ATLS: Initial Assessmentand

ManagementSAUSHEC 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.

PreparationPre-Hospital System

• Transport guidelines/protocols

• On-line medical direction

• Mobilization of resources

• Periodic review of care

• Closest appropriate facility

PreparationIn-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 Considerationstrauma in the elderly

• 5th leading cause of death

• decreased physiologic reserve

• comorbidities: diseases/medications

• Outcome depends on early, aggressive care

Primary SurveyA

• 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

Primary SurveyB

• Assess

• Oxygenate

• Ventilate

• Pitfalls:– Airway vs ventilation problem– iatrogenic pneumothorax/tension

pneumothorax

Primary SurveyC

• Assessment of organ perfusion– Level of Consciousness– Skin color and temperature– Pulse rate and character

Primary SureveyC

• Circulatory Management– Control Hemorrhage– Restore Volume– Reassess

• Pitfalls:– elderly, athletes, children– medications

Primary SurveyD

• Disability– Baseline neurologic evaluation– GCS Scoring– Pupillary response

• Continuously reassess for deterioration/changes

Primary SurveyE

• Exposure– 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 SurveyKey Components

• History

• Complete head-to-toe examination

• “Tubes and Fingers in every orifice”

• Complete Neuro exam

• Special diagnostic tests

• Reevaluation

Secondary SurveyHistory

• A Allergies

• M Medications

• P Past Medical/Surgical History/Pregnancy

• L Last meal

• E Events/Environment related to injury

Secondary SurveyHead

• Complete Neuro exam

• GCS Score

• Comprehensive eye/ear exams

• Pitfalls:– unconscious patient– periorbital edema– occluded auditory canal

Secondary SurveyMaxillofacial

• Bony crepitus/stability

• Palpable deformity

• Pitfalls:– potential airway obstruction– cribriform plate fracture– frequently missed injuries

Secondary SurveyCervical Spine

• Palpate for tenderness/stepoffs/crepitus

• Complete motor/sensory exams

• Reflexes

• C-spine imaging

• Pitfalls:– altered LOC for any reason– distracting injury

Secondary SurveyNeck (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

Secondary SurveyChest

• Inspect

• Palpate

• Percuss

• Auscultate

• X-rays

• Pitfalls:– elderly, children

Secondary SurveyAbdomen

• 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 SurveyMusculoskeletal:Extremities

• contusion, deformity

• pain

• perfusion

• peripheral NV status

• X-rays as indicated

Secondary SurveyMusculoskeletal:Pelvis

• Pain on palpation

• increased symphysis width

• uneven leg length

• instability

• special X-rays as indicated

Secondary SurveyMusculoskeletal

• Pitfalls:– potential blood loss– missed fractures– soft-tissue or ligamentous injuries– compartment syndrome

Secondary SurveyNeurologic

• Spine/Cord:– complete motor and sensory exams– reflexes– imaging as indicated

• CNS:– frequent reevaluation– prevent secondary brain injury

• Early neurosurgical consultation

Secondary SurveyNeurologic

• Pitfalls:– 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

Definitive Care? Transfer

• Patient– 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

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