Trauma Management Using ATLS: Airway, Breathing, Circulation …

Before talking about the fracture management, first we have to understand the trauma management using the advanced trauma life support (ATLS)

Trauma systems

• After the patient got injured, you need to do the critical procedures required for them to stay alive and then you manage their fractures and less critical injuries
• There is systems for that including the ATLS developed by American college of surgeons and which we will discuss here but also there is other systems like PHTLS and ETC depending on your institution and what system they follow

ATLS

• ATLS contain three sections: primary survey, resuscitation and secondary survey
• Primary survey is rapid assessment of patients ABCDE
  • Airway and cervical spine control
  • Breathing
  • Circulation and hemorrhage control
  • Disability
  • Exposure and environment

Airway

• Assessed for patency
• If patient is talking or screaming then airway is patent at the moment
• Noisy or absent breath sounds suggest compromised airway
• Immediate interventions to airway such as head tilt and chin lift or jaw thrust in comatose patients, suctioning relief airway compromise in many patients and use of oropharyngeal or nasopharyngeal airway maybe necessary => search it on YouTube
• Head tilt chin lift maneuvre is contraindicated in cervical spine injuries and not recommended if you are not sure about the condition of the cervical spine

• Jaw thrust maneuver can be applied even in cervical spine injuries

• Sometimes the immediate interventions are enough but other times you need an advanced airway 

Advanced airway

• Types: orotracheal and nasotracheal intubation (non operative) , if failed then cricothyroidotomy and emergency tracheostomy needed (operative) => search it on YouTube
• Indications of advanced airway
  • Apnea
  • Inability to protect airway (GCS <8)
  • Impending airway compromise in cases of inhalation injury, neck penetrating injuries (hematoma formation)
  • Extensive subcutanous air in the neck
  • Inability to maintain oxygenation

Cervical spine control 

• All patients with blunt trauma require cervical spine immobilization until injury excluded
• Immobilization achieved by semi rigid cervical collar or placing sandbags on both sides of the head and the forehead taped across the bags
• Soft collars are not effective
• In penetrating neck wounds, cervical collars not recommended because they interfere with treatment
• Search cervical  collars on google and see what is the types and differences

Breathing

• Second priority after the airway
• All trauma patients should receive High flow oxygen and monitored by pulse oximetry
• Watch for chest movement on examination
• Rapid evaluation for life threatening chest injuries
  • Tension pneumothorax
  • Open pneumothorax
  • Massive hemothorax
  • Flail chest

Circulation

• Initially palpate pulses to check for cardiovascular status
  • Palpable carotid pulse = systolic BP of 60 mmHg
  • Palpable Femoral pulse = systolic BP of 70
  • Palpable Radial pulse = systolic BP of 80
• Blood pressure measurement gives you idea about the grade of hypovolemia if the patient is hypovolemic
• Hypotension (systolic BP < 90) assume that it is caused by hemorrhage until proven otherwise

Grades of hypovolemic shock

Clinical feature	Grade I	Grade II	Grade III	Grade IV
Blood loss (mL)	Up to 750	750-1500	1500-2000	≥2000
Blood loss (%)	<15	15-30	30-40	>40
Pulse rate (beats/min)	<100	100-120	120-140	>140
Blood pressure (mmHg)	Normal	Normal	Decreased	Decreased
Pulse pressure	Normal or increased	Decreased	Decreased	Decreased
Respiratory rate (breaths/min)	14-20	20-30	30-40	>35
Urine output (mL/hr)	>30	20-30	5-15	Negligible
Mental status	Slightly anxious	Mildly anxious	Confused	Lethargic

Circulation Continued

• Place two large bore IV cannula and blood should be drawn before starting resuscitation with fluids to prevent RBC cross linking and agglutination
• Blood drawn for:
  • Cross matching
  • Bedside hemoglobin level and trauma panel
  • Coagulation panel
  • ABG for base deficit
• Rapid evaluation for:
  • Massive hemothorax
  • Cardiac tamponade
  • Massive hemoperitoneum
  • Mechanically unstable pelvic fractures with bleeding

