Trauma deaths have a trimodal distribution
- First peak
- Within minutes of injury
- Due to major neurological or vascular injury
- Medical treatment can rarely improve outcome
- Second peak
- Occurs during the 'golden hour'
- Due to intracranial haematoma, major thoracic or abdominal injury
- Primary focus of intervention for the Advanced Trauma Life Support
(ATLS) methodology
- Third peak
- Occurs after days or weeks
- Due to sepsis and multiple organ failure
ATLS methodology
- Primary survey and resuscitation
- A = Airway and cervical spine
- B = Breathing
- C = Circulation and haemorrhage control
- D = Dysfunction of the central nervous system
- E = Exposure
- Secondary survey
- Definitive treatment
Primary survey and resuscitation
Airway and cervical spine
- Always assume that patient has cervical spine injury
- Place in hard collar and keep on until cervical spine has been
'cleared'
- If patient can talk then he is able to maintain own airway
- If airway compromised initially attempt a chin lift and clear airway
of foreign bodies
- If gag reflex present insert nasopharyngeal airway
- If no gag reflex patient will need endotracheal intubation
- If unable to intubate will require a cricothyroidotomy
- Give 100% oxygen through a Hudson mask
Picture provided by Dr Ovidiu Florica, Royal Melbourne
Hospital, Melbourne, Australia
Breathing
- Check position of trachea, respiratory rate and air entry
- If clinical evidence of tension pneumothorax will need immediate
relief
- Place venous cannula through second intercostal space in the
mid-clavicular line
- If open chest wound seal with occlusive dressing
Circulation and haemorrhage control
- Assess pulse, capillary return and state of neck veins
- Identify exsanguinating haemorrhage and apply direct pressure
- Place two large calibre intravenous cannulas
- Take venous blood for FBC, U+Es, and Cross match
- Take sample for arterial blood gasses
- Give intravenous fluids
- Crystalloid or colloid in adequate volume
- Attach patient to ECG monitor
- Insert urinary catheter
Dysfunction
- Assess level of consciousness using AVPU method
- A = alert
- V = responding to voice
- P = responding to pain
- U = unresponsive
- Assess pupil size, equality and responsiveness
Exposure
- Fully undress patients
- Avoid hypothermia
Recent developments
- Plain radiographs remains integral to primary survey
- Focussed ultrasonography remains useful for identifying cause of
shock
- Whole-body CT has increasing role to identify injuries missed y
traditional assessment
- CT identifies more spinal injuries than plain radiographs
- Imaging modality of choice for identifying blunt aortic and solid
organ injuries
Bibliography
Nolan J P, Parr M J A. Aspects of resuscitation in trauma.
Br J Anaesth 1997; 79: 226-240. Harris T,
Davenport R, Hurst T et al. Improving outcomes in
severe trauma: What's new in ABC? Imaging, bleeding and brain
injury. Postgrad Med J 2012; 88: 595-603 |