Initial Trauma Assessment

OVERVIEW

ATLS approach:

  1. Identification of life threatening injuries (primary survey)
  2. Resuscitation
  3. Head to Toe assessment (secondary survey)
  4. Definitive Therapy (+/- transfer)
  5. Documentation of injuries post investigations (Tertiary survey)
  6. Further appropriate care
  • if unable to resolve a problem don’t not leave issue until resolved.
  • at any point if there is deterioration start at airway again.

PRIMARY SURVEY

Airway

  • air must be able to pass to lungs
    signs: obstruction can occur due to direct injury, oedema, foreign body or depressed LOC
    -> establish airway

Breathing

  • ability to ventilate and oxygenate
  • signs: absence of breathing, asymmetrical or absent breath sounds, SOB, hyperresonance, dullness, chest wall instability (ATOMFC injuries)
    -> chest drain
    -> SpO2

Circulation

  • signs: collapsed or distended neck veins, external haemorrhage (hypovolaemia, cardiac tamponade, external haemorrhage)
    -> IV access -> blood tests, fluid resuscitation (crystalloids -> if unresponsive blood products, compression
    -> ECG, NIBP

Disability

  • decreased LOC, pupillary asymmetry, gross weakness
    -> head or spinal cord injury

Exposure

  • expose patient
  • prevent hypothermia

Other investigations

  • xrays: lateral c-spine, CXR, pelvis
  • bloods: G+H, Hb, electrolytes, amylase
  • N/G or O/G to decompress the stomach once intubated
  • foley catheter (contraindicated if: blood at meatus, ecchymosis of scrotum or labium, high riding prostate -> retrograde urethrogram)
  • FAST scan: free fluid

SECONDARY SURVEY

  • head to toe examination
  • if awake take AMPLE history
  • exclude (FATAL TRAUMA):
  • flail chest
  • airway compromise
  • tamponade
  • air leaks
  • lung contusion
  • tracheal injury
  • ruptured diaphragm
  • aortic disruption
  • unseen haemorrhage
  • myocardial injury
  • any neurological injury

Investigations

  • laparotomy: haemodynamically unstable + positive FAST
  • CT: head, neck, chest, abdo/pelvis (double contrast), aortogram
  • angiography: suspected aortic injury, pelvic or retroperitoneal bleeding, organ specific embolisation

Special situations

  • burns: first aid, early intubation in airway/inhalation injury, escharotomies
  • hypothermia: warm IVF
  • high voltage electricity: low threshold for measuring compartment pressures, myoglobinuria

References and Links

  • Styner JK. The birth of advanced trauma life support. J Trauma Nurs. 2006 Apr-Jun;13(2):41-4. PMID: 16884131.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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