1. Trauma Care

2. Objectives Importance of Trauma Care Principles of primary assessment
Principles of secondary assessment
None operative management of solid organ injury
Pelvic injury
ATLS is primarily directed at providing initial care during the “Golden Hour.”
This is the window of opportunity for the physician to have the greatest impact on morbidity and mortality of the trauma patient.

3. The Need The leading cause of death in the first four decades of life.
More than 5 million trauma-related deaths each year worldwide.
Motor vehicle crashes cause over 1 million deaths per year.
Injury accounts for 12% of the world’s burden of disease.

4. Trimodal Death Distribution
There are three peaks of death from trauma.
First peak: Immediate – unsurvivable injuries, impacted by trauma prevention.
Second peak: Early – golden hour of care, impacted by early hospital care.
Third peak: Late – caused by sepsis and multiple organ dysfunction syndrome (MODS), impacted by optimal early care and trauma center management.

5. ATLS Concept ABCDE approach to evaluation and treatment
Treat greatest threat to life first
Definitive diagnosis not immediately important
Time is of the essence
Do no further harm
ABCDE is the universal language for the primary exam.
ABCDE is the order in which the injuries will kill patients.
Definitive diagnosis and an in-depth history are not required initially.

6. ATLS Concept
Airway with c-spine protection Breathing / ventilation / oxygenation Circulation: stop the bleeding! Disability / neurological status Expose / Environment / body temperature

7. Initial Assessment / Management
Injury
Transfer
Primary Survey
Adjuncts
Optimize patient status
Resuscitation
Reevaluation
Reevaluation
Detailed
Secondary Survey
Adjuncts

8. What is a quick, simple way to assess a patient in 10 seconds?
Quick Assessment
What is a quick, simple way to assess a patient in 10 seconds?
1-7 Quick Assessment
What is a quick, simple method to assess the patient in 10 seconds?
After asking this question, allow the students adequate time to consider the most efficient way of assessing for a patent airway, sufficient respiratory reserve to speak, and the level of cognition to process the question and respond appropriately.
Answers appear on next slide.

9. Quick Assessment
What is a quick, simple way to assess a patient in 10 seconds?
Identify yourself
Ask the patient his or her name
Ask the patient what happened
Quick Assessment
What is a quick, simple method to assess the patient in 10 seconds?
After asking this question, allow the students adequate time to consider the most efficient way of assessing for a patent airway, sufficient respiratory reserve to speak, and the level of cognition to process the question and respond appropriately.
Answers appear on next slide.

10. Appropriate Response Confirms
A Patent airway
B Sufficient air reserve to permit speech
C Sufficient perfusion to permit cerebration
D Clear sensorium
1-9 Appropriate Response Confirms…
Emphasize the need for adequate cardiac output to ensure clear sensorium.
The patient who fails this simple test needs immediate attention.

11. Primary Survey Airway with c-spine protection
Breathing with adequate oxygenation
Circulation with hemorrhage control
Disability
Exposure / Environment
1-10 Primary Survey
This is the student’s first encounter with the “ABCDEs,” so be sure to allow adequate time to discuss why the priorities are ordered in this manner.

12. Primary Survey Airway Basic Airway Techniques
Establish patent airway and protect c-spine
Basic Airway Techniques
Chin-lift Maneuver
Jaw-thrust Maneuver
Advanced Airway Techniques
Orotracheal intubation
Cricothyroidotomy
1-13 Primary Survey: Establish patent airway and protect c-spine
Concerns regarding the c-spine may be new to those students who are familiar with cardiac life support procedures, but have not taken the ATLS Course.
Emphasize the need to protect the c-spine during airway management, especially avoiding the ACLS head-tilt maneuver.
You may then query the students about what pitfalls they may encounter with managing the airway or, depending on available time, caution the students to avoid these pitfalls.

13. Primary Survey Breathing Ensure adequate oxygenation & ventilation
What are the Immediate life threatening injuries that could affect breathing ?
How do you assess and Ensure adequate oxygenation and ventilation?
Respiratory rate
Chest movement
Air entry
Oxygen saturation
Emphasize that, if the patient is receiving high-flow oxygen, adequate oxygenation is no guarantee of adequate ventilation.

14. Primary Survey Breathing The Immediate life threatening injuries
Laryngeotracheal injury / Airway obstruction
Tension pneumothorax
Open pneumothorax
Flail chest and pulmonary contusion
Massive hemothorax
Cardiac tamponade
How do you assess and Ensure adequate oxygenation and ventilation?
Respiratory rate
Chest movement
Air entry
Oxygen saturation
Emphasize that, if the patient is receiving high-flow oxygen, adequate oxygenation is no guarantee of adequate ventilation.

