A.T.L.S.

Primary Secondary Survey

Head Injury
Spinal Injury

Primary survey
A : Airway
B : Breathing
C : Circulation
D : Disability
E : Exposure
Goal : recognizing life threatening condition and simultaneously do
resuscitation

Airway
Cervical Spine Control (Assume injury until proven otherwise)
Airway assessment
Obstruction? Patient can talk airway clear
Look (cyanosis/breathing pattern/uses of accessories muscle/RR/Pox )
Listen (grunting/stridor/ total obstruction silent)
Feel (decreased/absent airflow)
Airway management
Triple airway maneuver only if w/o possible cervical spine injury :
Slight neck extension
Jaw thrust ( elevation of mandible)
Mouth opening
Possible cervical injury : without neck extension
Adjunctive devices : oropharyngeal airway ( only if no gag reflex) /
Nasopharyngeal airway ( KI: susp. Basilar skull fracture/coagulapaty)

Breathing
Assesment : Look ( sign of respiratory distress/ equal chest rise /RR/P
ox) /Listen ( lung sound ) /Feel ( trachea position /crepitus ,emphysema subcutis)
/P
Management : Oxygen supplement / Assisted ventilation
Manual assisted ventilation
Indication : Apneic/Inadequate ventilation
Bag valve mask , RR:12 to 16 x/min, 100 % oxygen with max flow ( >10
l/min)

Circulation
Assestment : pulse ( carotid/femoral/radial) / BP/HR /evaluate quickly for
areas of large hemorrhaging that can easily be stopped with direct pressure
Management :
2 Large/short IV bore : 16 or intraosseous needle
NS /RL 2-3 L/min or 20 cc/kg bolus in children
No response, blood , O negative

Disability (Neuro)
AVPU ( Alert / Verbal response/Pain response/Unresponsive)
GCS ( Adult/children)

Exposure
Undress patient for thorough examination
 Remember hypothermia
Remember neck/spinal immobilization

Addition on primary survey

Vital sign monitor ( BP/P ox/HR or Pulse rate) / Cardiac monitor
ECG
Urinary catheter
Check for possible urethra rupture ( blood OUE/scrotal or perineal
hematome/ RT : unpalpable / high prostate)
If susp. Urethra rupture, need urethra-systogram
X-ray : Cervical ( lateral ) / Thorax (AP) /Pelvic ( AP)

Secondary survey
After primary survey / resuscitation and ABC stabilize
Examine patient from head to toe
Anamnesis : AMPLE ( Allergy / Medication/ Past medical history/ Last
meal/ Event , mechanism of injury)

HEENT
Examine face for facial fractures
Examine eyes for any gross injury, shattered glass should be irrigated then
flourescein
Examine ears for hemotympanum
Examine mouth for jaw fractures/loose teeth

Neck
Ask patient if s/he has any neck pain
Midline tenderness?
Penetrating wound : which zone ? trauma to the arteries/airway?

Chest
Palpate entire chest for area of crepitus/tenderness
Look for Seat belt sign/bruising /asymmetric
Listen to breath sounds, symmetric ? other additional sounds?
Listen to heart sound
Abdomen
Look for distension / bruising / seat belt sign
Examine for area of tenderness
Pelvic
Examine for tenderness AP/Lateral compression
Genitourinary/rectal
Examine externally for signs of bleeding
Rectal exam for blood/position of prostate( male)

Back
Log roll
Look for bruising / tenderness on bone palpation / penetrating wound
Extremities
Look for deformity/laceration / bleeding site /abrasion
Palpation for area of tenderness/crepitus/pulsation

Neurologic
 GCS/Mental Status
Limited sensory/motor exam

Laboratory test
Cervical spine : AP/Lateral/open mouth ( odontoid)
Hemoglobin : serial : 3x q 15 min
Urinalysis
Extremities X-ray
USG abdomen /CT

Head Injury
Classification
Mild Head Injury : GCS : 13-15
Moderate Head Injury : GCS : 9 12
Severe Head Injury : GCS : 3-8

