Slide Guide

Chapter 1
Initial Assessment and Management

SLIDE 1-1 Title Slide

Introduce the topic and explain to students that, based on their preparation for the
course, a series of questions will be asked throughout the lecture. Their active partici-
pation and responses are expected.
Emphasize that this lecture summarizes the information provided throughout the
course, and that all major components will be covered in depth during individual
lectures, skill stations, and demonstrations.
Because you will use the slide show to emphasize key points, it is important to be
familiar with every slide. Proper sequencing of questions and responses facilitates an
interactive presentation.
Be sure to carefully manage the time allotted for this lecture.

SLIDE 1-2 Chapter Statement

SLIDE 1-3 Case Scenario

After the students read the scenario, advance to the next slide and pose the questions.

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2 CHAPTER 1 n Initial Assessment and Management

SLIDE 1-4 Case Scenario

After the students read the scenario, discuss the 3 questions. Conclude that it is un-
necessary nor is it frequently possible to identify the specific injuries. Management is
based on priorities related to degree of life threat.
1. Do you need to identify the specific injuries before initial management of this
patient?
2. If not, how do you proceed?
3. What is the sequence of priorities in assessing the patient?

SLIDE 1-5 Objectives 110

Review the objectives with the students as provided on the slide.
Emphasize that ATLS has a unique language, including such terms as primary and
secondary survey, ABCDEs, and definitive care. Those individuals who complete the
course will speak the same language, and thereby communicate more effectively.
Primary and secondary survey will be defined.
Management priorities and their rationale will be discussed, including resuscitation
and monitoring.
Recognize the possibility of pitfalls.
These objectives relate to the lecture/interactive discussion. There may be additional
objectives related to this topic that will be covered in the skills station and the initial as-
sessments. Please refer to the book for the complete list of objectives related to this topic.

SLIDE 1-6 Standard Precautions

Standard precautions are one component of preparing for the patient in the hospital.
You may query what items are needed to protect the patient and the trauma team
members.
Emphasize the need to protect the patient and trauma team members from com-
municable diseases.

SLIDE 1-7 Initial Assessment

We recognize that, when a team is present, many individuals accomplish disparate
tasks simultaneously.
The ABCDE format serves the purpose of establishing priorities and helping the student
to return to A (home base) whenever the patients condition worsens or the patient
does not respond as anticipated during the initial assessment process.
 CHAPTER 1 n Slide Guide 3

SLIDE 1-8 Concepts of Initial Assessment

Initial assessment and management refers to the entire process of evaluating, treating,
conducting a detailed head-to-toe evaluation, reevaluating the patient, and transfer-
ring that patient, as necessary, to a facility with the resources to provide optimal care.

SLIDE 1-9 Quick Assessment

What is a quick, simple method to assess the patient in 10 seconds?
After asking this question, allow the students adequate time to consider the most
efficient way of assessing for a patent airway, sufficient respiratory reserve to speak,
and the level of cognition to process the question and respond appropriately.
Answers appear on next slide.

SLIDE 1-10 Quick Assessment

SLIDE 1-11 Appropriate Response Confirms

Emphasize the need for adequate cardiac output to ensure clear sensorium.
The patient who fails this simple test needs immediate attention.
Explain how the answers relate to A, B, C and D.
Inappropriate or no response requires urgent intervention.
4 CHAPTER 1 n Initial Assessment and Management

SLIDE 1-12 Primary Survey

This is the students first encounter with the ABCDEs, so be sure to allow adequate
time to discuss why the priorities are ordered in this manner.

SLIDE 1-13 Special Considerations

Remind the students that there are special issues to consider with each of these types
of trauma patients, but that the priorities remain the same.
Explain the rationale for special considerations:
Elderlydiminished reserve, cormobidity, medsearly decompensation.
Pediatricearly compensation, sudden deteriorationaggressive approach.
Pregnancy2 patientsbest treatment is resuscitation of the mother.
Athletecompensate because of reserve. Lack of tachycardia early.

