Early Assessment of Trauma

Patients and ATLS

Mesele M (MD)
 Objectives
• To define trauma and its potential damage
• To rapidly and accurately assesse trauma
patients
• To resuscitate and stabilize trauma pts
• To understand the priority in trauma Mg’t
(Triage)
• To organize quality trauma care at health care
system
 Introduction
• Trauma, or injury, is defined as cellular disruption
caused by an exchange with environmental
energy that is beyond the body's resilience
• Most common cause of death for age groups
between 1 and 44 years
• Third most common cause of death regardless of
age
• trauma must be considered a major public health
issue
 Intro….
• Initial assessment is the most important factor
in the subsequent outcome of the trauma
patient
• The Advanced Trauma Life Support (ATLS)
principles were introduced into practice in the
late 1970s
 Types of injury

 Blunt, e.g. car bonnet

 Penetrating, e.g. knife
 Blast, e.g. bomb
 Crush, e.g. building collapse
 Thermal
 Blunt trauma

•The most common cause is motor vehicle accident (MVA)

•Speed is a critical factor: a 10 % increase in impact speed
translates to a 40 % rise in the case fatality
•Use of seatbelts reduces the risk of death or serious
injury for front-seat occupants by approximately 45%;
But
Patients with seatbelt marks have been found to have a
four-fold increase in thoracic trauma and an eight-fold
increase in intra-abdominal trauma
 Penetrating trauma

• Important factors include the proximity of the

underlying viscera to the path of the
penetrating object, and the velocity of the
missile
• The distance from the weapon to the wound
 Six phases in trauma mg’t
• Access phase
• Pre hospital and triage phase
• Early hospital or resuscitation phase
• Operative phase
• Intensive care phase
• Rehabilitative phase
 Pre Hospital Trauma Life support
• Scene size up & extrication
• Primary survey and basic life support
• Spinal protection in LSB
• Splinting extremities
• Control of external hemorrhage
• Aim: to stabilize the pt – platinum 10 minutes
• Load and go within Golden first hour
 Field triage – color coding
• Triage is sorting of pts by injury severity and need
for transport
• Red :- most critically injured immediate transfer
to hospital
• Yellow:- less critically injured – delayed transport
to hospital without endangering life
• Green :- no life or limb threatening injury-
ambulatory pts
• Black:- dead pts
 ASSESSMENT AND MANAGEMENT OF
THE SERIOUSLY INJURED

‘Trimodal distribution of death’ in trauma pts

1. Immediate - 50 per cent of all deaths
• Not possible to save
• Usually the result of massive head
injury or severe cardio-pulmonary insults
2. Early - within the first few minutes to hours
• Airway or breathing problem, or because the circulation has
failed and so oxygen cannot be delivered to the tissues
3. Late - 20 per cent of deaths.
Usually from multiple organ failure and sepsis, influenced by
inadequate early resuscitation and care
The ATLS principles are aimed primarily at the ‘early’ group of
patients
 PRIMARY SURVEY AND
RESUSCITATION

• The primary survey comprises the fundamental principles

of the ATLS system, the ‘ABCDE’ of trauma care
A, Airway with cervical spine protection
B, Breathing and ventilation
C, Circulation with haemorrhage control
D, Disability: neurological status
E, Exposure: completely undress the patient and assess for
other injuries
 Airway with cervical spine protection
• patient’s airway is of paramount importance, and
hence this is assessed first
• If there is a vocal response from the patient, then the
airway cannot be immediately compromised
• clearing the mouth and suction, or manoeuvres such
as a jaw thrust or chin lift
• GCS of 8 or less, then a definitive airway (such as
endotracheal intubation) may be required
• patient who has had significant trauma (especially to
the head) has a suspected cervical spine injury until
proven otherwise - cervical spine must be immobilized
by using traditional collar, sandbags and tape
 Breathing and ventilation

• Oxygen should be administered to all trauma

patients
• Ventilation requires an adequately functioning
chest wall, lungs and diaphragm, and each
must be systematically evaluated
 Breathing…
• The following conditions may constitute an
immediate threat to life because of
inadequate ventilation:
1) Tension pneumothorax,
2) Open pneumothorax,
3) Flail chest
4) Pulmonary contusion
 Tension pneumothorax
• The diagnosis of tension pneumothorax is implied by
respiratory distress and hypotension in combination with any of
the following physical signs in patients with chest trauma:
– tracheal deviation away from the affected side,
– lack of or decreased breath sounds on the affected side, and
– subcutaneous emphysema on the affected side
• Patients may have distended neck veins due to impedance of
the superior vena cava, but the neck veins may be flat due to
systemic hypovolemia
• hypotension qualifies the pneumothorax as a tension
pneumothorax.
 Tension pneumothorax…
• In cases of tension pneumothorax, the parenchymal tear
in the lung acts as a one-way valve, with each inhalation
allowing additional air to accumulate in the pleural space.
• The normally negative intrapleural pressure becomes
positive, which depresses the ipsilateral hemidiaphragm
and shifts the mediastinal structures into the contralateral
chest.
• Subsequently, the contralateral lung is compressed and
the heart rotates about the superior and inferior vena
cava; this decreases venous return and ultimately cardiac
output, which results in cardiovascular collapse.
 open pneumothorax
• An open pneumothorax or "sucking chest wound" occurs with
full-thickness loss of the chest wall, permitting free
communication between the pleural space and the
atmosphere.
• This compromises ventilation due to equilibration of
atmospheric and pleural pressures, which prevents lung
inflation and alveolar ventilation, and results in hypoxia and
hypercarbia.
• Complete occlusion of the chest wall defect without a tube
thoracostomy may convert an open pneumothorax to a
tension pneumothorax

