ATLS (Advanced Trauma Life Support)

Teaching Protocol
A. Pretest (30 min)
B. Context of Tutorial (2 hours)
1. General Principles
Concept
Inhospital phase clinical procedure/process
Important points/ cautions/ pitfalls
Brief discussion on traumatic shoc/ !lood transfusion
2. "horacic "rauma
3. A!dominal "rauma
C. Answers of pretests (30 min)
#. Skills: (1hour)
1. Air$a% and &entilator% mana'ement
a. (et insufflation
!. )ar%n'oscope / *a'ill forcep / +uction de,ice
c. Adult intu!ation
d. Infant intu!ation
e. Cricoth%roidotom%
2. Immo!ili-ation
a. In.line immo!ili-ation/ lo'.roll techni/ues
!. Cer,ical collar
a. )on' spine Bac!oard
!. +coop stretcher
c. "raction +plint
3. Ad0uncts to sur,e%s /monitorin'/ resuscitation
a. Pulse 12imeter
!. #P)
c. 3A+"
d. 4eedle decompression
e. "u!e thoracostom%
f. +eal 1pen peumothora2
'. Pericardiocentesis
h. Intraosseous puncture
Avanced Trauma Life Support
eneral Principles:
"he concept5
"hree underl%in' concepts of A")+ pro'ram 5

1.
"reat the 'reatest threat to life first
2.
"he lac of a definite dia'nosis should ne,er impede the application
of an indicated treatment
3.
A detailed histor% $as not essential to !e'in the e,aluation of an
acutel% in0ured patient
+pecific principles 'o,ern the mana'ement of trauma patients in 6#5
1.
1r'ani-ed team approach
2.
Priorities
3.
Assumption of the most serious in0ur%
7.
"reatment !efore dia'nosis
8.
"horou'h e2amination
9.
3re/uent reassessment
:.
*onitorin'
Inhospital phase clinical process5
+%stemic; or'ani-ed approach to seriousl% in0ured patients is mandator%.

Preparation
"ria'e
Primar% sur,e% (ABC#6s)
<esuscitation
Ad0uncts to primar% sur,e% = resuscitation
+econdar% sur,e% (>ead to toe 6,aluation)
Ad0uncts to secondar% sur,e%
Continued postresuscitation monitorin' and ree,aluation
#efiniti,e care

