ADVANC ED TRAUMA LIFE

SUPPORT
chapter 1. Initial Assessment and Management

Anesthesiology RS Husada

Initial Assestment :
Preparation
Triage
Primary survey (ABCDEs)
Resuscitation
Adjuncts to primary survey and resuscitation
Consideration of the need for patient transfer
Secondary survey (head-to-toe evaluation and patient history)
Adjuncts to the secondary survey
Continued postresuscitation monitoring and reevaluation
Definitive care
The primary survey should be repeated frequently to identify any
deterioration in the patients status that indicates the need for additional
intervention.
The primary and secondary surveys should be repeated frequently to
identify any change in the patients status that indicates the need for
additional intervention.

Prehospital Phase
During the prehospital phase,
emphasis should be placed on
airway maintenance, control of
external bleeding and shock,
immobilization of the patient,
and immediate transport to the
closest appropriate facility,
preferably a verified trauma
center.

Hospital Phase

A resuscitation area should be

available for trauma patients.
Properly
functioning
airway
equipment (e.g., laryngoscopes and
tubes) should be organized, tested,
and strategically placed where it is
immediately accessible. Warmed
intravenous crystalloid solutions
should be immediately available for
infusion, as should appropriate
monitoring devices.
All personnel who are likely to have
contact with the patient must wear
standard precaution devices.
A protocol to summon additional
medical assistance should be in
place, as well as a means to ensure
prompt responses by laboratory

Triage
Triage involves the sorting of patients based on their needs for treatment
and the resources available to provide that treatment. Treatment is
rendered based on the ABC priorities (Airway with cervical spine
protection, Breathing, and Circulation with hemorrhage control).
Other factors that may affect triage and treatment priority include injury
severity, salvageability, and available resources.
Triage also includes the sorting of patients in the field so that a decision
can be made regarding the appropriate receiving medical facility. It is the
responsibility of prehospital personnel and their medical directors to
ensure that appropriate patients arrive at appropriate hospitals.

Triage situations are categorized as multiple casualties or mass

casualties.
In multiple-casualty incidents, although there is more than one
patient, the number of patients and the severity of their injuries do not
exceed the capability of the facility to render care. In such situations,
patients with life-threatening problems and those sustaining multiplesystem injuries are treated first.
In mass-casualty events, the number of patients and the severity of
their injuries exceed the capability of the facility and staff. In such
situations, the patients having the greatest chance of survival and
requiring the least expenditure of time, equipment, supplies, and
personnel, are treated first.

Primary Survey (ABCDEs) +

Resuscitation
Airway maintenance with cervical spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neurologic status
Exposure/Environmental control: Completely undress the
patient, but prevent hypothermia
What is a quick, simple way to assess a patient in 10 seconds?
ASKING THE PATIENT FOR HIS OR HER NAME, and asking
what happened.
?? An appropriate response suggests that there is no major airway
compromise (ability to speak clearly), breathing is not severely
compromised (ability to generate air movement to permit speech),
and there is no major decrease in level of consciousness (alert
enough to describe what happened).
?? Failure to respond to these questions suggests abnormalities in

Airway

Upon initial evaluation of a

trauma patient, the airway
should be assessed first to
ascertain patency.

This rapid assessment for

signs
of
airway
obstruction should include
suctioning and inspection for
foreign bodies and facial,
mandibular,
or
tracheal/laryngeal fractures
that can result in airway
obstruction.

Airway maintenance
with cervical spine protection

The airway should be protected in all patients and secured when

there is a potential for airway compromise. The jaw-thrust or
chin-lift maneuver may suffice as an initial intervention.

If the patient is unconscious and has no gag reflex, the

establishment of an oropharyngeal airway can be helpful
temporarily.

A definitive airway (i.e., intubation) should be established if

there is any doubt about the patients ability to maintain airway
integrity. Patients with Glasgow Coma Scale score of 8 or less
(severe head injuries) usually require the placement of a
definitive airway (i.e., cuffed, secured tube in the trachea).

An airway should be established surgically if intubation is

contraindicated or cannot be accomplished.

This procedure should be performed with continuous

Airway maintenance
with cervical spine protection
Assume a cervical spine injury in
patients with blunt multisystem
trauma, especially those with an
altered level of consciousness or a
blunt injury above the clavicle.

Evaluation and diagnosis of specific

spinal injury, including imaging,
should be done later.

If immobilization devices must be

removed temporarily, one member
of
the
trauma
team
should
manually stabilize the patients
head and neck using inline
immobilization techniques.

