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

head tilt/chin lift

Head tilt/chin lift
Public domain via Wikimedia Commons

Jaw thrust maneuver can be applied even in cervical spine injuries

jaw thrust
Jaw thrust in manikin with oropharyngeal airway, credit: Randhillon, CC BY-SA 4.0 <a href="https://creativecommons.org/licenses/by-sa/4.0">link</a>, via Wikimedia Commons

oropharyngeal airway
Oropharyngeal airway, picture credit: ICUnurses, CC BY-SA 4.0 <a href="https://creativecommons.org/licenses/by-sa/4.0">link</a>, via Wikimedia Commons

nasopharyngeal airway
Nasopharyngeal airway, public domain via Wikimedia commons

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

endotracheal tube
Endotracheal tube, credit: bigomar2, CC BY-SA 3.0 <a href="http://creativecommons.org/licenses/by-sa/3.0/">link</a>, via Wikimedia Commons

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

philadelphia collar
BruceBlaus, CC BY-SA 4.0 <a href="https://creativecommons.org/licenses/by-sa/4.0">link</a>, via Wikimedia Commons

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

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
Saltanat ebli, CC0, via Wikimedia Commons

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

• Coagulopathy PLT<120, INR>1.5: consumption of clotting factors (solved by using platelets and fresh frozen plasma early in the resuscitation)
• Hypothermia <35C: exposure to cold and from fluid resuscitation and lead to impaired enzyme dependent pathways including clotting
• 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

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 Topics

This article is a part from the Orthopedics trauma basic principles course, this course also includes these topics:

• Course Introduction
• Bone fracture mechanisms
• Types of bone fractures
• Fracture displacement patterns and fracture description
• Bone healing process
• Fractures healing outcomes
• Trauma management using ATLS
• History taking and examination in orthopedic trauma
• Orthopedic X-ray interpretation basics
• Soft tissue injuries
• Closed fracture treatment
• Gustilo Anderson classification of open fractures
• Open fractures treatment
• Stress fractures
• Pathological fractures
• Growth plate fractures
• Compartment syndrome
• Complication of fractures
• Joint injuries