15. Primary Survey Circulation Ensure adequate oxygenation & ventilation
Circulatory Management
Control hemorrhage
Restore volume
Reassess patient
Lethal triad
How do you assess and Ensure adequate circulation?
Level of consciousness
Skin color and temperature
Pulse rate and character
Emphasize the reasons for assessing for signs of inadequate tissue perfusion instead of focusing on the patient’s blood pressure.
Circulatory Management
Emphasize the need to control hemorrhage or stop the bleeding.
Also emphasize that the patient may require an operation to stop the bleeding. Stress the importance of reassessing the patient’s response to treatment.
What is the Lethal triad?

16. Primary Survey Disability Glasgow Coma Scale score Pupillary response
Baseline neurologic evaluation
Glasgow Coma Scale
score
Pupillary response
Disability
Emphasize that it is essential to identify neurologic injury using the tools of GCS score and pupil response early in order to avoid secondary brain injury, identify surgically correctible lesions rapidly, and provide a baseline GCS score to identify trends and changes.

17. Primary Survey Exposure & Environment
Exposure to make sure no injuries are missed
Exposure and Environment
The ‘E’ of the ABCDEs.
Emphasize the need to completely undress the patient to adequately assess the entire patient, while at the same time preventing hypothermia and respect religion and privacy.

18. Resuscitation Protect and secure airway Ventilate and oxygenate
Stop the bleeding!
Vigorous shock therapy
Protect from hypothermia
Resuscitation
Emphasize that treatment is administered at the time the life-threatening problem is identified and that assessment and treatment during the primary survey and resuscitation phases of the initial assessment process often are done simultaneously.

19. Adjuncts to Primary Survey
The primary purpose of these adjuncts during the primary survey is to determine where occult bleeding may be occurring that is not obvious on clinical exam.
Emphasize the need to determine the source of shock.
Portable chest and pelvic x-rays in the emergency department are the ONLY x-rays obtained during the primary survey. Previous editions of the course included lateral cervical spine x-rays, but this film is now obtained selectively and at the appropriate time, based on the doctor’s judgment.
(X-rays courtesy of Dr. Ray McGlone, A&E Consultant, Royal Lancaster Infirmary; UK.)

20. Adjuncts to Primary Survey
Diagnostic Tools
FAST
DPL
Adjuncts to Primary Survey
DPL and FAST may also be used during the primary survey to detect intraabdominal blood.

21. Adjuncts to Primary Survey
Consider Early Transfer
Use time before transfer for resuscitation
Do not delay transfer for diagnostic tests
Adjuncts to the Primary Survey: Consider Early Transfer
Emphasize that the time to initiate the transfer process is when the need is recognized. Therefore, the need to transfer must be considered early. The sooner the need is recognized and communicated, the more efficiently it occurs.
In addition, transfer should not be delayed to perform the secondary survey or to perform diagnostic tests such as CT scans. The time spent waiting for transportation to arrive should be spent stabilizing the patient.

22. Case Scenario

23. What is the secondary survey?
The complete
history and
physical
examination
1-25 What is the secondary survey?
Expand upon the definition of the secondary survey after eliciting students’ responses.

24. Secondary Survey When do I start the secondary survey? After
Primary survey is completed
ABCDEs are reassessed
Vital functions are returning to normal
1-26 Secondary Survey: When do I start it?
These slides transition the student to the secondary survey.
Emphasize that issues identified during the primary survey have been addressed and reevaluated before proceeding to the secondary survey.

25. Secondary Survey What are the components of the secondary survey?
History
Physical exam: Head to toe
Complete neurologic exam
Special diagnostic tests
Reevaluation
1-27 Secondary Survey: What are the components of the secondary survey?
You may use these items as a summary of the discussion on the components of the secondary survey.
This slide also serves as an introduction to each component of the secondary survey.

26. Secondary Survey Allergies Medications Past illnesses Last meal
History
Allergies
Medications
Past illnesses
Last meal
Events / Environment / Mechanism
1-28 Secondary Survey: History
Introduce this simple mnemonic for obtaining an “AMPLE” or complete patient history.

27. Occluded auditory canal
Secondary Survey
Head
External exam
Scalp palpation
Comprehensive eye and ear exam
Including visual acuity
Pitfalls
Unconsciousness
Periorbital edema
Occluded auditory canal
1-30 Secondary Survey: Head
You may query the student about what to examine and/or evaluate during the examination of the injured patient’s head.

