A.T.L.S.

Primary Secondary Survey

Head Injury
Spinal Injury
Primary survey
A : Airway
B : Breathing
C : Circulation
D : Disability
: !posure
"oal : recogni#ing li$e threatening condition and simultaneously do
resuscitation
Airway
Cervical Spine Control %Assume injury until proven otherwise&
Airway assessment
' (bstruction) Patient can tal* airway clear
' +oo* %cyanosis,breathing pattern,uses o$ accessories muscle,--,Po! &
' +isten %grunting,stridor, total obstruction silent&
' .eel %decreased,absent air$low&
Airway management
' /riple airway maneuver only i$ w,o possible cervical spine injury :
Slight nec* e!tension
0aw thrust % elevation o$ mandible&
1outh opening
' Possible cervical injury : without nec* e!tension
' Adjunctive devices : oropharyngeal airway % only i$ no gag re$le!& ,
2asopharyngeal airway % 3I: susp4 Basilar s*ull $racture,coagulapaty&
Breathing
Assesment : +oo* % sign o$ respiratory distress, e5ual chest rise ,--,P
o!& ,+isten % lung sound & ,.eel % trachea position ,crepitus 6emphysema subcutis&
,P
1anagement : (!ygen supplement , Assisted ventilation
1anual assisted ventilation
' Indication : Apneic,Inade5uate ventilation
' Bag valve mas* 6 --:78 to 79 !,min6 7:: ; o!ygen with ma! $low % <7:
l,min&
Circulation
Assestment : pulse % carotid,$emoral,radial& , BP,H- ,evaluate 5uic*ly $or
areas o$ large hemorrhaging that can easily be stopped with direct pressure
1anagement :
' 8 +arge,short I= bore : 79 or intraosseous needle
' 2S ,-+ 8>? +,min or 8: cc,*g bolus in children
' 2o response6 blood 6 ( negative
Disability (Neuro)
A=P@ % Alert , =erbal response,Pain response,@nresponsive&
"CS % Adult,children&
!"osure
@ndress patient $or thorough e!amination
-emember hypothermia
-emember nec*,spinal immobili#ation
Addition on primary survey
=ital sign monitor % BP,P o!,H- or Pulse rate& , Cardiac monitor
C"
@rinary catheter
' Chec* $or possible urethra rupture % blood (@,scrotal or perineal
hematome, -/ : unpalpable , high prostate&
' I$ susp4 @rethra rupture6 need urethra>systogram
A>ray : Cervical % lateral & , /hora! %AP& ,Pelvic % AP&
Secon#ary survey
A$ter primary survey , resuscitation and ABC stabili#e
!amine patient $rom head to toe
Anamnesis : A1P+ % Allergy , 1edication, Past medical history, +ast
meal, vent 6 mechanism o$ injury&
$NT
!amine $ace $or $acial $ractures
!amine eyes $or any gross injury6 shattered glass should be irrigated
then $lourescein
!amine ears $or hemotympanum
!amine mouth $or jaw $ractures,loose teeth
Nec%
As* patient i$ s,he has any nec* pain
1idline tenderness)
Penetrating wound : which #one ) trauma to the arteries,airway)
Chest
Palpate entire chest $or area o$ crepitus,tenderness
+oo* $or Seat belt sign,bruising ,asymmetric
+isten to breath sounds6 symmetric ) other additional sounds)
+isten to heart sound
Ab#omen
+oo* $or distension , bruising , seat belt sign
!amine $or area o$ tenderness
Pelvic
!amine $or tenderness AP,+ateral compression
"enitourinary,rectal
!amine e!ternally $or signs o$ bleeding
-ectal e!am $or blood,position o$ prostate% male&
Bac%
+og roll
+oo* $or bruising , tenderness on bone palpation , penetrating wound
!tremities
+oo* $or de$ormity,laceration , bleeding site ,abrasion
Palpation $or area o$ tenderness,crepitus,pulsation
Neurologic
"CS,1ental Status
+imited sensory,motor e!am
