The Need

Trauma is leading cause of death in the first 4 decades of life in most developed countries. 3.8 million deaths / year worldwide 312 million injured / year worldwide 3 patients permanently disabled / death

ATLS Concept
ABCDE-approach to evaluation / treatment Treat greatest threat to life first Definitive diagnosis not immediately important Time is of the essence Do no further harm

s
Airway with c-spine protection Breathing / ventilation / oxygenation Circulation : Stop the bleeding !

Disability (neuro status)

Expose / Environment / body temp

 Documented improvements in care of injured patient after implementation of program Injury mortality Lower per capita injury death Retention of organizational and procedural skills

Prepare for a smooth transition from the prehospital environ?

Transport guidelines / protocols Online medical direction Mobilization of resources Periodic review of care Closest, appropriate facility

Prepare for a smooth transition to the inhospital environ?

Preplanning is essential Equipment, personnel, services Standard precautions Prearranged transfer agreements

Standard Precautions
Cap Gown Gloves Mask Shoe Covers Goggles / face shield

Quick, simple way to asses the patient in 10 seconds?

Identify yourself Ask the patient his / her name Ask the patient what happened

Primary Survey

The priorities are the same for all patients.

Special Considerations
Trauma in the elderly Pediatric trauma Trauma in pregnant women

Primary Survey
Establish patent airway Protect c-spine Pitfalls? Equipment failure Inability to intubate Occult airway injury Progressive loss of airway

Primary Survey
Assess and ensure adequate oxygenation and ventilation Pitfalls? Airway vs ventilation problem? Iatrogenic pneumothorax or tension pneumothorax

Assess for organ perfusion?

Level of consciousness Skin color and temperature Pulse rate and character

Primary Survey
Circulatory Management
Control hemorrhage Restore volume Reassess parameters Pitfalls? Elderly Children Athletes Medications

Primary Survey
Disability Baseline neurologic evaluation GCS scoring Pupillary response Observe for neurologic deterioration

Primary Survey
Exposure / Environment Completely undress the patient

Prevent hypothermia

Resuscitation
Protect and secure airway Ventilate and oxygenate Stop the bleeding Vigorous shock therapy Protect from hypothermia

Adjuncts to Primary Survey

Diagnostic Tools
DPL FAST

When do I start it?

After
Primary survey is completed ABCDEs are reassessed Vital functions are returning to normal

What are the components?

History Physical exam: Head-to-toe Tubes and fingers in every orifice Complete neurologic exam Special diagnostic tests Reevaluation

Secondary Survey
History
Allergies Medications Past illnesses Last meal Events / Environment

Secondary Survey
Head
GCS Score Neurologic exam Comprehensive eye and ear exam

Pitfalls? Unconsciousness Periorbital edema Occluded auditory canal

Secondary Survey
Maxillofacial
Bony crepitus Deformity Malocclusion Pitfalls? Potential airway obstruction Cribriform plate fracture Frequently missed

Secondary Survey
Cervical Spine Tenderness Complete motor/ sensory exams Reflexes Imaging studies

Pitfalls? Altered sensorium Inability to cooperate with clinical exam

Secondary Survey
Neck (soft tissues) Mechanism: Blunt vs penetrating Symptoms: Airway obstruction, hoarseness Findings: Crepitus, hematoma, stridor, bruit

Secondary Survey
Neck (soft tissues): Pitfalls
Delayed symptoms and signs Progressive airway obstruction Occult injuries

Secondary Survey
Chest Inspect Palpate Percuss Auscultate Obtain x-rays

Secondary Survey
Abdomen
Inspect Auscultate Palpate Percuss Reevaluate Special studies

Secondary Survey
Abdomen: Pitfalls?
Hollow viscus injury Retroperitoneal injury Excessive pelvic manipulation

Secondary Survey
Perineum
Rectum
Contusions, hematomas, lacerations, urethral blood
Sphincter tone , highriding prostate, pelvic fracture, rectal wall integrity, blood

Vagina
Pitfalls

Blood, lacerations
Urethral injury in women, pregnancy

Secondary Survey
Musculoskeletal: Extremities
Contusion, deformity Pain Perfusion Peripheral neurovascular status X-rays as needed

Secondary Survey
Musculoskeletal: Pelvis Pain on palpation Symphysis width Leg length unequal Instability X-rays as needed

Secondary Survey
Musculoskeletal: Pitfalls Potential blood loss Missed fractures Soft-tissue or ligamentous injury Compartment syndrome (especially with altered sensorium / hypotension)

Secondary Survey
Neurologic: Brain

GCS Score Lateralizing signs Frequent reevaluation Prevent secondary brain injury

Early neurosurgical consult

Secondary Survey
Neurologic: Spine and Cord
Complete motor and sensory exams Imaging as indicated Reflexes Early neurosurgical / orthopaedic consult

Secondary Survey
Neurologic: Pitfalls Incomplete immobilization Subtle in ICP with manipulation Rapid deterioration

Adjuncts to Secondary Survey

Special diagnostic test as indicated Pitfalls? Patient deterioration Delay of transfer

Minimize missed injuries?

High index of suspicion Frequent reeveluation and monitoring

Pain Management
Relief of pain /anxiety as appropriate Administer intravenously Careful monitoring is essential

Which patients do I transfer?

Those whose injuries exceed institutional capabilities Examples Multisystem or complex injuries Patient with comorbidity or age extremes

When do I transfer the patient?

As soon as possible after stabilizing measures are completed Airway and ventilatory control Hemorrhage control (operation)

Avoid needless delay

Records, Legal Considerations

Concise, choronologic documentation Consent for treatment Forensic evidence