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Atls Chapter 1

Atls Chapter 1

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Published by prislopan13may5852
advanced trauma life support
advanced trauma life support

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Published by: prislopan13may5852 on Dec 08, 2009
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01/30/2013

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I
CHAPTEB
InitialAssesrnentandManaent
IOBJECTIVES:
Upon completionof thistopic, thestudentwill be able to demonstrate theability to applythe principlesofemergencymedical care tothemultiplyinjured patient.Specifically,the doctorwill be ableto:A. Identify the correctsequenceofprioritiesin assessinghe multiply injuredpatient.B. Applythe principles outlinedin the primaryand secondary evaluation surveysto theassessmentofthemultiplyinjured patient.C. Applyguidelinesand techniquesintheinitial resuscitative and definitive-care phasesof treatmentof themultiplyinjuredpatient.D. Identify how thepatient'smedicalhistory and the mechanism ofinjury contribute to theidentificationofinjuries.E. Anticipate the pitfatlsassociatedwith theinitial assessment andmanagementoftheinjuredpatientandapplystepsto minimizetheirimpact.F. Conduct aninitial assessmentsurveyon a simulatedmultiplv injuredpatient,usingthe correct sequenceof prioritiesand explainingmanagementtechniquesfor primary treatment and stabilization.
idilautcedTraunm ifeSupport
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ICHAPTEBINITIALSSESSMENTNDMANAGEMENTI.INTRODUCTION
'fhetreartmentof theserioush'injureclpatientre-quiresrtrpiclassesslllentfthe'njuriesandinstitu-tio.ofiiie-preser'ingtherapr'.Becauseimeisoftheessencc,Systemarticp1-rroachhatcelubeearsilt'revic-l,t,edurclracticecls desirable.Thisprocessstermerl"itritialclSS€SSll1€nt"ltdinclucles:1.Preparartictn2.Triage3.prinarysurye\,(ABCDEs)l.Resuscit.ttiotr5.Adjunctsto primarvsurvevantlresuscitation6.Seconclarvsurvel'(heacl-to-toeer';rluatic-runclhistorv)7.AcljunctstothesecondarvsurvevB.Continueclpostresuscitationmonitoringanclreevaluation9.DefinitivecareTheprimaryandsecondarysurveysshouldberepeatedfrequentlytoascertainanydeteriorationinthepatient'sstatusandanynecessaryreatmenttobeinstitutedatthetimeanadversechangeisidentified.Thissequences presentedn thischapterasalongi-tudinalprogressionoferrents.ntheactualclinicalsituation,manyoftheseactivitiesoccurinparal-lelorsimultaneously.Thelinearorlongitudinalprogressionallorvstl-redoctoranopportunitt'to^"r-rtolivre\riert,theprogressof anactualtraumaresuscitation.ATLSo'isintendedtoguidetheassessmentandresuscitationofinjuredpatients'judgment isrequiredtodeterminewhatproceduresareneces-,uiy,becausenotallpatientsrequirealloftheseprocedures.
II.PREPARATION
Preparationforthetraumapatientoccursin2dif-ferentclinicalsettings.First,duringtheprehospitalphase,alleventsmustbecoordinatedn'iththedoctorsatthereceivinghospital.second,duringthehospitalphase,preparationsmustbemadetorapiclh,,facilitatetl'reresuscitatior-rpfthetraumapatient.
A.Prehospitalhase
coclrclinationr.r,iththeprc-hospitalagellcvatrclpersonnelcangreatlt'expe-clitehetreaturentitrihefielcl'TheprehospitarlS)'stetlrhoulclbesetupsuchtirattl-reece'ivinghospitalisnotiiieclbeforetheprehospritalpersonneltrausl'rortthepatientiromthescene.Thisallort'smobilizationofthehospital'straumateamnte.t'nbersc'rhatallneces-soatlpersonnelandresourcesc-lrcPresc'lrtrithe.errrerge.llcyr'partrne'ntatthe-iuretlfthepatietrt'sarrivil.En-rphasisntheprehospitalphaseshoultlbeplacedtrr',oirovovlaintellance,coutrolofexternalLleeclinganrlshock,irnmolrilizationofthepeltierlt,anclmmecliaterarnsporto theclosestappropriatefacility,preie-rablvaVerifiedtraurnarenter'Everveffort-shoulclemacletorninimizesceneime.(SeeFlorvchart1,TriageDe.cisiorrchr.me.)heNationalAssociationofEmergencr.IVIec-licalechuicians'PrehospitalTraurnaLifeSupportCommittee',in.nop"titionrviththeCommitteeonTrarumaCOT)oftireAtnericarnCollegeofSurgeons(ACS),hastle-VelopedacoLlrse'ithaformatsirnilartotheATLSCouisethatadclressesheprehospit.llcarerssuesortheinjuredpatient.Emphasisalsoshouldbeplace-clorrobtaininganclreportinginformationneedeclortriargeatthehospital,eg,timeofiniurr',e'\'entse-latedtotheinjurv,and patienthistorr'.Themecha-nistnsofinjun'malrsuggestthetlegreeofinjurvasrvellasspecificinjuriesforr.t'hichhepatietrtmustbeevaluatecl.
B.Inhospitalhase
Aclvanceclplanningforthetraumapatient'sarrivalisessential.deallv,a resuscitationareashouidbeavailableortraunrapatients.Properairwavequip-ment(eg,arr.'ngoscopes,ube's)houIclbegrgauizecl,testecl,anclplacedwhereitisip-rnediatelyacces-sible.Warmedintravenouscrvstalloidsolutions(eg,Ringer'sactate)houldbeavailableandreat11'ton-fusen,henthepatientarrives.Appropriatemonitor-ingcapabilitiesshouldbeimmediatelyar''ailable'Amethoc-lo summonextramedicalassistanceshoulclbein place.AmeanstoassurepromptresponsebvlaboratorvandradiologvpersollnelisnecessarY.Transferagreementsrvitha verifiedtrautnacentershoulclbeestablishedandoperatiolal.(Reference:ACSCommitteeonTrauma,Resottrc?sttrOptinmlCareo.fheniuredPLtiutt.)Perioclicrevielvof patientcarethroughthequalitr,'improvementprocessisanessentialcomponentofthehospital'straumaproEirarll.
12
ArnericnttCollet'ofSurgeorrc
 