28. Potential airway obstruction Cribriform plate fracture
Secondary Survey
Maxillofacial
Bony crepitus
Deformity
Malocclusion
Potential airway obstruction
Cribriform plate fracture
Frequently missed
Pitfalls
1-31 Secondary Survey: Maxillofacial
Students should be instructed to check mid-face stability, dental occlusion, and contraindications for nasogastric tubes.

29. Delayed symptoms and signs Progressive airway obstruction
Secondary Survey
Neck (Soft Tissues)
Mechanism: Blunt vs penetrating
Symptoms: Airway obstruction, hoarseness
Findings: Crepitus, hematoma, stridor, bruit
Pitfalls
1-32 Secondary Survey: Neck (soft-tissues)
You may query the student about they should look for during the examination of the injured patient’s maxillofacial area.
Delayed symptoms and signs
Progressive airway obstruction
Occult injuries

30. Secondary Survey Chest Inspect Palpate Percuss Auscultate X-rays
The photograph shows an unrestrained passenger who was thrown into the dashboard.
Ecchymosis of chest wall from blunt trauma.
Review how the chest is evaluated during secondary survey, including appropriate imaging studies.

31. Secondary Survey Chest The Potential life threatening injuries
Blunt cardiac injury
Traumatic aortic disruption
Blunt esophageal rupture
Traumatic diaphragmatic injury
1-33 Secondary Survey: Chest
The photograph shows an unrestrained passenger who was thrown into the dashboard.
Ecchymosis of chest wall from blunt trauma.
Review how the chest is evaluated during secondary survey, including appropriate imaging studies.

32. Retroperitoneal injury
Secondary Survey
Abdomen
Inspect / Auscultate
Palpate / Percuss
Reevaluate
Special studies
1-34 Secondary Survey: Abdomen
Review how the abdomen is evaluated during secondary survey, including appropriate imaging studies.
The lap portion of the belt appears to have been applied incorrectly.
You may wish to emphasise the use of x-ray for pelvic assessment
Remind the students that the back also is a part of the torso and requires examination.
Appropriate spine precautions and protection must be taken whenever the patient is suspected of having a spinal cord or vertebral injury.
Photograph used with the permission of Trauma.org; Bradley R. Davis, MD, wound 0005b;
Pitfalls
Hollow viscous injury
Retroperitoneal injury

33. Secondary Survey Indications for Laparotomy – Blunt Trauma
Hemodynamically abnormal with suspected abdominal injury (DPL / FAST)
Free air
Diaphragmatic rupture
Peritonitis
Positive CT
1-34 Secondary Survey: Abdomen
Review how the abdomen is evaluated during secondary survey, including appropriate imaging studies.
The lap portion of the belt appears to have been applied incorrectly.
You may wish to emphasise the use of x-ray for pelvic assessment
Remind the students that the back also is a part of the torso and requires examination.
Appropriate spine precautions and protection must be taken whenever the patient is suspected of having a spinal cord or vertebral injury.
Photograph used with the permission of Trauma.org; Bradley R. Davis, MD, wound 0005b;

34. Secondary Survey Indications for Laparotomy – Penetrating Trauma
Hemodynamically abnormal
Peritonitis
Evisceration
Positive DPL, FAST, or CT
1-34 Secondary Survey: Abdomen
Review how the abdomen is evaluated during secondary survey, including appropriate imaging studies.
The lap portion of the belt appears to have been applied incorrectly.
You may wish to emphasise the use of x-ray for pelvic assessment
Remind the students that the back also is a part of the torso and requires examination.
Appropriate spine precautions and protection must be taken whenever the patient is suspected of having a spinal cord or vertebral injury.
Photograph used with the permission of Trauma.org; Bradley R. Davis, MD, wound 0005b;

35. Secondary Survey Perineum Rectum Vagina Pitfalls
Contusions, hematomas, lacerations, urethral blood
Rectum
Sphincter tone, high-riding prostate, pelvic fracture,
rectal wall integrity, blood
Vagina
Blood, lacerations
1-35 Secondary Survey: Perineum/Genitalia
Inspect for injury.
If injury is present, emphasize the need for vaginal and rectal exam looking for pelvic fracture.
Prior to Foley catheter placement, evidence for injury necessitates a digital prostate exam.
Pitfalls
Urethral injury
Pregnancy

36. Excessive pelvic manipulation Underestimating pelvic blood loss
Secondary Survey
Pelvis
Pain on palpation
Leg length unequal
Instability
X-rays as needed
1-36 Secondary Survey: Pelvis
Review how the pelvis is evaluated during secondary survey, including appropriate imaging studies.
Emphasize the need to avoid pelvic manipulation in patients with unstable pelvic fractures that can cause hemorrhage.
Pitfalls
Excessive pelvic manipulation
Underestimating pelvic blood loss

37. Secondary Survey Extremities Contusion, deformity Pain Perfusion
Peripheral neurovascular status
X-rays as needed
1-37 Secondary Survey: Musculoskeletal Trauma—Extremities
Review how the extremities are evaluated during secondary survey, including appropriate imaging studies.

