Advanced Trauma Life Support ATLS STUDENT COURSE MANUAL NINTH EDITION

The treatment of seriously injured patients requires the rapid assessment of injuries and institution of life-preserving therapy. Because timing is crucial, a systematic approach that can be rapidly and accurately applied is essential. This approach is termed the “initial assessment” and includes the following elements: ■ Preparation ■ Triage ■ Primary survey (ABCDEs) ■ Resuscitation ■ Adjuncts to primary survey and resuscitation ■ Consideration of the need for patient transfer ■ Secondary survey (head-to-toe evaluation and patient history) ■ Adjuncts to the secondary survey ■ Continued postresuscitation monitoring and reevaluation ■ Definitive care The primary and secondary surveys should be repeated frequently to identify any change in the patient’s status that indicates the need for additional intervention. The 1 Assemble a team and prepare to resuscitate an injured patient. 2 Identify the correct sequence of priorities for assessment of a severely injured patient. 3 Apply the principles outlined in the primary and secondary surveys to the assessment of a multiply injured patient. 4 Apply guidelines and techniques to the initial resuscitative and definitive-care phases of the treatment of a multiply injured patient. 5 Explain how a patient’s medical history and the mechanism of injury contribute to the identification of injuries. 6 Identify the pitfalls associated with the initial assessment and management of an injured patient and describe steps to minimize their impact. 7 Conduct an initial assessment survey on a simulated multiply injured patient, using the correct sequence of priorities and explaining management techniques for primary treatment and stabilization. 8 Reevaluate a patient who is not responding appropriately to resuscitation and management. 9 Explain the importance of teamwork in the initial assessment of a trauma patient. •• Recognize patients who will require transfer for definitive management. Objectives ­4 CHAPTER 1  Initial Assessment and Management assessment sequence presented in this chapter reflects a linear, or longitudinal, progression of events. In an actual clinical situation, many of these activities occur in parallel, or simultaneously. The longitudinal progression of the assessment process allows clinicians an opportunity to mentally review the progress of an actual trauma resuscitation. ATLS® principles guide the assessment and resuscitation of injured patients. Judgment is required to determine which procedures are necessary, because not all patients require all of these procedures. Preparation ? How do I prepare for a smooth transition from the prehospital to the hospital environment? Preparation for a trauma patient occurs in two different clinical settings. First, during the prehospital phase, all events must be coordinated with the clinicians at the receiving hospital. Second, during the hospital phase, preparations must be made to rapidly facilitate the trauma patient’s resuscitation. PREHOSPITAL PHASE Coordination with prehospital agencies and personnel can greatly expedite treatment in the field ( FIGURE 1-1). The prehospital system should be set up to notify the receiving hospital before personnel transport the patient from the scene. This allows for mobilization of the hospital’s trauma team members so that all necessary personnel and resources are present in the emergency department (ED) at the time of the patient’s arrival. During the prehospital phase, emphasis should be placed on airway maintenance, control of external bleeding and shock, immobilization of the patient, and immediate transport to the closest appropriate facility, preferably a verified trauma center. Every effort should be made to minimize scene time, a concept that is supported by the Field Triage Decision Scheme, shown in  FIGURE 1-2. Emphasis also should be placed on obtaining and reporting information needed for triage at the hospital, including time of injury, events related to the injury, and patient history. The mechanisms of injury can suggest the degree of injury as well as specific injuries for which the patient must be evaluated. The National Association of Emergency Medical Technicians’ Prehospital Trauma Life Support Committee, in cooperation with the Committee on Trauma (COT) of the American College of Surgeons (ACS), has developed a course with a format similar to the ATLS Course that addresses the prehospital care of injured patients, which is called Prehospital Trauma Life Support (PHTLS). The use of prehospital care protocols and the ability to access online medical direction (direct medical control) can facilitate and improve care initiated in the field. Periodic multidisciplinary review of the care provided through quality improvement activities is essential. HOSPITAL PHASE Advance planning for the trauma patient’s arrival is essential. A resuscitation area should be available for trauma patients. Properly functioning airway equipment (e.g., laryngoscopes and tubes) should be organized, tested, and strategically placed where it is immediately accessible. Warmed intravenous crystalloid solutions should be immediately available for infusion, as should appropriate monitoring devices. A protocol to summon additional medical assistance should be in place, as well as a means to ensure prompt responses by laboratory and radiology personnel. Transfer agreements with verified trauma centers should be established and operational. See American College of Surgeons Committee on Trauma (ACS COT), Resources for Optimal Care of the Injured Patient, 2006) (electronic version only). Periodic review of patient care through the quality improvement process is an essential component of each hospital’s trauma program. All personnel who are likely to have contact with the patient must wear standard precaution devices. Due to concerns about communicable diseases, particularly hepatitis and acquired immunodeficiency syndrome (AIDS), the Centers for Disease Control and Prevention (CDC) and other health agencies strongly recommend the use of standard precautions