Initial Assessment and Management

Warren M. Roraldo M.D.,MHPEd,FPSGS,FPCS,FACS

ATLS INSTRUCTOR
Objectives
Differentiate the different mechanisms of trauma
Discuss the initial assessment and management of
the trauma patient at the Emergency Room
Discuss the management of life threatening injuries at
the Emergency room
Given a hypothetical situation the student should be
able to apply the principles outlined in the primary and
secondary surveys to the assessment and
management of a multiply injured.
3 Mechanisms of Injury:
1. Penetrating- stab wound, gunshot or any penetrating
objects to the body
2. Blunt- any blunt object. Example: fall, vehicular
accident
3. Blast injury- there may be blunt because of the force
there can also be penetrating because of sharp object
The goals of the primary survey are to identify and
treat conditions that constitute an immediate threat to
life.

GOALS
Rapid and accurate assessment
Resuscitate and stabilize by priority
Determine needs and capabilities of your
hospital
Arrange for transfer to definitive care
Ensure optimum care
The primary survey should be repeated frequently to
identify any deterioration in the patient's status that
indicates the need for additional intervention.
Kunwari okay ung airaway, okay din ung B, okay din ung
C, then biglang nahirapan huminga ang pasyente? Go
back to A! You don't need to proceed hangga't may
problema pa.
PROTECTIVE GEARS
Cap
Gown
Gloves
Mask
Shoe covers
Protective eyewear / face shield

ATLS CONCEPT
1. ABCDE approach to evaluation and treatment
Airway
Breathing
Circulation
Deficit neurologic status
Exposure/Environmental control
-You have to undress the patient, look for
possible missed injuries but you have to cover
her/him with blanket after to prevent
hypothermia
Why airway first?
Without oxygen patient will die. Accdg to Doc:
"Sinong mas mauunang mamatay? Yung hindi humihingi
o yung nagblebleed?"
2. Treat greatest threat to life first
3. Definitive diagnosis not immediately important
4. Time is of the essence (First hour is important)
2 causes of death:
(1) on site (2) after complications
How can we decrease the incidence of death due
to complications? Managing correctly the patient in the
ER so that we can decrease mortality because of
complications
5. Do no further harm
1

Prepare you ER room

Primary Survey- ABCDE
Resuscitation- goal of primary survey is to assess and
treat
What is a quick, simple way to
assess a patient in 10 seconds?
Ask the patient his or her name (if the
patient answer, the airway is patent!)
Ask the patient what happened
A Patent airway
B Sufficient air reserve to permit speech
C Sufficient perfusion
D Clear sensorium

PITFALLS
Occult airway injury
Progressive loss of airway
Equipment failure
Inability to intubate

MUST KNOW!!!
What is the Glascow Coma Scale that it is mandatory to intubate the patient?
8 AND BELOW! 7 means severe head injury

PRIMARY SURVEY
Airway with c-spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neuro status
Exposure / Environmental control
Goal of Primary Survey: Identify and treat lifethreatening injury

AIRWAY
Establish patent airway and protect c-spine
Make sure that the airway is patent and put a collar if
blunt injury (in fall and vehicular accident, it is mandatory
to put collar). There is no need to put collar if the injury
is penetrating in mechanism.

How do I manage the airway of a trauma patient?

Supplemental oxygen
Route in giving oxygen?
Nasal cannula (up to 4%, FiO2=28%)
Face mask (more is being delivered,
45%)
If more than 45% required= need for intubation
Basic techniques- Jaw thrust chin lift goal: para
yung airway mas diretso
Basic adjuncts
Short of intubating, short of putting a tracheostomy
(endotracheal tube muna!)
TIP: Kapag hindi mo nakita ang tracheostomy and
cricothyroidotomy, adjuncts lahat yan!
Definitive airway
Intubation with tube
Cricothyroidotomy with tube

cricothyrotomy

(also

called
2

thyrocricotomy, cricothyroidotomy, inferior

laryngotomy, intercricothyrotomy, coniotomy
oremergency airway puncture) is an incision
made through the skin and cricothyroid
membrane to establish a patent airway during
certain life-threatening situations, such as
airway obstruction by a foreign body,
angioedema, or massive facial trauma.
Tracheostomy

BREATHING
Assess and ensure adequate oxygenation and
ventilation
Respiratory rate (Normal RR= 12-20)
Chest movement (Normal: symmetrical)
Air entry (Normal: equal)
Oxygen saturation
During the primary survey, you are allowed to put
O2 Sat machine)
General rule: You don't do diagnostic exam on an
unstable patient
Pulse ox is an adjunct for primary survey

