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
dictates how patients are triaged and prioritized, what
injury types or patterns exceed the local capabilities or
available expertise, and which resources are in short
supply or unavailable.
These factors will include the following:
••
How many and what type of medical personnel
are available?
••
What medical and surgical expertise or
specialties are available?
••
What is the amount and type of blood products
available?
••
What are the critical supply shortages, if any?
••
Is resupply on short notice available, including
blood products?
••
Is there a need to initiate a fresh whole-blood
drive?
••
What is the available source of oxygen, and
how much supply is currently available?
••
Is direct communication with the next phase of
care available if a transfer is required?
••
What is the tactical situation, and is security
adequate?
The fluidity and potential chaos inherent to the
austere environment dictate the importance of the
zero survey in practice.
Triage decisions and initial care priorities may change
rapidly as situational factors and care capacity of the
facility evolve over time and between events. In this
environment, as personnel and supply resources
become more limited, triage decisions become
increasingly difficult.
Quaternary Survey
Although the standard ATLS course emphasizes
preparation of the injured patient for transfer from
the initial facility to a trauma center, this is typically
a single transfer over a relatively short distance by a
fully equipped medical team. In contrast, a patient in
the operational environment may undergo multiple
sequential transfers over prolonged distances while
initial resuscitation is ongoing. It is not uncommon for a
patient to undergo a major damage control surgery and
then be placed into the medical evacuation continuum
within minutes to hours of surgery and/or injury. These
transfers are often by helicopter in an environment
that makes continuous care exceedingly challenging.
Therefore, to minimize the likelihood of problems or
complications arising during transport, strict attention
must be paid to completely preparing the patient for
safe transportation.
The quaternary survey formalizes this preparation
for transfer. It should be repeated for each successive
transfer in the medical evacuation chain. In the
operational setting, the time in transit may be a matter
of minutes—or it may be many hours. This unknown
must be considered not only in preparation for transport
but also in deciding readiness for transport. En route
care capabilities must also be considered because
of potential variation in transportation facilities,
available en route care providers, equipment, supplies
and medications, environment, and the potential for
external threats.
Assessing the patient’s response to resuscitation
is critical. The potential of meeting desirable end
points of resuscitation versus the local resources
available to meet these end points are real and
important considerations. Although it is certainly
desirable to ensure that a severely injured patient is
clinically “stable,” has had a complete and thorough
evaluation with identification of all injuries, and has
been fully resuscitated to standard end points, this
is often not practical or possible in the operational
environment. The limited supply of critical resources
such as blood products and the limited holding
capacity of the most forward treatment facilities
(such as the Forward Surgical Team) make prolonged
care and sustained massive transfusions logistically
impossible. Thus, often the better of two suboptimal
choices must be made, and the patient is placed into
the transport system much sooner or in a more tenuous
phase of resuscitation than is frequently done in the
civilian setting.
The following are additional considerations as
patients are prepared for movement within the
operational environment:
••
Will weather or hostile action prevent
movement of casualties?
••
What supportive treatments must accompany
the patient (ventilator, suction, etc.), and what
potential en route problems or malfunctions
could occur?
••
Will the evacuation team have the skills
to manage a critically ill patient and the
supportive equipment accompanying
the patient?
• • What medications, fluids, blood products, and
other resuscitative or supportive treatments
can be realistically and reliably administered
during the transport?
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