"he primar% and secondar% sur,e%s should !e repeated fre/uentl%
In the actual clinical situation; man% of these acti,ities occur in parallel or
simultaneousl%.
!rgani"ed Team Approach:
"eam Captain 5 Coordinate; control the resuscitation
Assessin' the patient; orderin' needed procedures/ studies
*onitrin' the patient?s pro'ress.
Procedures !% other ph%sician team mem!ers.
4urses
Priorities #n $anagement and %esuscitation
Immediate / potential threats to life
1. >i'h.priorit% areas
Air$a%/ !reathin'
+hoc/ e2ternal hemorrha'e
Impendin' cere!ral hemorrha'e
Cer,ical spine
2. )o$.priorit% areas
4eurolo'ic
A!dominal
Cardiac
*usculoseletal
+oft tissue in0ur%
Assumption of the $ost Serious #n&ur'
Assume the $orst possi!le in0ur%
*echanism of in0ur%
Treatment (efore )iagnosis
Based on initial !rief assessment
"he more unsta!le the patient; the less necessar% to confirm alife.threatenin' dia'nosis
!efore it is e2peditiousl% treated
Thorough *xamination
@hen time and the patient?s sta!ilit% permit.
Anconscious/ alcohol into2icated patients
+re,uent %eassessment
#%namic process
+ome in0uries tae time to manifest
An% sudden $orsenin' in the ph%siolo'ic status of the patients mandates a return to the
BABC#6sC
$onitoring
&ital si'ns
Pulse o2imetr%
I/1
)a!5 ABG; >t
C&P
#nhospital Phase ATLS
P%*PA%AT#!-
<esuscitation area
Proper air$a% e/uipment
@armed I& cr%stalline solutions
*onitorin' capa!ilities
+ummon e2tra medical assistance
Prompt response !% la! and radiolo'% personnel
"ransfer route
Periodic re,ie$
+tandard precautions
T%#A*
Based on the ABC#6 priorit%
P%#$A%. S/%0*.
Air$a% $ith Cer,ical spine protection
(reathin' and ,entilation
Circulation $ith hemorrha'e control
)isa!ilit%5 4eurolo'ic status
*2posure/ *n,ironmental control
Airwa' $aintenance with Cervical Spine Protection
1 : 2hat are the pro3lems that lead to airwa' compromise 4
1 : 2hat are the indications for definite airwa' 4
#ndications +or )efinite Airwa'
-eed for Airwa' Protection -eed for 0entilation
Anconscious
GC+ D E
Apnea
4euromuscular paral%sis
Anconscious
+e,ere ma2illofacial fractures Inade/uate respirator% effort
"ach%pnea
>%po2ia
>%percar!ia
C%anosis
<is for aspiration
Bleedin'
&omitin'
+e,ere closed head in0ur% $ith
need for h%per,entilation
<is for o!struction
Assessment :
Ascertain patenc%
<apidl% assess for air$a% o!struction
3orei'n !odies; facial / mandi!ular / tacheal / lar%'eal fractures.
$anagement :
Chin lift / 0a$ thrust maneu,er
Clear the air$a% of 3B
Insert an orotracheal / nasophar%n'eal air$a%
6sta!lish a definiti,e air$a%
1. 1rotracheal / nasotracheal intu!ation
2. +ur'ical cricoth%roidotom%
(et insufflation
$aintain the cervical spine in a neutral position $ith manual immo!ili-ation as
necessar% $hen esta!lishin' an air$a%
#mmo3ili"ation of the c5spine $ith appropriate de,ices after esta!lishin' an air$a%.
#mportant -otes :
46 does not e2clude a cer,ical spine in0ur%
Assume a cer,ical spine in0ur% in an% patient $ith multis%stem trauma; especiall%
$ith an altered le,el of consciousness or a !lunt in0ur% a!o,e the cla,icle
Pitfalls :
6/uipment failure
Cannot !e intu!ated after paral%sis and accompanied $ith difficult sur'ical air$a%
Anno$n lar%n'eal fracture / incomplete air$a% transection.
(reathing and 0entilation
1 : 2hat are the in&uries that ma' acutel' impair ventilation in the primar'
surve'4
#n&uries that should 3e identified in the Primar' surve' :
1. "ension pneumothora2
2. 3lail chest $ith pulmonar% contussion
3. *assi,e hemothora2
7. 1pen pneumothora2
Assessment :
#nspection 6 palpation 6Auscultation 6 Percussion
62pose the nec and chest
<espirator% rate and depth
Inspect and palpate5 tracheal de,iation F s%mmetrical chest mo,ement F use of
accessor% muscles F si'ns of in0ur% F su!cutaneous emph%sema F
C%anosis F
Auscultate the chest
Percussion 5 dullnessF h%perresonanceF
$anagement :
Administer hi'h concentrations of o2%'en
&entilate $ith B&*
Alle,iate tension pneumothora2 5 needle decompression / Place chest tu!e
Indication for thoracotom%
+eal an open pneumothora2
Pulse o2imeter
#mportant -otes :
Al$a%s chec for one.lun' intu!ation; chest G.ra%s should !e performed
Pitfalls :
