Advanced Trauma Life Support ATLS Student Course Manual 2018

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PRIMARY SURVEY WITH RESUSCITATION 217 determinant of mortality, host factors also played a significant role. Common mechanisms of injury encountered in older patients include falls, motor vehicle crashes, burns, and penetrating injuries. Falls The risk of falling increases with age, and falls are the most common mechanism of fatal injury in the elderly population. Nonfatal falls are more common in women, and fractures are more common in women who fall. Falls are the most common cause of traumatic brain injury (TBI) in the elderly. Nearly one-half of deaths associated with ground-level falls are a result of TBI. One-half of elderly patients suffering a hip fracture will no longer be able to live independently. Risk factors for falls include advanced age, physical impairments, history of a previous fall, medication use, dementia, unsteady gait, and visual, cognitive, and neurological impairments. Environmental factors, such as loose rugs, poor lighting, and slippery or uneven surfaces, play an additional role in fall risk. Motor Vehicle Crashes In general, older people drive fewer total miles, on more familiar roads, and at lower speeds than younger drivers. They also tend to drive during the day. Thus most of the elderly traffic fatalities occur in the daytime and on weekends, and they typically involve other vehicles. Contributing risk factors in the elderly for motor vehicle crashes include slower reaction times, a larger blind spot, limited cervical mobility, decreased hearing, and cognitive impairment. Additionally, medical problems such as myocardial infarction, stroke, and dysrhythmias can result in conditions that precipitate a collision. Burns MechANism of Injury Burn injury can be particularly devastating in elderly patients. The impact of age on burn mortality has long been recognized; however, despite significant declining mortality in younger age groups, the mortality associated with small- to moderate-sized burns in older adults remains high. In examining deaths from structural fires, researchers find the elderly are particularly at risk because of decreased reaction times, impaired hearing and vision, and the inability to escape the burning structure. Spilled hot liquids on the leg, which in a younger patient may re-epithelialize due to an adequate number of hair follicles, will result in a full-thickness burn in older patients with a paucity of follicles. Their aging organ systems have a major impact on the outcomes of elderly burn patients; changes in the skin are obvious, but the patient’s inability to meet the physiological demands associated with burn injury likely has the most influence on outcome and survival. Penetrating Injuries By far, blunt trauma is the predominant mechanism of injury in older adults; however, a significant number of people over the age of 65 years are victims of penetrating injury. In fact, penetrating injury is the fourth most common cause of traumatic death in individuals 65 years and older. Many deaths associated with gunshot wounds are related to intentional self-harm or suicide. As with all trauma patients, the application of ATLS principles in assessment and management of older adults follows the ABCDE methodology. Clinicians must take into consideration the effects of aging on organ systems and their implications for care, as outlined in n TABLE 11-1. (Also see Effects of Aging on MyATLS mobile app.) Airway Primary Survey with Resuscitation The elderly airway poses specific challenges for providers. Given that older adults have significant loss of protective airway reflexes, timely decision making for establishing a definitive airway can be lifesaving. Patients may have dentures that may loosen and obstruct the airway. If the dentures are not obstructing the airway, leave them in place during bag-mask ventilation, as this improves mask fit. Some elderly patients are edentulous, which makes intubating easier but bag-mask ventilation more difficult. Arthritic changes may make mouth opening and cervical spine management difficult (n FIGURE 11-2). When performing rapid sequence intubation, reduce n BACK TO TABLE OF CONTENTS
218 CHAPTER 11 n Geriatric Trauma table 11-1 effects of aging on organ systems and implications for care ORGAN SYSTEM FUNCTIONAL CHANGES IMPLICATIONS FOR CARE Cardiac Pulmonary Renal Skin/Soft Tissue/ Musculoskeletal Endocrine Brain mass Eye disease Depth perception Discrimination of colors Pupillary response Respiratory vital capacity Renal function 2- to 3-inch loss in height Impaired blood flow to lower leg(s) Degeneration of the joints Total body water • Declining function • Decreased sensitivity to catecholamines • Decreased myocyte mass • Atherosclerosis of coronary vessels • Increased afterload • Fixed cardiac output • Fixed heart rate (β-blockers) • Thoracic kyphoscoliosis • Decreased transverse thoracic diameter • Decreased elastic recoil • Reduced functional residual capacity • Decreased gas exchange • Decreased cough reflex • Decreased mucociliary function • Increased oropharyngeal colonization • Loss of renal mass Nerve damage (peripheral neuropathy) • Decreased glomerular filtration rate (GFR) • Decreased sensitivity to antidiuretic hormone (ADH) and aldosterone • Loss of lean body mass • Osteoporosis • Changes in joints and cartilages • Degenerative changes (including c-spine) • Loss of skin elastin and subcutaneous fat • Decreased production and response to thyroxin • Decreased dehydroepiandrosterone (DHEA) • Lack of “classic” response to hypovolemia Stroke • Risk for cardiac ischemia • Increased risk of dysrythmias Diminished hearing • Elevated baseline blood pressure Sense of smell and taste Saliva production • Increased risk for respiratory failure • Increased risk for pneumonia • Poor tolerance to rib fractures Esophageal activity Cardiac stroke volume and rate Heart disease and high • Routine renal labs will be normal (not reflective blood of dysfunction) pressure • Drug dosing for renal insufficiency • Decreased ability to concentrate urine Kidney disease • Urine flow may be normal with hypovolemia • Increased risk for acute kidney injury Gastric secretions • Increased risk for fractures • Decreased mobility Number of • Difficulty for oral intubation • Risk of skin body injury cells due to immobility • Increased risk for hypothermia • Challenges in rehabilitation Elasticity of skin Thinning of epidermis • Occult hypothyroidism • Relative hypercortisone state • Increased risk of infection 15%–30% body fat n FIGURE 11-2 Arthritic changes can complicate airway and cervical spine management. This sagittal T2-weighted image shows severe multilevel degenerative changes affecting disk spaces and posterior elements, associated with severe central canal stenosis, cord compression, and small foci of myelomalacia at the C4-C5 level. 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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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
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RIGHT INTERNATIONAL STANDARDS FOR N
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DOCUMENTATION OF SPINAL CORD INJURI
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SPECIFIC TYPES OF SPINAL INJURIES 1
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RADIOGRAPHIC EVALUATION 139 Penetra
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GENERAL MANAGEMENT 141 When the low
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GENERAL MANAGEMENT 143 them to the
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BIBLIOGRAPHY 145 Bibliography 1. Bi
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8 MUSCULOSKELETAL TRAUMA Injuries t
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150 CHAPTER 8 n Musculoskeletal Tra
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Page 219 and 220: 166 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 268 and 269: CHAPTER 11 Outline Objectives iNtro
Page 272 and 273: PRIMARY SURVEY WITH RESUSCITATION 2
Page 274 and 275: SPECIFIC INJURIES 221 table 11-6 ph
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Page 279 and 280: 12 TRAUMA IN PREGNANCY AND INTIMATE
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Page 310 and 311: Appendix A OCULAR TRAUMA OBJECTIVES
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Page 318 and 319: 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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