CHAPTERI
All personnelwho have contactwith the patientmustbe protectedfromcommunicable diseases.Most prominentamong these diseases arehepati-tis andthe acquiredimmune deficiencysyndrome(AIDS).The CentersforDisease Control andPre-vention(CDC) and otherhealth agenciesstronglyrecommendthe use ofstandard precautions(eg,facemask,eye protection,water-imperviousapron,leggings,and gloves)whencoming in contact withbodyfluids.The ACS COT considersthese tobeminimumprecautionsand protectionfor all healthcare providers.This also is anOccupational SafetyandHealthAdministration(OSHA) requirementintheUnited States.
III.TRIAGE
Triageis thesorting of patientsbased on theneedfortreatmentand theavailable resources o providethat treatment.Treatment isrenderedbasedon theABC priorities(Airway with cervicalspineprotec-tion,Breathing, and Circulationwith hemorrhagecontrol)as outlinedlater in this chapter.Triage also pertainsto the sortingof patientsin thefield andthemedical facility to whichthey are to betransported.It is the responsibilityof the prehospi-tal personneland theirmedicaldirectorto seethattheappropriatepatients arriveat the appropriatehospital.It is inappropriatefor prehospital per-sonnel todeliver aseverely traumatizedpatient toa nontraumacenter hospitalif a trauma centerisavailable.(SeeFlowchart7, Tfiage Decision Scheme,adaptedwith permissionfrom ACS Committee onI'rauma,ResourcesforOptimalCare ofthe Injured Pa-tirltt.) Prehospitaltraumascoring ishelpful in iden-tifying those severelyinjured patientswho shouldlrc transportedto a trauma center.(SeeAppendix1,'l'riageScenariosandAppendix 5,TraumaScores:l{evised andPediatric.)Twotypesof triage situa-tions usually exist:
l.Multiple asualties
,irt.:l"hcumber ofpatientsandthe severityoftheirin-Jurit'sdonot exceedthe ability of thefacility to ren-*rcare. In this situation,patientswith life-threaten-problems andthose sustainingmultiple-systemuricsare treatedfirst.useof prehospitalcare protocolsand onlineiealdirection canfacilitate andimprovecareni-in thefield. Periodic multidisciplinaryreview
INITIATSSESSMENTNDMANAGEMENT
ofthe care providedthrough qualityassurance/improvementactivitiesis essential.
B.MassCasualties
Thenumber ofpatients and theseverity of theirin-juriesexceedthe capabilityof the facility andstaff.In thissituation, thosepatientswiththe greatestchance ofsurvivaland with the least expenditureoftime, equipment,supplies,and personnel,are man-aged first.
IV. PRIMARYURVEY
Patients are assessedandtheir treatment prioritiesestablishedbasedon theirinjuries,theirvital signs,andthe injurymechanism.Inthe severelyinjuredpatient,logical sequentialtreatment prioritiesmustbe establishedbasedon overall patientassessment.The patient'svital functionsmust be assessed uick-ly and efficiently.Patientmanagement must consistofa rapid primaryevaluation,resuscitation ofvitalfunctions,a more detailedsecondary assessment,and,finally, theinitiation of definitive care.ThisprocessconstitutestheABCDEs of trauma careandidentifies life-threateningconditionsby adheringtothis sequence:A Airwaymaintenancewithcervicalspine pro-tectionB Breathingand ventilationCCirculationwith hemorrhagecontrolD Disability:NeurologicstatusEExposure/Environmentalcontrol: Com-pletelyundressthe patient, but preventhypothermiaDuringthe primary survey,life-threatening condi-tionsare identifiedand managementis institutedsimultaneously.The prioritized assessmentandmanagementproceduresreviewedin this chapterareidentified assequential stepsin order of impor-tanceand forthe purpose ofclarity. However, thesestepsarefrequently accomplished simultaneously.Prioritiesfor the care ofthe pediatric patient are thesameas thosefor adults.Although the quantitiesofblood,fluids, andmedications,the size of the child,degreeandrapidity ofheatloss,and injury patternsmay differ,assessmentand management prioritiesare dentical.Specific problemsof the pediatric trau-t't'il'fauma Ltfe Support

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