If the ,entilation pro!lem is produced !% a pneumothra2; intu!ation $ith *& could
lead to deterioration.
"he procedure itself ma% produce a pneumothora2
Circulation with 7emorrhage Control
1 : 2hat are the elements that provide the information a3out the hemod'namic
status of the in&ured patients8
These elements are:
1. )e,el of consciousness
2. +in color
3. Pulse ( /ualit%; rate; re'ularit% )
Presence of a carotid pulse +BP 90 mm>'
femoral pulse +BP :0 mm>'
radial puse +BP E0 mm>'
*xternal 3leeding is identified and controlled in the primar% sur,e%.
!perative intervention for internal !leedin' control.
1 : 2hat are the in&uries that ma' acutel' impair circulation status 4
"hese in0uries are 5
1. 62ternal/internal !leedin' $ith h%po,olemic shoc
2. *assi,e hemothora2
3. Cardiac tamponade
Assessment:
Identif% source of e2ternal hemorrha'e
Identif% potential source(s) of internal hemorrha'e /
Pulse / sin color; capillar% refill / Blood pressure
$anagement:
Appl% direct pressure to e2ternal !leedin' site.
Internal hemorrha'e F 4eed for sur'ical inter,ention F
6sta!lish I& access / central line / I1
3luid resuscitation / !lood replacement
#mportant -otes 5
>%potension follo$in' in0ur% must !e considered to !e h%po,olemic in ori'in until
pro,ed other$ise.
Pitfalls :
"he elderl%; children; athletes and others $ith chronic medical conditions do not
respond to ,olume loss in similar manner
)isa3ilit'
Assessment 5
Level of consciousness in the A&PA scale
Alert
0oice illicits response
Pain illicits response
/nresponsi,e
GC+
Pupils si-e; e/ualit% and reaction
$anagement 5
Intu!ation and allo$ mild h%per,entilation
Administer I& mannitol ( 1.8.2.0'/' )
Arran'e for !rain C"
#mportant notes :
C" is contraindicated $hen the patient is hemod%namicall% unsta!le
A decrease in the le,el of consciousness ma% due to5
a.
#ecreased cere!ral o2%'enation (A;B)
!.
#ecreased cere!ral perfusion (C)
c.
#irect cere!ral in0ur% (#)
d.
Alcohol / dru's
Al$a%s rule out h%po2emia and h%po,olemia first.
<ee,aluation
Pitfalls :
)ucid inter,al of acute 6#>; ree,aluation is important.
*xposure 6 *nvironment Control
Completel% undressed the patient.
Pre,ent h%pothermia
In0ured patients ma% arri,e in h%pothermic condition
)o'.roll
%*S/SC#TAT#!-
"o re,erse immediatel% life.threatenin' situations and ma2imi-e patient sur,i,al
T%*AT$*-T P%#!%#T. 46CC6++A<H P<1C6#A<6
Air$a% 1. (a$ thrust/chin lift/
2. +uction
3. Intu!ation
7. Cricoth%roidotom%
( $ith protection of C.spine )
Breathin'/&entilation/o2%'enation 1. Chest needle decompression
2. "u!e thoracostom%
3. +upplemental o2%'en
7. +eal open pneumothora2
Circulation/hemorrha'e control 1. I& line/ central line
2. &enous cutdo$n
3. 3luid resuscitation/Blood transfusion
7. "horocostom% for massi,e
hemothora2
8. Pericardiocentesis for cardiac
tamponade
#isa!ilit% 1. Burr holes for trans.tentorial
herniation
2. I& mannitol
62posure/6n,ironment 1. @armed cr%stalloid fluid
2. "emperature
A)9/-CTS T! P%#$A%. S/%0*. A-) %*S/SC#TAT#!-
6lectrocardio'raphic *onitorin'.
Arinar% Catheter
Gastric Catheter
*onitorin'
ABG
Pulse o2imeter
Blood pressure
G.ra%s
AP CG<
AP pel,is
C.spine
#ia'nostic peritoneal la,a'e
A!dominal ultrasono'raph% (3A+")
C!-S#)*% -**) +!% PAT#*-T T%A-S+*%
S*C!-)A%. S/%0*.
"he secondar% sur,e% does not !e'in until5
the primar% sur,e% is completed;
resuscitation efforts are $ell esta!lished;
the patient is demonstratin' normali-ation of ,ital functions.
>ead.to.toe e,aluation
Complete histor% and P6
<eassessment of all ,ital si'ns.
Complete 46.
Indicated 2.ra%s are o!tained.
+pecial procedures
"u!es and fin'ers in e,er% orifice
7istor' :
A$PL* histor%
Aller'ies
$edications currentl% used
Past illness/ Pre'nanc%
Last meal
*,ents/ *n,ironment related to the in0ur%
*echanism/!lunt/penetratin'/!urns/cold/ha-ardous en,ironment
Ph'sical *xamination 5
"a!le 1.
Pitfalls:
3acial edema in patients $ith massi,e facial in0ur% or patients in coma can preclude
a complete e%e e2amination.
Blunt in0ur% to the nec ma% produce in0uries in $hich clinical si'ns and s%mptoms
de,elop late.(e.'. In0ur% to the intima of the carotid a.)
"he identification of cer,ical n. root/!rachial ple2us in0ur% ma% not !e possi!le in