 Adequate
gas
exchange
is
required to maximize oxygenation
and carbon dioxide elimination.
Injuries that severely impair ventilation
in the short term include tension
pneumothorax, flail chest with
pulmonary
contusion,
massive
hemothorax,
and
open
pneumothorax. These injuries should
be identified during the primary survey
and may require immediate attention
for ventilatory efforts to be effective.
Simple pneumothorax or hemothorax,
fractured
ribs,
and
pulmonary
contusion can compromise ventilation
to a lesser degree and are usually
identified during the secondary survey.

Breathing, Ventilation, and

Oxygenation
A
tension
pneumothorax
compromises
ventilation and circulation dramatically and
acutely; if one is suspected, chest decompression
should follow immediately.
Every injured patient should receive
supplemental oxygen. If not intubated, the
patient should have oxygen delivered by a maskreservoir device to achieve optimal oxygenation.
The pulse oximeter should be used to monitor
adequacy of oxygen hemoglobin saturation.
Maintaining

oxygenation

and

preventing

 Circulatory compromise in trauma

patients can result from many different
injuries. Blood volume, cardiac
output, and bleeding are major
circulatory issues to consider.
Once tension pneumothorax has
been eliminated as a cause of shock,
hypotension following injury must be
considered to be hypovolemic in
origin until proven otherwise.
Definitive bleeding control is essential
along with appropriate replacement of
intravascular volume.
The elements of clinical observation
that yield important information within
seconds are level of consciousness,
skin color, and pulse.

Circulation with hemorrhage control

Rapid, external blood loss is managed by direct manual
pressure on the wound. Tourniquets are effective in massive
exsanguination from an extremity, but carry a risk of ischemic
injury to that extremity and should only be used when direct
pressure is not effective.
The major areas of internal hemorrhage are the chest,
abdomen, retroperitoneum, pelvis, and long bones.
The source of the bleeding is usually identified by physical
examination and imaging (e.g., chest x-ray, pelvic x-ray,
Diagnostic Peritoneal Lavage [DPL] or Focused Assessment
Sonography in Trauma [FAST]).
Management may include chest decompression, pelvic binders,
splint application, and surgical intervention.

Exposure/Enviromental Control
After the patients clothing has been removed and the
assessment is completed, the patient should be covered
with warm blankets or an external warming device to
prevent hypothermia in the trauma receiving area.
Intravenous fluids should be warmed before being infused,
and a warm environment (i.e., room temperature) should

Adjuncts to Primary Survey and

Resuscitation
Adjuncts that are used during the primary survey include :
Electrocardiographic monitoring; urinary and gastric catheters;
other monitoring, such as ventilatory rate, arterial blood gas
(ABG) levels, pulse oximetry, blood pressure, pulse rate, body
temperature, and x-ray examinations (e.g., chest and pelvis)

Urethral injury should be suspected in the presence of one

of the following:
Blood at the urethral meatus
Perineal ecchymosis
High-riding or nonpalpable prostate

Adjuncts to Primary Survey and

Resuscitation

Consider Need for Patient Transfer

During the primary survey and resuscitation phase, the
evaluating physician frequently obtains enough information
to indicate the need to transfer the patient to another facility.

Secondary Survey
What is the secondary survey, and when does
it start?
The secondary survey does not begin until the
primary survey (ABCDEs) is completed, resuscitative
efforts are underway, and the normalization of vital
functions has been demonstrated.
When additional personnel are available, part of the
secondary survey may be conducted while the other
personnel attend to the primary survey. In this setting the
conduction of the secondary survey should not interfere
with the primary survey, which takes first priority.

Secondary Survey
The secondary survey is a head-to-toe evaluation of the
trauma patient, that is, a complete history and physical
examination, including reassessment of all vital signs.
AMPLE history (Allergies ; Medications currently used ; Past
illnesses/Pregnancy ; Last meal ; Events/Environment related to
the injury)
Complete patient evaluation requires repeated physical
examinations. During the secondary survey, a complete
neurologic examination is performed, including a repeat GCS
score determination.
Special procedures, such as specific radiographic evaluations
and laboratory studies, also are performed at this time.

Adjuncts to the Secondary Survey

These include :
Additional x-ray examinations of the spine and extremities; CT
scans of the head, chest, abdomen, and spine; contrast urography
and angiography; transesophageal ultrasound; bronchoscopy;
esophagoscopy; and other diagnostic procedures

Reevaluation
Trauma patients must be reevaluated constantly to ensure
that new findings are not overlooked and to discover
deterioration in previously noted findings.

Definitive Care
Which patients do I transfer to a higher level of care? When
should the transfer occur?

THANK QIU