Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 4 Outline Objectives iNtroduction PrimARy Survey: Life-Threatening Injuries • Airway Problems • Breathing Problems • Circulation Problems SecondARy Survey • Potentially Life-Threatening Injuries • Other Manifestations of Chest Injuries Teamwork Chapter Summary BibliogRAphy OBJECTIVES After reading this chapter and comprehending the knowledge components of the ATLS provider course, you will be able to: 1. Identify and describe treatment of the following life-threatening injuries during the primary survey: airway obstruction, tracheobronchial tree injury, tension pneumothorax, open pneumothorax, massive hemothorax, and cardiac tamponade. 2. Identify and describe treatment of the following potentially life-threatening injuries during the secondary survey: simple pneumothorax, hemothorax, flail chest, pulmonary contusion, blunt cardiac injury, traumatic aortic disruption, traumatic diaphragmatic injury, and blunt esophageal rupture. 3. Describe the significance and treatment of subcutaneous emphysema, thoracic crush injuries, and sternal, rib, and clavicular fractures. n BACK TO TABLE OF CONTENTS 63
64 CHAPTER 4 n Thoracic Trauma Thoracic trauma is a significant cause of mortality; in fact, many patients with thoracic trauma die after reaching the hospital. However, many of these deaths can be prevented with prompt diagnosis and treatment. Less than 10% of blunt chest injuries and only 15% to 30% of penetrating chest injuries require operative intervention. Most patients who sustain thoracic trauma can be treated by technical procedures within the capabilities of clinicians trained in ATLS. Many of the principles outlined in this chapter also apply to iatrogenic thoracic injuries, such as hemothorax or pneumothorax from central line placement and esophageal injury during endoscopy. The physiologic consequences of thoracic trauma are hypoxia, hypercarbia, and acidosis. Contusion, hematoma, and alveolar collapse, or changes in intrathoracic pressure relationships (e.g., tension pneumothorax and open pneumothorax) cause hypoxia and lead to metabolic acidosis. Hypercarbia causes respiratory acidosis and most often follows inadequate ventilation caused by changes in intrathoracic pressure relationships and depressed level of consciousness. Initial assessment and treatment of patients with thoracic trauma consists of the primary survey with resuscitation of vital functions, detailed secondary survey, and definitive care. Because hypoxia is the most serious consequence of chest injury, the goal of early intervention is to prevent or correct hypoxia. Injuries that are an immediate threat to life are treated as quickly and simply as possible. Most life-threatening thoracic injuries can be treated with airway control or decompression of the chest with a needle, finger, or tube. The secondary survey is influenced by the history of the injury and a high index of suspicion for specific injuries. Primary Survey: Life-Threatening Injuries As in all trauma patients, the primary survey of patients with thoracic injuries begins with the airway, followed by breathing and then circulation. Major problems should be corrected as they are identified. Airway Problems It is critical to recognize and address major injuries affecting the airway during the primary survey. Airway Obstruction Airway obstruction results from swelling, bleeding, or vomitus that is aspirated into the airway, interfering with gas exchange. Several injury mechanisms can produce this type of problem. Laryngeal injury can accompany major thoracic trauma or result from a direct blow to the neck or a shoulder restraint that is misplaced across the neck. Posterior dislocation of the clavicular head occasionally leads to airway obstruction. Alternatively, penetrating trauma involving the neck or chest can result in injury and bleeding, which produces obstruction. Although the clinical presentation is occasionally subtle, acute airway obstruction from laryngeal trauma is a life-threatening injury. (See Chapter 2: Airway and Ventilatory Management.) During the primary survey, look for evidence of air hunger, such as intercostal and supraclavicular muscle retractions. Inspect the oropharynx for foreign body obstruction. Listen for air movement at the patient’s nose, mouth, and lung fields. Listen for evidence of partial upper airway obstruction (stridor) or a marked change in the expected voice quality in patients who are able to speak. Feel for crepitus over the anterior neck. Patients with airway obstruction may be treated with clearance of the blood or vomitus from the airway by suctioning. This maneuver is frequently only temporizing, and placement of a definitive airway is necessary. Palpate for a defect in the region of the sternoclavicular joint. Reduce a posterior dislocation or fracture of the clavicle by extending the patient’s shoulders or grasping the clavicle with a penetrating towel clamp, which may alleviate the obstruction. The reduction is typically stable when the patient remains in the supine position. Tracheobronchial Tree Injury Injury to the trachea or a major bronchus is an unusual but potentially fatal condition. The majority of tracheobronchial tree injuries occur within 1 inch (2.54 cm) of the carina. These injuries can be severe, and the majority of patients die at the scene. Those who reach the hospital alive have a high mortality rate from associated injuries, inadequate airway, or development of a tension pneumothorax or tension pneumopericardium. Rapid deceleration following blunt trauma produces injury where a point of attachment meets an area of mobility. Blast injuries commonly produce severe injury at air-fluid interfaces. Penetrating trauma produces injury through direct laceration, tearing, n BACK TO TABLE OF CONTENTS