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 Sucking chest wound

The defect is temporarily managed with an occlusive dressing that is

taped on three sides, which allows accumulated air to escape from the
pleural space and thus prevents a tension pneumothorax
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 Hemothorax
• A massive hemothorax (life-threatening injury
number one) is defined as >1500 mL of blood
or, in the pediatric population, one third of the
patient's blood volume in the pleural space.
• Tube thoracotomy is the only reliable means
to quantify the amount of hemothorax
 Cardiac tamponade

• Is (life-threatening injury number two) occurs most commonly

after penetrating thoracic injuries, although occasionally blunt
rupture of the heart, particularly the atrial appendage, is
seen.
• Acutely, <100 mL of pericardial blood may cause pericardial
tamponade.
• The classic diagnostic Beck's triad
 dilated neck veins,
 muffled heart tones, and
 A decline in arterial pressure (Hypotension)

21
 Flail chest
• Flail chest occurs when three or more contiguous ribs
are fractured in at least two locations.
• Paradoxical movement of this free-floating segment
of chest wall may be evident in patients with
spontaneous ventilation, due to the negative
intrapleural pressure of inspiration.
• Rarely the additional work of breathing and chest
wall pain caused by the flail segment is sufficient to
compromise ventilation
• Pulmonary contusion often progresses during the first
12 hours 22
 Circulation and control of bleeding
• Assessment here centers on three critical clinical observations:
1. Conscious level - If this is impaired or altered, in the absence
of obvious head injury, one must assume that the patient has
lost a significant amount of blood and that cerebral perfusion
has become compromised.
2. Skin color - A patient with pink skin and warm peripheries
is rarely critically hypovolaemic, and the converse is true for a
pale, ashen, grey-looking patient with ominous signs of
hypovolaemia.
3. Pulse - A full, slow, regular peripheral pulse is usually the sign
of relative normovolaemia, whereas a rapid, thready pulse or,
worse still, one that is not peripherally palpable is a grave sign of
hypovolaemic shock, and blood volume must be rapidly restored
 Circulation…
• A rough first approximation of the patient's
cardiovascular status is obtained by palpating
peripheral pulses.
– SBP of 60 mmHg is required for the carotid pulse to be
palpable,
– SBP of 70 mmHg for the femoral pulse and
– SBP of 80 mmHg for the radial pulse
• BP and PR should be measured manually at least every 5 minutes in
patients with significant blood loss until normal vital sign values are
restored. 24
 Circulation
– External control of hemorrhage should be obtained
before restoring circulating volume.

– Manual compression and splints frequently control

extremity hemorrhage as effectively as tourniquets and
with less tissue damage.

– Digital control of hemorrhage for penetrating injuries of

the head, neck, thoracic outlet, groin, and extremities

25
 Circulation
• Intravenous access
– Two peripheral catheters, 16-gauge or larger in an
adult
– Saphenous vein cutdowns at the ankle
– Percutaneous femoral vein catheter introducers
– interosseous cannulation should be performed in the
proximal tibia, or in the distal femur
Blood sample should be sent for blood-group
typing

26
 Circulation…
• Four life-threatening injuries that must be identified during
circulation phase primary survey are:
– Massive hemothorax,
– Cardiac tamponade,
– Massive hemoperitoneum, and
– Mechanically unstable pelvic fractures.
• Three critical tools used to differentiate these in the
multisystem trauma patient are
 chest radiograph,
 pelvis radiograph, and
 focused abdominal sonography for trauma (FAST)

27
 Circulation…
• Isotonic crystalloid is used for initial resuscitation
in the ED.
• If the patient does not respond to crystalloid
infusion at levels exceeding 30 ml/kg, blood
should be administered (o neg. for all)
• Early empirical blood transfusions are indicated
in patients who arrive in severe shock or who
have injuries associated with significant bleeding
(e.g., a vertical shear pelvic fracture or bilateral
femur fractures)
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 Shock Classification and Initial Fluid Resuscitation

• Fluid resuscitation
– The goal of fluid resuscitation is to re-establish tissue
perfusion.
– Begin with
• 2 L (adult) or
• 20 mL/kg (child) IV bolus of isotonic crystalloid
• Repeated once in an adult and twice in a child
– Red blood cells (RBCs) are administered if
hypotension still persists

29
 Fluid resuscitation

– Good response
• Normalization of vital signs, clearing of the sensorium
• Evidence of good peripheral perfusion (warm fingers
and toes with normal capillary refill)
• Urine output
– 0.5 mL/kg /hour in an adult
– 1 mL/kg/ hour in a child
– 2 mL/kg/hour in an infant

30
Shock Classification

31
• Classic signs and symptoms of shock are tachycardia,
hypotension, tachypnea, mental status changes, diaphoresis,
and pallor.
• Tachycardia is often the earliest sign of ongoing blood loss.
• One should systematically evaluate the five potential sources
of blood loss:
– scalp,
– chest,
– abdomen,
– pelvis, and
– extremities.