Laboratory test
Cervical spine : AP,+ateral,open mouth % odontoid&
Hemoglobin : serial : ?! 5 7B min
@rinalysis
!tremities A>ray
@S" abdomen ,C/
$ea# &n'ury
Classi$ication
1ild Head Injury : "CS : 7?>7B
1oderate Head Injury : "CS : C ' 78
Severe Head Injury : "CS : ?>D
"oal
Discover all moderate,severe head injury
Discover mild head injury with intracranial injury especially needing
surgery
' (bservation,education : patient that $irst appear with mild injury may
worsen over several hours
' -is* strati$ying
' Cost 'e$$ectiveness
"lasgow Comatose Scale
Adult ,Children % chec* in PDA : epocrates , table, "CS &
Serial chec*
(il# $ea# &n'ury
Clinical predictor :
' "CS , +oss o$ consciousness
"CS 7B , +(C %E& : 7: ; Intracranial injury %E& 6 7; need surgery
"CS 7?, +(C %E& : ?D ; Intracranial injury %E& 6 D ; need surgery
' +ocation o$ injury : temporo>parietal 6 increased ris* o$ epidural bleeding
' Signi$icant retrograde amnesia
' (lder patient
' Pree!isting condition : on anticoagulant , hemophiliac
' Di$$iculty to determine +evel o$ Consciousness in into!icated patient
% alcohol , drugs&
' Sign o$ basilar $racture % battles sign , raccoon eyes, CS. lea*age $rom
nose 6ear , hemotympanum &
Head A>ray
' (nly i$ patient stable otherwise donFt waste time
' .or $acial $racture
C/ scan
' In$ant G 78 months 6 all unless :
.all less than 7metres % ? $eet&
2ormal neuro e!am
2o evidence o$ scalp trauma % bruising,hematoma etc&
' (lder children and adult
Ab2 neuro e!am,"CS G 7B
Prolonged +(C % < 7B min&
-etrograde amnesia < ?: min
-epeated vomiting
Horsened,severe headache
Depressed s*ull $racture,basilar s*ull $racture
Special consideration : % anticoagulation , older patient with
+(C,Into!icated &
' 2ot sure , concerning mechanism o$ injury : C/ Scan
' C/ scan %>& but ab2 neuro e!am 6 plan $or another C/ in 8I,ID hours or
signi$icant worsening o$ symptoms4
Disposition
' 1ild Head Injury 6 2o neurological de$icit 6 "CS : 7B 4 low ris* strati$ication
' 2o Intra cranial injury on Head C/ 6 normal neuro e!am
' (bservation $or 8I hours 6 including neuro chec*s 5 8>I hours by
responsible adult % Head Injury patient lea$let&
' .ollow up the ne!t day
Admission
' Intra cranial injury %E& on Head C/
' All ab2 2euro e!am , "CS G 7B
(ther consideration
' Second Impact syndrome
' Head Injury in sports 6 Can I return to the game)
Post concussive syndrome
' Headache , di##iness , poor concentration , memory problems, emotional
problems4
' 1ost resolves a$ter $ew wee*s 6 C: ; resolves in 7 year 6 7: ; became
chronic
' I$ worsening 6 2euro evaluation , Head C/
(o#erate ) Severe $ea# &n'ury
ABC
Cervical immobili#ation
1aintain good o!ygenation ,per$usion % avoid hypotension $rom shoc*&
Prophyla!is anti sei#ures % phenytoin& ,1anitol
Head C/
-e$erral hospital , 2eurosurgeon , 2eurologist
S"ine &n'ury
ABCD , Primary survey , A with cervical immobili#ation ,Spine
immobili#ation with long spine board,bac* board4
1aintain in line immobili#ation 6 i4e4 hold the head with your hands, +og
roll during e!amination
@sage o$ bac* board : $or transportation 6 < 8 hours can cause decubitus
ulcer 6 i$ < 8 hours need to log roll 5 8 hourly
2eurological e!am :
' Sensory e!am 6 chec* level
' 1otor e!am 6 score : ' B 6 chec* level
' Proprioseptive , vibratory $unction % posterior column&
' Deep tendon re$le!