Goal
Discover all moderate/severe head injury
Discover mild head injury with intracranial injury especially needing
surgery
Observation/education : patient that first appear with mild injury may
worsen over several hours
Risk stratifying
Cost effectiveness

Glasgow Comatose Scale

Adult /Children ( check in PDA : epocrates / table/ GCS )

Serial check
Mild Head Injury
Clinical predictor :
GCS / Loss of consciousness
GCS 15 / LOC (+) : 10 % Intracranial injury (+) , 1% need surgery
GCS 13/ LOC (+) : 38 % Intracranial injury (+) , 8 % need surgery
Location of injury : temporo-parietal , increased risk of epidural bleeding
Significant retrograde amnesia
Older patient
Preexisting condition : on anticoagulant / hemophiliac
Difficulty to determine Level of Consciousness in intoxicated patient
( alcohol / drugs)
Sign of basilar fracture ( battles sign / raccoon eyes/ CSF leakage from
nose ,ear / hemotympanum )

Head X-ray
Only if patient stable otherwise dont waste time
For facial fracture

CT scan
Infant < 12 months , all unless :
Fall less than 1metres ( 3 feet)
Normal neuro exam
No evidence of scalp trauma ( bruising/hematoma etc)
Older children and adult
AbN neuro exam/GCS < 15
Prolonged LOC ( > 15 min)
Retrograde amnesia > 30 min
 Repeated vomiting
Worsened/severe headache
Depressed skull fracture/basilar skull fracture
Special consideration : ( anticoagulation / older patient with
LOC/Intoxicated )
Not sure / concerning mechanism of injury : CT Scan
CT scan (-) but abN neuro exam , plan for another CT in 24/48 hours or
significant worsening of symptoms.

Disposition
Mild Head Injury , No neurological deficit , GCS : 15 . low risk stratification
No Intra cranial injury on Head CT , normal neuro exam
Observation for 24 hours , including neuro checks q 2-4 hours by
responsible adult ( Head Injury patient leaflet)
Follow up the next day

Admission
Intra cranial injury (+) on Head CT
All abN Neuro exam / GCS < 15

Other consideration
Second Impact syndrome
Head Injury in sports , Can I return to the game?

Post concussive syndrome

Headache / dizziness / poor concentration / memory problems/ emotional
problems.
Most resolves after few weeks , 90 % resolves in 1 year , 10 % became
chronic
If worsening , Neuro evaluation / Head CT

Moderate / Severe Head Injury

ABC
Cervical immobilization
Maintain good oxygenation /perfusion ( avoid hypotension from shock)
Prophylaxis anti seizures ( phenytoin) /Manitol
Head CT
Referral hospital / Neurosurgeon / Neurologist

Spine Injury
ABCDE / Primary survey / A with cervical immobilization /Spine
immobilization with long spine board/back board.
Maintain in line immobilization , i.e. hold the head with your hands/ Log
roll during examination
Usage of back board : for transportation , > 2 hours can cause decubitus
ulcer , if > 2 hours need to log roll q 2 hourly

Neurological exam :
Sensory exam , check level
Motor exam , score 0 5 , check level
Proprioseptive / vibratory function ( posterior column)
Deep tendon reflex
Anogenital ( sacral sparing) : Bulbocavernosus /cremaster /TSA

Classification
Level
 Lowest segment ( caudal) of the spinal cord that still have motoric ( 3/5)
/normal sensoric function bilaterally
Partial preservation
Spinal injury level not the same with Level of bone fracture
Neurologic Deficit
Complete /Incomplete
Spinal Cord syndrome
Anterior cord
Central cord
Brown Sequard
Cauda Equina
Spinal shock
Morfology
Fracture
Fracture/Dislocation
SCIWORA
Penetration injury e.g gun shot

Cervical spine injury

Cervical collar ? If you are worried or unsure assume theres cervical
injury until proven otherwise . Immobilize /X-ray
Ruled out C-spine injury, Low risk if following guidelines :
No midline tenderness
Alert / no neurological deficit
Not intoxicated
No other distracting injury

