Advanced Trauma Life Support ATLS Student Course Manual 2018

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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
166 CHAPTER 8 n Musculoskeletal Trauma 5. Knowledge of the mechanism of injury and history of the injury-producing event can guide clinicians to suspect potential associated injuries. 6. Early splinting of fractures and dislocations can prevent serious complications and late sequelae. Careful neurovascular examination must be performed both prior to and after application of a splint or traction device. Special thanks to Julie Gebhart, PA-C, Lead Orthopedic Physician Assistant, and Renn Crichlow, MD, Orthopedic Trauma Surgeon, OrthoIndy and St. Vincent Trauma Center, for all their help and collaboration with this project, as well as provision of many of the photographs used in the chapter. Bibliography 1. Beekley AC, Starnes BW, Sebesta JA. Lessons learned from modern military surgery. Surg Clin North Am 2007;87(1):157–184, vii. 2. Brown CV, Rhee P, Chan L, et al. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference? J Trauma 2004;56:1191. 3. Bulger EM, Snyder D, Schoelles C, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care 2014;18:163–173. 4. Clifford CC. Treating traumatic bleeding in a combat setting. Mil Med 2004;169(12 Suppl): 8–10, 14. 5. Elliot GB, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br 2003;85:625–630. 6. German Trauma Society. Prehospital (section 1). Emergency room, extremities (subsection 2.10). In: S3—Guideline on Treatment of Patients with Severe and Multiple Injuries. (English version AWMF-Registry No. 012/019). Berlin: German Trauma Society (DGU). 7. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1985;24:742. 8. Inaba K, Siboni S, Resnick S, et al. Tourniquet use for civilian extremity trauma. J Trauma 2015:79(2):232–237. 9. King RB, Filips D, Blitz S, et al. Evaluation of possible tourniquet systems for use in the Canadian Forces. J Trauma 2006;60(5):1061–1071. 10. Kobbe P, Micansky F, Lichte P, et al. Increased morbidity and mortality after bilateral femoral shaft fractures: myth or reality in the era of damage control? Injury 2013Feb;44(2):221–225. 11. Konda SR, Davidovich RI, Egol KA. Computed tomography scan to detect traumatic arthrotomies and identify periarticular wounds not requiring surgical intervention: an improvement over the saline load test. J Trauma 2013;27(9):498–504. 12. Kostler W, Strohm PC, Sudkamp NP. Acute compartment syndrome of the limb. Injury 2004;35(12):1221–1227. 13. Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma 2003;54(5 Suppl):S221–S225. 14. Mabry RL. Tourniquet use on the battlefield. Mil Med 2006;171(5):352–356. 15. Medina O, Arom GA, Yeranosian MG, et al. Vascular and nerve injury after knee dislocation: a systematic review. Clin Orthop Relat Res 2014Oct;472(1):2984–2990. 16. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma 2004;56:1261–1265. 17. Natsuhara KM. Yeranosian MG, Cohen JR, et al. What is the frequency of vascular injury after knee dislocation? Clin Orthop Relat Res 2014Sep;472(9):2615–2620. 18. Ododeh M. The role of reperfusion-induced injury in the pathogenesis of the crush syndrome. N Engl J Med 1991;324:1417–1421. 19. Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am 2006;88:2739–2748. 20. Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg 2005;13(7):436–444. 21. O’Brien CL, Menon M, Jomha NM. Controversies in the management of open fractures. Open Orthop J 2014;8:178–184. 22. O’Toole RV, Lindbloom BJ, Hui E, et al. Are bilateral femoral fractures no longer a marker for death? J Orthoped Trauma 2014 Feb;28(2): 77–81. 23. Schmitt SK, Sexton DJ, Baron EL. Treatment and Prevention of Osteomyelitis Following Trauma in Adults. UpToDate. http://www.uptodate. com/contents/treatment-and-prevention-ofosteomyelitis-following-trauma-in-adults. October 29, 2015. 24. Steinhausen E, Lefering R, Tjardes T, et al. A risk-adapted approach is beneficial in the management of bilateral femoral shaft fractures 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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100 CHAPTER 5 n Abdominal and Pelvi
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6 HEAD TRAUMA The primary goal of t
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104 CHAPTER 6 n Head Trauma Head in
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106 CHAPTER 6 n Head Trauma fibrous
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108 CHAPTER 6 n Head Trauma n FIGUR
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110 CHAPTER 6 n Head Trauma table 6
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112 CHAPTER 6 n Head Trauma covery.
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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
Page 192 and 193: RADIOGRAPHIC EVALUATION 139 Penetra
Page 194 and 195: GENERAL MANAGEMENT 141 When the low
Page 196 and 197: GENERAL MANAGEMENT 143 them to the
Page 198 and 199: BIBLIOGRAPHY 145 Bibliography 1. Bi
Page 201 and 202: 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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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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