IV Cannula

Cannula color	Gauge	Flow rate (ml/min)
Yellow	24G	20
Blue	22G	36
Pink	20G	60
Green	18G	90
Gray	16G	180
Orange	14G	240

Hemorrhage control

• Start with manual compression with a single gauze and a gloved hand
• Bleeding of the extremities might be managed with tourniquets for the short term
• Open fracture bleeding is controlled by reduction and stabilization with splints
• Pelvis should be stabilized with a sheet or binder

Fluid resuscitation

• The best resuscitation is achieved with blood but that is not usually ready until later
• So start with isotonic crystalloids typically Ringer’s lactate which is superior to normal saline (avoid hyperchloremic acidosis)
• In massive transfusion give packed RBCs , platelets and fresh frozen plasma in ratio of  1:1:1
• Aim for hypotensive resuscitation systolic pressure target of about 100 in bleeding patient (to protect the clot that has formed and thus decrease bleeding
• Assess by monitoring vitals: pulse, BP, RR, SpO2, urine output
• Also by monitoring labs: Hb, coagulation, lactate and base deficit

The lethal triad

• Lethal triad is 3 physiological abnormalities indicating inadequate resuscitation and increase risk of death
  1. Coagulopathy PLT<120, INR>1.5: consumption of clotting factors (solved by using platelets and fresh frozen plasma early in the resuscitation)
  2. Hypothermia <35C: exposure to cold and from fluid resuscitation and lead to impaired enzyme dependent pathways including clotting
  3. Acidosis pH<7.25: maybe inadequate oxygenation (respiratory acidosis) or inadequate peripheral tissue hypoperfusion

Disability

• Neurologic evaluation include: level of consciousness (conscious, drowsy, confused, stuporous or comatose), pupil size and reactivity and motor function
• Common causes of neurological deficits in trauma include: head injury, hypoxia, shock and alcohol or drugs intake
• Assessment of disability by AVPU scale or GCS
• AVPU: awake , responds to verbal, responds to pain, unresponsive

Adult Glasgow Coma Scale

Score	Eye opening	Verbal response	Motor response
1	None	None	None
2	Open to pain	Incomprehensible sounds (like moaning)	Extensor posturing
3	Open to voice	Inappropriate words (random)	Flexor posturing
4	Open spontaneously	Confused or disoriented	Withdrawal in response to pain
5		Oriented	Localize pain
6			Follows commands

• after giving scores to each of the eye opening, verbal response and motor response, then scores are summed up and When GCS applied to head trauma patients, results interpreted like this:
  • GCS 13-15= mild injury
  • GCS 9-12= moderate injury
  • GCS 3-8= severe injury (requires intubation)

Exposure and Environment

• All clothes of trauma patient are removed using scissors in order to make sure to examine all body parts from head to toe for trauma
• Keep the body warm using blankets to prevent hypothermia
• Hypothermia is used only in cases of severe brain injury

Secondary survey

• Head to toe examination
• SAMPLE: signs and symptoms of the patient, allergies, medications, past medical history, last meal (when and what), event history

Trauma films

• Blunt trauma: lateral cervical spine x ray + erect AP chest + AP pelvis
• Penetrating trauma: all of the above + x ray for the site of injury
• eFAST
• RUSH: rapid ultrasound for shock and hypotension

Orthopedics trauma management

• Recovery from orthopedic trauma is done by stabilizing the injuries
• Early total care: definitive stabilization of all long bone fractures within 24 hours of injury if the patient is stable within that period
• Damage control surgery: immediate surgery that is required to save life and limb when patient is unable to undergo early total care, other procedures delayed until patient’s condition improved ; DCS include stabilization of unstable fractures (pelvis, femur, vertebrae) also includes decontamination of open wounds, amputation and decompression of limb compartments
• Patient should undergo as much of their surgery as is safe, as soon as they are physiologically able to cope with that surgery

Course Menu

This article is apart from Orthopedic Trauma Basic Principles Course, This course covers these topics: