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ATLS 2022Objectives
• Airway (A)
o Assess the cervical spine and immobilise it if/when required whilst assessing and
managing the rest of the airway
o Assess the airway, perform skills to keep the airway open if/when required, including
using airway adjuncts
o Describe the definition of a definitive airway
• Breathing (B)
o Assess the adequacy of ventilation by clinical features and vital sign parameters
o Recognise and manage life-threatening cause(s) of inadequate ventilation and
oxygenation, including performing a needle thoracentesis and placing a chest drain.
• Circulation (C)
o Describe the definition of the shock.
o Recognise different classes of shock with associated volume loss by clinical features
and vital signs.
o Identify the cause of the blood loss, start the initial treatment, including blood
transfusion and early surgical consultation.
• Disability (D)
o Perform a focused neurological examination.
o Explain the importance of adequate resuscitation in neuroprotection.
o Evaluate a patient with suspected traumatic brain injury.
o Evaluate a patient with suspected spinal injury.
• Exposure (E)
o Explain the importance of hypothermia in the triad of blood loss, coagulopathy and
acidosis.
o Initiate the treatment of a patient with burns and associated injuries.
o Describe the differences in the care for paediatric, geriatric and pregnant patients
involved in trauma.
o Perform a safe and efficient log-roll in a team.
o Perform a full secondary survey.
,Course book
Chapter 1. Initial assessment and management
Objectives
• Explain importance of prehopsital and hospital preparation to facilutate rapid resuscitation
of trauma patients
• Identify correct sequence of priorities for assessment of injured patients
• Explain principles of primary survey, as they apply tot he assessment of an injured patient
• Explain how a patient’s medical history and mechanism of injury contribute to the
identification of injuries
• Explain need for immediate resuscitation during primary survey
• Describe the initial assessment of a multiply injured patient, using correct sequence of
priorities
• Identify pitfalls associated with initial assessment and management of injured patients and
describe ways to avoid them
• Explain management techniques employed during the primary assessments and stabilization
of a multiply injured patient
• Identify adjuncts to the assessment and management of injured patients as part of primary
survey and recognize contraindications to their use
• Recognize patients who require transfer to another faculty for definitive management
• Identify components of secondary survey, including adjuncts that may be appropriate during
its performance
• Discuss the importance of reevaluating a patient who is not responding appropriately to
resuscitation and management
• Explain importance of teamwork in initial assessment of trauma patients
Initial assessment includes:
- Preparation
- Triage
- Primary survey (ABCDEs) with immediate resuscitation of patients with life-threatening
injuries
- Adjuncts to primary survey and resuscitation
- Consideration of the need for patient transfer
- Secondary survery (head-to-toe evaluation and patient history)
- Adjuncts to secondary survey
- Continued post-resuscitation monitoring and reevaluation
- Definitive care
Preparation
Occurs in the field and in the hospital
The prehospital phase → events are coordinated with the clinicians at the receiving hospital.
• Providers emphasize airway maintenance, control of external bleeding and shock,
immobilization of the patient and immediate transport tot he closest appropriate facility.
• Obtaining and reporting information needed for triage at the hospital, including time of
injury, events related to injury, mechanism of injury and patient history.
,
,The hopsital phase → preparations are made to facilitate rapid trauma patient resuscitation
• Hospital preparation includes
o Resuscitation area
o Properly functoning airway equipment (e.g. laryngoscopes and endotracheal tubes)
is organized, tested and strategically placed to be easily accessible
o Warmed intravenous crystalloid solutions are immediately available for infusion, as
are appropriate monitoring devices
o Protocol to summon additional medial assistance, means to ensure prompt
responses by laboratory and radiology personnel
o Transfer agreements with verified trauma centers are established and operational
Triage = sorting of patients based on the resources required for treatment and the resources that are
actually available.
The order of treatment is based on ABC priorities.
Other factors that influence triage are severity of injury, ability to survive and available resources.
