JasonWolfe'sATLSTraumaMoulage

Page
(ThoughtsontheManagementoftheMultiplyInjured
Patient)

Aim: Togivepeopleaframeworkforthinkingaboutthemanagementofth
aculminationoftheteachingandexperiencesIgainedduringapast

ATLS: TheATLScourseitselfisanexcellentwayofpracticingthetheoreti
traumapatientstodoit.
Note:

ThisisnotmeantasashortcutwhichnegatestheneedtoreadtheA
don'treadtheATLSmanual.

PS:

Notethattheterm'ATLS'isaregisteredtrademarkofthe'American

GeneralPrinciplesofTrauma
Management

1.Thereisaneedforrapidevaluationofthetraumapatient.Timewastedcosts
2. Theabsenceofadefinitivediagnosisshouldneverimpedetheapplicationofe
3. Thefirst'GoldenHour'iscrucialtoboththeshortandlongtermsurvivalofth
4. Thereisaneedtoestablishmanagementpriorities:Thethingswhichwillkill
thepatientlateraremanagedlater.Thus,airwayproblemsaremanagedandtr

5. Alltreatmentmodalitiesshouldbegovernedbytheabidingprincipleof'First

OverviewofATLSProtocol:
(Stages&SubjectHeadings)

1.Preparation
2. Triage
3. PrimarySurvey(ABCDE)&Resuscitation
4. AdjunctstoPrimarySurvey&Resuscitation
5. ConsiderneedforPatientTransfer
6. SecondarySurvey(withAMPLEHistory)
7. ContinuedPostResuscitationMonitoring&Re
evaluation
8. TransfertoDefinitiveCare

1.PreparationEquipmentneededforPractice
Youshouldfamiliariseyourselfwithallthefollowingequipment.Youshould
beableexplaineachitem'suse,notonlyjustbyphysicaldemonstrationbut
alsobyverbaldescription.

GENERALEQUIPMENT

OneLivePatient(usuallyanactorwithcopiousbutexpertmake
uptoensurerealism)

OneNurseAssistant(whousuallyisaninexperiencedstudent)
OneCandidate(withlargeamountsofadrenalineinbloodstream
andsuitablyfastbeatingheart)
OneExaminer(tomakelifedifficultandgenerallythrowa
spannerintheworks)
UniversalPrecautions
Toilet+/Cigaretteforafterwards

CERVICALSPINEEQUIPMENT

LongSpinalBoard
HardCollarsofvarioussizes
Sandbags
Tapeforsecuringhead

Suction
Oxygen
Ventilator
Laryngoscopes(varioussizes&shapes)
BagandMaskwithReservoir
FlexibleBougie
TongueDepressor
Oropharyngeal/NasopharyngealTubes
Orotracheal/Nasotracheal/EndotrachealTubes
NeedleCricothyroidotomySet
FormalCricothyroidotomySet
Tracheostomyset(forchildrenunder12yrs)
SurgicalDrapes
10mlSyringes
Scalpel

AIRWAYEQUIPMENT

BREATHINGEQUIPMENT

Stethoscope
LargeBoreCannula
ChestDrainSetincluding:

Antisepticswap
LocalAnaesthetic
Scalpel
Dissectingforceps
ChestDrain
Tubing
Suitablecontainerwithunderwaterseal
StitchMaterial
Occlusivedressing

CIRCULATIONEQUIPMENT

PressureDressings&Swabs
Antisepticswaps
HypodermicNeedles
IntravenousCannulas
LongvenousCannulasforusewithSeldingersTechnique
Pericardiocentesisovertheneedlecannulas
VenousCutdownset
PeritonealDialysisCatheter
AdhesiveTape
Givingsets
Syringes
WarmedCrystalloid/Colloid/Blood
PASG:PneumaticAntiShockGarment

SetofResuscitationTrolleyDrugs
Lignocaine(+/Adrenaline)L/AInjection
LignocaineGelforCatheterisation
XylocaineSprayforOro/NasopharyngealL/A
Heparin

DRUGS

MISCELLANEOUSSTUFF

Resuscitationtrolley
Defibrillator

PulseOximeter
BloodPressureMonitor
CardiacMonitor
Capnograph
Normal&LowRangeThermometers
NasogastricTube
UrinaryCatheter
FastIntravenousInfuser/WarmerDevice
Ophthalmoscope&Otoscope
FractureSplints
GlasgowComaScaleChart
BroselowPaediatricResuscitationMeasuringTape
XRayViewingBox
WarmingBlanket
PolaroidCamera
Hammer&Nailstopreventtheparamedicswhobroughtthe
patientinfromleavingthedepartmentbeforetheyhavegivenan
amplehistory.