SLIDE 1-14 Special Considerations

Remind the students that there are special issues to consider with each of these types
of trauma patients, but that the priorities remain the same.
Explain the rationale for special considerations:
Elderlydiminished reserve, cormobidity, medsearly decompensation.
Pediatricearly compensation, sudden deteriorationaggressive approach.
Pregnancy2 patientsbest treatment is resuscitation of the mother.
Athletecompensate because of reserve. Lack of tachycardia early.

SLIDE 1-15Primary Survey: Establish patent airway and

protect c-spine
Concerns regarding the c-spine may be new to those students who are familiar with
cardiac life support procedures, but have not taken the ATLS Course.
Emphasize the need to protect the c-spine during airway management, especially
avoiding the ACLS head-tilt maneuver.
You may then query the students about what pitfalls they may encounter with manag-
ing the airway or, depending on available time, caution the students to avoid these
pitfalls.
 CHAPTER 1 n Slide Guide 5

SLIDE 1-16Primary Survey: Assess and ensure adequate

oxygenation and ventilation
Emphasize the need to attend to adequate oxygenation and ventilation in the injured
patient, recognizing that altered chest wall mechanics may be new to those doctors
who have taken only the cardiac life support course.
Emphasize that, if the patient is receiving high-flow oxygen, adequate oxygenation is
no guarantee of adequate ventilation.

SLIDE 1-17Primary Survey: Assess and ensure adequate

oxygenation and ventilation
Emphasize the need to attend to adequate oxygenation and ventilation in the injured
patient, recognizing that altered chest wall mechanics may be new to those doctors
who have taken only the cardiac life support course.
Discuss how interventions may lead to pneumothorax and tension pneumothorax
(referring to the role of positive pressure ventilation).

SLIDE 1-18 Primary Survey: Assess for organ perfusion

Emphasize the reasons for assessing for signs of inadequate tissue perfusion instead of
focusing on the patients blood pressure.
Explain how generalized hypoperfusion manifests itself by the signs on the slide.

SLIDE 1-19 Primary Survey: Circulatory Management

Emphasize the need to control hemorrhage or stop the bleeding.
Also emphasize pitfalls students may encounter with managing the airway or, depend-
ing on available time, caution the students to avoid these pitfalls.
Explain that hemorrhage is the major source of hypoperfusion in the trauma patient
and the prime goal is to identify and stop the hemorrhage.
The different responses of the elderly, child and athlete to hypoperfusion and the effect
of medications such as B-blocker should be discussed.
6 CHAPTER 1 n Initial Assessment and Management

SLIDE 1-20 Primary Survey: Disability

Emphasize that it is essential to identify neurologic injury using the tools of GCS score
and pupil response early in order to avoid secondary brain injury, identify surgically
correctible lesions rapidly, and provide a baseline GCS score to identify trends and
changes.

SLIDE 1-21 Primary Survey: Exposure and Environment

The E of the ABCDEs.
Emphasize the need to completely undress the patient to adequately assess the entire
patient, while at the same time preventing hypothermia.
Explain the need to examine the patient completely to avoid missed injuries.

SLIDE 1-22 Resuscitation

Emphasize that treatment is administered at the time the life-threatening problem is
identified and that assessment and treatment during the primary survey and resuscita-
tion phases of the initial assessment process often are done simultaneously.

Photograph Courtesy of Charles Aprahamian, MD,

FACS.

SLIDE 1-23 Adjuncts to the Primary Survey

Emphasize that adjuncts are done selectively, depending on the patients spectrum of
injuries and physiologic responses.
 CHAPTER 1 n Slide Guide 7

SLIDE 1-24 Adjuncts to Primary Survey

The primary purpose of these adjuncts during the primary survey is to determine where
occult bleeding may be occurring that is not obvious on clinical exam.
Emphasize the need to determine the source of shock.
Portable chest and pelvic x-rays in the emergency department are the ONLY x-rays
obtained during the primary survey. Previous editions of the course included lateral
cervical spine x-rays, but this film is now obtained selectively and at the appropriate
time, based on the doctors judgment.
These x-rays assist in identifying the cause of shock in C of the A, B, Cs of the
X-rays courtesy of Dr. Ray McGlone, A&E Consultant, primary survey.
Royal Lancaster Infirmary; UK.

