Advanced Trauma Life Support

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Chapter 1: Initial assessment and management

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“initial assessment” includes the following elements:
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• Definitive care

Note: Primary and secondary surveys are repeated frequently to identify any change
in the patient’s status.

• Preparation
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Two phases:
• Pre Hospital (Field Triage Decision Scheme)
- airway maintenance
- control of external bleeding and shock
- immobilization of the patient
- immediate transport to the closest appropriate facility
• Hospital
- Resuscitation area
- Properly functioning airway equipment
- Warmed intravenous crystalloid solutions
- Protocol to summon additional medical assistance
- Transfer agreements with verified trauma centers

• Triage
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"Sorting of patients based on the resources required for treatment."
The order of treatment is based on the ABC priorities:
- Airway with cervical spine protection
- Breathing
- Circulation with hemorrhage control

Triage situations are categorized as 'multiple casualties' or 'mass casualties'

Multiple casualties : do not exceed the capability of the facility ----> life-
threatening problems treated first
Mass casualties : does exceed the capability of the facility ----> greatest chance
of survival treated first

• Primary survey
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"identifies life-threatening conditions"
Sequence:- 'ABCDE'
• Airway maintenance with restriction of cervical spine motion
- INDICATIONS:
- Signs of airway obstruction
- Foreign bodies
- Facial, mandibular, tracheal/laryngeal fractures
- Suctioning blood/other secretions
- GCS score of 8 or lower
- Non purposeful motor movements

• Breathing and ventilation

- INDICATIONS:
- Jugular venous distension
- Position of trachea
- Chest wall excursion
 - Visual inspection and palpation - injuries to chest wall
(tension/open pneumothorax,hemothorax etc)
- Percussion and auscultation - ensure gas flow in lungs

Note: 'Every injured patient should receive supplemental oxygen' - with pulse
oximeter monitoring

• Circulation
with hemorrhage control
- Blood
volume & cardiac output INDICATIONS:
-
Level of consciousness - cerebral perfusion
-
Skin perfusion - injured hypovolemic patients
-
Pulse - rapid, thready - hypovolemia
- absent centrally - immediate resustication
- Bleeding INDICATIONS:
- External - direct manual pressure ; if not enough - torniquet
- Internal - physical examination and imaging(x-ray,focused
sonography,peritoneal lavage)
- Replacement of intravascular volume
- Vascular access: two peripheral venous catheters
- Baseline hematological studies
- Pregnancy testing and blood typing with cross matching
Note: 'Aggressive and continued volume resuscitation is not a 'substitute' for
definitive control of hemorrhage'
- IV fluid therapy w/ crystalloids (pre-warmed 37°-40°c)
- If unresponsive - blood transfusion

• Disability(neurologic evaluation)
- Level of consciousness and pupillary size/reaction - Glasgow Coma
Score
- Lateralising signs
- Spinal cord injury level assesssment

• Exposure/Environmental control
- Complete undressing of patient - examination & assessment
- Covering with warm blanket/external warming device - prevent
hypothermia
- Maintain warm environment - high flow fluid warmer - worst case:
microwave heating crystalloids

• Adjuncts to the primary survey and resuscitation

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• Continuous Electrocardiographic Monitoring - Dysrhythmias, Pulseless
electrical activity
• Pulse Oximetry - relative oxygenation - not partial pressure measurement
• Ventilatory rate and arterial blood gas analysis - End tidal CO2 levels
- confirm intubation of airway
- assessment of adequate oxygenation
- acid-base information
• Urinary and Gastric catheters
- volume status and perfusion assessment
- urinary catheter - indwelling bladder catheter + urine specimen
analysis
- contraindicated in uretheral/perineal injury
- insertion only after examination of perineum and
genitalia
- gastric catheter - decompress stomach distension + decrease
aspiration + check for hemorrhage
- cribriform fracture - insert orally for any
nasopharyngeal instrument
 • Diagnostic studies
- x-rays - show life-threatning injuries & fractures that require early
blood transfuion
- sonography - detecting intraabdominal blood, pneumothorax, hemothorax

• Consideration of the need for patient transfer

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'During the primary survey, evaluating doctor obtains sufficient information to
determine the need to transfer'
Note: "important not to delay transfer to perform an indepth diagnostic evaluation"