' Anogenital % sacral sparing& : Bulbocavernosus ,cremaster ,/SA
Classi$ication
' +evel
+owest segment % caudal& o$ the spinal cord that still have motoric % ?,B&
,normal sensoric $unction bilaterally
Partial preservation
Spinal injury level not the same with +evel o$ bone $racture
' 2eurologic De$icit
Complete ,Incomplete
' Spinal Cord syndrome
Anterior cord
Central cord
Brown Se5uard
Cauda 5uina
Spinal shoc*
' 1or$ology
.racture
.racture,Dislocation
SCIH(-A
Penetration injury e4g gun shot
Cervical s"ine in'ury
Cervical collar ) I$ you are worried or unsure assume thereFs cervical
injury until proven otherwise 4 Immobili#e ,A>ray
-uled out C>spine injury6 +ow ris* i$ $ollowing guidelines :
' 2o midline tenderness
' Alert , no neurological de$icit
' 2ot into!icated
' 2o other distracting injury
Physical e!am
Sensory e!am 1otor e!am
C8 /op o$ head >
C? ar >
CI 2ec* C?,I,B diaphragm
CB Shoulder Shoulder shrug
C9 /humb Biceps % elbow $le!ion&
CJ 1iddle $inger /riceps % elbow e!tension&
CD +ittle $inger .inger muscle
Posterior column sensation proprioception % $inger up,down&
Imaging Studies
A>ray : +ateral , (pen 1outh (dontoid %(1(& ,AP % chec* proc4 spinosus&
C/ 'Scan :
' /o illustrate detail o$ $racture
' I$ $racture is suspected but no ade5uate A>ray
1-I :
' +igament ,spinal cord
1anagement :
1ethyl prednisolone6 initial dose : ?: mg , *g I= over 7 hour $ollowed by B4Img
,*g,hour $or the ne!t 8? hours % total 8I hours&
!clusion criteria :
/o be given within D hours
< 7? years old
2o serious injury
2ot pregnant
2ot already ta*ing other steroids
2ot given nalo!one recently
2eurogenic Shoc* :
2ot common 4 Cause by spinal cord injury 4 Decreased vascular tone and
relative bradycardia4 % symphatic enervation o$ the heart&
Spinal shoc*
A$ter spinal cord injury 4 .lacid , loss o$ re$le!es4 /emporary 4
T$*+AC&C T+A,(A
+i$e threatening condition that need to be identi$ied and treated immediately on
Primary Survey
Airway
+aryngeal Injury
Sign o$ upper airway obstruction % stridor&
Hoarseness,emphysema subcutaneous emphysema,palpable $racture o$
the laryn!
Humidi$ied (!ygen,I= access,Prepare $or early intubation or surgical
airway, 2/ consult
I$ edema laryn! : De!amethasone6 adult I mg I=6 ped: :48B mg ' :4B
mg,*g I=
.racture ,Dislocation o$ Sternoclavicular joint
(bvious sign o$ trauma on the base o$ the nec* with palpable de$ect on
the sternoclav4 0oint
Closed reduction o$ the sternoclavicular joint in supine position
Breathing
/ension Pneumothora!
Clinical diagnosis : Chest pain , respiratory distress,tachycardia,
hypotension, tracheal deviation,unilateral absence o$ breath,0=D,cyanosis
2eedle thoracocentesis % large bore needle 6 7I>79 "6 8
nd
intercostal
space6 midclav& $ollowed by insertion o$ chest tube
(pen Pneumothora!
+arge de$ects o$ chest wall which remain open or suc*ing chest wound
Close the de$ect with sterile occlusive dressing6 large enough to overlap
the wound6 tapes securely on ? sides
.lail chest
1ultiple ribs $ractures ie6 two or more ribs $ractured in two or more places
Parado!ical movement o$ the chest wall % inspiration,e!piration&
1ain problem is the underlying lung disease : Pulmonary contusion
Humidi$ied o!ygen,$luid resuscitation,analgesic
Asses ade5uate ventilation $or the need $or assisted ventilation ,intubation
Circulation
1assive Hemothora!
< 7B:: ml blood in the chest cavity or blood loss < 8:: ml,hour $or 8 to I
hours
shoc* associated with the absence o$ breath sound and or dullness on
percussion on one side o$ the chest
1anagement : .luid resuscitation,blood trans$usion simultaneously with
decompression o$ chest cavity % chest tube&
Cardiac /amponade
Commonly associated with penetrating injury
Bec*Fs triad : 0=D,hypotension,mu$$led heart sounds6 not always present
PA in the absence o$ hypovolemia,tension pneumothora!
Pericardiocentesis
Secondary Survey
.urther physical e!amination
CA-
P o! ,Blood "as Analysis
C"
Simple Pneumothora!
Decreased breath sounds , hyperresonance ,CA-
I$ pneumothora! G 7B ;6 no cardiovascular or respiratory compromise :
observe $or I to 9 hours and repeat CA- 6 i$ no change : discharge
otherwise chest tube insertion
Hemothora!
Shown in CA- 6 needed to be evacuated with chest tube
Pulmonary contusion
Cause respiratory $ailure
Intubation
Blunt Cardiac Injury
/raumatic Aortic Disruption
Persistent hypotension
CA-: widened mediastinum
Subcutaneous emphysema
2ot re5uire treatment
@nderlying injury
I$ needed to assist ventilation with positive pressure6 anticipate possible
pneumothora!