SLIDE 1-25 Adjuncts to Primary Survey

Explain the role of FAST and DPL (not generally used) in assessing for a source of
hemorrhage.

SLIDE 1-26Adjuncts to the Primary Survey: Consider Early

Transfer
Emphasize that the time to initiate the transfer process is when the need is recognized.
Therefore, the need to transfer must be considered early. The sooner the need is
recognized and communicated, the more efficiently it occurs.
In addition, transfer should not be delayed to perform the secondary survey or to
perform diagnostic tests such as CT scans. The time spent waiting for transportation to
arrive should be spent stabilizing the patient.
Early identification of the need for transfer and prompt transfer should not await
conduct of unnecessary diagnostic tests.

SLIDE 1-27 What is the secondary survey?

Expand upon the definition of the secondary survey after eliciting students responses.
8 CHAPTER 1 n Initial Assessment and Management

SLIDE 1-28 Secondary Survey: When do I start it?

These slides transition the student to the secondary survey.
Emphasize that issues identified during the primary survey have been addressed and
reevaluated before proceeding to the secondary survey.

SLIDE 1-29 Secondary Survey: What are the components of

the secondary survey?
You may use these items as a summary of the discussion on the components of the
secondary survey.
This slide also serves as an introduction to each component of the secondary survey.
Discuss the components of the secondary survey as outlined emphasizing the need for
re-evaluation.

SLIDE 1-30 Secondary Survey: History

Introduce this simple mnemonic for obtaining an AMPLE or complete patient
history.

SLIDE 1-31 Secondary Survey: Mechanisms of Injury

Ask the students how the mechanism of injury can influence the type and pattern of
injury sustained.
 CHAPTER 1 n Slide Guide 9

SLIDE 1-32 Secondary Survey: Head

You may query the students about what to examine and/or evaluate during the
examination of the injured patients head.
Describe the components as depicted on the slide and how the pitfalls may complicate
the assessment.

SLIDE 1-33 Secondary Survey: Maxillofacial

Students should be instructed to check mid-face stability, dental occlusion, and
contraindications for nasogastric tubes.
Discuss how these findings could be missed and the need for accurate assessment.

SLIDE 1-34 Secondary Survey: Neck (soft-tissues)

You may query the students about what they should look for during the examination
of the injured patients maxillofacial area.
Review the mechanism, symptoms and presentation of neck injuries and the pitfalls.

SLIDE 1-35 Secondary Survey: Chest

The photograph shows an unrestrained passenger who was thrown into the dash-
board.
Ecchymosis of chest wall from blunt trauma.
Review how the chest is evaluated during secondary survey, including appropriate
imaging studies.
10 CHAPTER 1 n Initial Assessment and Management

SLIDE 1-36 Secondary Survey: Abdomen

Review how the abdomen is evaluated during secondary survey, including appropriate
imaging studies.
The lap portion of the belt appears to have been applied incorrectly.
You may wish to emphasise the use of x-ray for pelvic assessment
Remind the students that the back also is a part of the torso and requires examination.
Appropriate spine precautions and protection must be taken whenever the patient is
suspected of having a spinal cord or vertebral injury.
Emphasize the elements of physical examination of the abdomen, the need to reevaluate
and the role of special studies (contrast studies) in the hemodynamically normal patient.
Review how hollow viscus and retroperitoneal injuries can be easily missed.

SLIDE 1-37 Secondary Survey: Perineum/Genitalia

Inspect for injury.
If injury is present, emphasize the need for vaginal and rectal exam looking for pelvic
fracture.
Prior to Foley catheter placement, evidence for injury necessitates a digital prostate
exam.
Outline the importance of identifying the abnormalities depicted on the slide.
Discuss the need to identify and diagnose urethral injury.