2.Triage.
Triageistheprioritisationorrankingofpatientsaccordingtoboththeir
clinicalneedandtheavailableresourcestoprovidetreatment.Theprocessis
basedonthesameABCprinciplesasexplainedbelow.

3.SummaryofPrimarySurvey&Resuscitation:
(Explainedinfulldetaillater)

AAirway&CervicalSpineControl
BBreathing&Oxygenation
CCirculation&HaemorrhageControl
DDysfunction&DisabilityoftheCNS
EExposure&EnvironmentalControl

4.AdjunctstoPrimarySurvey&Resuscitation:
Thesearevarioususefulmonitoringortherapeuticmodalitieswhich
supplementtheinformationalreadyobtainedusingclinicalskillsinthe
PrimarySurvey.

Theyinclude:
1.PulseOximeter
2. BloodPressure
3. CardiacMonitor/Electrocardiogram
4. ArterialBloodGases/EndTidalpCO2
XRaysChestXRay/Cervical
5.
Spine/Pelvis/Others
6. NasogastricTube&UrinaryCatheter
7. CoreTemperature

5.ConsidertheNeedforEmergencyPatient
Transfer.
Theparticularaccidentunitorhospitalwherethepatienthas
arrivedisnotalwaysthemostsuitableplaceforthedefinitive
careofthatpatienttobemanaged.Oncetheresuscitationis
wellunderwayandthepatientisstable,considerationshould
begiventotransferringthepatientelsewhere.Transfermay
betoanotherhospitalwhichismoregearedtotreatingthe
multiplyinjuredpatient(eg.alevel1traumacentre)orto
anotherfacilitywhichcanadequatelydealwiththeparticular

setofspecialisedinjurieswhicharepeculiartoyourpatient
(eg.aneurosurgicalunit).Transfermayalsobetoadifferent
departmentofthesamehospital(eg.theatres/radiology).In
anycase,patienttransferisoftenthetimeofgreatestperilfor
thepatientbecauseitisalltooeasyforthe'levelofcare'to
decline.Thechallengethereforeistoensurethatthislevelof
caredoesnotdeteriorateatanytime.Transfershouldalways
beassoonapossibleafterthepatientisstabilised.The
acquiringofspecialisedinvestigationsshouldnotholdupthe
transferofthepatientastheseinvestigationsareoftenmore
appropriatelyperformedintheunitwherethepatientistobe
transferred.

6.SecondarySurvey.
AfullAMPLEhistoryistakenfromanyonewhoknowsthe
relevantdetails.Thisoftenincludesboththefamilyandthe
paramedicswhobroughtthepatientin.Thisisfollowedby
completeheadtotoe&systemsexamination.Allclinical,
laboratory&radiologicalinformationisassimilatedanda
managementplanisformulatedforthepatient.Duringthis
timethereisaprocessofcontinuedpostresuscitation
monitoring&reevaluation.Anysuddendeteriorationinthe
patientshouldimmediatelypromptthedoctortoreturntothe
primarysurveyforareassesmentoftheABCDE's.

AMPLEHistory:
AAllergies
MMedicines
PPastMedicalHistory/Pregnancy
LLastMeal

EEvents/Environmentleadingtothecurrenttrauma

7.TransfertoDefinitiveCare
Thisisgovernedbythesameprinciplesaswerementionedaboveinthe
emergencytransferofpatients.Thelevelofcareshouldnotdeteriorate.

ThePrimarySurvey&
Resuscitation.
(Thisisthemainpartwhichistestedinthepracticalmoulages,sothisthe
partwillbecoveredinthegreatestdetail)

NOTEFIRST:
9ImmediatelyLifeThreateningInjuriesor
ConditionswhichshouldbepickedupinABCDE
andtreatedimmediately:
1.InadequateAirwayProtection
2. AirwayObstruction
3. TensionPneumothorax
4. Openpneumothorax
5. FlailChestwithHypoxia
6. MassiveHaemothorax
7. CardiacTamponade
8. SevereHypothermia

9.

SevereShockfromHaemorrhageUnresponsivetoFluid
Resuscitation.

