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