acute trauma management (1)

Management of acute trauma

IC3Musculoskeletal Teaching weekGavin O’Reilly6/1/15

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

ATLS

• ATLS was developed by the American College of Surgeons• Deals with acute trauma in a stepwise manner• Each step is completed in turn• The next step is not attempted until the previous one is

completed– Airway & c-spine– Breathing– Circulation– Disability (Neurological assessment)– Exposure and environmental control

• A detailed secondary survey from head to toe is performed once initial resuscitation takes place

PRIMARY SURVEY• Airway (& c-spine)

– Is there any blockage in the airway?– Any signs of stridor?– If any blockage eg blood vomit this should be cleared– Airway should be opened (jaw thrust vs head tilt chin lift)– A definitive airway may be required

• Endotracheal intubation– A patient who is speaking to (or shouting at) you has a patent

airway and is unlikely to have any breathing problems– It should be assumed there is a cervical spine injury present

unless proven otherwise• Unconscious trauma patients require c-spine immobilization and

spinal boards• Patients with neck pain require c-spine immobilization and a spinal

board• Moving a patient with a spinal injury could exacerbate the issue

PRIMARY SURVEY

• Breathing– Chest is examined for breating by inspection, palpation,

percussion, auscultation– The quality of breathing is assessed– Tracheal deviation is assessed

• Circulation– Pulses

• Carotid• Radial

– Blood pressure– Any active bleeding should be controlled with pressure applied

• Disability / Neurological assessment– GCS scale– Neurological assessment for spinal injury– Pupil size and reaction– Lateralizing signs

• Exposure and environmental controls– Patient should be undressed and covered in warm blankets– Warmed IV fluid can be used

LIFE THREATENING THORACIC CONDITIONS

• Airway obstruction• Tension pneumothorax (occurs when a pneumothorax forms a one

way valve allowing air in but not out of the lung – consequent overexpansion compresses airway)

• Massive haemothorax (blood in thoracic cavity)• Open pneumothorax (a pneumothorax that communicates with

outside)• Flail chest with pulmonary contusions (rib fractures resulting in a

floating segment that moves paradoxically with respiration)• Cardiac tamponade (Blood in pericardium compressing heart)

MANAGEMENT OF LIFE THREATENING THORACIC CONDITIONS

• Airway obstruction– Clear airway if possible– Open airway– Pass endotracheal tube– If all above unsuccessful cricothyroidotomy can be attempted

• Tension pneumothorax– Needle decompression– This condition should be a clinical diagnosis and should NEVER

be diagnosed on x-ray


• Open pneumothorax– A bandage should be applied to a sucking chest wound– It should be applied to three sides of the wound so as to allow air

exit but prevent entry• Massive haemothorax

– A chest drain should be applied to a haemothorax– Significant output and signs of hypovolemic shock are

indications for cardiothoracic surgeon involvement• Flail chest with pulmonary contusions

– Management is supportive– Intubation if required


• Cardiac tamponade– Needle thoracocentesis to drain the excess blood causing the

tamponade effect

acute trauma management (1)

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