Trauma

ATLS: General Principles

Scope of Problem

1. Significant nationwide healthcare problem
   • MVCs > 1 million deaths/year
     • 20-50 million significant injuries
     • Leading cause of death world-wide
2. Massive effect on society
   • Physical costs
   • Emotional costs
   • Lost wages, etc.
3. ATLS training in a developing country has resulted in
   • Decrease in injury mortality.
   • Lower per capita rates of deaths from injuries
   • Improves the knowledge base, psychomotor skills, and their use in resuscitation
   • Improves confidence and performance of doctors

Trauma System

1. Regional planning
2. Designated trauma centers
   • Level I
     • All essential specialties/services
     • All available in-house
     • All available 24/7
   • Level II
     • Most/Some specialties
     • Most available in-house
     • Most available 24/7
   • Level III
     • Some specialists
     • Available 24/7
     • Has resources for resuscitation, surgery, and ICU
     • Has transfer capabilities with Level 1 or Level II trauma
   • Level IV
     • Trauma treatment for those in remote rural areas
3. Ongoing quality assurance
4. Integration of EMS
   • EMS intervention protocols
   • Designated destination protocols

Key Principles and Assumptions

1. TEAM approach is essential
   • Injuries and problems are prioritized
     • Airway, Breathing, Circulation
   • ALWAYS ASSUME THE WORST POSSIBLE INJURY
   • COMPLETE AND THOROUGH EXAM
   • FREQUENT RE-ASSESSMENT
2. Approach divided into Primary and Secondary surveys
   • PRIMARY SURVEY ("ABCDE")
     • Treat Immediate and Potential life-threatening injuries AS THEY ARE FOUND
       • Airway integrity
       • Breathing adequacy/Bleeding and shock
       • Circulation
       • Disability
       • Environment/exposure
   • SECONDARY SURVEY
     • Done in ≤ 15 min
     • Used to prioritize treatment plan
     • Many procedures done here
     • Detailed search for further injuries in a "Head to Toe" direction
       • Facial fractures
       • Pupils
       • JVD/neck contusions
       • Clavicles
       • Chest rise/contusions/flail/breath sounds
       • Abdomen
         • Seat belt sign
         • Tenderness/Contusions
         • Flank ecchymosis
       • Genito-rectal
         • Blood in urethral meatus
         • Rectal in suspected pelvic fractures
       • Pelvic stability
       • Extremities
         • Pulses
       • Back

Team Approach

1. A team approach is vital to successful trauma resuscitation
2. Team members should be clear on their individual responsibilities
   • Many aspects of resuscitation take place SIMULTANEOUSLY
   • Each member should know what their specific job is
3. Always assume worst possibilities based on mechanism
4. The following should all be performed in first 1-2 minutes of trauma victim arrival
   • Applying 100% O2 via NRB mask or BVM
   • Inserting 2 large bore IVs
   • Checking vital signs, including pulse oximetry
     • Note: severe hypoventilation can still occur with a normal pulse oximetry
   • Removing all clothing and jewelry
   • Applying EKG monitor leads
   • Applying limb splints as needed
   • Obtaining O-negative or type-specific blood for transfusion (if hemodynamically unstable/hemorrhage)
     • Use of tranexamic acid in trauma pt w/ significant bleeding reduces mortality by 1.5% w/o increasing thromboembolic events
     • It is an inexpensive therapy that should be included in the care of these critically injured patients
   • Obtain blood for laboratory studies
     • CBC
     • Type and screen (or Type and Cross)
     • Electrolytes, BUN/Cr, glucose
     • PT/PTT and platelets, LFTs
     • Amylase/lipase, CK/troponin
     • U/A, pregnancy test
     • EtOH, tox screen (usually done)
   • Advanced life support is not superior to standard prehospital care

Imaging

1. Imaging studies held until AFTER "ABCDEs" (see Primary Survey)
   • Generally PORTABLE
   • CXR
   • Pelvis
   • X-table lateral C-spine
2. Many institutions obtain early CT as necessary when the patient is stable
   • Head, C-spine
   • Chest
   • Abdomen, Pelvis

References

1. Stewart RM, Rotondo MF, Henry SM, et al; The Committee on Trauma, American College of Surgeons. Advance Trauma Life Support, 10th ed., Chicago, Ill:American College of Surgeons, 2018
2. Rotondo, MF. Fildes, J. Brasel, KJ. et al. Advanced Trauma Life Support Student Manual 9th Edition. American College of Surgeons, 2012;pp.2-21
3. Marx, JA. Hockberger, RS. Walls, RM. et al. Rosen's Emergency Medicine Concepts and Clinical Practice 8th Edition. Saunders, an imprint of Elsevier Inc, 2014;pp 287-295
4. Gin-Shaw SL, Jorden RC. Multiple Trauma. In: Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed.,2002;pp.242-255
5. Hoyt DB, Coimbra R, Potenza B. Management of Acute Trauma. In: Townsend: Sabiston Textbook of Surgery, 17th ed.,2004;pp.483-529

Contributor(s)

1. Bruner, David, MD, FAAEM
2. Ballarin, Daniel, MD

Updated/Reviewed: January 2021