Physical exam
Sensory exam Motor exam
C2 Top of head -
C3 Ear -
C4 Neck C3/4/5 diaphragm
C5 Shoulder Shoulder shrug
C6 Thumb Biceps ( elbow flexion)
C7 Middle finger Triceps ( elbow extension)
C8 Little finger Finger muscle

Posterior column sensation proprioception ( finger up/down)

Imaging Studies
X-ray : Lateral / Open Mouth Odontoid (OMO) /AP ( check proc. spinosus)
CT Scan :
To illustrate detail of fracture
If fracture is suspected but no adequate X-ray
MRI :
Ligament /spinal cord

Management :
Methyl prednisolone, initial dose : 30 mg / kg IV over 1 hour followed by 5.4mg
/kg/hour for the next 23 hours ( total 24 hours)

Exclusion criteria :
To be given within 8 hours
> 13 years old
No serious injury
Not pregnant
Not already taking other steroids
 Not given naloxone recently

Neurogenic Shock :
Not common . Cause by spinal cord injury . Decreased vascular tone and
relative bradycardia. ( symphatic enervation of the heart)
Spinal shock
After spinal cord injury . Flacid / loss of reflexes. Temporary .

THORACIC TRAUMA
Life threatening condition that need to be identified and treated immediately on
Primary Survey

Airway
Laryngeal Injury
Sign of upper airway obstruction ( stridor)
Hoarseness/emphysema subcutaneous emphysema/palpable fracture of
the larynx
Humidified Oxygen/IV access/Prepare for early intubation or surgical
airway/ ENT consult
If edema larynx : Dexamethasone, adult 4 mg IV, ped: 0.25 mg 0.5
mg/kg IV

Fracture /Dislocation of Sternoclavicular joint

Obvious sign of trauma on the base of the neck with palpable defect on
the sternoclav. Joint
Closed reduction of the sternoclavicular joint in supine position

Breathing
Tension Pneumothorax
Clinical diagnosis : Chest pain / respiratory distress/tachycardia/
hypotension/ tracheal deviation/unilateral absence of breath/JVD/cyanosis
Needle thoracocentesis ( large bore needle , 14-16 G, 2 nd intercostal
space, midclav) followed by insertion of chest tube

Open Pneumothorax
Large defects of chest wall which remain open or sucking chest wound
Close the defect with sterile occlusive dressing, large enough to overlap
the wound, tapes securely on 3 sides

Flail chest
Multiple ribs fractures ie, two or more ribs fractured in two or more places
Paradoxical movement of the chest wall ( inspiration/expiration)
Main problem is the underlying lung disease : Pulmonary contusion
Humidified oxygen/fluid resuscitation/analgesic
Asses adequate ventilation for the need for assisted ventilation /intubation

Circulation
Massive Hemothorax
> 1500 ml blood in the chest cavity or blood loss > 200 ml/hour for 2 to 4
hours
 shock associated with the absence of breath sound and or dullness on
percussion on one side of the chest
Management : Fluid resuscitation/blood transfusion simultaneously with
decompression of chest cavity ( chest tube)

Cardiac Tamponade
Commonly associated with penetrating injury
Becks triad : JVD/hypotension/muffled heart sounds, not always present
PEA in the absence of hypovolemia/tension pneumothorax
Pericardiocentesis

Secondary Survey
Further physical examination
CXR
P ox /Blood Gas Analysis
ECG

Simple Pneumothorax
Decreased breath sounds / hyperresonance /CXR
If pneumothorax < 15 %, no cardiovascular or respiratory compromise :
observe for 4 to 6 hours and repeat CXR , if no change : discharge
otherwise chest tube insertion

Hemothorax
Shown in CXR , needed to be evacuated with chest tube

Pulmonary contusion
Cause respiratory failure
Intubation

Blunt Cardiac Injury

Traumatic Aortic Disruption

Persistent hypotension
CXR: widened mediastinum

Subcutaneous emphysema
Not require treatment
Underlying injury
If needed to assist ventilation with positive pressure, anticipate possible
pneumothorax