Note:-
Special populations for initial assessment:-
"have physiologic responses and anatomic differenes that require special
consideration"
- children - show only few signs of hypovolemia - despite severe volume
depletion
- pregnant women
- older adults - diminished physiologic reserve + comorbidities + longterm
medication usage
- obese patients - intubation: difficult and hazardous
- diagnostic tests: difficult and unreliable
- cardiopulmonary disease: limited compensation to injury and stress
- fluid resustication: exacerbate comorbidites
- athletes - reduced signs of shock, tachycardia, tachypnea + normally low
sys and dia blood pressure

• Secondary survey (head-to-toe evaluation and patient history)

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- Begins only after primary survey is completed & patient's vitals are shown to
improve
- Head-to-toe evaluation of trauma patient - history, physical examination,
reassesment of vitals

• History(AMPLE)
- Allergies
- Medications currently being used
- Past illnesses
- Last meal
- Events/Environment related to injury
- mechanism of injury - blunt, penetrating, burns, hazardous
toxins, radiation
- suspected injury patterns

• Physical examination(follows a sequence)

- Head
- lacerations, contusions, fracture evidences on scalp and head
- eyes:
- visual acuity
- pupillary size
- hemorrhage of conjunctiva/fundi
- penetrating injury
- contact lenses/dislocation of lens
- ocular entrapment

- Maxillofacial structures
- palpation of all bony structures
- assessment of occlusion
 - intra-oral examination
- assessmeent of soft tissues

- Cervical spine and neck

- patients with maxillofacial or head trauma should be presumed
to have a cervical spine injury
- hence, cervical spine motion must be restricted
- injury should be presumed until evaluation of the
cervical spine - x-ray/CT
- inspection, palpation, auscultation
- cervical spine tenderness
- subcutaneous emphysema
- tracheal deviation
- laryngeal fracture
- carotid arteries - palpated and auscultated for bruits
- common signs : seatbelt mark, traction injury from shoulder
harness, penetrating/blunt injury

- Chest
- anteroposterior visual evalution - pneumothorax, flail chest
etc
- palpation - ribcage - clavicles, ribs, sternum (painful if
fracture sternum)
- auscultation - anterior + high - pneumothorax
- posterior + base - hemothorax
- faint heart sounds - cardiac tamponade
- distended neck veins: cardiac tamponade/tension pneumothorax
- percussion - hyperresonance
- chest x-ray/sonography - confirm hemothorax, pneumothorax
- widened mediastinum - aortic rupture

- Abdomen and pelvis

- must be treated agressively w/ early surgical intervention
- frequent re-evaluation - important for blunt injuries
- pelvic fracture indications
- ecchymosis over iliac wings, pubis, labia or scrotum
- pain on palpation of pelvic ring
- assessment of peripheral pulses

- Perineum, rectum and vagina

- perineum - contusions, lacerations, hematomas and urethral
bleeding
- rectum - blood within bowel, integrity of rectal wall,
sphincter tone
- vaginal examination - only when at risk of injury
- lacerations, hemorrhage
- pregnancy test for all females of
childbearing age

- Musculoskeletal system
- inspection of extremities: contusions, deformities
- palpation of bones and examination for tenderness
- ligament rupture: joint instability
- altered/impaired sensations - ischemia, compartment syndrome
- "not completed without examination of back"

- Neurological system
- motor and sensory evaluation + GCS re-evaluation
- protection of spinal cord until disproved
 - all neurologic deficits should be documented

• Adjuncts to the secondary survey

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- specialized diagnostic tests: x-ray, CT scans, contrast urography and
angiography, transesophageal ultrasound, bronchoscopy etc..
- complete cervical and thoracolumbar spine imaging

• Continued postresuscitation monitoring and reevaluation

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- ensure new findings not overlooked + discover deterioration of previous findings
- maintenance of vitals and urinary output - 0.5 ml/kg/hr (pediatric - 1 ml/kg/hr)
- relief of severe pain

• Definitive care
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- patient’s treatment needs exceed the capability of the receiving institution
- interhospital transfer guidelines will help determine which patients require the
highest level of trauma care