the comatose patient.
#ecu!itus ulcer from immo!ili-ation on a ri'id spine !oard/cer,ical collar.
Children often sustain si'nificant in0ur% to the intrathoracic structures $ithout
e,idence of thoracic seletal trauma.
A normal initial e2amination of the a!domen does not e2clude a si'nificant
intraa!dominal in0ur%.
Patients $ith impaired sensorium secondar% to alcohol/dru's are at ris.
In0ur% to the retroperitoneal or'ans ma% !e difficult to identif%.
3emale urethral in0ur% are difficult to detect.
Blood loss from pel,ic fractures can !e difficult to control and fatal hemorrha'e ma%
result.
3ractures in,ol,in' the !ones of e2tremities are often not dia'nosed.
*ost of the dia'nostic and therapeutic maneu,ers increase ICP.
A)9/-CTS T! T7* S*C!-)A%. S/%0*.
"hese speciali-ed tests should not !e performed until the patient?s hemod%namic status has
!een normali-ed and the patient has !een carefull% e2amined.
Additional 2.ra%s of the spine and e2tremities
C" of the head; chest; a!domen; and spine
Contrast uro'raph%
An'io'raph%
Bronchoscop%
6sopha'oscop%
1thers
%**0AL/AT#!-
"he trauma patient must !e ree,aluated constantl% to assure that ne$ findin's are not
o,erlooed.
A hi'h inde2 of suspicion
Continuous monitorin' of ,ital si'ns and urinar% output is essential.
ABG/cardiac monitorin'/ pulse o2imetr%
Pain reli,e. I& opiates/an2iol%tics.
)*+#-#T#0* CA%*
"ransfer to a trauma center or closest appropriate hospital.
T%A/$AT#C S7!C:
%ecognition of Shock :
6arl%5 "ach%cardia and cutaneous ,asoconstriction
4ormal heart rate ,aries $ith a'e; tach%cardia is present $hen
Infant5 I190 BP*
Preschool a'e child5 I170 BP*
+chool a'e to pu!ert%5 I120 BP*
Adult5 I100 BP*
"he elderl% patient ma% not e2hi!it tach%cardia !ecause of the limited cardiac
response to catecholamine stimulation / use of medications
)ifferentiation of shock:
7emorrhagic shock h%po,olemic shoc
-onhemorrhagic shock:
a. Cardio'enic shoc5 Blunt cardiac in0ur%; cardiac tamponade; air em!olus;
m%ocardial infarction.
!. "ension pneumothora2
c. 4euro'enic shoc
d. +eptic shoc
"he normal !lood ,olume of adult is : J of !od% $ei'ht. @hereas that of a child is E.KJ
of !od% $ei'ht.
*stimated +luid and (lood Losses: ( +or a ;<5kg man )
Class # Class ## Class ### Class #0
(lood Loss (ml) Ap to :80 :80.1800 1800.2000 I2000
(lood Loss
(= (lood 0olume)
Ap to 18 J 18.30 J 30.70 J I70 J
Pulse %ate L100 I100 I120 I170
(lood Pressure 4ormal 4ormal #ecreased #ecreased
Pulse Pressure
(mm7g)
4ormal or
increased
#ecreased #ecreased #ecreased
%espirator' %ate 17.20 20.30 30.70 I 38
/rine !utput
(mL6hr)
I30 20.30 8.18 4e'li'i!le
C-S6$ental status +li'htl%
an2ious
*ildl%
an2ious
An2ious;
Confused
Confused;
lethar'%
+luid %epacement
(>:? rule)
Cr%stalloid Cr%stalloid Cr%stalloid
and !lood
Cr%stalloid
and !lood
+luid Therap':
+luid 3olus: 1.2 liters for an adult and 20m)/' for a pediatric patient
>:? rule
>@ C ( 1 liter fluid; micro$a,e; hi'h po$er; 2 minutes )
(lood %eplacement:
P<BC/@hole !lood
Crossmatched/t%pe.specific/ t%pe 1 !lood
33P ( 1A 33P for e,er% 8 A P<BC)
C&P monitorin'
Thoracic Trauma
PAT7!P7.S#!L!.
?8 7'poxia: a. >%po,olemia (!lood loss)M !. Pulmonar% ,entilation / perfusion
mismatch (contusion; hematoma; al,eolar collapse)M c. Chan'es in intrathoracic pressure
relationships (tension pneumothora2; open pneumothora2)
A8 7'percar3ia: a. Inade/uate ,entilation due to chan'es in intrathoracic pressureM !.
#epressed le,el of consciousness
>8 $eta3olic acidosis: >%poperfusion of the tissues (shoc)
ASS*SS$*-T B $A-A*$*-T:
*ust consist of5
1. Primar% sur,e%
2. <esuscitation of ,ital functions
3. #etailed secondar% sur,e%
7. #efiniti,e care
P%#$A%. S/%0*. ( Life5threatening in&uries )
Airwa':
%ecognition of: +tridor; chan'e of ,oice /ualit%; o!,ious trauma
$a&or pro3lems:
1. 3B o!structions;
2. )ar%n'eal in0ur%;
3. Posterior dislocation / fracture dislocation of the sternocla,icular 0oint.
$anagement: 6sta!lishin' a patent air$a%/ 6" intu!ationM closed reduction.
(reathing:
%ecognition of: 4ec ,ein distention; respirator% effort and /ualit% chan'es;
c%anosis
$a&or pro3lems:
1. "ension pneumothora25

