1

(Initial assessment and management in multisystem

trauma)

.. 1983 Trunkey D(1)

3 (Trimodal distribution of

death) 1
 2

1 60

(severe head injury)

50

(Prevention)

2 1-4

30

(Golden hour)

3 1

(Multiple organs

failure, MOF) 20
 3

(torso trauma)

(hypothermia) poor

tissue perfusion cellular shock

(anaerobic metabolism) metabolic acidosis

metabolic acidosis

(coagulopathy)

Bloody vicious cycle

2 Blood vicious cycle(2)

shock

(coagulopathy, hypothermia metabolic acidosis ) deadly triad

 4

Advanced

Trauma Life Support(3) ATLS

.. 1978

(life threatening condition)

ATLS

(Initial assessment and management)(3)

ATLS

(Primary survey)
 5

(Life threatening conditions)

ATLS

(airway) (breathing) (circulation)

(disability)

ABCDE

A Airway management with cervical spine protection

B Breathing and ventilation

C Circulation and hemorrhage control

D Disability (Neurologic status)

E Exposure/Environment control

(Airway
management with cervical spine protection)

(cervical spine injury)

Hard collar Philadelphia collar 3

3 Philadelphia collar
 7

(unconscious)

(suction)

chin-lift jaw-thrust 4 5

head tilt and chin lift

4 chin-lift maneuver 5 jaw-thrust

maneuver

(severe head

injury)

definitive airway

cuff definitive airway 2

(endotracheal intubation)

(surgical airway)

(endotracheal intubation) 2

(nasotracheal intubation) (orotracheal

 8

intubation)

manual inline stabilization (MIS) 3

2 cricoid pressure (Sellicks maneuver)

1:

3 2: inline stabilization

3: cricoid pressure (Sellicks

2
maneuver)

6 manual inline stabilization (MIS)

7.5

21-23

chest x-ray

3-5 carina nasogastric

tube
 9

base of skull fracture

surgical airway

cricothyroidotomy emergency tracheostomy 7

7 Cricothyroidotomy(4)

cricothyroidotomy 12

subglottic stenosis

emergency

tracheostomy

(flexion) (extension)

Philadelphia collar
 10

inline stabilization

8 inline stabilization pre oxygenation

Cricoid pressure Sellicks maneuver

cuff

Philadelphia collar

Philadelphia
collar

(Breathing and ventilation)

2
 11

(pneumothorax)

(hemothorax)

mask with

reservoir bag

tension pneumothorax massive hemothorax open

pneumothorax (flail chest with lung contusion)

cardiac tamponade air embolism

Tension pneumothorax

intercostal space

(ICS) 2 (midclavicular line)

 12

needle decompression needle thoracentesis 9

(chest drain)

9 needle decompression

open pneumothorax (Sucking chest wound)

2/3

hypoxia
hypercarbia

3 point fixation 10

 13

10 three point fixation(4)

massive hemothorax

1500 .

200 . 2-4

aorta

85

(chest drain)
11

36

 14

A: ICS 4-5 just anterior to

midaxillary line

B: pleural space

rib

C:

D: postero-superior

11 (chest drain) (4)

(flail chest)

2 (3)

(blunt trauma)

(lung contusion)

paradoxical

movement

air embolism
 15

(penetrating injury)

bronchovenous fistula

positive pressure

coronary artery myocardial ischemia

(Trendelenburgs

position) (thoracotomy)

cardiac tamponade

Cardiac box

suprasternal notch xiphoid process

12

12 cardiac box
 16

Becks triads hypotension,

distant heart sound jugular vein engorgement

pericardial FAST (Focus assessment sonography in trauma)

pericardiocentesis 13

13 pericardiocentesis(4)

pericardiocentesis

pericardial window

median sternotomy

(fracture ribs)

(simple pneumothorax) (lung contusion)

 17

(Circulation and hemorrhage

control)

(direct pressure) 14

14

(pelvic fracture)

shock pelvic stabilization pelvic

volume 2

internal rotation 2 15
 18

15 pelvic stabilization

2 venous

cutdown (basilic vein) (great saphenous vein)

16 central venous catheterization

subclavian, internal jugular femoral

16 venous cutdown great saphenous(4)

resuscitation normal saline

Ringers Lactate Solution shock 2000

. (free flow)

