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 don’t 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 there’s 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
 Beck’s 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