Advanced Trauma Life Support ATLS Student Course Manual 2018

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PRIMARY SURVEY: LIFE-THREATENING INJURIES 67 Collapsed lung Pneumothorax Sucking chest wound n FIGURE 4-3 Open Pneumothorax. Large defects of the chest wall that remain open can result in an open pneumothorax, or sucking chest wound. Air or greater, air passes preferentially through the chest wall defect with each inspiration. Effective ventilation is thereby impaired, leading to hypoxia and hypercarbia. Open pneumothorax is commonly found and treated at the scene by prehospital personnel. The clinical signs and symptoms are pain, difficulty breathing, tachypnea, decreased breath sounds on the affected side, and noisy movement of air through the chest wall injury. For initial management of an open pneumothorax, promptly close the defect with a sterile dressing large enough to overlap the wound’s edges. Any occlusive dressing (e.g. plastic wrap or petrolatum gauze) may be used as temporary measure to enable rapid assessment to continue. Tape it securely on only three sides to provide a flutter-valve effect (n FIGURE 4-4). As the patient breathes in, the dressing occludes the wound, preventing air from entering. During exhalation, the open end of the Advanced Trauma Life Support for Doctors dressing allows air to escape from the pleural space. Student Course Manual, 9e Taping all four edges of the dressing can cause air to American College of Surgeons accumulate in the thoracic cavity, resulting in a tension KB Figure# 04.04 pneumothorax Dragonfly Media unless Groupa chest tube is in place. Place a chest 10/26/2011 tube remote from the wound as soon as possible. WC Subsequent definitive surgical closure of the wound is frequently required. (See Appendix G: Breathing Skills.) Massive Hemothorax The accumulation of >1500 ml of blood in one side of the chest with a massive hemothorax can significantly NP n FIGURE 4-4 Dressing for Treatment of Open Pneumothorax. Promptly close the defect with a sterile occlusive dressing that is large enough Approved to overlap the wound’s Changes edges. needed Tape it securely on three Date sides to provide a flutter-valve effect. Pitfall Tension pneumothorax develops after placing dressing over open chest wound. prevention • Ensure the occlusive dressing is secured only on three sides. • Treat pneumothorax with placement of chest tube through intact skin. n BACK TO TABLE OF CONTENTS
68 CHAPTER 4 n Thoracic Trauma compromise respiratory efforts by compressing the lung and preventing adequate oxygenation and ventilation. Insert a chest tube to improve ventilation and oxygenation, request emergent surgical consultation, and begin appropriate resuscitation. Massive acute accumulation of blood produces hypotension and shock and will be discussed further in the section below. n TABLE 4-1 outlines the different presentations of tension pneumothorax and massive hemothorax. Circulation Problems Major thoracic injuries that affect circulation and should be recognized and addressed during the primary survey are massive hemothorax, cardiac tamponade, and traumatic circulatory arrest. Pulseless electrical activity (PEA) is manifested by an electrocardiogram (ECG) that shows a rhythm while the patient has no identifiable pulse. This dysrhythmia can be present with cardiac tamponade, tension pneumothorax, or profound hypovolemia. Severe blunt injury can result in blunt rupture of the atria or the ventricles, and the only manifestation may be PEA arrest. Other causes of PEA arrest include hypovolemia, hypoxia, hydrogen ion (acidosis), hypokalemia/ hyperkalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade, tension pneumothorax, and thrombosis (coronary or pulmonary). Inspect the skin for mottling, cyanosis, and pallor. Neck veins should be assessed for distention, although they may not be distended in patients with concomitant hypovolemia. Listen for the regularity and quality of the heartbeat. Assess a central pulse for quality, rate, and regularity. In patients with hypovolemia, the distal pulses may be absent because of volume depletion. Palpate the skin to assess its temperature and determine whether it is dry or sweaty. Measure blood pressure and pulse pressure, and monitor the patient with electrocardiography and pulse oximetry. Patients with blunt chest injury are at risk for myocardial dysfunction, which is increased by the presence of hypoxia and acidosis. Dysrhythmias should be managed according to standard protocols. Massive Hemothorax Massive hemothorax results from the rapid accumulation of more than 1500 mL of blood or onethird or more of the patient’s blood volume in the chest cavity (n FIGURE 4-5). It is most commonly caused by a penetrating wound that disrupts the systemic or hilar vessels, although massive hemothorax can also result from blunt trauma. In patients with massive hemothorax, the neck veins may be flat due to severe hypovolemia, or they may be distended if there is an associated tension pneumothorax. Rarely will the mechanical effects of massive intrathoracic blood shift the mediastinum enough to cause distended neck veins. A massive hemothorax is suggested when shock is associated with the absence of breath sounds or dullness to percussion on one side of the chest. Massive hemothorax is initially managed by simultaneously restoring blood volume and decompressing the chest cavity. Establish largecaliber intravenous lines, infuse crystalloid, and begin transfusion of uncrossmatched or type-specific blood as soon as possible. When appropriate, blood from the chest tube can be collected in a device suitable for autotransfusion. A single chest tube (28-32 French) is inserted, usually at the fifth intercostal space, just anterior to the midaxillary line, and rapid restoration of volume continues as decompression of the chest cavity is completed. The immediate return of 1500 mL or more of blood generally indicates the need for urgent thoracotomy. table 4-1 differentiating tension pneumothorax and massive hemothorax PHYSICAL SIGNS CONDITION BREATH SOUNDS PERCUSSION TRACHEAL POSITION NECK VEINS CHEST MOVEMENT Tension pneumothorax Decreased or absent Hyperresonant Deviated away Distended Expanded immobile Massive hemothorax Decreased Dull Midline Collapsed Mobile 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
Page 97 and 98: 44 CHAPTER 3 n Shock The first step
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Page 115 and 116: 4 THORACIC TRAUMA Thoracic injury i
Page 117 and 118: 64 CHAPTER 4 n Thoracic Trauma Thor
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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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118 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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