Level of consciousness
Skin color and temperature
Pulse rate and character
Palpable radial pulse= the patient's BP is at least
80mmHg
If wala, go to femoral pulse= 70mmHg, then
carotid= 60mmHg
Sites of bleeding???
External (laceration)
Chest- hindi mo agad makikita
Abdomen
Pelvic fracture- retroperitoneal hematoma (massive
bleeding)
Long bone fracture- massive bleeding (minsan hindi
life threatening)
Chest, abdomen and retroperitoneum- LIFE
THREATENING!!!
In trauma patients, kapag nasa C (circulation) ka na,
lagyan mo agad ng IV fluid= 1L bolus, fast drip! (ATLS
Concept)

750 mL Blood Volume Loss (15%)

Slightly anxious
How to treat?
Normal blood pressure
a. Thoracentesis
Heart rate < 100 / min
Respirations 14-20 / min
What differentiates simple pneumothorax to a tension pneumothorax?
Urinary output 30 mL / hour
Tension pneumothorax= PNEUMOTHORAX + HYPOTENSION
Crystalloids
*Normal vital signs
Where to insert the needle?
*In trauma, signs of hypoperfusion is considered
Pneumothorax- 2nd ICS (below the clavicle)
hypovolemic until proven otherwise
Put the needle superior to rib
Put the needle inferior to ICS
750-1500 mL Blood Volume Loss (15-30%)
b. Tube thoracostomy- 5th ICS just anterior to the midAnxious
axillary line
Normal blood pressure
c. 3 sided taped gauze- in patients with Open
Heart rate > 100 / min
Pneumothorax
Decreased pulse pressure
Hindi lahat ng sides, it may cause Tension
Respirations 20-30 / min
pneumothorax
Urinary output 20-30 mL / hour
d. Mechanical Ventilator
Crystalloids
* dito nagstart tumaas ang HR (patient is
PITFALLS
TACHYCARDIC)
Airway versus ventilation problem?
Airway- kapag nakapagsalita, patent ang airway,
horaseness= (+) obstruction
Iatrogenic pneumothorax or tension pneumothorax?
You don't need an X-ray to diagnose tension
pneumothorax

From Doc:
Dyspneic ang patient, nagkakamali kasi intubate agad. Ooops! Check mo muna yung B (Breathing).
Kapag okay ka sa B, then you can intubate the patient. Malay mo tension pneumothorax, na-aggravate
mo pa kasi kapag nag-intubate ka you need to pre-oxygenate the patient.
CIRCULATION
Assess for organ perfusion
3

How do you determine the Total Blood Volume of a patient?

60% of TBW= water
40% intracellular fluid
20% ECF
15% intertitial
5% plasma
+3% blood components
8% of total body weight (7% for pediatrics) !!!
For example, in a 50kg male, the total blood volume is 4L (50kg x 0.08)
A 50kg male, tachycardic, how much blood volume ang nawawala sa kanya?
30% of 4L= 1.2L
If the weight is given, you remember the percent!
1500-2000 mL Blood Volume Loss (30-40%)
Confused, anxious
Decreased blood pressure
Heart rate > 120 / min
Decreased pulse pressure
Respirations 30-40 / min
Urinary output 5-15 mL / hour
Crystalloid, blood components, definitive control of
bleeding
*look for the source of bleeding
> 2000 mL Blood Volume Loss (> 40%)
Confused, lethargic
Hypotension
Heart rate > 140 / min
Decreased pulse pressure
Respirations > 35 / min
Urinary output negligible
Blood components, definitive control of bleeding
How to treat?
Control hemorrhage
Restore volume
You put a line, fast drip 1L then reassess
Reassess patient
ATLS Concept: Any doctor can man the emergency
room.
PITFALLS
Elderly- sometimes naka beta blockers or
antuhypertensive
Children- iba iba ang normal values, kapag bumaba
ng 7yo iba na normal
Athletes- bradycardic, compensation for blood loss
maganda akala mo okay pa sila yun pala
may blood loss na
Medications
Pregnant- seemingly normal kahit may blood loss
since maganda ang compensation nila
DISABILITY
Baseline neurologic evaluation
Glasgow Coma Scale score
Universal determination of neurologic status (you
have to memorize the GCS)
Lowest score=3

Do mandatory intubation if
the GCS is 8 and below
Pupillary response
Dilate? There is impending
uncal herniation
PITFALLS
Observe for neurologic deterioration
EXPOSURE
Completely undress the patient
Prevent hypothermia
Missed injuries

Do your secondary survey when:

