Trimodal distribution of death:
- First peak is at time of injury usually due to lacerations of brain or large blood vessels thus the patient dies before arrival.
- Second peak: occurs within minutes to hours of injury and is generally due to tension pneumothorax, haemorrhage and intracranial bleeding. These deaths maybe reversed using medical intervention and this is where ATLS maybe useful.
- Third peak: these occur days to weeks after the injury and involve sepsis or multiorgan failure. This can be reduced by optimisation of care when in hospital.
ATLS aims to treat life threatening injuries in order of importance ie as blocked airway will kill before a tension pneumothorax. Hence, the ABCDE approach.
ATLS is divided in to the primary survey which aims to identify and treat life threatening injuries as they are found (ABCDE) and the secondary survey which is a thorough examination of the patient once they are stable.
It is imperative that the patient is continuously re-evaluated especially after any intervention.
- Airway with C-spine control:
- C-spine control should be immediately undertaken using a collar, blocks and tape if there is any suspicion of c-spine damage (ie injury above clavicle, fall from height, decelerating injury etc…)
- Whilst the C-spine is being immobilised, air way can be easily assessed if the patient is conscious and talking then their airway is unlikely to be compromised. For those who are unconscious nasopharygeal (if no base of skull injury is suspected), oropharyngeal or endotracheal airways can be placed. The latter needs to be placed by someone who has been trained to insert it. Airway compromise should be suspected in those with facial injuries, facial/neck burns, inhalation injuries and vomiting. All patients who are unconscious (GCS<8) should be intubated.
- Patients whose airway is compromised but who are awake must be anaesthetised prior to endotracheal intubation thus only someone who is skilled in this should attempt it.
- C-spine immobilisation must be maintained until xrays are obtained and cleared.
- Once the airway is secure and the patients reassessed, one should assess breathing. This is done by looking at the chest for obvious trauma (bruising/burns) and asymmetry in chest movement such as see-saw or flail chest. Auscultation can be used to assess air entry and percussion for dullness in haemothorax or hyper-resonance in tension pneumothorax.
- Tension pneumothoraces should be managed initially with needle decompression then a chest drain.
- Haemothorax requires chest drain insertion and possibly thoracotomy if >2L of blood are drained or >200mL/hour.
- Once a problem is solved reassess patient from beginning using ABCDE
- Pulse, blood pressure, respiratory rate, capillary refill and urine output can indicate severity of shock. It is important to secure IV access via 2 large bore cannulae in the antecubital fossa and take blood including group, save and crossmatch. A venous gas can quickly give haemoglobin.
- Fluid resus should be attempted initially using a crystalloid given quickly (squeezed if necessary).
- Source of blood loss should be sought by looking for bruises over the abdomen and tenderness, long bone fractures, perineal haematoma and asymmetry in pulses for blood vessel damage.
- The lab should be asked for 5 units of O-negative blood, 5 units of type specific and 5 units of crossmatched blood.
- Fast Scanning can be used to look for free fluid in the chest, abdomen or pelvis but it is operator dependent.
- CT scan is useful but only if the patient is stable.
- Diagnositic peritoneal lavage can be used if abdominal viscous perforation is suspected and the patient is too unstable to go to CT. However it must be conducted by someone who is experienced in this technique.
- Long bone fractures should be splinted and open book pelvic fractures should be closed using a belt or sheet. Orthopaedic opinion should be sought early on.
- Once haemodynamic stability is achieved, the patient should be reassessed from the beginning.
- AVPU can be used to quickly assess patient but GCS should be recorded early on.
- BM should also be undertaken as this may reduce consciousness if low.
- Patients clothing should be removed and the patient should be inspected from head to toe to assess for injury.
- Log rolling (minimum of three people) should be undertaken and midline tenderness overall vertebra should be assessed. PR exam should be performed to look for blood and assess anal tone. If awake, perineal anaesthesia should be checked.
- During the primary survey, it is important to conduct a trauma series (xrays of the c-spine, chest, abdomen, pelvis and long bones that are suspected of being fracture).
- ECG should be performed.
- Unless there is evidence of urethral damage (Blood at meatus, high riding prostate or scrotal haematoma), then a urinary catheter should be inserted for fluid balance monitoring.
- If DPL is to be attempted then as well as a urinary catheter, an NG tube is vital prior to the procedure. However, cribiform fracture should be excluded first.