Advanced Trauma Life Support ATLS Student Course Manual 2018

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267 APPENDIX B n Hypothermia and Heat Injuries Ventricular fibrillation becomes increasingly common as the temperature falls below 28°C (82.4°F) and at temperatures below 25°C (77°F), asystole can occur. Cardiac drugs and defibrillation are not usually effective in the presence of acidosis, hypoxia, and hypothermia. In general, postpone these treatment methods until the patient is warmed to at least 28°C (82.4°F). Given the high potential for cardiac irritability, large-bore peripheral IVs—or if necessary, femoral central lines— are preferred for access. When subclavian or internal jugular routes are used, do not advance the wire into the heart. Administer 100% oxygen while the patient is being rewarmed. Do not let attempts to actively rewarm the patient delay his or her transfer to a critical care setting. Management The trauma teams’ immediate attention should be focused on addressing the ABCDEs, including initiating cardiopulmonary resuscitation (CPR) and establishing intravenous access if the patient is in cardiopulmonary arrest. Prevent heat loss by removing the patient from the cold environment and replacing wet, cold clothing with warm blankets. Administer oxygen via a bagreservoir device. Use the proper rewarming technique as determined by the core temperature, clinical condition of the patient, available techniques, and experience of the trauma team (n TABLE B-2). Mild hypothermia is usually treated with noninvasive, passive external rewarming. Repeat temperature measurements to identify falling temperatures that may require escalation of the warming technique. Moderate hypothermia can be treated with passive external rewarming in a warm room using warm blankets, ambient overhead heaters, warmed forcedair blankets, and warmed intravenous fluids. Severe hypothermia may require active core rewarming methods. Provide humidified and warmed air through mechanical ventilation. Warm fluid lavage through a bladder catheter, thoracostomy tube, or peritoneal dialysis catheter may be effective. Use extracorporealassisted rewarming in cases of severe hypothermia. Rapid rewarming is possible with this technique; rewarming rates of 1.5 to 10 degrees per hour have been reported. Special equipment and expertise is required. These patients require close monitoring of their organ function during the warming process. n FIGURE B-1 presents an algorithm for warming strategies for trauma patients after arrival to the hospital. Warming strategies are escalated based on degree of hypothermia. Care must be taken to identify the presence of an organized cardiac rhythm; if one exists, sufficient table b-2 rewarming techniques REWARMING TECHNIQUE • Dry patient • Warm environment • Shivering • Blankets or clothing • Cover head External • Heating pad • Warm water, blankets, and warm water bottles • Warm water immersion • External convection heaters (lamps and radiant warmers) Internal • Heated intravenous fluids • Gastric or colonic lavage • Peritoneal lavage • Mediastinal lavage • Warmed inhalational air or oxygen Extracorporeal Rewarming • Hemodialysis • Continuous arteriovenous rewarming (CAVR) • Continuous venovenous rewarming (CVVR) • Cardiopulmonary bypass PASSIVE REWARMING ACTIVE REWARMING LEVEL OF HYPOTHERMIA Mild (HTI) hypothermia 35°C to 32° C (95-89.6 F) Mild (HT I) (35°C to 32° C [95-89.6 F]) and moderate (HT II) hypothermia < 32°C to 28° C (< 89.6-82.4 F) Moderate (HT II) < 32°C to 28° C (< 89.6-82.4 F) and severe hypothermia (HT III and IV) < 28°C to < 24°C (
268 APPENDIX B n Hypothermia and Heat Injuries Hospital evaluation Initial management • Obtain temperature • Evaluate for signs of hypothermia (shivering, vasoconstriction, mental status changes) • Remove wet clothing, warm environment • Ensure warm IV fluids, warm blankets • Reassess temp every 15 minutes CT scan ATLS protocol, Ongoing resuscitation and stabilization Surgery vs. Angiography Observation Ongoing Temperature Evaluation 32°C (89.6°F) 32°C to 36°C (89.6°F to 98.6°F) 36°C (96.8°F) 37°C (98.6°F) and higher * Cease warming * Closely monitor temperature PRN Level 3 Warming • Continually monitor temperature • Early consideration of: o Body cavity lavage o Extracorporeal membrane oxygenation/bypass o Continuous arteriovenous rewarming o Patient transfer, if capabilities not present + Level 2 Warming • Maximize forced-air and fluid warming • Underbody