• Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal ecchymosis
• Be suspicious of free fluid without evidence of solid organ injury
FAST Exam
• Focused Abdominal Scanning in Trauma• To find free fluid (blood) around heart
(pericardiac eff.) or abdominal organ (hemoperitoneum) after trauma
• 4 views:– Cardiac– RUQ (Morison’s Pouch)– LUQ (Perispleenic Space)– Pelvic (Pouch of Doughlas)
Splenic Injury
• Most commonly injured organ in blunt trauma• Often associated with other injuries• Left lower rib pain may be indicative• Often can be managed non-
operatively
Liver injury• Second most common solid organ injury• Can be difficult to manage surgically • Often associated with other abdominal
injuries
Hollow Viscous Injury
• Injury can involve stomach, bowel, or mesentery
• Symptoms are a result from a combination of blood loss and peritoneal contamination
• Small bowel and colon injuries result most often from penetrating trauma
• Deceleration injuries can result in bucket-handle tears of mesentery
• Free fluid without solid organ injury is a hollow viscus injury until proven otherwise
32
Definitive Care Secondary Survey followed by radiographic
evaluation– CatScan– Consultation
NeurosurgeryOrthopedic SurgeryVascular Surgery
Transfer to Definitive Care– Operating Room– ICU– Higher level facility
Bucket-handle Tear of Mesentery
34
Conclusion Assessment of the trauma patient is a standard algorithm
designed to ensure life threatening injuries do not get missed
Primary Survey + Resuscitation– Airway– Breathing– Circulation– Disability– Exposure
Secondary Survey Definitive Care
References1. Bailey and Love’s Short Practice of Surgery. 25th Edition.2. Kumar MV (2014) Clinical Companion in Surgery. 2nd
Edition3. Davidson’s Principles and Practice of Medicine 21st Edition4. Carmont MR (2005). "The Advanced Trauma Life Support
course: a history of its development and review of related literature". Postgraduate Medical Journal 81(952): 87–91.
5. Styner, Randy (2012). The Light of the Moon - Life, Death and the Birth of Advanced Trauma Life Support. Kindle Books: Kindle Books. p. 267.
6. Committee on Trauma, American College of Surgeons (2008). ATLS: Advanced Trauma Life Support Program for Doctors (8th ed.). Chicago: American College of Surgeons.