Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER SUMMARY 183 reserved for identified infections. Keep the wounds clean, and leave uninfected nonhemmorhagic blisters intact for 7 to 10 days to provide a sterile biologic dressing to protect underlying epithelialization. Tobacco, nicotine, and other vasoconstrictive agents must be withheld. Instruct the patient to minimize weight bearing until edema is resolved. Numerous adjuvants have been attempted in an effort to restore blood supply to cold-injured tissue. Unfortunately, most are ineffective. Sympathetic blockade (e.g., sympathectomy or drugs) and vasodilating agents have generally not proven helpful in altering the progression of acute cold injury. Heparin and hyperbaric oxygen also have failed to demonstrate substantial treatment benefit. Retrospective case series have suggested that thrombolytic agents may show some promise, but only when thrombolytic therapy was administered within 23 hours of the frostbite injury. Occasionally patients arrive at the ED several days after suffering frostbite, presenting with black, clearly dead toes, fingers, hands, or feet. In this circumstance, rewarming of the tissue is not necessary. With all cold injuries, estimations of depth of injury and extent of tissue damage are not usually accurate until demarcation is evident. This often requires several weeks or months of observation. Dress these wounds regularly with a local topical antiseptic to help prevent bacterial colonization, and debride them once demarcation between live and dead tissue has developed. Early surgical debridement or amputation is seldom necessary, unless infection occurs. core temperature below 32°C (89.6°F). Hypothermia is common in severely injured individuals, but further loss of core temperature can be limited by administering only warmed intravenous fluids and blood, judiciously exposing the patient, and maintaining a warm environment. Avoid iatrogenic hypothermia during exposure and fluid administration, as hypothermia can worsen coagulopathy and affect organ function. The signs of hypothermia and its treatment are explained in more detail in Appendix B: Hypothermia and Heat Injuries. The team leader must: TeamWORK •• Ensure that the trauma team recognizes the unique aspects of applying the ATLS principles to treating burn-injured patients. •• Help the team recognize the importance of limiting exposure to minimize hypothermia in the patient and infection of the burn. •• Encourage the trauma team to communicate early and regularly regarding concerns about the challenges of resuscitating a burninjured patient (e.g., IV access and need for escharotomies). Cold Injury: Systemic Hypothermia Trauma patients are susceptible to hypothermia, and any degree of hypothermia in them can be detrimental. Hypothermia is any core temperature below 36°C (96.8°F), and severe hypothermia is any Pitfall prevention Chapter Summary 1. Burn injuries are unique; burn inflammation/edema may not be immediately evident and requires comprehension of the underlying pathophysiology. 2. Immediate lifesaving measures for patients with burn injury include stopping the burn process, recognizing inhalation injury and assuring an adequate airway, oxygenation and ventilation, and rapidly instituting intravenous fluid therapy. Patient becomes hypothermic. • Remember, thermoregulation is difficult in patients with burn injuries. • If irrigating the burns, use warmed saline. • Warm the ambient temperature. • Use heating lamps and warming blankets to rewarm the patient. • Use warmed IV fluids. 3. Fluid resuscitation is needed to maintain perfusion in face of the ongoing fluid loss from inflammation. The inflammatory response that drives the circulatory needs is directly related to the size and depth of the burn. Only partial and full thickness burns are included in calculating burn size. The rule of nines is a useful and practical guide to determine the size of the burn, with children having proportionately larger heads. n BACK TO TABLE OF CONTENTS
184 CHAPTER 9 n Thermal Injuries 4. Attention must be paid to special problems unique to thermal injuries. Carbon monoxide poisoning should be suspected and identified. Circumferential burns may require escharotomy. 5. Nonthermal causes of burn injury should be recognized and appropriate treatment started. Chemical burns require immediate removal of clothing to prevent further injury, as well as copious irrigation. Electrical burns may be associated with extensive occult injuries. Patients sustaining thermal injury are at risk for hypothermia. Judicious analgesia should not be overlooked. 6. The American Burn Association has identified types of burn injuries that typically require referral to a burn center. Transfer principles are similar to non-burned patients but include an accurate assessment of the patient’s burn size and depth. 