Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX C n Trauma Care in Mass-Casualty, Austere, and Operational Environments
to do so without the benefit of the plentiful personnel,
supplies, and technology that are routinely available
in civilian settings. ATLS-OE emphasizes the unique
challenges as described earlier and provides students
with information that is critical to success in these
difficult environments.
ATLS-OE incorporates this additional subject matter
in two ways; (1) through addition/supplementation
of military relevant information to key ATLS lectures
or skills stations and (2) through the addition of
several unique and military-specific lectures to the
curriculum. For example, new topics such as situational
awareness, damage control, and team dynamics have
been added.
While the standard ATLS course teaches the primary
and secondary surveys, ATLS-OE also stresses the
importance of the tertiary survey. Once a patient has
reached definitive care, the tertiary survey is performed
to ensure that all injuries have been identified and none
have been overlooked.
A key foundation of ATLS-OE involves the addition of
two additional components that must be incorporated
into the trauma assessment; the zero survey and
quaternary survey. Initial trauma care in the austere
environment requires careful consideration of internal
capabilities and external factors (zero survey).
Additionally, patients are often rapidly transported
across multiple facilities and require careful attention
to preparation for safe evacuation to the next higher
echelon of care (quaternary survey). n FIGURE C-1
diagrams the components of ATLS-OE.
Zero Survey
The standard ATLS course briefly addresses preparation
to receive trauma patients as they flow from the
prehospital environment to the hospital. The zero
survey is implied, but it is not specifically characterized
or formalized as a separately named survey. ATLS-
OE formalizes this prearrival preparation as a critical
concept for the student. While this preparation
is important to the care of any severely wounded
patient, it is absolutely critical as the first step in
making appropriate triage decisions in the setting
of multiple casualties. The process emphasizes the
importance of an accurate inventory of local resources,
staffing, expertise, environmental and operational
conditions, and any other anticipated or potential
challenges in preparation for the arrival of one or more
injured patients.
The zero survey identifies provider and/or systems
issues that may not yet have been identified or mitigated
and that may significantly affect decisions made during
the initial evaluation. These are factors and issues that
the student never may have considered, but they may be
equally or even more important than the actual patient
injuries or required interventions. The zero survey
ATLS-OE
Primary Survey
Identify and treat immediate life
threatening injuries
Zero Survey
• Tactical situation
• Personnel
• Logistics/Supplies on hand
• Holding capacity
• Security
Pre-arrival preparation
• Medevac capabilities
• Number of incoming casualties
• Critical care capability
• Resuscitative surgical capability
X
A
B
C
D
E
eXsanguinating hemorrhage
(use of tourniquets)
Airway
Breathing
Circulation Secondary Survey
Disability
Exposure Identify all injuries
• Complete Head to Toe exam
• Adjuncts
Tertiary Survey
Re-assess to identify any undetected
injuries
•• Review all imaging
•• Focus on musculoskeletal injury
•• Evaluate adequacy of resuscitation
QUATERNARY SURVERY
Preparation for transfer
• Stability for transfer vs
need for next echelon care
• Transport needs
• Receiving facility capabilities
• Critical care needs
• Medevac time/ method
• Evacuation delays
(weather/tactical/etc)
• Ongoing resuscitation?
n FIGURE C-1 Expanded ATLS-OE Trauma Survey incorporates tourniquet use into Primary survey (X) and the new Zero and Quaternary surveys.
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