Advanced Trauma Life Support ATLS Student Course Manual 2018

CHAPTER SUMMARY 165
2. Thoroughly reexamine all extremities, with
special emphasis on the hands, wrists, feet, and
the joints above and below fractures
and dislocations.
3. Visually examine the patient’s back, including
the spine and pelvis.
4. Document open injuries and closed soft-tissue
injuries that may indicate an unstable injury.
5. Review the x-rays obtained in the secondary
survey to identify subtle injuries that may be
associated with more obvious trauma.
Occult Skeletal Injuries
Not all injuries can be diagnosed during the initial
assessment. Joints and bones that are covered or wellpadded
within muscular areas may contain occult
injuries. It can be difficult to identify nondisplaced
fractures or joint ligamentous injuries, especially if the
patient is unresponsive or has other severe injuries. In
fact, injuries are commonly discovered days after the
injury incident—for example, when the patient is being
mobilized. Therefore, it is crucial to reassess the patient
repeatedly and to communicate with other members
of the trauma team and the patient’s family about the
possibility of occult skeletal injuries.
Pitfall
Occult injuries may not
be identified during the
primary assessment or
secondary survey.
TeamWORK
prevention
• Logroll the patient and
remove all clothing
to ensure complete
evaluation and avoid
missing injuries.
• Repeat the head-totoe
examination once
the patient has been
stabilized to identify
occult injuries.
••
Musculoskeletal injuries, especially open
fractures, often appear dramatic and can
potentially distract team members from more
urgent resuscitation priorities. The team leader
must ensure that team members focus on lifethreatening
injuries first
••
Because potentially life-threatening
musculoskeletal injuries can be detected during
the assessment of circulation, the team leader
must rapidly direct the team to control external
hemorrhage using sterile pressure dressings,
splints, or tourniquets as appropriate. The
trauma team’s ability to work on different tasks
simultaneously is particularly relevant in
this scenario.
••
More than one team member may be required
to apply a traction splint, and the team leader
may direct other assistants or specialist team
members (e.g., vascular and orthopedic
surgeons) to assist the team.
••
The team must be able to recognize limbthreatening
injuries and report these accurately
to the team leader so decisions can be made for
managing these injuries in conjunction with
life-threatening problems involving airway,
breathing, and circulation.
••
Ensure that the trauma team performs a
complete secondary survey, so injuries are not
overlooked. Occult injuries are particularly
common in patients with a depressed level of
consciousness, and the team leader should
ensure timely reevaluation of the limbs to
minimize missed injuries.
Chapter Summary
1. Musculoskeletal injuries can pose threats to both
life and limb.
2. The initial assessment of musculoskeletal trauma
is intended to identify those injuries that pose a
threat to life and/or limb. Although uncommon,
life-threatening musculoskeletal injuries must
be promptly assessed and managed. A staged
approach to hemorrhage control is utilized by
applying direct pressure, splints, and tourniquets.
3. Most extremity injuries are appropriately diagnosed
and managed during the secondary survey. A
thorough history and careful physical examination,
including completely undressing the patient, is
essential to identify musculoskeletal injuries.
4. It is essential to recognize and manage arterial
injuries, compartment syndrome, open fractures,
crush injuries, and dislocations in a timely manner.
n BACK TO TABLE OF CONTENTS