1. If you're done with primary survey
2. Patient is becoming stable
RESUSCITATION
Protect and secure airway
Ventilate and oxygenate
Stop the bleeding!
Crystalloid / blood resuscitation
Protect from hypothermia
ADJUNCTS
ABGs
PULSE OXIMETER/ CO2
GASTRIC & URINARY CATHETER
ECG
X-ray portable- acceptable diagnostic exam during
primary survey, sa B (breathing)
Pelvic X-ray portable (important sa C-circulation,
hemorrhage)
Focused Assesment Sonography in trauma
Component: Pericardium, Right and Left gutter
and Pelvis
DPL
Consider Early Transfer
Use time before transfer for resuscitation
Do not delay transfer for diagnostic tests
Which patients do I transfer to a higher level of care?
Those
whose
injuries
exceed
institutional
capabilities
When do I start the secondary survey?
After Primary survey is completed
ABCDEs are reassessed
Vital functions are returning to normal
The priorities are the same for all patients.
Immediate threat to life due to inadequate ventilation
tension pneumothorax
open pneumothorax
flail chest with underlying pulmonary contusion
4

(other than these 3 hindi siya life threatening sa BBreathing)

hypotension? DECREASED CARDIAC OUTPUT

Initiating factor? MEDIASTINAL SHIFT

LIFE THREATENING INJURIES due to inadequate

circulation
massive hemothorax
cardiac tamponade
massive hemoperitoneum
mechanically unstable pelvic fractures.
*long bone fracture is not included
TENSION PNEUMOTHORAX

In any penetrating injury inside the cardiac box (superior

border: clavicle, inferior border: subcostal, midclavicular
line lateral to the left and to the right), always consider
the possibility of cardiac tamponade kahit hindi pa
hypotensive ang patient initially, like stab wound at the
back

Decreased breath sounds- ipsilateral

Tracheal shift- contralateral
Hyperresonant- ipsilateral

Given for example, stab wound at the :

6th ICS anterior axillary line, would you consider
cardiac injury? NO!
Right 5th ICS midclavicular line? YES!

In tension pneumothorax, which is the direct cause of

SECONDARY SURVEY
5

 Allergies
Medications
Past illnesses / Pregnancy
Last meal
Events / Environment / Mechanism
Detailed Head to foot examination
Radiologic examination
Definitive Care
Admit
Transfer
Operating room

BLOOD VOLUME LOSS*

750 ml Blood Volume Loss (15%)
Slightly anxious
Normal blood pressure
Heart rate < 100 / min
Respirations 14-20 / min
Urinary output 30 mL / hour
Crystalloids
*Normal vital signs

750-1500 ml Blood Volume Loss

(15-30%)
Anxious
Normal blood pressure
Heart rate > 100 / min
Decreased pulse pressure
Respirations 20-30 / min
Urinary output 20-30 mL / hour
Crystalloids
* dito nagstart tumaas ang HR
(patient is TACHYCARDIC)

1500-2000 ml Blood Volume Loss

(30-40%)
Confused, anxious
Decreased blood pressure
Heart rate > 120 / min
Decreased pulse pressure
Respirations 30-40 / min
Urinary output 5-15 mL / hour
Crystalloid,
blood
components,
definitive control of bleeding
*look for the source of bleeding

> 2000 ml Blood Volume Loss (>

40%)
Confused, lethargic
Hypotension
Heart rate > 140 / min
Decreased pulse pressure
Respirations > 35 / min
Urinary output negligible
Blood components, definitive control
of bleeding

MUST KNOWS!!! Isaksak mo sa isip mo! Pwede din naman sa puso mong bigo! :)
What is the Glascow Coma Scale that it is mandatory to intubate the

patient? 8 AND BELOW! 7 means severe head injury

*long bone fracture is not included

Total Blood Volume= 8% of total body weight (7% for pediatrics) !!!

What differentiates simple pneumothorax to a tension pneumothorax?

Tension pneumothorax= PNEUMOTHORAX + HYPOTENSION

TIP: Kapag hindi mo nakita ang tracheostomy and cricothyroidotomy,
adjuncts lahat yan!
In trauma patients, kapag nasa C (circulation) ka na, lagyan mo agad
ng IV fluid= 1L bolus, fast drip! (ATLS Concept)
Sites of bleeding: Chest, abdomen and retroperitoneum- LIFE
THREATENING!!!
In tension pneumothorax, which is the direct cause of hypotension?
DECREASED CARDIAC OUTPUT

For example, in a 50kg male, the total blood volume is 4L (50kg x 0.08)
A 50kg male, tachycardic, how much blood volume ang nawawala sa
kanya?
30% of 4L= 1.2L
If the weight is given, you remember the percent!

Immediate threat to life due to inadequate ventilation

tension pneumothorax
open pneumothorax
flail chest with underlying pulmonary contusion
(other than these 3 hindi siya life threatening sa B-Breathing)
LIFE THREATENING INJURIES due to inadequate circulation
massive hemothorax
cardiac tamponade
massive hemoperitoneum
mechanically unstable pelvic fractures.
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END OF TRANSCRIPTIONS! (sabi sayo walang forever e!)