-ib $ractures
@pper ribs : 7>? : severe injury 6 associated with other serious injury
% major blood vessels&
+ower ribs : 7: >78 : considered hepatosplenic injury
Common associated injury : pneumohemato thora!
/reatment : ade5uate pain management to improve ventilation4 -is* o$
in$ection esp4 in elderly
/raumatic Diaphragmatic injury
1ore common in the le$t side
Sternum,scapular $ractures
"enerally results o$ direct pressure
Sternum $racture can accompanied by lung contusion,blunt cardiac injury
ABD*(&NAL T+A,(A
Primary survey : ABCD 6 Hypotension)
(bvious sign o$ trauma on the abdomen : blunt,penetrating injury
Internal organ injury : +iver,spleen,pancreas,hollow viscus,*idney
Sign o$ peritonitis % distension ,tenderness,muscle guarding, rebound&
Serial Hb,urinalysis,pregnancy test
Abdominal series ,@S"
Pelvic Injury 6 associated with major blood vessel
"enito>urinary trauma : blood (@,scrotal>perineal hematoma,high riding
prostate or blood on the rectal e!am 6 precaution $or urinary catheter4
Penetrating injury : closed wound with gau#e soa*ed with 2S
(,SC,L*S-LTAL T+A,(A
AB C D
I=,(8 ,1onitor
Hipovolemic shoc* .emur $r4
Pain management 4 2arcotic pain relie$ % Pethidine,1orphine&
Asses 2 = D % 2eurovascular distal& 4 Always chec*
colour,pulsation,capillary re$ill , sensation6 compare bilaterally6 and
documented prior and a$ter every manipulation ,splint
(pen wound (pen $ractures ) 6 cover with sterile dressing
Splint 6 immobili#ed one joint above and one joint below the injury site
1al>aligned, compromise 2=D : attempt to realign by gentle traction4 I$
a$ter traction 2=D compromise worsened bac* to position be$ore and
splint in that position
Do not $orced re>alignment i$ di$$icult splint in that position
/etanus prophyla!is : vaccine,Ig
Antibiotic : Ce$a#olin % gr I & 6 E gentamycine % gr II , III & 6 dose chec* on
B1C
(rthopedic consult
Compartment syndrome
o Pain is the earliest symptoms esp4 with passive stretching o$ the
involved groups o$ muscle
o (ther ischemic sign: B P :pain ,pressure,paresis,paresthesia,pulse
o @nconscious patient is at increased ris*
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)
n near drowning! aspiration as little as 2 cc"#g may cause lung damage"hypo$ia :
Surfactant loss"alveolar dysfunction
Direct tissue to$icity ! pulmonary edema
%"& mismatch ! vasoconstriction
'ven without aspiration! life threatening pulmonary edema may occur due to cerebral
hypo$ia or cardiac failure ( dry drowning)
Management
Prehospital
()CD' with nec#"spinal in*ury and hypothermia ( especially in children)
precaution
)egin C+, immediately with ma$ -$ygen
%" .onitor
No role for trying to evacuate water by /eimlich or other maneuvers
(symptomatic patient still need to be observe for possible secondary drowning
+atient with Cardio pulmonary arrest "0+ o$ 1 23 4 with ma$ -$ygen! should be
transported to hospital with facility of ntubation
Emergency Department
Consider other associated in*uries ( spine"head"other trauma) and medical condition
( (."Disrythmia" stro#e)
+atient who arrived awa#e but with respiratory distress or hypo$ia
% "-2 ma$ with N,)".onitor
C5, +("6at and other 57ray if needed
'C8 " ()8 " electrolyte")9N "Creatinin"C)C" 8lucose
f unable to maintain + o$ : 23 4 with ma$ -2! need to intubate
(ntibiotic : 6evoflo$acine ;33 mg &D
-bservation for 1272< hours
,epeat C5,"lab test every = to 12 hours
+atient who arrived without any symptoms
f physical e$am"C5, and +o$ normal ! patient may be discharged after = hours
of observation ( repeat C5,"lab test)
/igh ris# patient
6oss of consciousness
Cardiopulmonary arrest
Cyanotic "tachypnoe " respiratory distress
Sei>ures
+rolonged time under water "water ingestion
+ree$isting medical condition "elderly"young children