Advanced Trauma Life Support ATLS Student Course Manual 2018

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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 n BACK TO TABLE OF CONTENTS
14 CHAPTER 1 n Initial Assessment and Management table 1-1 mechanisms of injury and suspected injury patterns MECHANISM OF INJURY SUSPECTED INJURY PATTERNS MECHANISM OF INJURY SUSPECTED INJURY PATTERNS BLUNT INJURY Frontal impact, automobile collision • Bent steering wheel • Knee imprint, dashboard • Bull’s-eye fracture, windscreen • Cervical spine fracture • Anterior flail chest • Myocardial contusion • Pneumothorax • Traumatic aortic disruption • Fractured spleen or liver • Posterior fracture/dislocation of hip and/or knee • Head injury • Facial fractures Rear impact, automobile collision Ejection from vehicle • Cervical spine injury • Head injury • Soft tissue injury to neck • Ejection from the vehicle precludesmeaningful prediction of injury patterns, but places patient at greater risk forvirtually all injury mechanisms. Side impact, automobile collision • Contralateral neck sprain • Head injury • Cervical spine fracture • Lateral flail chest • Pneumothorax • Traumatic aortic disruption • Diaphragmatic rupture • Fractured spleen/liver and/or kidney, depending on side of impact • Fractured pelvis or acetabulum Motor vehicle impact with pedestrian Fall from height • Head injury • Traumatic aortic disruption • Abdominal visceral injuries • Fractured lower extremities/pelvis • Head injury • Axial spine injury • Abdominal visceral injuries • Fractured pelvis or acetabulum • Bilateral lower extremity fractures (including calcaneal fractures) PENETRATING INJURY THERMAL INJURY Stab wounds • Anterior chest • Left thoracoabdominal • Abdomen • Cardiac tamponade if within ”box” • Hemothorax • Pneumothorax • Hemopneumothorax • Left diaphragm injury/spleen injury/hemopneumothorax • Abdominal visceral injury possible if peritoneal penetration Thermal burns Electrical burns Inhalational burns • Circumferential eschar on extremity or chest • Occult trauma (mechanism of burn/means of escape) • Cardiac arrhythmias • Myonecrosis/compartment syndrome • Carbon monoxide poisoning • Upper airway swelling • Pulmonary edema Gunshot wounds (GSW) • Truncal • High likelihood of injury • Trajectory from GSW/retained projectiles help predict injury • Extremity • Neurovascular injury • Fractures • Compartment syndrome n BACK TO TABLE OF CONTENTS
Page 1 and 2:
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
Page 16 and 17: ACKNOWLEDGMENTS It is clear that ma
Page 18 and 19: xvii ACKNOWLEDGMENTS Bertil Bouillo
Page 20 and 21: xix ACKNOWLEDGMENTS Oscar Guillamon
Page 22 and 23: xxi ACKNOWLEDGMENTS Mahesh Misra, M
Page 24 and 25: xxiii ACKNOWLEDGMENTS James Vosswin
Page 26 and 27: xxv ACKNOWLEDGMENTS James A. Geilin
Page 28: xxvii ACKNOWLEDGMENTS Tone Slåke R
Page 31 and 32: xxx COURSE OVERVIEW m. Protection o
Page 33 and 34: xxxii COURSE OVERVIEW Atls and Trau
Page 35 and 36: xxxiv COURSE OVERVIEW a systematize
Page 37 and 38: xxxvi COURSE OVERVIEW 69. Switzerla
Page 39 and 40: xxxviii COURSE OVERVIEW United Stat
Page 41 and 42: xl COURSE OVERVIEW 67. Hendrickson
Page 43 and 44: xlii COURSE OVERVIEW 122. Palusci V
Page 46: BRIEF CONTENTS Foreword Preface Ack
Page 49 and 50: xlviii DETAILED CONTENTS Teamwork 5
Page 51: l DETAILED CONTENTS Introduction 21
Page 55 and 56: 1 INITIAL ASSESSMENT AND MANAGEMENT
Page 57 and 58: 4 CHAPTER 1 n Initial Assessment an
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Page 75 and 76: 2 AIRWAY AND VENTILATORY MANAGEMENT
Page 77 and 78: 24 CHAPTER 2 n Airway and Ventilato
Page 95 and 96: 3 SHOCK The first step in the initi
Page 97 and 98: 44 CHAPTER 3 n Shock The first step
Page 99 and 100: 46 CHAPTER 3 n Shock Recognition of
Page 101 and 102: 48 CHAPTER 3 n Shock However, the a
Page 103 and 104: 50 CHAPTER 3 n Shock Class II Hemor
Page 105 and 106: 52 CHAPTER 3 n Shock hypothermia, a
Page 107 and 108: 54 CHAPTER 3 n Shock replacement du
Page 109 and 110: 56 CHAPTER 3 n Shock aggregation an
Page 111 and 112: 58 CHAPTER 3 n Shock Presence of Pa
Page 113 and 114: 60 CHAPTER 3 n Shock rate can be ac
Page 115 and 116: 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
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PRIMARY SURVEY WITH RESUSCITATION 2
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PRIMARY SURVEY WITH RESUSCITATION 2
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SPECIFIC INJURIES 221 table 11-6 ph
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BIBLIOGRAPHY 223 comprise only 12%
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12 TRAUMA IN PREGNANCY AND INTIMATE
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228 CHAPTER 12 n Trauma in Pregnanc
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240 CHAPTER 13 n Transfer to Defini
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Appendix A OCULAR TRAUMA OBJECTIVES
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259 APPENDIX A n Ocular Trauma In c
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261 APPENDIX A n Ocular Trauma to t
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Appendix B HYPOTHERMIA AND HEAT INJ
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267 APPENDIX B n Hypothermia and He
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Appendix C TRAUMA CARE IN MASS-CASU
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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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