Clinical dia'nosis

Chest pain; air hun'er; respirator% distress; tach%cardia; h%potension; tracheal

de,iation; unilateral a!sence of !reath sounds; nec ,ein distention;
c%anosis. (&.+. cardiac tamponade)

>%perresonant percussion.

Immediate decompression5 4eedle decompression/ chest tu!e.

2. 1pen pneumothora25

2/3 of the diameter of the trachea N impaired effecti,e ,entilation

+terile occlusi,e dressin'; taped securel% on 3 sides.

Chest tu!e (remote)

3. 3lail chest5

2 ri!s fractured in t$o or more places.

+e,ere disruption of normal chest $all mo,ement.

Parado2ical mo,ement of the chest $all.

Crepitus of ri!s.

"he ma0or difficult% is underl%in' lun' in0ur% ( pulmonar% contusion)

Pain.

Ade/uate ,entilation; humidified o2%'en; fluid resuscitation.

"he in0ured lun' is sensiti,e to !oth underresuscitation of shoc and fluid

o,erload.
7. *assi,e hemothora25

Compromise respirator% efforts !% compression; pre,ent ade/uate ,entilation.

Circulation:
Assessment: Pulse /ualit%; rate and re'ularit%. BP; pulse pressure; o!ser,in' and
palpatin' the sin for color and temperature. 4ec ,eins.
#mportant notes: 4ec ,eins ma% not !e distented in the h%po,olemic patient $ith
cardiac tamponade; tension pneumothora2;or traumatic diaphra'matic in0ur%.
$onitor with: Cardiac monitor/pulse o2imeter.
$a&or pro3lems:
1.
*assi,e hemothora25

<apid accumulation of I 1800 m) o !lood in the chest ca,it%.

>%po2ia

4ec ,eins ma% !e flat secondar% to h%po,olemia

A!sence of !reath sounds and/or dullness to percussion on one side of the chest

*ana'ement5 <estoration of !lood ,olume and decompression of the chest ca,it%.

Indication of thoracotom%5 a. Immediatel% 1800 m)of !lood e,acuated. !.

200m)/hr for 2.7 hrs. c. Patient?s ph%siolo'% status. d. Persistent !lood
transfusion re/uirements.
2.
Cardiac tamponade5

Bec?s triad5 ,enous pressure ele,ation; decline in arterial pressure; muffled heart
tones.

Pulsus parado2icus.

Oussmaul?s si'n.

