ATLS: Initial Assessment and Management SAUSHEC Medical Student Lecture Series
Objectives Identify sequence of priorities in assessing the multiply injured patient Apply principles outlined in primary and secondary evaluation surveys Apply guidelines and techniques in the initial resuscitative and definitive-care phases of treatment Identify how patient s medical history and mechanism of injury contribute to identification of injuries
Objectives Identify pitfalls associated with initial assessment and management and apply steps to minimize their impact Be able to conduct an initial assessment survey, using the correct sequence of priorities and management techniques for primary treatment and stabilization
Concepts of Initial Assessment Rapid primary survey Resuscitation Adjuncts to primary survey/resuscitation Detailed secondary survey Adjuncts to secondary survey Reevaluation Definitive care
Initial Assessment Primary survey and resuscitation of vital functions are done simultaneously-a team approach.
Preparation Pre-Hospital System Transport guidelines/protocols On-line medical direction Mobilization of resources Periodic review of care Closest appropriate facility
Preparation In-Hospital Preplanning Equipment, personnel, services Standard precautions Transfer agreement
Standard Precautions Cap Gown Gloves Mask Shoe covers Goggles/face shields
Triage Sorting of patients according to: ABCDE s available resources Multiple casualties Mass casualties
Primary Survey adult/pediatric/pregnant women=priorities are the same A airway with C-spine protection B breathing C circulation with hemorrhage control D disability E exposure/environment
Special Considerations trauma in the elderly 5th leading cause of death decreased physiologic reserve comorbidities: diseases/medications Outcome depends on early, aggressive care
Primary Survey A Establish patent airway assume C-spine trauma Pitfalls equipment failure inability to intubate occult airway injury progressive loss of airway
Primary Survey Suspect C-spine injury spinal protection C-spine X-ray when appropriate
Assess Oxygenate Ventilate Pitfalls: Primary Survey B Airway vs ventilation problem iatrogenic pneumothorax/tension pneumothorax
Primary Survey C Assessment of organ perfusion Level of Consciousness Skin color and temperature Pulse rate and character
Primary Surevey C Circulatory Management Control Hemorrhage Restore Volume Reassess Pitfalls: elderly, athletes, children medications
Disability Primary Survey D Baseline neurologic evaluation GCS Scoring Pupillary response Continuously reassess for deterioration/changes
Exposure Primary Survey E Completely undress the patient Environment core temperature prevent hypothermia
Resuscitation Protect and secure the airway Ventilate and oxygenate Stop the bleeding Protect from hypothermia
Adjuncts to Primary Survey Vital Signs/ECG monitoring ABGs POX/CO2 Urinary/gastric catheters Urinary output ECG
Adjuncts to Primary Survey Diagnostic tools CXR, C-spine, Pelvis DPL Ultrasound
Adjuncts to Primary Survey Consider Early Transfer do not delay transfer for diagnostic tests time to transfer=resuscitation
Reevaluate Proceed to secondary survey after: Primary survey completed ABCDE s reassessed initial resuscitation of vital functions
Secondary Survey Key Components History Complete head-to-toe examination Tubes and Fingers in every orifice Complete Neuro exam Special diagnostic tests Reevaluation
A Allergies M Medications Secondary Survey History P Past Medical/Surgical History/Pregnancy L Last meal E Events/Environment related to injury
Secondary Survey Head Complete Neuro exam GCS Score Comprehensive eye/ear exams Pitfalls: unconscious patient periorbital edema occluded auditory canal
Secondary Survey Maxillofacial Bony crepitus/stability Palpable deformity Pitfalls: potential airway obstruction cribriform plate fracture frequently missed injuries
Secondary Survey Cervical Spine Palpate for tenderness/stepoffs/crepitus Complete motor/sensory exams Reflexes C-spine imaging Pitfalls: altered LOC for any reason distracting injury
Secondary Survey Neck (soft tissues) Mechanism: blunt vs penetrating Symptoms: airway obstruction, hoarseness Findings: crepitus, hematoma, stridor, bruit Pitfalls: may have delayed symptoms/signs progressive airway obstruction occult injuries
Inspect Palpate Percuss Auscultate X-rays Pitfalls: Secondary Survey Chest elderly, children
Secondary Survey Abdomen Inspect, auscultate, palpate, percuss Reevaluate frequently Special studies Pitfalls: hollow viscus and retroperitoneal injuries excessive pelvic manipulation
Secondary Survey Perineum-contusions, hematomas, lacerations, urethral blood Rectum-sphincter tone, prostate, pelvic fracture, rectal wall integrity, blood Vagina-blood, lacerations Pitfalls: urethral injury, pregnancy
Secondary Survey Musculoskeletal:Extremities contusion, deformity pain perfusion peripheral NV status X-rays as indicated
Secondary Survey Musculoskeletal:Pelvis Pain on palpation increased symphysis width uneven leg length instability special X-rays as indicated
Pitfalls: Secondary Survey Musculoskeletal potential blood loss missed fractures soft-tissue or ligamentous injuries compartment syndrome
Spine/Cord: Secondary Survey Neurologic complete motor and sensory exams reflexes imaging as indicated CNS: frequent reevaluation prevent secondary brain injury Early neurosurgical consultation
Pitfalls: Secondary Survey Neurologic incomplete immobilization subtle increases in ICP with manipulation rapid deterioration
Adjuncts to Secondary Survey Special diagnostic tests as indicated Pitfalls: patient deterioration delay of transfer
Reevaluation Minimizing missed injuries high index of suspicion frequent reevaluation and continuous monitoring
Reevaluation Pain Management relief of pain/anxiety IV titration monitor carefully
Patient Definitive Care? Transfer injuries physiologic status concurrent diseases factors that may alter prognisis Hospital overall capabilities specialized care
Records, Legal Considerations concise, complete, chronologic documentation consent for treatment forensic evidence
Summary Primary Survey Resuscitation Adjuncts Secondary Survey Adjuncts Definitive Care