Author:
JorgeFernand ez
Sam L.Frenkel
Peter L.Steinwald
Description
- ATLS provides a stand ardized approach to trauma including rapid assessment and treatment
- Life-threatening injuries must be immediately stabilized before moving along the primary survey
- A primary survey should be repeated whenever the patients' status deteriorates
Etiology
Variety of causes including:
- Penetrating trauma
- Motor vehicle and motorcycle accidents
- Falls from height
- Assault (including domestic violence)
- Mass-casualty events (including terrorism)
- Burns
- High-risk patients: Extremes of age, pregnancy, bleeding disorders (including potent antiplatelet or anticoagulant use), GCS <14, abnormal vital signs, dangerous mechanism
- In general, severely injured patients (especially those with unstable vital signs) with a potential need for acute surgical intervention should be transported immediately to the nearest major trauma center
- Triage to major trauma center per EMS protocol
- A primary survey should be performed at the scene and upon ED arrival
Signs and Symptoms
- Primary survey (ABCDE):
- Airway (with cervical spine precautions):
- Assess and stabilize the airway before moving to the next step in the primary survey
- Maintain C-spine precautions throughout
- Indicators of airway patency: Clear speech or effectively/silently moving air
- Indicators of airway obstruction: Gurgling, stridor, snoring, choking, or no air movement
- Breathing:
- Assess and stabilize breathing before moving to the next step in the primary survey
- Indicators of effective breathing: Symmetric chest wall rise/fall, equal bilateral breath sounds, normal resp rate, and O2 saturation
- Indicators of ineffective breathing: Asymmetric or minimal chest movement, unequal breath sounds, abnormal resp rate or O2 saturation
- Tension pneumothorax: Suggested by unilateral decreased breath sounds, tracheal shift (to opposite side), hyperexpansion, hyperresonance to percussion, subcutaneous air, hypoxia, and /or hemodynamic compromise
- Hemothorax: Suggested by decreased breath sounds and /or dullness to percussion
- Circulation:
- Assess and stabilize circulation before moving to the next step in the primary survey
- Assess HR, BP, pulse quality, and end-organ (e.g., mentation, capillary refill, urine output); when abnormal, assume internal hemorrhage
- Disability:
- Assess and stabilize disability before moving to the next step in the primary survey
- Assess level of consciousness, gross motor and sensory function, pupillary size/reactivity
- Glasgow Coma Scale is commonly used; score of ≤8 indicates severe head injury/coma
- Spinal cord injuries: Grossly assess for lateralization of motor/sensory deficits
- Assess brainstem function via pupillary size and reactivity to light
- Exposure:
- Undress completely, then warm passively
- Secondary survey:
- Performed after the primary survey
- Complete physical exam from head to toe
- “Finger in every orifice”
History
- Key features: Initial clinical presentation, mechanism of injury, suspected injuries, and treatment rendered should be elicited from EMS personnel, family, and bystand ers
- MVCs: Note approximate speed of all vehicles, impact point, location of patient in vehicle, seatbelt use, passenger space intrusion, steering column damage, or extrication by EMS
- AMPLE history: Allergies, medical/surgical issues, past medical, last oral, events leading up to trauma. (Discuss tetanus status if stable)
Essential Workup
- Primary and secondary surveys
- Critically ill patients: Activate trauma team, rapid transfusion and lab/imaging stand by
- Point of care (POC) US (e-FAST)
- Portable radiographs include AP chest, AP pelvis, and lateral cervical spine
- Computed tomography: Only when hemodynamically stable or adequately stabilized
- Use evidence-based clinical decision rules (e.g., NEXUS, Canadian) to avoid unnecessary imaging
Diagnostic Tests & Interpretation
Lab
- POC Hgb serially if hemorrhagic shock
- POC glucose if altered mental status
- Blood type, CBC, coags, blood gas, lactate, renal function, lipase, and UA for major trauma patients
- Pregnancy test in all females of childbearing age
- Consider cardiac enzymes to r/o cardiac injury
Imaging
- Significant chest trauma requires objective evaluation of the lungs, heart, and great vessels with e-FAST, CXR, CT, angiography, and /or thoracotomy
- Blunt abdominal trauma requires objective evaluation using e-FAST followed by abdominal CT or ex-lap:
- If free fluid on e-FAST
- Hemodynamically stable: CT with IV contrast
- Hemodynamically unstable: Exploratory lap
- For head trauma, CT is recommended if prolonged loss of consciousness, amnesia, persistent altered level of consciousness, or severe HA or vomiting
- For cervical spine fractures: CT is highly sensitive
- Pan CT scan, (head, neck, chest, abdomen/pelvis in a single pass with IV contrast) lower missed injury rate but significant radiation exposure
- Suspected spine injuries (with neuro deficits): emergent MRI
- Extremity injuries:
- Plain films identify most fractures (aside from scaphoid, hip, tibial plateau, talus, etc.)