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TENTH EDITION ATLS ® Advanced Trau
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Chair of Committee on Trauma: Ronal
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FOREWORD My first exposure to Advan
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viii PREFACE MyATLS Mobile Applicat
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x PREFACE Gary A. Vercruysse, MD, F
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xii PREFACE Jacqueline Bustraan, MS
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ACKNOWLEDGMENTS It is clear that ma
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xvii ACKNOWLEDGMENTS Bertil Bouillo
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xix ACKNOWLEDGMENTS Oscar Guillamon
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xxi ACKNOWLEDGMENTS Mahesh Misra, M
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xxiii ACKNOWLEDGMENTS James Vosswin
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xxv ACKNOWLEDGMENTS James A. Geilin
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xxvii ACKNOWLEDGMENTS Tone Slåke R
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xxx COURSE OVERVIEW m. Protection o
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xxxii COURSE OVERVIEW Atls and Trau
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xxxiv COURSE OVERVIEW a systematize
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xxxvi COURSE OVERVIEW 69. Switzerla
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xxxviii COURSE OVERVIEW United Stat
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xl COURSE OVERVIEW 67. Hendrickson
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xlii COURSE OVERVIEW 122. Palusci V
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BRIEF CONTENTS Foreword Preface Ack
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xlviii DETAILED CONTENTS Teamwork 5
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l DETAILED CONTENTS Introduction 21
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1 INITIAL ASSESSMENT AND MANAGEMENT
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4 CHAPTER 1 n Initial Assessment an
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10 CHAPTER 1 n Initial Assessment a
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Page 75 and 76: 2 AIRWAY AND VENTILATORY MANAGEMENT
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Page 95 and 96: 3 SHOCK The first step in the initi
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Page 115: 4 THORACIC TRAUMA Thoracic injury i
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Page 135 and 136: ABDOMINAL AND 5 PELVIC TRAUMA When
Page 137 and 138: 84 CHAPTER 5 n Abdominal and Pelvic
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Page 155 and 156: 6 HEAD TRAUMA The primary goal of t
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114 CHAPTER 6 n Head Trauma n FIGUR
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120 CHAPTER 6 n Head Trauma necessa
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122 CHAPTER 6 n Head Trauma Use 0.2
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124 CHAPTER 6 n Head Trauma not rea
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126 CHAPTER 6 n Head Trauma 18. Mar
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CHAPTER 7 Outline Objectives iNtrod
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ANATOMY AND PHYSIOLOGY 131 B A n FI
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RIGHT INTERNATIONAL STANDARDS FOR N
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DOCUMENTATION OF SPINAL CORD INJURI
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SPECIFIC TYPES OF SPINAL INJURIES 1
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RADIOGRAPHIC EVALUATION 139 Penetra
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GENERAL MANAGEMENT 141 When the low
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GENERAL MANAGEMENT 143 them to the
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BIBLIOGRAPHY 145 Bibliography 1. Bi
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8 MUSCULOSKELETAL TRAUMA Injuries t
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150 CHAPTER 8 n Musculoskeletal Tra
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9 THERMAL INJURIES The most signifi
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170 CHAPTER 9 n Thermal Injuries Th
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172 CHAPTER 9 n Thermal Injuries Ch
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174 CHAPTER 9 n Thermal Injuries Pi
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176 CHAPTER 9 n Thermal Injuries th
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178 CHAPTER 9 n Thermal Injuries ju
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180 CHAPTER 9 n Thermal Injuries Im
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182 CHAPTER 9 n Thermal Injuries lo
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184 CHAPTER 9 n Thermal Injuries 4.