heating pads • Radiant warmer • Humidified ventilation • Circulating water garment • Reassess every 5 minutes + Level 1 Warming • Warm environment • Warm IV fluids • Warm blanket • Forced-air blanket • Reassess every 15 minutes n FIGURE B-1 Warming Strategies in Trauma. An algorithm for early, goal-directed therapy for hypothermia in trauma. Adapted with permission from Perlman R, Callum J, Laflammel C, Tien H, Nascimento B, Beckett A, & Alam A. (2016). A recommended early goal-directed management guideline for the prevention of hypothermia-related transfusion, morbidity, and mortality in severely injured trauma patients. Critical Care, 20:107 Treat the patient in a critical care setting whenever possible, and continuously monitor cardiac activity. Do a careful Advanced search Trauma for associated Life Support disorders for Doctors (e.g., diabetes, sepsis, Student and Course drug Manual, or alcohol 10e ingestion) and occult injuries, American and College treat the of disorders Surgeons promptly. Obtain blood samples Figure# for B.01 complete blood count (CBC), coagulation profile, Dragonfly fibrinogen, Media electrolytes, Group blood glucose, alcohol, 3/1/2017, 3/20/2017, toxins, creatinine, amylase, liver function tests, and 4/13/2017 blood cultures. Treat any abnormalities accordingly; for example, hypoglycemia requires intravenous glucose administration. Determining death can be difficult in patients with severe hypothermia. In patients who appear to have suffered a cardiac arrest or death as a result of hypothermia, do not pronounce them dead until having made full efforts to rewarm. Remember the axiom: “You are not dead until you are warm and dead.” An exception to this rule is a patient with 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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176 CHAPTER 9 n Thermal Injuries th
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178 CHAPTER 9 n Thermal Injuries ju
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180 CHAPTER 9 n Thermal Injuries Im
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182 CHAPTER 9 n Thermal Injuries lo
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184 CHAPTER 9 n Thermal Injuries 4.
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10 PEDIATRIC TRAUMA Injury remains
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188 CHAPTER 10 n Pediatric Trauma I
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190 CHAPTER 10 n Pediatric Trauma c
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192 CHAPTER 10 n Pediatric Trauma A
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194 CHAPTER 10 n Pediatric Trauma b
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196 CHAPTER 10 n Pediatric Trauma b
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198 CHAPTER 10 n Pediatric Trauma t
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200 CHAPTER 10 n Pediatric Trauma f
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202 CHAPTER 10 n Pediatric Trauma t
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204 CHAPTER 10 n Pediatric Trauma G
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206 CHAPTER 10 n Pediatric Trauma C
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208 CHAPTER 10 n Pediatric Trauma
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210 CHAPTER 10 n Pediatric Trauma 1
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212 CHAPTER 10 n Pediatric Trauma 6
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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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Page 293 and 294: 240 CHAPTER 13 n Transfer to Defini
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Page 310 and 311: Appendix A OCULAR TRAUMA OBJECTIVES
Page 312 and 313: 259 APPENDIX A n Ocular Trauma In c
Page 314 and 315: 261 APPENDIX A n Ocular Trauma to t
Page 318 and 319: Appendix B HYPOTHERMIA AND HEAT INJ
Page 322 and 323: 269 APPENDIX B n Hypothermia and He
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Page 328 and 329: Appendix C TRAUMA CARE IN MASS-CASU
Page 330 and 331: 277 APPENDIX C n Trauma Care in Mas
Page 342 and 343: Appendix D DISASTER PREPAREDNESS AN
Page 344 and 345: 291 APPENDIX D n Disaster Preparedn
Page 352 and 353: Pitfall Inadequate security Failed
Page 356 and 357: Appendix E ATLS AND TRAUMA TEAM RES
Page 358 and 359: 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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