NOTEALSO:
13PotentiallyLifeThreatening"NonObvious"
Injurieswhichshouldbeconsideredinthe
traumatisedpatient,butwhosemanagementcan
oftenwaituntilafterABCDEuntilthetimeof
definitivecare:

1.SimplePneumothorax
2. Haemothorax
3. PulmonaryContusion
4. TracheoBronchialInjury
5. BluntCardiacInjury
6. TraumaticAorticDisruption
7. DiaphragmaticRupture
8. MediastinalTraversingWounds
9. BluntOesophagealTrauma
10. Sternal/Scapular/RibFractures
11. RupturedLiverorSpleen
12. Ruptureofanabdominalorpelvicviscus
13. Anyotherchest/abdominal/orpelvicinjurieswhichhaveresultedinorgand
shock

HowtoapproachthePrimarySurveyandwhattodo
:
Thisnextsectionassumesyouareinamoulagescenarioandgoesthrough
yourpossibleactionsandreactionsinresponsetowhatyoufindwithyour
patient.

AAIRWAY&CERVICALSPINECONTROL

Sayyouarewearinguniversalprecautions.
Approachpatientfromheadsideandstabilisecervicalspineusing
inlineimmobilisation.Trytoavoidplacingyourhandsoverthe
patient'sears.
Introduceyourselfandreassurepatient.
AssesspreliminaryABCfrompatientsresponsetothis.
IFTHEAIRWAYISNOTATLEASTPARTIALLYSECURE,
thendefinitivecervicalspinecontrolwillhavetowait.Askthe
nursetotakeoverthefunctionofinlineimmobilisationofthe
cervicalspine,andMOVEONTOAIRWAYMANAGEMENT.
Don'tforgettocomebacktocervicalspinemanagementlater.
CERVICALSPINEMANAGEMENT:
Askforahardneckcollar.Measurethesizeofcollarby
measuringfromtheangleofmandibletothetopofshoulder/
trapezius.Thecollarshouldbethesamesizefromtheblack
markerpegtothebaseofthehardpartofthecollar.
ApplySandbagsandTape.
AIRWAYMANAGEMENT:
Inthetraumapatient,ifthepatientislikelytoneedintubation
eventually,thenearlyintubationispreferred,soastopreventthe
patientfromtiringandbecomingacidotic.
Suctionouttheairwayorremoveforeignbodiesifnecessary.

IFBREATHINGISSPONTANEOUSANDTHEPATIENTIS
CONSCIOUS,BUTAIRWAYISCOMPROMISEDBYPOOR
PHARYNGEALTONE/REDUCEDLEVELOF
CONSCIOUSNESS(GCS913):
Tryjawthrust/chinliftandaskforresponse.
Iftheresponseisgood,insertanoropharyngeal(Guedel)or
nasopharyngealairway.
Notes:
Theoropharyngealairwayismeasuredfromtheedgeofthemouth
tothetragusoftheear.
Thenasopharyngealairwayismeasuredfromthenostriltothe
tragusoftheear.Itsdiameterisalsoconvenientlyestimatedby
lookingatthepatient'slittlefinger.
Don'tattempttoinsertanasopharyngealairwayifthepatienthasa
headinjurywiththepossibilityofabasalskullfracture.
Assumingthepatientrespondstothis,applyoxygenusingaface
maskwithattachedreservoirbag.
Ifyouhaven'talreadydoneso,mostpatientsshouldnowhavetheir
neckimmobilisedwithahardneckcollar,sandbagsandtape.
IFTHESUPPORTIVEMEASURESABOVEHAVEFAILED,
ORIFPATIENTISUNCONSCIOUSWITHAGCSOF8OR
LESS,ORIFTHEPATIENTISAPNOEIC:
Thepatientneedsadefinitiveairway.
Callforananaesthetist.
IfthepatientisCOMPLETELYUNRESPONSIVE,itisnecessary
toproceedstraighttoendotrachealintubation.
MethodofENDOTRACHEALINTUBATION.
Preoxygenatewithbagandmask.
Theneckcollarwillneedtoberemovedduringintubationand
duringthistimeyourassistantmustprovideinlineimmobilisation
oftheneck.