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10 PEDIATRIC TRAUMA Injury remains
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188 CHAPTER 10 n Pediatric Trauma I
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190 CHAPTER 10 n Pediatric Trauma c
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192 CHAPTER 10 n Pediatric Trauma A
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194 CHAPTER 10 n Pediatric Trauma b
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196 CHAPTER 10 n Pediatric Trauma b
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198 CHAPTER 10 n Pediatric Trauma t
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200 CHAPTER 10 n Pediatric Trauma f
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202 CHAPTER 10 n Pediatric Trauma t
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204 CHAPTER 10 n Pediatric Trauma G
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206 CHAPTER 10 n Pediatric Trauma C
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208 CHAPTER 10 n Pediatric Trauma
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210 CHAPTER 10 n Pediatric Trauma 1
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212 CHAPTER 10 n Pediatric Trauma 6
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CHAPTER 11 Outline Objectives iNtro
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PRIMARY SURVEY WITH RESUSCITATION 2
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PRIMARY SURVEY WITH RESUSCITATION 2
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SPECIFIC INJURIES 221 table 11-6 ph
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BIBLIOGRAPHY 223 comprise only 12%
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12 TRAUMA IN PREGNANCY AND INTIMATE
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228 CHAPTER 12 n Trauma in Pregnanc
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240 CHAPTER 13 n Transfer to Defini
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Appendix A OCULAR TRAUMA OBJECTIVES
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259 APPENDIX A n Ocular Trauma In c
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261 APPENDIX A n Ocular Trauma to t
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Appendix B HYPOTHERMIA AND HEAT INJ
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267 APPENDIX B n Hypothermia and He
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Appendix C TRAUMA CARE IN MASS-CASU
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277 APPENDIX C n Trauma Care in Mas
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Appendix D DISASTER PREPAREDNESS AN
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291 APPENDIX D n Disaster Preparedn
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Pitfall Inadequate security Failed
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Appendix E ATLS AND TRAUMA TEAM RES
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305 APPENDIX E n ATLS and Trauma Te
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Appendix F TRIAGE SCENARIOS OBJECTI
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319 APPENDIX F n Triage Scenarios T
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333 APPENDIX F n Triage Scenarios 4
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Skill Station A AIRWAY Part 1: Basi
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339 APPENDIX G n Skills One-Person
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341 APPENDIX G n Skills STEP 5. Con
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343 APPENDIX G n Skills STEP 13. Co
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346 APPENDIX G n Skills STEP 1. D
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Skill Station C CIRCULATION LEARNIN
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351 APPENDIX G n Skills manual trac
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353 APPENDIX G n Skills STEP 3. Aft
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355 APPENDIX G n Skills STEP 2. If
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358 APPENDIX G n Skills A. Note fac
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360 APPENDIX G n Skills •• Flex
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362 APPENDIX G n Skills Utilization
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366 APPENDIX G n Skills n FIGURE G-
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368 APPENDIX G n Skills less than 1
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372 APPENDIX G n Skills G. Inspect
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374 APPENDIX G n Skills in the inju
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378 INDEX LTA for, 31-32, 32f Malla
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380 INDEX atlanto-occipital disloca
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382 INDEX Frostbite, 181-183, 182f
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384 INDEX Kussmaul’s sign, 69 Lac
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386 INDEX PEA. See Pulseless electr
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388 INDEX for musculoskeletal traum
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390 INDEX Tibial fractures, 163 Tou
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TRAUMA SCORES Correct triage is ess
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394 TRAUMA SCORES on Field Triage,
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396 INJURY PREVENTION Safety Admini
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398 INJURY PREVENTION providers to
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BIOMECHANICS OF INJURY Injuries occ
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402 BIOMECHANICS OF INJURY Ejection
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404 BIOMECHANICS OF INJURY •• A
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406 BIOMECHANICS OF INJURY in a 30-
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408 TETANUS IMMUNIZATION •• Wou
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410 TETANUS IMMUNIZATION Summary Gu
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SAMPLE TRAUMA FLOW SHEET Page 1 of
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414 SAMPLE TRAUMA FLOW SHEET Page 3
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420 SAMPLE TRAUMA FLOW SHEET Some h
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Advanced Trauma Life Support ATLS Student Course Manual 2018

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