- Suspected vascular injury: Duplex US or CT angiography
Differential Diagnosis
Consider medical conditions leading to trauma (e.g., seizures, dysrhythmias, and suicide attempt)
Initial Stabilization/Therapy
- Primary survey: Immediately stabilize any serious injuries once identified:
- Airway (with cervical spine precautions):
- Use jaw thrust, suction, oropharyngeal vs. nasopharyngeal airways, and /or McGill forceps
- Rapid sequence intubation: the preferred technique in major trauma; consider ketamine or etomidate to minimize peri-intubation hypotension
- Video laryngoscopy may allow endotracheal intubation with minimal impact on traumatic brain or unstable cervical spine injuries
- Failed airway: Extraglottic device (e.g., laryngeal mask airway) or cricothyroidotomy
- Breathing:
- 100% oxygen and respiratory monitoring
- Pre-oxygenation: 8 deep breaths or 3 min of tidal volume
- Tension pneumothorax: (Diagnosed clinically) emergently decompress with needle thoracostomy followed by tube thoracostomy
- Hemothorax: Tube thoracostomy (28F) is usually indicated; if massive hemothorax consider autotransfusion and thoracotomy in the OR
- Open chest wounds: Cover with a 3-sided adherent dressing and consider tube thoracostomy
- Flail segment, pulmonary contusion, burns: Treat respiratory distress with mechanical ventilation (use low tidal volume + PEEP for lung protection)
- Circulation:
- Place on a cardiac monitor
- Obtain IV access (ideally 2 large-bore peripheral IVs; alternatives include intraosseous lines, central lines, or venous cut down)
- Control external bleeding with direct pressure or tourniquets temporarily
- Crystalloid fluid bolus (10-20 cc/kg) is controversial (e.g., allow permissive hypotension)
- Replace lost blood with blood products in 1:1:1 ratio of PRBC, FFP, and platelets
- Treat unstable pelvic fractures with pelvic binding/
- Consider giving tranexamic acid (TXA) to all patients with hemorrhagic shock, as part of a massive transfusion protocol
- Pericardial tamponade:
- Stable: Emergent pericardiocentesis window
- Unstable; thoracotomy
- Penetrating chest trauma and witnessed arrest: Consider thoracotomy (if an available surgeon)
- Disability:
- If
glasgow coma scale score of ≤8 + head injury: Treat elevated intracranial pressure with mannitol or hypertonic saline, controlled ventilation (ideal PCO2 30-35 mm Hg), and elevating head to 30 degrees (while maintaining spine immobilization) - Intracranial bleeding or spinal cord injury: Obtain neurosurgical consultation; high-dose steroids are generally not recommended
ED Treatment/Procedures
- Definitive treatment may require emergent surgery or interventional radiology
- Prompt stabilization, early recognition of the need for operative intervention, and appropriate surgical consultation are paramount
- Re-evaluation is key to identify occult/delayed injuries
Medication
- Dictated by need for specific interventions
- Consider giving TXA to all patients in hemorrhagic shock, as part of a massive transfusion protocol
- Consider short-acting, hemodynamically neutral meds
- Consider prophylactic antibiotics in penetrating trauma
- Ensure an updated tetanus status
Pediatric Considerations |
- Intraosseous access is a viable alternative to IV access
- CT does not always reliably exclude spinal cord injury: Consider MRI
|
Disposition
Admission Criteria
- Many major trauma patients are routinely admitted for observation, monitoring, and re-evaluation
- Patients with significant injuries or hemodynamic instability should be admitted to the OR/ICU
- Patients requiring frequent assessments should be admitted to a monitored setting
Discharge Criteria
Patients with major or minor trauma and negative objective workup/imaging may be discharged after a period of observation
Issues for Referral
The availability of subspecialists, such as trauma surgeons, neurosurgeons, orthopedic/hand surgeons, otolaryngologists, plastic surgeons, and burn specialists may significantly impact morbidity and mortality
Follow-up Recommendations
Follow-up should be driven by the types of injuries and subspecialty care required
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See Also (Topic, Algorithm, Electronic Media Element)