38. Secondary Survey Musculoskeletal Pitfalls
Potential blood loss Missed fractures Soft tissue or ligamentous injury Compartment syndrome (especially with altered sensorium / hypotension)
1-38 Secondary Survey: Musculoskeletal Trauma—Pitfalls
Emphasize the potential for hidden hemorrhage, compartment syndrome, missed fracture, and soft tissue injury.

39. Secondary Survey Neurologic: Brain GCS Pupil size and reaction
Lateralizing signs
Frequent reevaluation
Prevent secondary brain injury
1-39 Secondary Survey: Neurologic—Brain
Note the need for an in depth evaluation of the patient’s central nervous system status and frequent documented reevaluation.
Emphasize prevention of secondary brain injury by avoiding hypotension and hypoxia.
Early
neurosurgical
consult

40. Inability to cooperate with clinical exam
Secondary Survey
Neurologic: Spinal Assessment
Whole spine
Tenderness and swelling
Complete motor and sensory exams
Reflexes
Imaging studies
Pitfalls
1-40 Secondary Survey: Neurologic—Spinal Assessment
Review how the spine and spinal cord function is evaluated during the secondary survey, including appropriate imaging studies.
Review patient conditions that impair evaluation.
Altered sensorium
Inability to cooperate with clinical exam

41. Secondary Survey Neurologic: Spine and Cord
Conduct an in-depth evaluation of the patient’s spine and spinal cord
1-41 Secondary Survey: Neurologic—Spine and Cord
Emphasize the need to carefully evaluate the patient’s entire back and take precautionary/protective measures when logrolling the patient.
Early neurosurgical /
orthopedic consult

42. Adjuncts to Secondary Survey
Special Diagnostic Tests as Indicated
Pitfalls
Patient deterioration
Delay of transfer
Deterioration during transfer
Poor communication
1-43 Adjuncts to Secondary Survey
These include specialized radiographic studies.
Emphasize that adjuncts should NOT delay appropriate transfer to definitive care.

43. How do I minimize missed injuries?
High index of suspicion
Frequent reevaluation and monitoring
1-44 Missed Injuries
Emphasize that meticulous attention to detail, integrated with clues from the mechanism of injury and physical findings, and continued reassessment, are the best methods to avoid missed injuries.
Some institutions conduct a “tertiary” survey within 24 hours of admission to assess for missed injuries.

44. Pain Management Relief of pain / anxiety as appropriate
Administer intravenously
Careful monitoring is essential
1-45 Pain Management
Emphasize the need for judicious relief of pain associated with careful patient monitoring.

45. Transfer Which patients do I transfer to a higher level of care?
Answers appear on next slide

46. Transfer Which patients do I transfer to a higher level of care?
Those whose injuries exceed institutional capabilities:
Multisystem or complex injuries
Patients with comorbidity or age extremes
1-47 Which patients do I transfer?
Emphasize who needs transfer, the mechanics and rules of transfer, and the importance of doing it efficiently.

47. Transfer When should the transfer occur? 1-48 When to transfer?
Elicit responses from the audience. Answers appear on next slide

48. Transfer Which patients do I transfer to a higher level of care?
As soon as possible after stabilization:
Airway and ventilatory control
Hemorrhage control
1-47 Which patients do I transfer?
Emphasize who needs transfer, the mechanics and rules of transfer, and the importance of doing it efficiently.

49. Summary Rapid accurate assessment
Resuscitate and stabilize by priority
Determine needs and capabilities
Arrange for transfer to definitive care
Ensure optimum care

50. Summary ABCDE approach to trauma care Do no further harm
Treat the greatest threat to life first
One safe way
A common language

51. Summary Primary Survey Definitive Care Adjuncts Resuscitation
Reevaluation
1-6 Concepts of Initial Assessment
Initial assessment and management refers to the entire process of evaluating, treating, conducting a detailed head-to-toe evaluation, reevaluating the patient, and transferring that patient, as necessary, to a facility with the resources to provide optimal care.
Reevaluation
Detailed
Secondary Survey
Adjuncts

52. Trauma Care
Questions