Standingabovetheheadofthepatient,insertalaryngoscopeinto
theoropharynx,pushingthetonguetotheleft.Pullthescope
upwardsandawayfromyourselfuntilthevocalchordsbecome
visible.
Sliptheendotrachealtubethroughthevocalchords,ifnecessary
usingagumelasticbougie.Inflatethetube'sballoonsealand
connectthetubetoareservoired'bag&mask'orventilator.Some
patientsmaybesuffientlystablewiththeETtubeinsitutobreathe
spontaneouslywithouttheneedforbag&maskorventilator.
Ensurepositioningoftubeintracheabylisteningtothechest
(listentothelungapices,basesandoverthestomach).Final
confirmationcanbemadebyconnectingthetubetoacapnograph.
SecurethetubeusingacommerciallyavailableETtubesecuring
device.
Oncefinished,reestablishcervicalspinecontrolusingthehard
neckcollar,sandbagsandtape.
IfthepatientisSTILLPARTIALLYCONSCIOUSAND
RESPONSIVE,thenintubationwillneedtobecarriedoutby
'RAPIDSEQUENCEINDUCTION',usinganaestheticdrugs.The
procedureshouldonlybecarriedoutbypractitionerswhoarequite
familiarwithits'insandouts'(whichusuallyexcludeseveryone
exceptexperiencedanaesthetists).Ifyouaren'texperienced
enoughtoperformRSI,then'bag&mask'untiltheanaesthetist
arrives.

IFTHEACTIVEMEASURESABOVEHAVEFAILED,OR
THEREISPARTIALUPPERAIRWAYOBSTRUCTIONWITH
STRIDOR,ORTHEPATIENTISAPNOEICFROM
COMPLETEAIRWAYOBSTRUCTION:
PerformNEEDLECRICOTHYROIDOTOMYanddescribethis
method.
Alargeborecannulaisinsertedthroughthecricothyroid

membraneandisthenconnectedtohighflowoxygenat15litres/
minute.Inspiration/Expirationisachievedbyintermittently
holdingonesthumboverthesideofanopenYconnectorattached
tothecannula1secondinspiration,4secondsexpiration.The
patientcanonlybeadequatelyoxygenatedusingthismethod
forabout3045minutes.
Callforananaesthetist.
Finallyestablishdefinitiveairwaybyformalcricothyroidotomy
anddescribethismethod.

OTHERINDICATIONSFORADEFINITIVEAIRWAY
INCLUDE:
Severemaxillofacial/laryngeal/neckinjurieswithimpending
obstruction.Thepatientwillalmostcertainlyrequireasurgical
airway.
SevereClosedHeadInjurieswithareducedlevelofconsciousness,
ariskofaspiration,andtheneedforhyperventilation.
Ifyouhaven'talreadydoneso,apply100%oxygen.
AsknursetoapplyPulseOximeter,BloodPressureMonitorand
CardiacMonitor.Askhertotakereadingsfromallthesemonitors.

BBREATHING&OXYGENATION

Ifpatientsuddenlydeterioratesatanypoint,movebackandcheck
airwayagain.
Movedownneck.
AssessCarotidpulseforRate,Character&Volume.
CheckNeckveinsfordistension.
CheckforWounds,Laryngealcrepitus&Subcutaneous
emphysema.
CheckifTracheaiscentral.

Thenmoveontochest.
InspectforBruising/Asymmetryofexpansion.
Palpateanyareasofinterest.
CheckforSubcutaneousemphysemaandFlailchest.
PercussandAuscultatebothanteriorandlateralchestandaskfor
results.
IFPATIENTHASASIMPLEPHEUMOTHORAX:
Hyperresonantchest,reduced/absentbreathsounds,butneck
veinsdownandtracheacentral.
AskthenursetosetupformalChestDrainset.
Don'tinsertthechestdrainyet,butstatethatyouintendtoinsertit
later.
CHESTDRAININSERTION:
Drape&surgicallypreparethechest.
Ifthereistime,giveaninjectionoflignocainelocalanaesthetic.
Makeanincisioninthe5thintercostalspacejustanteriortothe
midaxillaryline,andjustabovetheupperborderofthe6thrib.
Bluntdissectdownthroughtheintercostalmuscles,untilthepleura
ispunctured.Clearawayadhesions,clotsorforeignbodiesusinga
fingersweep.
Clamptheproximalendofthechestdrainandthenadvanceitinto
thechesttothedesiredlength.
Connectthechestdraintoanunderwatersealapparatusandthen
unclampit.
Checkthedrainisfunctioningcorrectlythewatercolumnatthe
underwatersealapparatusshouldmoveuponinspirationand
bubbleduringexpiration.
Suturethetubeinplaceusingapursestringsutureandthenapply
anadhesivenongaspermeabledressingtothesite.Applythe
dressingto3outof4sidesofthedraintube.
Finallyreexaminethechestandobtainanearlychestxray.

