Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 12 Outline Objectives iNtroduction Anatomical and Physiological AlteRAtions of pRegnancy ANAtomical Differences • Blood Volume and Composition • Hemodynamics • Respiratory System • Gastrointestinal System • Urinary System • Musculoskeletal System • Neurological System MechANisms of Injury • Blunt Injury • Penetrating Injury Severity of Injury Assessment and Treatment • Primary Survey with Resuscitation • Adjuncts to Primary Survey with Resuscitation • Secondary Survey • Definitive Care Perimortem Cesarean Section iNtimate Partner Violence Teamwork Chapter Summary Additional Resources BibliogRAphy OBJECTIVES After reading this chapter and comprehending the knowledge components of the ATLS provider course, you will be able to: 1. Describe the anatomical and physiological alterations of pregnancy and their impact on patient treatment. 2. Identify common mechanisms of injury in pregnant patients and their fetuses. 3. Outline the treatment priorities and assessment methods for pregnant patients and their fetuses during the primary and secondary surveys, including use of adjuncts. 4. State the indications for operative intervention that are unique to injured pregnant patients. 5. Explain the potential for isoimmunization and the need for immunoglobulin therapy in pregnant trauma patients. 6. Identify patterns of intimate partner violence. n BACK TO TABLE OF CONTENTS 227
228 CHAPTER 12 n Trauma in Pregnancy and Intimate Partner Violence Pregnancy causes major physiological changes and altered anatomical relationships involving nearly every organ system of the body. These changes in structure and function can influence the evaluation of injured pregnant patients by altering the signs and symptoms of injury, approach and responses to resuscitation, and results of diagnostic tests. Pregnancy also can affect the patterns and severity of injury. Clinicians who treat pregnant trauma patients must remember that there are two patients: mother and fetus. Nevertheless, initial treatment priorities for an injured pregnant patient remain the same as for the nonpregnant patient. The best initial treatment for the fetus is to provide optimal resuscitation of the mother. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or pelvic ultrasound. Monitoring and evaluation techniques are available to assess the mother and fetus. If x-ray examination is indicated during the pregnant patient’s treatment, it should not be withheld because of the pregnancy. A qualified surgeon and an obstetrician should be consulted early in the evaluation of pregnant trauma patients; if not available, early transfer to a trauma center should be considered. Anatomical and Physiological AlteRAtions of Pregnancy An understanding of the anatomical and physiological alterations of pregnancy and the physiological relationship between a pregnant patient and her fetus is essential to providing appropriate and effective care to both patients. Such alterations include differences in anatomy, blood volume and composition, and hemodynamics, as well as changes in the respiratory, gastrointestinal, urinary, musculoskeletal, and neurological systems. Anatomical differences The uterus remains an intrapelvic organ until approximately the 12th week of gestation, when it begins to rise out of the pelvis. By 20 weeks, the uterus is at the umbilicus, and at 34 to 36 weeks, it reaches the costal margin (n FIGURE 12-1; also see Changes in Fundal Height in Pregnancy on MyATLS mobile app). During the last 2 weeks of gestation, the fundus frequently descends as the fetal head engages the pelvis. As the uterus enlarges, the intestines are pushed cephalad, so that they lie mostly in the upper abdomen. Umbilicus (maternal) Symphysis pubis 40 36 32 28 24 20 16 12 n FIGURE 12-1 Changes in Fundal Height in Pregnancy. As the uterus enlarges, the bowel is pushed cephalad, so that it lies mostly in the upper abdomen. As a result, the bowel is somewhat protected in blunt abdominal trauma, whereas the uterus and its contents (fetus and placenta) become more vulnerable. As a result, the bowel is somewhat protected in blunt abdominal trauma, whereas the uterus and its contents (fetus and placenta) become more vulnerable. However, penetrating trauma to the upper abdomen during late gestation can result in complex intestinal injury because of this cephalad displacement. Clinical signs of peritoneal irritation are less evident in pregnant women; therefore, physical examination may be less informative. When major injury is suspected, further investigation is warranted. During the first trimester, the uterus is a thickwalled structure of limited size, confined within the bony pelvis. During the second trimester, it enlarges beyond its protected intrapelvic location, but the small fetus remains mobile and cushioned by a generous amount of amniotic fluid. The amniotic fluid can cause amniotic fluid embolism and disseminated intravascular coagulation following trauma if the fluid enters the maternal intravascular space. By the third trimester, the uterus is large and thin-walled. In the vertex presentation, the fetal head is usually in the pelvis, and the remainder of the fetus is exposed above the pelvic brim. Pelvic fracture(s) in late gestation can result in skull fracture or serious intracranial injury to the fetus. Unlike the elastic myometrium, the placenta has little elasticity. This lack of placental 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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9 THERMAL INJURIES The most signifi
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170 CHAPTER 9 n Thermal Injuries Th
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172 CHAPTER 9 n Thermal Injuries Ch
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174 CHAPTER 9 n Thermal Injuries Pi
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Page 239 and 240: 10 PEDIATRIC TRAUMA Injury remains
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Page 270 and 271: PRIMARY SURVEY WITH RESUSCITATION 2
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Page 310 and 311: Appendix A OCULAR TRAUMA OBJECTIVES
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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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