Advanced Trauma Life Support ATLS Student Course Manual 2018

SECONDARY SURVEY 153
debridement. Remove gross contamination and
particulate matter from the wound, and administer
weight-based dosing of antibiotics as early as possible
in patients with open fractures. (See Appendix G:
Circulation Skills.)
Qualified clinicians may attempt reduction of joint
dislocations. If a closed reduction successfully relocates
the joint, immobilize it in the anatomic position with
prefabricated splints, pillows, or plaster to maintain
the extremity in its reduced position.
If reduction is unsuccessful, splint the joint in the
position in which it was found. Apply splints as soon as
possible, because they can control hemorrhage and pain.
However, resuscitation efforts must take priority
over splint application. Assess the neurovascular
status of the extremity before and after manipulation
and splinting.
X-ray Examination
Although x-ray examination of most skeletal injuries
is appropriate during the secondary survey, it may be
undertaken during the primary survey when fracture is
suspected as a cause of shock. The decisions regarding
which x-ray films to obtain and when to obtain them
are based on the patient’s initial and obvious clinical
findings, the patient’s hemodynamic status, and the
mechanism of injury.
SecondARy Survey
Important elements of the secondary survey of patients
with musculoskeletal injuries are the history and
physical examination.
History
Key aspects of the patient history are mechanism of
injury, environment, preinjury status and predisposing
factors, and prehospital observations and care.
Mechanism of Injury
Information obtained from the patient, relatives,
prehospital and transport personnel, and bystanders
at the scene of the injury should be documented
and included as a part of the patient’s history. It is
particularly important to determine the mechanism
of injury, which can help identify injuries that may not
be immediately apparent. (See Biomechanics of Injury.)
The clinician should mentally reconstruct the injury
scene, consider other potential injuries the patient
may have sustained, and determine as much of the
following information as possible:
1. Where was the patient located before the crash?
In a motor vehicle crash, the patient’s precrash
location (i.e., driver or passenger) can suggest
the type of fracture—for example, a lateral
compression fracture of the pelvis may result
from a side impact collision.
2. Where was the patient located after the crash—
inside the vehicle or ejected? Was a seat belt or
airbag in use? This information may indicate
certain patterns of injury. If the patient was
ejected, determine the distance the patient
was thrown, as well as the landing conditions.
Ejection generally results in unpredictable
patterns of injury and more severe injuries.
3. Was the vehicle’s exterior damaged, such as
having its front end deformed by a head-on
collision? This information raises the suspicion
of a hip dislocation.
4. Was the vehicle’s interior damaged, such as a
deformed dashboard? This finding indicates a
greater likelihood of lower-extremity injuries.
5. Did the patient fall? If so, what was the distance
of the fall, and how did the patient land? This
information helps identify the spectrum
of injuries.
6. Was the patient crushed by an object? If so,
identify the weight of the crushing object,
the site of the injury, and duration of weight
applied to the site. Depending on whether a
subcutaneous bony surface or a muscular area
was crushed, different degrees of soft-tissue
damage may occur, ranging from a simple
contusion to a severe degloving extremity
injury with compartment syndrome and
tissue loss.
7. Did an explosion occur? If so, what was the
magnitude of the blast, and what was the
patient’s distance from the blast? An individual
close to the explosion may sustain primary
blast injury from the force of the blast wave. A
secondary blast injury may occur from debris
and other objects accelerated by the blast (e.g.,
fragments), leading to penetrating wounds,
lacerations, and contusions. The patient may
also be violently thrown to the ground or against
other objects by the blast effect, leading to
blunt musculoskeletal and other injuries (i.e., a
tertiary blast injury).
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