Trauma scores:
- Glasgow Coma Score (GCS
- Trauma Score (TS) → ranging between 1 and 1, based on 5 variables
o GCS
o Respiratory rate (RR)
o Respiratory effort
o Systolic blood pressure (SBP)
o Capillary refill.
- Revised Trauma Score (RTS) → based on values (0 – 4) assigned to 3 variables
o GCS
o SBP
o RR
- Pediatric Trauma Score (PTS) → based on the sum of 6 measures
o Child’s weight
o SBP
o Level of consciousness
o Presence of fracture
o Presence of open wound
o State of airway
- Abbreviated Injury Severity Score (AIS) → grade injuries related to all types of blunt and
penetrating trauma. From1 (minor) to 6 (insurvivable)
- Injury Severity Score (ISS) → sum of squares of highest three scores in six body regions (head
and neck, face, chest, abdomen, limbs and external). Range from 1 to 75
- New Injury Severity Score (NISS)
- Geriatric Trauma Outcome Score (GTOS) → 3 a priori variables. GTO = age + (2.5 x ISS) + 22 (if
any pRBCs are transufsed in the first 24 hours after injury)
o Age
o ISS
o 24-hour trnasfusion requirement
, - Trauma Associated Severe Hemorrhage
(TASH) score → 7 variables
o SBP
o Hemoglobin
o FAST
o Presence of long-bone or pelvic
fracture
o HR
o Base Excess (BE)
o Gender
- McLaughlin score → 4 variables to
predict need for massive transfusion
o HR > 105
o SBP > 110 mmHg
o pH < 7.25
o Hematocrit < 32%
Mass casualties = the number of patients and
severity of their injuries does exceed the
capability of the facilty and staff. In such cases,
patients having the greatest chance of survival
and requiring the least expenditure of time,
equipment, supplies and perosnnel are treated
first.
Primary survey → ABCDEs
• A = airway maintenance with restriction of cervical spine motion
• B = breathing and ventilation
• C = circulation with hemorrhage control
• D = disability (assessment of neurologic status)
• E = exposure/environmental control
, 10-second assessment to quickly assess A, B, C and D → identyfing yourself, asking the patient
his/her name and asking what happened.
• Appropriate response suggests that there is:
o No major airway compromise (ability tos peak clearly)
o Breathing is not severly compromised (ability to generate air movement to permit
speech)
o Level of consciousness is not markedly decreased (alert enough to describe what
happened)
For example, airway compromise can occur secondary to head trauma, injuries causing shock, or
direct physical trauma to the airway. Regardless of the injury causing airway compromise, the first
priority is airway management: clearing the airway, suctioning, administering oxygen, and opening
and securing the airway
Airway maintenance
- Inspecting for foreign bodies
- Identifying facial, mandibular and/or tracheal/laryngeal fractures and other injuries that can result
in airway obstruction
- Suctioning to clear accumulated blood or secretions that may lead to or be causing airway
obstruction
First intervention = jaw-thrust or chinlift
• GCS < 8 → usually require the placement of definitive airway → cuffed, secured tube in
trachea
• Unconscious and no gag reflex → temporarily helpful to place an oropharyngeal airway
Protect cervical spine with a cervical collar.
When airway management is necessary the cervical collar is opened and a team member manually
restricts motion of the cervical spine.
Breathing and ventilation
Ventilation requires adequate function of the lungs, chest wal land diaphragm → examine and
evaluate each component
• Expose patient’s neck and chest to assess:
o Jugular venous distention
o Position of trachea
o Chest wall excursion
• Perform auscultation to ensure gas flow in the lungs
• Visual inspection + palpation to detect injuries tot he chest wall that may be compromising
ventilation
• Every injured patient should receive supplemental oxygen
Significantly impaired ventilation in short term are most often
- Tension pneumothorax
- Massive hemothorax
- Open pneumothorax
- Tracheal or bronchial injuries
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