Advanced Trauma Life Support ATLS Student Course Manual 2018

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ASSESSMENT AND MANAGEMENT 89 of the nasal tube through the cribriform plate into the brain. A urinary catheter placed during resuscitation will relieve retention, identify bleeding, allow for monitoring of urinary output as an index of tissue perfusion, and decompress the bladder before DPL (if performed). A full bladder enhances the pelvic images of the FAST. Therefore, if FAST is being considered, delay placing a urinary catheter until after the test is completed. Gross hematuria is an indication of trauma to the genitourinary tract, including the kidney, ureters, and bladder. The absence of hematuria does not exclude an injury to the genitourinary tract. A retrograde urethrogram is mandatory when the patient is unable to void, requires a pelvic binder, or has blood at the meatus, scrotal hematoma, or perineal ecchymosis. To reduce the risk of increasing the complexity of a urethral injury, confirm an intact urethra before inserting a urinary catheter. A disrupted urethra detected during the primary or secondary survey may require insertion of a suprapubic tube by an experienced doctor. Pitfall In a patient with midface fractures, a nasogastric tube can pass into the sinuses and cranial cavity. Pediatric patients have high rates of acute gastric distention following trauma. Passage of a gastric tube may be impossible in patients with hiatal hernias (more common in older adults). Other Studies prevention • Avoid a nasogastric tube in patients with midface injury; instead use an orogastric tube. • A gastric tube may be beneficial in pediatrics patients to reduce the risks of aspiration and vagal stimulation. • To avoid iatrogenic injury, do not continue to attempt nasogastric tube placement if several attempts are unsuccessful. Eventual placement may require radiologic or other assistance. With preparation and an organized team approach, the physical examination can be performed very quickly. In patients with hemodynamic abnormalities, rapid exclusion of intra-abdominal hemorrhage is necessary and can be accomplished with either FAST or DPL. The only contraindication to these studies is an existing indication for laparotomy. Patients with the following findings require further abdominal evaluation to identify or exclude intraabdominal injury: •• Altered sensorium •• Altered sensation •• Injury to adjacent structures, such as lower ribs, pelvis, and lumbar spine •• Equivocal physical examination •• Prolonged loss of contact with patient anticipated, such as general anesthesia for extraabdominal injuries or lengthy radiographic studies •• Seat-belt sign with suspicion of bowel injury When intra-abdominal injury is suspected, a number of studies can provide useful information. However, when indications for patient transfer already exist, do not perform time-consuming tests, including abdominal CT. n TABLE 5-2 summarizes the indications, advantages, and disadvantages of using DPL, FAST, and CT in evaluating blunt abdominal trauma. X-rays for Abdominal Trauma An AP chest x-ray is recommended for assessing patients with multisystem blunt trauma. Hemodynamically abnormal patients with penetrating abdominal wounds do not require screening x-rays in the emergency department (ED). If the patient is hemodynamically normal and has penetrating trauma above the umbilicus or a suspected thoracoabdominal injury, an upright chest x-ray is useful to exclude an associated hemothorax or pneumothorax, or to determine the presence of intraperitoneal air. With radiopaque markers or clips applied to all entrance and exit wounds, a supine abdominal x-ray may be obtained in hemodynamically normal penetrating trauma patients to demonstrate the path of the missile and determine the presence of retroperitoneal air. Obtaining two views (i.e., AP and lateral) may allow for spatial orientation of foreign bodies. An AP pelvic x-ray may help to establish the source of blood loss in hemodynamically abnormal patients and in patients with pelvic pain or tenderness. An alert, awake patient without pelvic pain or tenderness does not require a pelvic radiograph. n BACK TO TABLE OF CONTENTS
90 CHAPTER 5 n Abdominal and Pelvic Trauma table 5-2 comparison of dpl, fast, and ct in abdominal trauma DPL FAST CT SCAN Advantages • Early operative determination • Performed rapidly • Can detect bowel injury • No need for transport from resuscitation area • Early operative determination • Noninvasive • Performed rapidly • Repeatable • No need for transport from resuscitation area • Anatomic diagnosis • Noninvasive • Repeatable • Visualizes retroperitoneal structures • Visualizes bony and soft-tissue structures • Visualizes extraluminal air Disadvantages • Invasive • Risk of procedure-related injury • Requires gastric and urinary decompression for prevention of complications • Not repeatable • Interferes with interpretation of subsequent CT or FAST • Low specificity • Can miss diaphragm injuries • Operator-dependent • Bowel gas and subcutaneous air distort images • Can miss diaphragm, bowel, and pancreatic injuries • Does not completely assess retroperitoneal structures • Does not visualize extraluminal air • Body habitus can limit image clarity • Higher cost and longer time • Radiation and IV contrast exposure • Can miss diaphragm injuries • Can miss some bowel and pancreatic injuries • Requires transport from resuscitation area Indications • Abnormal hemodynamics in blunt abdominal trauma • Penetrating abdominal trauma without other indications for immediate laparotomy • Abnormal hemodynamics in blunt abdominal trauma • Penetrating abdominal trauma without other indications for immediate laparotomy • Normal hemodynamics in blunt or penetrating abdominal trauma • Penetrating back/flank trauma without other indications for immediate laparotomy Focused Assessment with Sonography for Trauma When performed by properly trained individuals, FAST is an accepted, rapid, and reliable study for identifying intraperitoneal fluid (n FIGURE 5-4). It has the advantage of being repeatable and can also detect pericardial tamponade, one of the nonhypovolemic causes of hypotension. FAST includes examination of four regions: the pericardial sac, hepatorenal fossa, splenorenal Pitfall False–negative FAST examination prevention • Recognize that obesity can degrade images obtained with FAST. • Maintain a high index of suspicion. • Use alternative diagnostic testing and/or repeat evaluation(s). • Recognize that FAST is insensitive for the diagnosis of hollow visceral injury. fossa, and pelvis or pouch of Douglas (n FIGURE 5-5A). After doing an initial scan, clinicians may perform a single or multiple repeat scans to detect progressive hemoperitoneum (n FIGURE 5-5B). FAST can be performed at the bedside in the resuscitation room at the same time other diagnostic or therapeutic procedures are performed. See Appendix G: Circulation Skills, and FAST video on MyATLS mobile app. Diagnostic Peritoneal Lavage DPL is another rapidly performed study to identify hemorrhage (n FIGURE 5-6). Because it can significantly alter subsequent examinations of the patient, the surgical team caring for the patient should perform the DPL. Note that DPL requires gastric and urinary decompression for prevention of complications. The technique is most useful in patients who are hemodynamically abnormal with blunt abdominal trauma or in penetrating trauma patients with multiple cavitary or apparent tangential trajectories. Finally, 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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2 AIRWAY AND VENTILATORY MANAGEMENT
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24 CHAPTER 2 n Airway and Ventilato
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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
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Page 135 and 136: ABDOMINAL AND 5 PELVIC TRAUMA When
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Page 155 and 156: 6 HEAD TRAUMA The primary goal of t
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Page 182 and 183: CHAPTER 7 Outline Objectives iNtrod
Page 184 and 185: ANATOMY AND PHYSIOLOGY 131 B A n FI
Page 186 and 187: RIGHT INTERNATIONAL STANDARDS FOR N
Page 188 and 189: DOCUMENTATION OF SPINAL CORD INJURI
Page 190 and 191: 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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