SLIDE 1-38 Secondary Survey: Pelvis

Review how the pelvis is evaluated during secondary survey, including appropriate
imaging studies.
Emphasize the need to avoid pelvic manipulation in patients with unstable pelvic
fractures that can cause hemorrhage.
Present the findings suggesting bony pelvic injury and its risk of massive hemorrhage
as well as the need to avoid excessive manipulation, which could worsen hemorrhage
as well as pain.

SLIDE 1-39Secondary Survey: Musculoskeletal Trauma

Extremities
Review how the extremities are evaluated during secondary survey, including appropri-
ate imaging studies.
Explain the importance of not missing these findings.
 CHAPTER 1 n Slide Guide 11

SLIDE 1-40Secondary Survey: Musculoskeletal Trauma

Pitfalls
Emphasize the potential for hidden hemorrhage, compartment syndrome, missed
fracture, and soft tissue injury.

SLIDE 1-41 Secondary Survey: NeurologicBrain

Note the need for an in depth evaluation of the patients central nervous system status
and frequent documented reevaluation.
Emphasize prevention of secondary brain injury by avoiding hypotension and hypoxia.
Emphasize need for continued assessment to detect deterioration and the need to
prevent secondary brain injury by maintaining oxygenation and perfusion.

SLIDE 1-42 Secondary Survey: NeurologicSpinal Assessment

Review how the spine and spinal cord function is evaluated during the secondary
survey, including appropriate imaging studies.
Review patient conditions that impair evaluation.
Emphasize that the entire spine must be assessed and detailed neurologic assessment
is necessary.

SLIDE 1-43 Secondary Survey: NeurologicSpine and Cord

Emphasize the need to carefully evaluate the patients entire back and take
precautionary/protective measures when logrolling the patient.
12 CHAPTER 1 n Initial Assessment and Management

SLIDE 1-44 Secondary Survey: Neurologic pitfalls

Subtle changes may predict acute deterioration.
Emphasize the need for serial reevaluation.
Explain how incomplete immobilization can lead to neurologic deterioration.

SLIDE 1-45 Adjuncts to Secondary Survey

These include specialized radiographic studies.
Emphasize that adjuncts should NOT delay appropriate transfer to definitive care.

SLIDE 1-46 Missed Injuries

Emphasize that meticulous attention to detail, integrated with clues from the
mechanism of injury and physical findings, and continued reassessment, are the best
methods to avoid missed injuries.
Some institutions conduct a tertiary survey within 24 hours of admission to assess
for missed injuries.
Missed injuries are avoided by frequent reevaluation, monitoring and having a high
index of suspicion.

SLIDE 1-47 Pain Management

Emphasize the need for judicious relief of pain associated with careful patient
monitoring.
Careful monitoring is required.
 CHAPTER 1 n Slide Guide 13

SLIDE 1-48 Which patients do I transfer?

Pose the question to the students and discuss their response and go to the next slide.

SLIDE 1-49 Which patients do I transfer?

Emphasize who needs transfer, the mechanics and rules of transfer, and the impor-
tance of doing it efficiently.

SLIDE 1-50 When to transfer?

Elicit responses from the audience. Answers appear on next slide.

SLIDE 1-51 When to transfer?

Define what degree of stabilization is needed at minimum prior to transfer.
Emphasize the need to avoid delay and unnecessary tests.
Discuss the stabilization of the patient using the A, B, C system.
14 CHAPTER 1 n Initial Assessment and Management

SLIDE 1-52 Transfer to Definitive Care

Use this slide to summarize transfer to definitive care.
Emphasize the need for established transfer agreements and relationships.

SLIDE 1-53 Case Scenario

Revisit the Case Scenario that was presented at the beginning of the slide set to give
the students the opportunity to apply what theyve learned in this lesson.

SLIDE 1-54 Questions

Ask for questions from the students and then pause, allowing the students adequate
time to form and ask their questions.

SLIDE 1-55 Summary

Summarize the components of Primary Survey to Definitive Care as depicted on the
slide.