Advanced Trauma Life Support ATLS Student Course Manual 2018

TEAMWORK 19
Reevaluation
Trauma patients must be reevaluated constantly to
ensure that new findings are not overlooked and
to discover any deterioration in previously noted
findings. As initial life-threatening injuries are
managed, other equally life-threatening problems
and less severe injuries may become apparent, which
can significantly affect the ultimate prognosis of the
patient. A high index of suspicion facilitates early
diagnosis and management.
Continuous monitoring of vital signs, oxygen
saturation, and urinary output is essential. For adult
patients, maintenance of urinary output at 0.5 mL/kg/h
is desirable. In pediatric patients who are older than
1 year, an output of 1 mL/kg/h is typically adequate.
Periodic ABG analyses and end-tidal CO 2
monitoring
are useful in some patients.
The relief of severe pain is an important part of
treatment for trauma patients. Many injuries, especially
musculoskeletal injuries, produce pain and anxiety
in conscious patients. Effective analgesia usually
requires the administration of opiates or anxiolytics
intravenously (intramuscular injections are to be
avoided). These agents are used judiciously and in small
doses to achieve the desired level of patient comfort
and relief of anxiety while avoiding respiratory status
or mental depression, and hemodynamic changes.
Definitive Care
Whenever the patient’s treatment needs exceed the
capability of the receiving institution, transfer is considered.
This decision requires a detailed assessment of
the patient’s injuries and knowledge of the capabilities
of the institution, including equipment, resources,
and personnel.
Interhospital transfer guidelines will help determine
which patients require the highest level of trauma care
(see ACS COT’s Resources for Optimal Care of the Injured
Patient, 2014). These guidelines take into account
the patient’s physiologic status, obvious anatomic
injury, mechanisms of injury, concurrent diseases,
and other factors that can alter the patient’s prognosis.
ED and surgical personnel will use these guidelines
to determine whether the patient requires transfer
to a trauma center or the closest appropriate hospital
capable of providing more specialized care. The closest
appropriate local facility is chosen, based on its overall
capabilities to care for the injured patient. The topic
of transfer is described in more detail in Chapter 13:
Transfer to Definitive Care.
Records and Legal
ConsideRAtions
Specific legal considerations, including records,
consent for treatment, and forensic evidence, are
relevant to ATLS providers.
Records
Meticulous record keeping is crucial during patient
assessment and management, including documenting
the times of all events. Often more than one clinician
cares for an individual patient, and precise records are
essential for subsequent practitioners to evaluate the
patient’s needs and clinical status. Accurate record
keeping during resuscitation can be facilitated by
assigning a member of the trauma team the primary
responsibility to accurately record and collate all
patient care information.
Medicolegal problems arise frequently, and precise
records are helpful for all individuals concerned.
Chronologic reporting with flow sheets helps the
attending and consulting doctors quickly assess
changes in the patient’s condition. See Sample Trauma
Flow Sheet and Chapter 13: Transfer to Definitive Care.
Consent for Treatment
Consent is sought before treatment, if possible. In
life-threatening emergencies, it is often not possible to
obtain such consent. In these cases, provide treatment
first, and obtain formal consent later.
Forensic Evidence
If criminal activity is suspected in conjunction
with a patient’s injury, the personnel caring for
the patient must preserve the evidence. All items,
such as clothing and bullets, are saved for law
enforcement personnel. Laboratory determinations
of blood alcohol concentrations and other drugs
may be particularly pertinent and have substantial
legal implications.
In many centers, trauma patients are assessed by a team
TeamWORK
whose size and composition varies from institution to
institution (n FIGURE 1-8). The trauma team typically
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