Key facts
- Trauma is the leading cause of death in the first four decades oflife but three people are permanently disabled for every one killed.
- Death from injury occurs in one of three time periods(trimodal).
- First peakwithin seconds to minutes. Very few can be saved dueto severity of their injuries.
- Second peakwithin minutes to several hours. Deaths occur due tolife-threatening injuries.
- Third peakafter several hours to weeks. Deaths from sepsis andmultiple organ failure.
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The advanced trauma life support (ATLS) system
- Accepted as a standard for trauma care during the golden hourand focuses on the second peak.
- Emphasizes that injury kills in certain reproducible time frames ina common sequence: loss of airway; inability to breathe; loss of circulatingblood volume; expanding intracranial mass.
- The primary survey following these areas (ABCDEs) with simultaneousresuscitation is emphasized.
Prehospital care and the trauma team
- Effort is made to minimize scene time, emphasizing immediatetransport to the closest appropriate facility (scoop and run).
- Hospital is informed of the impending arrival of thecasualty.
- Trauma team usually comprises an anaesthetist, generalsurgeon, orthopaedic surgeon, and A & E specialist, A & E nurses, andradiographers.
- Information from paramedics should include mechanism of injury,injuries identified, vital signs at scene, and any treatment administered (MIST).
- Triage is the process of prioritizing patients according totreatment need and the available resources (those with life-threateningconditions and with the greatest chance of survivalare treated first).
Primary survey
Identify and treat life-threatening conditions according topriority (ABCDE).
Airway maintenance with cervical spineprotection
- Protect spinal cord with immobilization devices or using manualin-line immobilization. Protect until cervical spine injury is excluded.
- Access airway for patency. If patient can speak, airway is notimmediately threatened.
P.439
- Consider foreign body; facial, mandibular, or tracheal/laryngealfractures if unconscious. Perform chin lift/jaw thrust. Considernasopharyngeal/oropharyngeal airway.
- If patient unable to maintain airway integrity secure a definitiveairway (orotracheal, nasotracheal, cricothyroidotomy).
Breathing and ventilation
- Administer high-flow oxygen using a non-rebreathingreservoir.
- Inspect for chest wall expansion, symmetry, respiratory rate, andwounds. Percuss and auscultate chest. Look for tracheal deviation, surgicalemphysema.
- Identify and treat life-threatening conditions: tensionpneumothorax, open pneumothorax, flail chest with pulmonary contusion, massivehaemothorax.
Circulation with haemorrhagecontrol
- Look for signs of shock.
- Hypotension is usually due to blood loss. Think: chest, abdomen,retroperitoneum, muscle compartment, open fractures (blood on the floor andfour more).
- Control external bleeding with pressure.
- Obtain IV access using two 12G cannulae. Sendblood for cross-match, FBC, clotting, U& E.
- Commence bolus of warmed Ringer's lactate solution; unmatched,type-specific blood only for immediate life-threatening blood loss.
- Consider surgical control of haemorrhage (laparotomy,thoracotomy).
Disability
- Perform a rapid neurological evaluation. AVPU method (Alert,responds to Vocal stimuli, responds only to Painful stimuli, Unresponsive to allstimuli), Glasgow coma scale.
- After excluding hypoxia and hypovolumia, consider changes in levelof consciousness to be due to head injury.
Exposure/environment control
- Undress patient for through examination.
- Prevent hypothermia by covering with warm blankets/warming device.Use warm IV fluids.
Adjuncts to primary survey
- Monitoring: pulse, non-invasive BP, ECG, pulse oximetry.
- Urinary catheter (after ruling out urethral injury).
- Diagnostic studies: X-rays (lateral cervical spine, AP chest, andAP pelvis), ultrasound scan, CT scan, diagnosticperitoneal lavage.
Secondary survey
Begin only after primary survey is complete and resuscitation iscontinuing successfully.
- Take history: AMPLE (allergy, medication,past medical history, last meal, events of the incident).
- Perform a head to toe physical examination.
- Continue reassessment of all vital signs.
- Perform specialized diagnostic tests that may berequired.
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