Trauma: A Brief Review

by Christopher Beach, MD, and Edited by Robin R. Hemphill, MD

This article is meant to be a brief review for those providers that have had ATLS or are about to take it. It is in no way meant to replace the ATLS course or formal trauma training. We recommend the ATLS course for all providers who do not receive formal training in trauma management, but may be in a position to receive and evaluate trauma patients. This review summarizes many of the major points made in the ATLS course and text.

Purpose, History and Concepts of ATLS:
- Designed for initial assessment and management after a blunt or penetrating trauma in the FIRST HOUR
- Trauma is a leading cause of death in ages 1-44
- Disability from injury dwarfs mortality 3:1
- Costs us $100 Billion dollars annually - 40% of health care dollar
- 60 million injuries annually, 3.6 million require hospitalization
- Trimodal distribution of death:
  - First peak - seconds to minutes of injury (we cannot do much for this group).
  - Second peak - minutes to hours after injury (this is the group we hope to intervene in).
  - Third peak - days to weeks after injury
- ABCDE mnemonic developed because life-threatening injury kills in reproducible time frames. i.e. loss of airway kills before loss of ability to breath before loss of blood volume, etc.
- ATLS gives one acceptable, easily taught, method for safe, immediate management and ability to:
  - Assess patient condition rapidly and accurately
  - Resuscitate and stabilize on a priority basis
  - Determine if needs will exceed a facilities capabilities
  - Arrange for transfer
- Course revised every 4 years (last 1993)
- As of 1993 15 countries provide ATLS to their physicians
Initial Assessment and Management:
1. Preparation
2. Triage
3. Primary Survey
4. Resuscitation
5. Secondary Survey
6. Re-evaluation and post-resuscitation monitoring
7. Definitive Care
8. Records and legal considerations
The primary and secondary surveys should be repeated frequently to ascertain any deterioration in patient status, and necessary treatment instituted immediately.
- Preparation
  - Prehospital phase: emphasis on obtaining and reporting pertinent information to receiving hospital(events, pt history, pt status, etc.) as well as on airway maintenance, control of bleeding/shock, immobilization and immediate transport to closest, appropriate facility.
  - Triage Decision Scheme overtriages approximately 30%
  - Inhospital Phase: ED preparation is a must! Have airway equipment, monitoring, lab, X-ray available, easy access to consultants and universal precautions. Always check equipment and know where it is.
- Triage
  - Prehospital personnel triage to appropriate center
  - 2 situations exist:
    1. Pt number and severity do not exceed ability to render care -- treat patients with life-threatening problems and multisystem injury first.
    2. Pt number and severity exceed capability of facility -- patient with best chance of survival, in least amount of time, equipment and supplies first.
- Primary Survey
  - ABCDE's, identify life-threatening conditions and treat simultaneously
  - Monitor vital signs and pulse oximetry
  - Airway with C-spine control:
    - Assess for patency, inspect for foreign bodies, fractures, swelling, etc.
    - Maintain C-spine immobilization, if needed use chin- lift, jaw thrust. Always assume C-spine injur in AMS.
    - check gag, dentures/loose teeth, bleeding, drooling, dysphasia/dysphonia
  - Breathing:
    - Assess oxygenation and ventilation. Listen to lungs, percuss for fluid/air in thorax, inspect for air exchange, palpate for fractures, etc. LI> check RR, pox, look for ecchymosis, flail areas, tracheal deviation, JVD
  - Circulation with hemorrhage control:
    - Assess hemodynamic status
    - check level of consciousness, skin color/capillary refill, bilateral pulses.
    - stop external hemorrhage with direct manual pressure, no hemostats
  - Disability:
    - Assess for neurologic injury.
    - AVPU mnemonic - alert, responds to voice, responds to pain, unresponsive. Pupillary light reaction, gag, etc.
    - check GCS in primary survey. Eye, Verbal, Motor responses, rectal tone, corneal reflex, gag/cough reflexes.
  - Exposure/Environmental Control: undress patient, apply warm blankets
Resuscitation:
- Airway: control as needed. See Airway section below
- Breathing: every pt should receive oxygen. See Airway section
- Circulation: minimum of 2 large bore IV's, draw blood for labs, initiate vigorous fluid therapy(now controversial for some patients) with LR/NS.
- If no response - Type specific blood (ready in 10-15 minutes) otherwise O neg. blood. Type and cross the patient early (this takes 45 minutes)
- Avoid hypothermia - use Level I warmer, blankets, hot lights.
- Catheters: Foley if no meatal blood, scrotal blood or high riding prostate






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