Rib fractures
Upper ribs : 1-3 : severe injury , associated with other serious injury
( major blood vessels)
Lower ribs : 10 -12 : considered hepatosplenic injury
Common associated injury : pneumohemato thorax
Treatment : adequate pain management to improve ventilation. Risk of
infection esp. in elderly

Traumatic Diaphragmatic injury

More common in the left side
Sternum/scapular fractures
Generally results of direct pressure
Sternum fracture can accompanied by lung contusion/blunt cardiac injury

ABDOMINAL TRAUMA
Primary survey : ABCDE , Hypotension?
Obvious sign of trauma on the abdomen : blunt/penetrating injury
Internal organ injury : Liver/spleen/pancreas/hollow viscus/kidney
Sign of peritonitis ( distension /tenderness/muscle guarding/ rebound)
Serial Hb/urinalysis/pregnancy test
Abdominal series /USG
Pelvic Injury , associated with major blood vessel
Genito-urinary trauma : blood OUE/scrotal-perineal hematoma/high riding
prostate or blood on the rectal exam , precaution for urinary catheter.
Penetrating injury : closed wound with gauze soaked with NS

MUSCULOSKELETAL TRAUMA
AB C DE
IV/O2 /Monitor
Hipovolemic shock Femur fr.
Pain management . Narcotic pain relief ( Pethidine/Morphine)
Asses N V D ( Neurovascular distal) . Always check
colour/pulsation/capillary refill / sensation, compare bilaterally, and
documented prior and after every manipulation /splint
Open wound Open fractures ? , cover with sterile dressing
Splint , immobilized one joint above and one joint below the injury site
Mal-aligned/ compromise NVD : attempt to realign by gentle traction. If
after traction NVD compromise worsened back to position before and
splint in that position
Do not forced re-alignment if difficult splint in that position
Tetanus prophylaxis : vaccine/Ig
Antibiotic : Cefazolin ( gr I ) , + gentamycine ( gr II / III ) , dose check on
5MEC
Orthopedic consult
Compartment syndrome
o Pain is the earliest symptoms esp. with passive stretching of the
involved groups of muscle
o Other ischemic sign: 5 P :pain /pressure/paresis/paresthesia/pulse
o Unconscious patient is at increased risk

NEAR DROWNING
Near Drowning : survival at least a day after submersion
Secondary drowning : Complication of near drowning after initially successful
resuscitation ( may be delayed by up to 12 hours in otherwise normal appearing patient)

In near drowning, aspiration as little as 2 cc/kg may cause lung damage/hypoxia :

Surfactant loss/alveolar dysfunction
Direct tissue toxicity , pulmonary edema
V/Q mismatch , vasoconstriction
Even without aspiration, life threatening pulmonary edema may occur due to cerebral
hypoxia or cardiac failure ( dry drowning)

Management
Prehospital
ABCDE with neck/spinal injury and hypothermia ( especially in children)
precaution
Begin CPR immediately with max Oxygen
IV/ Monitor
No role for trying to evacuate water by Heimlich or other maneuvers
Asymptomatic patient still need to be observe for possible secondary drowning

Patient with Cardio pulmonary arrest /.P ox < 90 % with max Oxygen, should be
transported to hospital with facility of Intubation

Emergency Department
Consider other associated injuries ( spine/head/other trauma) and medical condition
( AMI/Disrythmia/ stroke)

Patient who arrived awake but with respiratory distress or hypoxia

IV /O2 max with NRB/Monitor
CXR PA/Lat and other X-ray if needed
ECG / ABG / electrolyte/BUN /Creatinin/CBC/ Glucose
If unable to maintain P ox > 90 % with max O2, need to intubate
Antibiotic : Levofloxacine 500 mg QD
Observation for 12-24 hours
Repeat CXR/lab test every 6 to 12 hours

Patient who arrived without any symptoms

If physical exam/CXR and Pox normal , patient may be discharged after 6 hours
of observation ( repeat CXR/lab test)

High risk patient

Loss of consciousness
Cardiopulmonary arrest
Cyanotic /tachypnoe / respiratory distress
Seizures
Prolonged time under water /water ingestion
Preexisting medical condition /elderly/young children