Level 1 rapid infusion device

 19

shock

3:1 crystalloid 3 . 1 .

class of hemorrhage

1 class of hemorrhage

70 (4)

(Focused Assessment with

Sonography in Trauma, FAST) 17

18

FAST

FAST positive

 20

17 Focused Assessment with Sonography in Trauma (FAST)

A: Epigastrium

B: Right upper
quadrant

C: Left upper quadrant

D: Pelvic cavity

18 FAST

FAST

CT scan

FAST negative

diagnostic peritoneal lavage (DPL)

) 19

syringe 10 .

positive (laparotomy)

normal saline 1000 .

 21

positive

19 diagnostic peritoneal lavage (DPL) (4)

Criteria for positive finding on Diagnostic

Peritoneal Lavage

Red blood cell count > 100,000 cell/ml

White blood cell count > 500 cell/ml

Amylase level > 19 IU/L

Alkaline phosphatase level > 2 IU/L

Bilirubin level > 0.01 mg/dL

2 DPL (4)

(Disability/Neurologic status)

(level of consciousness)

 22

Glasgow Coma Scale (GCS) 3

sternum

GCS 3 15 GCS

- Mild head injury: GCS 13-15

- Moderate head injury: GCS 9-12

- Severe head injury: GCS 3-8

Assessment Area Score

Eye opening Spontaneous 4

To voice 3

To pain 2

None 1

Verbal Oriented 5

Confused 4

Inappropriate words 3

Incomprehensible sounds 2

None 1

Motor response Obeys commands 6

Localizes pain 5

Withdraws 4

Abnormal flexion (decorticate) 3

Abnormal extension (decerebrate) 2

None 1
 23

3 Glasgow Coma Scale score(4)

GCS 8 (severe head injury)

definitive airway

secondary brain damage

(reevaluation)

(Exposure and environment

control)

(hypothermia)

Log roll

20 3
1

(per rectal examination)

 24

1:
2 3

1
4
2:

3 4:
20 Log roll

(reevaluation)

(Adjunct to primary survey)

(nasogastric tube)

FAST (Focus assessment sonography in trauma)

arterial blood gas Diagnostic peritoneal lavage (DPL)

film trauma series (chest x-ray, cervical spine lateral

and pelvis AP)

(base of skull fracture)

(orogastric tube)

(urethral injury)
 25

suprapubic cystostomy

(Secondary survey)

(hemodynamic stable)

(head to toe evaluation)

(History taking)

AMPLE

A: Allergies

M: Medications aspirin, beta

blocker

P: Past illness/Pregnancy

L: Last meal

E: Event/Environment

(Physical examination)
 26

(head to toe evaluation)

(Head and maxillofacial structures)

2 contact lenses

- cranial nerve

- cerebrospinal fluid

(Cervical spine and neck)

(subcutaneous emphysema)

carotid bruit

 27

(Chest)

(subcutaneous emphysema)

(hemothorax) (pneumothorax)

cardiac tamponade

(Abdomen)

peritonitis

FAST DPL CT
scan abdomen

(Perineum/Rectum/Vagina)

- per rectal

examination

prostate gland

per

vaginal examination

(Musculoskeletal system)
 28

pelvic compression test

pelvic x-ray film

pulsatile bleeding,

expanding hematoma, audible thrill or palpable bruit distal

ischemia compartment syndrome

(Neurologic)

- Glasgow Coma Scale score

pupils

(Adjunct to secondary survey)

 29

(missed injury)

CT scan angiography

(Transfer to definitive care)

 30

1. Trunkey DD. Trauma. Sci Am 1983;249:2835.

2. Moore EE . Staged laparotomy for the hypothermia, acidosis

and coagulophathy syndrome. Am J Surg 1996;172:405-10.

3. American College of Surgeons: Advanced Trauma Life

Support, 8 ed. Chicago: American College of Surgeons, 2008.

th

4. Cothren CC, Moore EE, Biffl WL, Trauma. In: Brunicardi FC,

Anderson DK, Billiar TR, Dunn DL, Hunter JG, Matthews JF,

Pollock RE, eds. Schwartzs Principles of Surgery. 9 ed. New

th

York: McGraw-Hill, 2010;135-195.