ATLS: Initial Assessment

and
Management
SAUSHEC Medical Student
Lecture Series
 Objectives
Identify sequence of priorities in assessing the multiply
injured patient
Apply principles outlined in primary and secondary
evaluation surveys
Apply guidelines and techniques in the initial
resuscitative and definitive-care phases of treatment
Identify how patients medical history and mechanism of
injury contribute to identification of injuries
 Objectives
Identify pitfalls associated with initial assessment and
management and apply steps to minimize their impact
Be able to conduct an initial assessment survey, using
the correct sequence of priorities and management
techniques for primary treatment and stabilization
 Concepts of Initial Assessment
Rapid primary survey
Resuscitation
Adjuncts to primary survey/resuscitation
Detailed secondary survey
Adjuncts to secondary survey
Reevaluation
Definitive care
 Initial Assessment
Primary survey and resuscitation of vital
functions are done simultaneously-a team
approach.
 Preparation
Pre-Hospital System
Transport guidelines/protocols
On-line medical direction
Mobilization of resources
Periodic review of care
Closest appropriate facility
 Preparation
In-Hospital
Preplanning
Equipment, personnel, services
Standard precautions
Transfer agreement
 Standard Precautions
Cap
Gown
Gloves
Mask
Shoe covers
Goggles/face shields
 Triage
Sorting of patients according to:
ABCDEs
available resources
Multiple casualties
Mass casualties
 Primary Survey
adult/pediatric/pregnant women=priorities
are the same
A airway with C-spine protection
B breathing
C circulation with hemorrhage control
D disability
E exposure/environment
 Special Considerations
trauma in the elderly
5th leading cause of death
decreased physiologic reserve
comorbidities: diseases/medications
Outcome depends on early, aggressive
care
 Primary Survey
A
Establish patent airway
assume C-spine trauma
Pitfalls
equipment failure
inability to intubate
occult airway injury
progressive loss of airway
 Primary Survey
Suspect C-spine injury
spinal protection
C-spine X-ray when appropriate
 Primary Survey
B
Assess
Oxygenate
Ventilate
Pitfalls:
Airway vs ventilation problem
iatrogenic pneumothorax/tension
pneumothorax
 Primary Survey
C
Assessment of organ perfusion
Level of Consciousness
Skin color and temperature
Pulse rate and character
 Primary Surevey
C
Circulatory Management
Control Hemorrhage
Restore Volume
Reassess
Pitfalls:
elderly, athletes, children
medications
 Primary Survey
D
Disability
Baseline neurologic evaluation
GCS Scoring
Pupillary response
Continuously reassess for
deterioration/changes
 Primary Survey
E
Exposure
Completely undress the patient
Environment
core temperature
prevent hypothermia
 Resuscitation
Protect and secure the airway
Ventilate and oxygenate
Stop the bleeding
Protect from hypothermia
 Adjuncts to Primary Survey
Vital Signs/ECG monitoring
ABGs
POX/CO2
Urinary/gastric catheters
Urinary output
ECG
 Adjuncts to Primary Survey
Diagnostic tools
CXR, C-spine, Pelvis
DPL
Ultrasound
 Adjuncts to Primary Survey
Consider Early Transfer
do not delay transfer for diagnostic tests
time to transfer=resuscitation
 Reevaluate
Proceed to secondary survey after:
Primary survey completed
ABCDEs reassessed
initial resuscitation of vital functions
 Secondary Survey
Key Components
History
Complete head-to-toe examination
Tubes and Fingers in every orifice
Complete Neuro exam
Special diagnostic tests
Reevaluation
 Secondary Survey
History
A Allergies
M Medications
P Past Medical/Surgical History/Pregnancy
L Last meal
E Events/Environment related to injury
 Secondary Survey
Head
Complete Neuro exam
GCS Score
Comprehensive eye/ear exams
Pitfalls:
unconscious patient
periorbital edema
occluded auditory canal
 Secondary Survey
Maxillofacial
Bony crepitus/stability
Palpable deformity
Pitfalls:
potential airway obstruction
cribriform plate fracture
frequently missed injuries
 Secondary Survey
Cervical Spine
Palpate for tenderness/stepoffs/crepitus
Complete motor/sensory exams
Reflexes
C-spine imaging
Pitfalls:
altered LOC for any reason
distracting injury
 Secondary Survey
Neck (soft tissues)
Mechanism: blunt vs penetrating
Symptoms: airway obstruction, hoarseness
Findings: crepitus, hematoma, stridor, bruit
Pitfalls:
may have delayed symptoms/signs
progressive airway obstruction
occult injuries
 Secondary Survey
Chest
Inspect
Palpate
Percuss
Auscultate
X-rays
Pitfalls:
elderly, children
 Secondary Survey
Abdomen
Inspect, auscultate, palpate, percuss
Reevaluate frequently
Special studies
Pitfalls:
hollow viscus and retroperitoneal injuries
excessive pelvic manipulation
 Secondary Survey
Perineum-contusions, hematomas,
lacerations, urethral blood
Rectum-sphincter tone, prostate, pelvic
fracture, rectal wall integrity, blood
Vagina-blood, lacerations
Pitfalls:
urethral injury, pregnancy
 Secondary Survey
Musculoskeletal:Extremities
contusion, deformity
pain
perfusion
peripheral NV status
X-rays as indicated
 Secondary Survey
Musculoskeletal:Pelvis
Pain on palpation
increased symphysis width
uneven leg length
instability
special X-rays as indicated
 Secondary Survey
Musculoskeletal
Pitfalls:
potential blood loss
missed fractures
soft-tissue or ligamentous injuries
compartment syndrome
 Secondary Survey
Neurologic
Spine/Cord:
complete motor and sensory exams
reflexes
imaging as indicated
CNS:
frequent reevaluation
prevent secondary brain injury
Early neurosurgical consultation
 Secondary Survey
Neurologic
Pitfalls:
incomplete immobilization
subtle increases in ICP with manipulation
rapid deterioration
 Adjuncts to Secondary Survey
Special diagnostic tests as indicated

Pitfalls:
patient deterioration
delay of transfer
 Reevaluation
Minimizing missed injuries
high index of suspicion
frequent reevaluation and continuous
monitoring
 Reevaluation
Pain Management
relief of pain/anxiety
IV titration
monitor carefully
 Definitive Care
? Transfer
Patient
injuries
physiologic status
concurrent diseases
factors that may alter prognisis
Hospital
overall capabilities
specialized care
 Records, Legal Considerations
concise, complete, chronologic
documentation
consent for treatment
forensic evidence
 Summary
Primary Survey
Resuscitation
Adjuncts
Secondary Survey
Adjuncts
Definitive Care
?