IFNECKVEINSDILATED,TRACHEADEVIATED,
ABSENTORREDUCEDBREATHSOUNDSANDCHEST
HYPERRESONANT,THENTHINK
'TENSIONPNEUMOTHORAX':
AsknursetosetupformalChestDrainset.
Inthemeantime,performNeedleThoracostomyandcheckfor
hissingsound.Leavetheneedlethoracostomyopen.
Reexaminechestandaskforresponse.
Ifpatientstabilises,thenleaveformalchestdrainuntillater.
Iftheydon'tstabilise,performanotherNeedleThoracostomyand
proceedstraighttoformalChestDraininsertion.
Describethismethod.
IFPATIENTHASEVIDENCEOFCHESTTRAUMA,
DILATEDNECKVEINS,MUFFLEDHEARTSOUNDS,AND
DECREASEDARTERIALBLOODPRESSURE(POSSIBLY
EVENPULSELESSELECTRICALACTIVITY)(BECK's
TRIAD),THENTHINK'PERICARDIALTAMPONADE':
ProceedstraighttoNeedlePericardiocentesis.
Describethismethodandcheckforresponse.
NEEDLEPERICARDIOCENTESIS:
Monitorthepatient'svitalsignsandECGbefore,during&after
theprocedure.
Drape&surgicallypreparethexiphoidarea.
Usea#16gauge15cmneedle,3waytap,anda20cmsyringe.
Puncturetheskin12cmbelowandlateraltotheleftxiphi
chondraljunction,pointingtheneedleatanangle45totheskin
andaimingforthetipoftheleftscapula.
Advancetheneedleuntilthereisaflushbackofblood,andatthis
pointwithdrawasmuchbloodaspossible.
Iftheneedleisadvancedsothatitpenetratesthemyocardium,the

ECGpatternwillchange,producingwildSTTsegmentvariation
andwidened/enlargedQRScomplexes.Ifthisoccurs,theneedle
shouldbewithdrawnslightlyuntiltheECGpatternreturnsto
normal.
Itissometimesnecessarytoleaveacannulainsituforrepeat
aspirations,andsoheretheneedlemaybechangedtoaplastic
cannulausingtheSeldingertechnique.

IFPATIENTISHYPOXIC,SHOCKED,HASASTONY
DULLCHEST,ABSENTBREATHSOUNDSANDA
TRACHEADEVIATEDAWAYFROMTHISSIDE,THEN
THINK'MASSIVEHAEMOTHORAX':
Establishintravenousaccessusingtwolargeborecannulas.
Proceedimmediatelytoinsertionofchestdrain.
IFPATIENTHASAFLAILCHESTANDISHYPOXIC:
Earlyintubationisessential.
PerformOrotrachealintubationyourselfpreferablyby'Rapid
SequenceInduction'orcallforananaesthetisttodoit.
IFPATIENTHASANOPENPNEUMOTHORAX:
Coverthisopeningwithanocclusivedressing.
Securethedressingwellsoastopreventairleaks.
ProceedstraighttoChestDrain,placingthedrainwellawayfrom
thewoundoftheoriginalopenpneumothorax.