P6A

6chocardio'ram.

*ana'ement5 Pericardiocentesis.
%*S/SC#TAT#0* T7!%AC!T!$.
)eft anterior thoracotom%
"he therapeutic maneu,ers that can !e effecti,el% accomplished $ith a resuscitati,e
thoracotom% are5
6,acuation of pericardial !lood causin' tamponade.
#irect control of e2san'uinatin' intrathoracic hemorrha'e
1pen cardiac massa'e
Cross crampin' of the descendin' aorta to slo$ !lood loss !elo$ the diaphra'm and
increase perfusion to the !rain and heart.
S*C!-)A%. S/%0*.:
3urther in.depth P6; Chest 2.ra%s (PA); ABG; *onitorin'.
6i'ht lethal in0uries are considered5
1.
+imple pneumothora2
2.
>emothora2
3.
Pulmonar% contusion
7.
"racheo!ronchial three in0uries
8.
Blunt cardiac in0uries
9.
"raumatic aortic disruption
:.
"raumatic diaphra'matic in0ur%
E.
*ediastinal tra,ersin' $ounds.
Simple Pneumothorax
Breath sounds are decreased on the affected side. Percussion demonstrates
h%perresonance.
CG<
Chest tu!e insertion 3/A CG<..
4e,er use 'eneral anesthesia or positi,e pressure ,entilation to patient $ho sustains
traumatic pneumothora2 until a chest tu!e is inserted.
7emothorax
)un' laceration/ intercostal ,essel laceration/ Int.mammar% a. )aceration.
Chest tu!e
Guide line of sur'ical e2ploration.
Pulmonar' Contusion
<espirator% failure.
Patients $ith si'nificant h%po2ia should !e intu!ated.
*onitorin'.
Tracheo3ronchial Tree #n&ur'
>emopt%sis; su!cutaneous emph%sema; tension pneumothora2 $ith a mediastinal shift.
Pneumothora2 associated $ith a persistent lar'e air lea after tu!e thoracostom%.
Bronchoscop%
1pposite main stem !ronchial intu!ation.
Intu!ation ma% !e difficult operati,e inter,ention
(lunt Cardiac #n&ur'
<esult in5 *%ocardial muscle contusion; cardiac cham!er rupture; ,al,ular disruption.
>%potension; 6CG a!normalities; $all.motion a!normalit%
6CG5 &PC; sinus tach%cardia; Af; <BBB; +" se'. chan'es.
6le,ated C&P.
*onitor.
Traumatic Aortic )isruption
>i'h inde2 of suspicion
Ad0uncti,e radiolo'ical si'ns5
@idened mediastinum
1!literation of the aortic no!
#e,iation of the trachea to the ri'ht
1!literation of the space !et$een the pulmonar% arter% and the aorta
#epression of the left main !ronchus
#e,iation of the esopha'us to the ri'ht
@idened paratracheal stripe
@idened paraspinal interfaces
Presence of a pleural or apical cap
)eft hemothora2
3ractures of the first or second ri! or scapula.
An'io'raph% is the 'old standard.
1n critical.
Traumatic )iaphragmatic #n&ur'
*ore commonl% dia'nosed on the left side
4G tu!e
AGI series.
#irect repair.
$ediastinal Traversing 2ounds
+ur'ical consultation is mandator%.
>emod%namic a!normal 5 thoracic hemorrha'e; tension pneumothora2; pericardial
tamponade.
*ediastinal emph%sema5 esopha'eal or tracheo!ronchial in0ur%.
*ediastinal hematoma5 'reat ,essel in0ur%.
+pinal cord.
3or sta!le patient.
An'io'raph%
@ater.solu!le contrast esopha'o'raph%
Bronchoscop%
C"
Altrasono'raph%.
!thers
Su3cutaneous emph'sema
Traumatic Asph'xia
Compression of the +&C.
Apper torso; facial and arm plethora.
%i3C SternumC and Scapular fractures8
(lunt esophageal %upture
A3dominal Trauma
$echanism of #n&ur':
(lunt Trauma:
+pleen; li,er; retroperitoneal hematoma
Penetrating Trauma:
+ta!5 )i,er; small !o$el; diaphra'm; colon
Gunshot5 small !o$el; colon; li,er; a!dominal ,ascular structures.
Assessment:
7itor'8
P*:
#nspection
Auscultation:
1. Bo$el sounds
Percussion
1. si'ns of peritonitis
2. "%mpanic/ diffuse dullness
Palpation
1. In,oluntar% muscle 'uardin'
*valuation of penetrating wounds:
#etermine the depth
Assessing pelvic sta3ilit':
*anual compression
PenileC perineal and rectal examination:
1.
Presence of urethral tear.
2.
<ectal e2am5 Blunt (sphincter tone; position of the prostate; pel,ic !one fractures);
Penetration (sphincter tone; 'ross !lood from a perforation)
0aginal examination
luteal examination
#ntu3ation:
astric tu3e:

