Advanced Trauma Life Support ATLS Student Course Manual 2018

SECONDARY SURVEY 13
Special Populations
Patient populations that warrant special consideration
during initial assessment are children, pregnant
women, older adults, obese patients, and athletes.
Priorities for the care of these patients are the same
as for all trauma patients, but these individuals may
have physiologic responses that do not follow expected
patterns and anatomic differences that require special
equipment or consideration.
Pediatric patients have unique physiology and anatomy.
The quantities of blood, fluids, and medications
vary with the size of the child. In addition, the injury
patterns and degree and rapidity of heat loss differ.
Children typically have abundant physiologic reserve
and often have few signs of hypovolemia, even after
severe volume depletion. When deterioration does
occur, it is precipitous and catastrophic. Specific issues
related to pediatric trauma patients are addressed in
Chapter 10: Pediatric Trauma.
The anatomic and physiologic changes of pregnancy
can modify the patient’s response to injury. Early
recognition of pregnancy by palpation of the abdomen
for a gravid uterus and laboratory testing (e.g., human
chorionic gonadotropin [hCG]), as well as early fetal
assessment, are important for maternal and fetal
survival. Specific issues related to pregnant patients
are addressed in Chapter 12: Trauma in Pregnancy and
Intimate Partner Violence.
Although cardiovascular disease and cancer are
the leading causes of death in older adults, trauma is
also an increasing cause of death in this population.
Resuscitation of older adults warrants special attention.
The aging process diminishes the physiologic
reserve of these patients, and chronic cardiac,
respiratory, and metabolic diseases can impair their
ability to respond to injury in the same manner as
younger patients. Comorbidities such as diabetes,
congestive heart failure, coronary artery disease,
restrictive and obstructive pulmonary disease,
coagulopathy, liver disease, and peripheral vascular
disease are more common in older patients and may
adversely affect outcomes following injury. In addition,
the long-term use of medications can alter the usual
physiologic response to injury and frequently leads
to over-resuscitation or under-resuscitation in this
patient population. Despite these facts, most elderly
trauma patients recover when they are appropriately
treated. Issues specific to older adults with trauma are
described in Chapter 11: Geriatric Trauma.
Obese patients pose a particular challenge in the
trauma setting, as their anatomy can make procedures
such as intubation difficult and hazardous. Diagnostic
tests such as FAST, DPL, and CT are also more difficult.
In addition, many obese patients have cardiopulmonary
disease, which limits their ability to compensate
for injury and stress. Rapid fluid resuscitation can
exacerbate their underlying comorbidities.
Because of their excellent conditioning, athletes may
not manifest early signs of shock, such as tachycardia
and tachypnea. They may also have normally low
systolic and diastolic blood pressure.
SecondARy Survey
The secondary survey does not begin until the primary
survey (ABCDE) is completed, resuscitative efforts are
under way, and improvement of the patient’s vital
functions has been demonstrated. When additional
personnel are available, part of the secondary survey
may be conducted while the other personnel attend
to the primary survey. This method must in no way
interfere with the performance of the primary survey,
which is the highest priority.
The secondary survey is a head-to-toe evaluation
of the trauma patient—that is, a complete history
and physical examination, including reassessment of
all vital signs. Each region of the body is completely
examined. The potential for missing an injury or
failing to appreciate the significance of an injury
is great, especially in an unresponsive or unstable
patient. (See Secondary Survey video on MyATLS
mobile app.)
History
Every complete medical assessment includes a history
of the mechanism of injury. Often, such a history
cannot be obtained from a patient who has sustained
trauma; therefore, prehospital personnel and family
must furnish this information. The AMPLE history is
a useful mnemonic for this purpose:
••
Allergies
••
Medications currently used
••
Past illnesses/Pregnancy
••
Last meal
••
Events/Environment related to the injury
The patient’s condition is greatly influenced by the
mechanism of injury. Knowledge of the mechanism
of injury can enhance understanding of the patient’s
physiologic state and provide clues to anticipated
injuries. Some injuries can be predicted based on the
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