7. Early management of cold-injured patients includes adhering to the ABCDEs of resuscitation, identifying the type and extent of cold injury, measuring the patient’s core temperature, preparing a patient-care flow sheet, and initiating rapid rewarming techniques. Bibliography 1. Baxter CR. Volume and electrolyte changes in the early postburn period. Clin Plast Surg 1974;4:693–709. 2. Bruen KJ, Ballard JR, Morris SE, et al. Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy. Arch Surg 2007 Jun;142(6):546–551; discussion 551–553. 3. Cancio L. Airway management and smoke inhalation injury in the burn patient. Clin Plast Surg 2009 Oct;36(4):555–567. 4. Cancio LC. Initial assessment and fluid resuscitation of burn patients. Surg Clin North Am 2014 Aug;94(4):741–754. 5. Cancio LC, Lundy JB, Sheridan RL. Evolving changes in the management of burns and environmental injuries. Surg Clin North Am 2012 Aug;92(4):959–986, ix. 6. Carta T, Gawaziuk J, Liu S, et al. Use of mineral oil Fleet enema for the removal of a large tar burn: a case report, J Burns, 2015 Mar;41(2): e11-4. 7. Gentilello LM, Cobean RA, Offner PJ, et al. Continuous arteriovenous rewarming: rapid reversal of hypothermia in critically ill patients. J Trauma 1992;32(3):316–327. 8. Gonzaga T, Jenebzadeh K, Anderson CP, Mohr WJ, Endorf FW, Ahrenholz DH. Use of intraarterial thrombolytic therapy for acute treatment of frostbite in 62 patients with review of thrombolytic therapy in frostbite. J Burn Care Res, 2015. 9. Halebian P, Robinson N, Barie P, et al. Whole body oxygen utilization during carbon monoxide poisoning and isocapneic nitrogen hypoxia. J Trauma 1986;26:110–117. 10. Jurkovich GJ. Hypothermia in the trauma patient. In: Maull KI, Cleveland HC, Strauch GO, et al., eds. Advances in Trauma. Vol. 4. Chicago, IL: Yearbook; 1989:11–140. 11. Jurkovich GJ, Greiser W, Luterman A, et al. Hypothermia in trauma victims: an ominous predictor of survival. J Trauma 1987;27: 1019–1024. 12. Latenser BA. Critical care of the burn patient: the first 48 hours. Crit Care Med 2009 Oct;37 (10):2819–2826. 13. Moss J. Accidental severe hypothermia. Surg Gynecol Obstet 1986;162:501–513. 14. Mozingo DW, Smith AA, McManus WF, et al. Chemical burns. J Trauma 1988;28: 642–647. 15. Perry RJ, Moore CA, Morgan BD, et al. Determining the approximate area of burn: an inconsistency investigated and reevaluated. BMJ 1996; 312:1338. 16. Pham TN, Gibran NS. Thermal and electrical injuries. Surg Clin North Am 2007 Feb;87(1):185– 206, vii–viii. Review. 17. Pruitt BA. Fluid and electrolyte replacement in the burned patient. Surg Clin North Am 1978, 58;6:1313–1322. 18. Reed R, Bracey A, Hudson J, et al. Hypothermia and blood coagulation: dissociation between enzyme activity and clotting factor levels. Circ Shock 1990;32:141–152. 19. Saffle JR, Crandall A, Warden GD. Cataracts: a long-term complication of electrical injury. J Trauma 1985;25:17–21. 20. Schaller M, Fischer A, Perret C. Hyperkalemia: a prognostic factor during acute severe hypo-thermia. JAMA 1990;264: 1842–1845. 21. Sheehy TW, Navari RM. Hypothermia. Ala J Med Sci 1984;21(4):374–381. 22. Sheridan RL, Chang P. Acute burn procedures. Surg Clin North Am 2014 Aug;94(4):755–764. n BACK TO TABLE OF CONTENTS
Page 1 and 2:
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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120 CHAPTER 6 n Head Trauma necessa
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122 CHAPTER 6 n Head Trauma Use 0.2
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124 CHAPTER 6 n Head Trauma not rea
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126 CHAPTER 6 n Head Trauma 18. Mar
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CHAPTER 7 Outline Objectives iNtrod
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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
Page 203 and 204: 150 CHAPTER 8 n Musculoskeletal Tra
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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Page 245 and 246: 192 CHAPTER 10 n Pediatric Trauma A
Page 247 and 248: 194 CHAPTER 10 n Pediatric Trauma b
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Page 259 and 260: 206 CHAPTER 10 n Pediatric Trauma C
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Page 268 and 269: CHAPTER 11 Outline Objectives iNtro
Page 270 and 271: PRIMARY SURVEY WITH RESUSCITATION 2
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Page 274 and 275: SPECIFIC INJURIES 221 table 11-6 ph
Page 276 and 277: BIBLIOGRAPHY 223 comprise only 12%
Page 279 and 280: 12 TRAUMA IN PREGNANCY AND INTIMATE
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234 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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