CCIRCULATION&HAEMORRHAGE
CONTROL

AsknursetorepeatmeasurementsofOxygenSaturation,Blood

Pressure&Pulse.
Palpatethepatientsheadandhandslookingforsignsof
'shock'.Thisisdefinedasinsufficientorganperfusionand
oxygenation.Itissuspectedinapatientwithcold,clammy,pale,
peripherallyshutdownextremities.
MoveontoAbdomen&Pelvis.
ABDOMEN:
Inspectabdomenforinjuriesordistension.
Palpateabdomenforanymassesorsignsofperitonism.
Considerabdominalpercussion&auscultation.
Iftherearesignsofabdominalbleeding,askthenursetofastbleep
theoncallsurgeonandaskthemtocometocasualty.
Askthenursetostatethatyouhaveaclinicallyshockedpatientin
casualtywhoyoususpecthasabdominalbleeding,whoyouarein
theprocessofresuscitating,butwhomayurgentlyneedtobetaken
totheatreforlaparotomy.
PELVIS:
PalpatethePelvis.
Applybothlateralandanteroposteriorspringingforcesontothe
anteriorsuperioriliacspinesandfeelforabnormalmobilityor
crepitus.Onlyperformthisexaminationonce.
Askexaminerwhetherthepelvisisstableorunstable.
Iftherearesignsofafracturedpelvis,askthenursetofastbleep
theorthopaedicsurgeononcallandaskthemtocometocasualty.
Askthenursetostatethatyouhaveaclinicallyshockedpatientin
casualtywhoyoususpecthasanunstablefractureofthepelvis,
whoyouareintheprocessofresuscitating,butwhorequires
urgentstabilisationwithapelvicexternalfixator.
GiveconsiderationtotheuseofaPASGPneumaticAntiShock
Garmentorinternallyrotatethehips(whichmaycloseanunstable

openbookpelvicfractureandlimitthebleeding).
Trytogetapelvisxraybeforetheorthopaedicsurgeonarrives,
providedthisdoesn'tinterferewiththerestofyourresuscitation.

LIMBS:
Quicklymoveontothelimbs,cuttingoffclothesasnecessary,and
examiningforthepresenceofobviousdeformityorsofttissue
haematoma.
Anysourcesofexternalhaemorrhageshouldimmediatelybe
stemmedbyapplyingdirectpressureandwrappinginabandage.
IfthereareOpen(Compound)Fractures,thentheseshouldbe
photographed,andthenimmediatelypackedwithaBetadine
soakedbandageanddirectpressureapplied.Askthenursetostand
bywithintravenousmorphine,atetanusinjectionandintravenous
antibiotics(usuallycefuroxime&metronidazole).The
orthopaedicteamshouldbeinformedandaskedtoattendtheA&E
department.
FLUIDRESUSCITATION:
Havingexaminedthebodyforpotentialsourcesofhaemorrhageas
wellasstemminganyareasofoverthaemorrhage,fluid
resuscitationshouldbegininearnest.
Youneedtoplacetwolargebore(#14gauge)intravenous
cannulas,oneineachcubitalfossa.
BloodshouldbeaspiratedintoasyringeforFBC,U&E,and
CrossMatch.Askthenursetoensurethatthesampleisrushedto
thelab.Askfor24unitsofONegativeBlood,24unitsof
TypeSpecificBlood,and24unitsofCrossmatchedBlood,
dependingontheindividualcircumstances.
Ifcannulationisunsuccessful,thenalternativesincludetheother
cubitalfossa,thefemoralvein,thesubclavianvein,theexternal

jugularvein,theinternaljugularvein,oravenouscutdownforthe
greatsaphenousvein.
Immediatelysetup1litreofwarmedHartmannsforeachofthe
twocannulasandrunthroughusingafastinfuser.Thiscantake1
2minutestorunin.
Inchildrenunder6years,intraosseousinfusionisthepreferred
methodofaccessafter2unsuccessfulattemptsatcannulation.In
infants,scalpveinsmaybetried,andinneonatestheumbilical
veinoftenprovidesexcellentaccess.Thevolumeoftheinfusion
bolusinchildrenis20mls/kgandthiscanberepeated2or3times
dependingonresponse.
AskthenursetorepeatOxygenSaturation,BloodPressure,Pulse
&RespiratoryRate.CheckalsotheTemperature.
Accordingtoresponse,500mlsofcolloidcanthenbeinfused
througheachcannula,or(morelikely)intheabsenceofaclinical
improvement,the2unitsofONegativebloodwhichhavejust
arrivedfromthelabshouldbegivenusingthefastinfuser.Ifthe
patientcanwait10minutesfortypespecificblood,thenthisis
preferable.

CheckforClinicalResponse.

