Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 8 Outline Objectives iNtroduction pRimARy Survey and Resuscitation of Patients with Potentially Life-Threatening Extremity Injuries • Major Arterial Hemorrhage and Traumatic Amputation • Bilateral Femur Fractures • Crush Syndrome Adjuncts to the PrimARy Survey • Fracture Immobilization • X-ray Examination SecondARy Survey • History • Physical Examination Limb-Threatening Injuries • Open Fractures and Open Joint Injuries • Vascular Injuries • Compartment Syndrome • Neurologic Injury Secondary to Fracture Dislocation Other Extremity Injuries • Contusions and Lacerations • Joint and Ligament Injuries • Fractures Principles of Immobilization • Femoral Fractures • Knee Injuries • Tibial Fractures • Ankle Fractures • Upper Extremity and Hand Injuries Pain Control Associated Injuries Occult Skeletal 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. Explain the significance of musculoskeletal injuries in patients with multiple injuries. 2. Outline the priorities of the primary survey and resuscitation of patients with extremity injuries, quickly separating the potentially life-threatening injuries from those that are less urgent. 3. Identify the adjuncts needed in the immediate treatment of life-threatening extremity hemorrhage. 4. Describe key elements of the secondary survey of patients with musculoskeletal trauma, including the history and physical examination. 5. Explain the principles of the initial management of limb-threatening musculoskeletal injuries. 6. Describe the appropriate assessment and initial management of patients with contusions, lacerations, joint and ligament injuries, and fractures. 7. Describe the principles of proper immobilization of patients with musculoskeletal injuries. n BACK TO TABLE OF CONTENTS 149
150 CHAPTER 8 n Musculoskeletal Trauma Many patients who sustain blunt trauma also incur injuries to the musculoskeletal system. These injuries often appear dramatic, but only infrequently cause immediate threat to life or limb. However, musculoskeletal injuries have the potential to distract team members from more urgent resuscitation priorities. First, clinicians need to recognize the presence of life-threatening extremity injuries during the primary survey and understand their association with severe thoracic and abdominal injuries. The provider must also be familiar with extremity anatomy to be able to protect the patient from further disability, and anticipate and prevent complications. Major musculoskeletal injuries indicate that the body sustained significant forces (n FIGURE 8-1). For example, a patient with long-bone fractures above and below the diaphragm is at increased risk for associated internal torso injuries. Unstable pelvic fractures and open femur fractures can be accompanied by brisk bleeding. Severe crush injuries cause the release of myoglobin from the muscle, which can precipitate in the renal tubules and result in renal failure. Swelling into an intact musculofascial space can cause an acute compartment syndrome that, if not diagnosed and treated, may lead to lasting impairment and loss of the extremity. Fat embolism, an uncommon but highly lethal complication of long-bone fractures, can lead to pulmonary failure and impaired cerebral function. Musculoskeletal trauma does not warrant a reordering of the ABCDE priorities of resuscitation, but its presence does pose a challenge to clinicians. Musculoskeletal injuries cannot be ignored and treated at a later time; rather, clinicians must treat the whole patient, including musculoskeletal injuries, to ensure an optimal outcome. Despite careful assessment, fractures and soft tissue injuries may not be initially recognized in patients with multiple injuries. Continued reevaluation of the patient is necessary to identify all injuries. Primary Survey and Resuscitation of pAtients with Potentially Life-Threatening Extremity Injuries During the primary survey, it is imperative to recognize and control hemorrhage from musculoskeletal injuries. Potentially life-threatening extremity injuries include major arterial hemorrhage, bilateral femoral fractures, and crush syndrome. (Pelvic disruption is described in Chapter 5: Abdominal and Pelvic Trauma.) Deep soft-tissue lacerations may involve major vessels and lead to exsanguinating hemorrhage. Hemorrhage control is best achieved with direct pressure. Hemorrhage from long-bone fractures can be significant, and femoral fractures in particular often result in significant blood loss into the thigh. Appropriate splinting of fractures can significantly decrease bleeding by reducing motion and enhancing the tamponade effect of the muscle and fascia. If the fracture is open, application of a sterile pressure dressing typically controls hemorrhage. Appropriate fluid resuscitation is an important supplement to these mechanical measures. Pitfall Blood loss from musculoskeletal injuries is not immediately recognized. prevention • Recognize that femur fractures and any open long-bone fractures with major soft-tissue involvement are potential sites of significant hemorrhage. Major Arterial Hemorrhage and Traumatic Amputation n FIGURE 8-1 Major injuries indicate that the patient sustained significant forces, and significant blood loss is possible. Penetrating extremity wounds can result in major arterial vascular injury. Blunt trauma resulting in an extremity fracture or joint dislocation in close proximity to an artery can also disrupt the artery. These injuries may lead to significant hemorrhage through the open wound or into the soft tissues. Patients with 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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3 SHOCK The first step in the initi
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44 CHAPTER 3 n Shock The first step
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46 CHAPTER 3 n Shock Recognition of
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48 CHAPTER 3 n Shock However, the a
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50 CHAPTER 3 n Shock Class II Hemor
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52 CHAPTER 3 n Shock hypothermia, a
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54 CHAPTER 3 n Shock replacement du
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56 CHAPTER 3 n Shock aggregation an
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58 CHAPTER 3 n Shock Presence of Pa
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60 CHAPTER 3 n Shock rate can be ac
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4 THORACIC TRAUMA Thoracic injury i
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64 CHAPTER 4 n Thoracic Trauma Thor
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66 CHAPTER 4 n Thoracic Trauma shoc
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68 CHAPTER 4 n Thoracic Trauma comp
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70 CHAPTER 4 n Thoracic Trauma Norm
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72 CHAPTER 4 n Thoracic Trauma Seco
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74 CHAPTER 4 n Thoracic Trauma A B
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76 CHAPTER 4 n Thoracic Trauma Spec
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78 CHAPTER 4 n Thoracic Trauma temp
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80 CHAPTER 4 n Thoracic Trauma 18.
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ABDOMINAL AND 5 PELVIC TRAUMA When
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84 CHAPTER 5 n Abdominal and Pelvic
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Page 151 and 152: 98 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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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
Page 192 and 193: RADIOGRAPHIC EVALUATION 139 Penetra
Page 194 and 195: GENERAL MANAGEMENT 141 When the low
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Page 198 and 199: BIBLIOGRAPHY 145 Bibliography 1. Bi
Page 201: 8 MUSCULOSKELETAL TRAUMA Injuries t
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Page 221 and 222: 9 THERMAL INJURIES The most signifi
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Page 239 and 240: 10 PEDIATRIC TRAUMA Injury remains
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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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