32
• For each rib fracture there is approximately 100 to 200 mL of
blood loss;
• for tibial fractures, 300 to 500 mL;
• for femur fractures, 800 to 1000 mL; and
• for pelvic fractures >1000 mL

33
 Disability and Exposure

• The Glasgow Coma Scale (GCS) score should be

determined for all injured patients.
• It is calculated by adding the scores of the best
motor response, best verbal response, and eye
opening.
• Scores range from 3 (the lowest) to 15 (normal).
– Scores of 13 to 15 indicate = mild head injury,
– Scores of 9 to 12 = moderate head injury
– Scores of <9 = severe head injury.
• The GCS is useful for both triage and prognosis. 34
 Glasgow Coma Scale
    Adults Infants/Children
Eye 4 Spontaneous Spontaneous
opening 3 To voice To voice
2 To pain To pain
1 None None
Verbal 5 Oriented Alert, normal vocalization
4 Confused Cries but consolable
3 Inappropriate words Persistently irritable
2 Incomprehensible words Restless, agitated, moaning
1 None None
Motor 6 Obeys commands Spontaneous, purposeful
response
5 Localizes pain Localizes pain
4 Withdraws Withdraws
3 Abnormal flexion Abnormal flexion
2 Abnormal extension Abnormal extension
1 None None
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• AVPU – describes pts level of consciousness
• A- alart
• V- responds to vocal stimuli
• P- responds to pain stimuli
• U- unresponsive
• GCS to be done in secondary survey
 Adjuncts to the primary survey
• Blood tests – full blood count, urea and
electrolytes, clotting screen, glucose,
toxicology, cross-match
• ECG, pulse oximetry, arterial blood gas (ABG)
• Urinary and gastric catheters
 Secondary Survey
• Once the immediate threats to life have been
addressed, a thorough history is obtained and the
patient is examined in a systematic fashion.
• The patient and attendants should be queried to
obtain an AMPLE history
A = Allergies
M = Medications
P = Past illnesses or Pregnancy
L = Last meal
E = Events related to the injury
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 Secondary survey physical examination

• Head and face - penetrating injuries and depressed

fractures, and any evidence of bleeding or discharge
from the ears suggestive of a basal skull fracture
• Neck - Inspect and palpate the cervical spine anteriorly
and posteriorly for haematomas, crepitus, tenderness
• Chest - Review the primary survey and perform full
palpation and auscultation of the chest wall
• Neurological - Examine the GCS regularly
sensory and motor disturbance
• Abdomen and pelvis - Inspect for distension, bruising or
penetrating wounds
 Inspect and palpate for tenderness and signs of peritonism
 Rectal examination is needed to assess tone, prostate level
and to look for bleeding
• Extremities - deformed limbs should be manipulated into as
near anatomical alignment
 document the distal neurovascular status before and after the
intervention
• Log roll - Inspect and palpate the entire spine
from occiput to sacrum, looking and feeling for tenderness and
bony abnormalities
Definitive care and transfer
 Haemodynamically and cardiovascularly stable
 Life-saving surgery may need to be performed prior to transfer
for other injuries. This is called ‘damage control surgery’
 SPECIAL SUBGROUP CONSIDERATIONS

• The pediatric, the elderly and the pregnants need special

consideration though the initial assessment is similar for all
trauma pts
Pediatric trauma
 Less fat, less connective tissue and an immature skeleton;
therefore, injuries to more than one organ are more frequent
 hypothermia is a higher risk
 smaller and more anteriorly positioned and funnel shaped
larynx, floppy epiglottis, short trachea and large tongue
 hypotension is a very late and ominous sign of hypovolaemic
shock
 Trauma in the elderly population

• Challenging due to fragility of the patient’s physiological

status and comorbidities
• Pulmonary complications, such as atelectasis, pneumonia and
pulmonary oedema, occur with great frequency
• Cardiac reserve and maximum potential heart rate decreases
with age and, therefore, it may be difficult to detect ongoing
hypovolaemic shock
• Osteoporosis can lead to increased risk of spinal fractures
after even very minor injury
 Trauma in pregnancy

• pregnancy must be considered and excluded in all women of

child-bearing age
• Due to the increased intravascular volume in pregnancy, these
patients can lose significant amounts of blood before they
display the usual signs of hypovolaemia
• Mother may appear relatively stable while the fetus is in
distress due to a lack of placental perfusion
• Fetomaternal haemorrhage - Rh-negative patients should be
administered Rh immunoglobulin
Thank u