Ifthepatientfailstorespond,orinitiallyresponds
butsubsequentlydeteriorates,youshouldreflecton
thevariouspossiblecausesofthisstateofaffairs:

1.GobackandcheckAirway&Breathing.
2. ThepatientcouldbeBLEEDINGfasterthanyouarereplacingblood.Thesep

3. ThepatientcouldbeHYPOTHERMICandthereforemayberespondingmore
4. ThepatientcouldbeinCARDIOGENICSHOCK:Heretheheartpumpisfail
andactappropriatelyifrequired.ConsiderearlyCVPmonitoring.
5. ThepatientmaybePREGNANT.Ifmoderatelyorheavilypregnantwomena
Cava.Suchpatientsshouldbebolsteredsothattheyarelyingslightlyontheir
shouldbecarriedoutearlierratherthanlaterintheresuscitation.
6. ThepatientmaybeinNEUROGENICSHOCK:Thisoccurswithspinalcord
resultsinaclinicalpictureofhypotensionwithouttachycardiaorperipheralva
thejudicioususeofvasopressors.EarlyCVPmonitoring&SwanGanzpulm
7. SEPTICSHOCK:Thisisuncommonintheearlyperiodfollowingtraumabut
wherethewoundhasbeencontaminatedwithdirtyexogenousdebris,especial
tachycardia,pyrexiaandcutaneousvasodilation.

Alltheabovearetreatedbygenerousvolume
replacementalongwithdefinitivetreatmentofthe
causeoftheshock.
OtherConsiderationsintheDiagnosis&Treatment
ofShock.

1.OLDAGEElderlypatientshaveless'physiologicalreserve':Theyarelessa
decreasedbloodflowandhypoxiaassociatedwithshock.Thelungsarelesse
stimulusofthestresshormonesAldosterone,AntiDiureticHormone&Cortis
elderlypatienttopaymeticulousattentiontovolumeresuscitation,andthepla
devicesshouldbeplacedearlierratherthanlater.
2. YOUNGAGEChildrenandbabieshaveanespeciallyhighphysiologicalres
percentagesoftheirbloodvolume.Howeverwhenthepercentageofbloodlo
precipitously.Thelessonhereisthatchildrenmaystillhavenormalvitalobse
3. ATHLETESAlthletesmayhaveanincreasedbloodvolumeofupto1520%
lowerthanunfitindividuals.Thesefactsmeanthattheusualclinicalsignsof
4. PREGNANCYWomenhaveahigherplasmavolumeduringpregnancy.Ca

minute.Minuteventilationincreasesalso(primarilyduetoanincreaseinthe
increasethephysiologicalreserveofthemotherandmeanthatsignsofhypov
eveninmoderateshock,themothermaybequitewell,thefoetusmayactually
cardiotocographicmonitoringareoftenrequiredatanearlystagetominimise
5. DRUGSVariousdrugscanaffectthebody'sresponsetostress.Betablocke
picture.Diureticusecausesarelativehypovolaemiawhichmayimpairthebo
6. HEADINJURIESThebrainhasaveryhighdemandforoxygenandsoseco
blood.TheCerebralPerfusionPressureisequaltotheMeanArterialBloodP
pressure,orbyanincreaseinintracranialpressure.Headinjuriesmayincreas
cerebrospinalfluid.Subarachnoidhaemorrhageincreasesintracranialpress
CSFfrombeingreabsorbedbackintothevenoussystem.

Thereareanumberofconflictingprocessesintheheadinjuredpatientthatma
resuscitationwillresultinhypotensionwherasoverenthusiasticvolumeresusc
pressure.Thekeyaspectsintheoptimalmanagementoftheheadinjuredpatie
intubationtoassistwithhyperventilation,andearlyconsultationwithanexper

DDYSFUNCTION&DISABILITYOFTHE
CNS

AnAVPUorGCSassessmentiscarriedout.
Thepatient'spupilsareexaminedforsize,symmetry&reactiontolight.
Theconsensualpupillaryreflexcanalsobetestedhere.

AVPUAssessment:
AAlert
VRespondingtoVoice
PRespondingtoPain
UUnresponsive

GlasgowComaScale(GCS):

EyeOpening

4Spontaneous
3ToSpeech
2ToPain
1NoEyeOpening
BestVerbalResponse
5Orientated
4ConfusedConversation
3InappropriateWords
2IncomprehensibleSounds
1NoResponse
BestMotorResponse
6Obeyscommands
5Appropriatelocalisingresponsetopain
4Withdrawalresponse
3Abnormalflexionresponse(DecorticateRigidity)
2Extensionresponse(Decerebraterigidity)
1NoResponse

EEXPOSURE&ENVIRONMENTAL
CONTROL

Here,anyclotheswhichhaven'talreadygoneareremoved.
Careisstilltakentoprotectallareasofthespinefromundue
movement.
Finally,thepatientiscoveredwithablanketorothersuitable
warmcoveringtopreventhypothermia.
Hereendeththelesson!!