<elie,e acute 'astric dilatation.

Presence of !lood
/rinar' catheter:

<elie,e urine retention

*onitorin' urine output.

Caution: "he ina!ilit% to ,oid; unsta!le pel,ic fracture;!lood in the meatus; a

scrotal hematoma; perineal ecch%moses; hi'h.ridin' prostate.
D5ra's studies:
(lunt Trauma:

>emod%namicall% sta!le5
+upine/upri'ht a!dominal 2.ra%s
)eft lateral decu!itus film
Penetrating Trauma:

>emod%namicall% sta!le5
Apri'ht CG<.
Contrast Studies:
/rethrograph'
C'stogaph'
#0P
# series
Special diagnostic studies in 3lunt trauma:
)PL
/ltrsonograph'
Computed tomograph'
Special diagnostic studies in penetrating trauma:
Lower chest wounds
Anterior a3dominal
+lank63ack
#ndications +or Celiotom'
(ased on a3dominal evaluation
(lunt: Positi,e #P)/ ultrasound
(lunt: <ecurrent h%potension despite ade/uate resuscitation
Peritonitis
Penetrating: >%potension
Penetrating: Bleedin' from the stomach; rectum; GA tract.
unshot wounds: "ra,ersin' the peritoneal ca,it%
*visceration
(ased on x5ra's studies:
3ree air; retroperitoneal free air; rupture of the hemidiaphra'm
C" demonstrates ruptured or'an/ GI tract.
Special Pro3lems
(lunt Trauma:
)iaphragm
)uodemun
Pancrease
enitourinar'
Small 3owel
Pelvic +ractures:
Assessment:

"he flan; scrotum and perianl area should !e inspected

Blood at the urethral meatus; s$ellin'/!ruishin'/laceration in the peritoneum;

,a'ina; rectum; or !uttoc open pel,ic facture

Palpation of a hi'h.ridin' prostate 'land.

*anual manipulation of the pel,is should !e performed onl% once.

$anagement:
*xsanguination with6without
open pelvic fracture
((PE;<mm7g)
(lood pressure sta3ili"ees
with difficult' and
closed6unsta3le fracture
((P @<5??<mm7g)
(lood Pressure normal
and closed6unsta3le or
sta3le fracture ((P ?A<
mm7g)
Initiate ABC#6s

If transfer neccessar%; appl%
PA+G
If open 'o to 1< for possi!le
perineal e2ploration and
celiotom% M if closed;
supraum!ilical #P) or
Altrasound to e2clude
intraperitoneal hemorrha'e.

Positi,e 4e'ati,e

After operation <ed uce =
reduce = appl% appl%
fi2ation de,ice fi2ation de,ice
as appropriate as appropriate

>emod%namicall%
A!nomal
Initiate ABC#6s

If transfer neccessar%; appl%
PA+G
supraum!ilical #P) or
Altrasound to e2clude
intraperitoneal hemorrha'e.
Positi,e 4e'ati,e
After celiotom% <educe
reduce = appl% = appl%
fi2ation de,ice fi2ation
as appropriate de,ice as
appropriate
>emod%namicall%
A!nomal
Initiate ABC#6s

If transfer neccessar%;
appl% PA+G
6,aluate for other in0uries
Appl% fi2ation de,ice if
needed for patient mo!ilit%
An'io'raph%
An'io'raph%