AdvAnced TrAumA Life SupporT. AtlS. STUDENT COURSE MANUAL. ®. ®. ERRNVPHGLFRV . department (ED) at the time of the patient's arrival. During the. This ninth edition represents the latest in evidence based care for the injured. The course materials were thoroughly vetted by a group of international experts. Atls Student Manual 9th (ninth) Edition by Acs published by American College of Surgeons () on ruthenpress.info *FREE* shipping on qualifying offers.
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J Trauma Acute Care Surg. May;74(5) doi: /TA. 0beb82f5. Advanced trauma life support (ATLS®): the ninth edition. ATLS. The American College of Surgeons' Advanced Trauma Life Support (ATLS) course textbook teaches a systematic, concise approach to the early care of trauma. advanced trauma life support atls 9th edition pdf. Primary Survery Advanced Trauma Life Support ATLSATLSSTUDENT COURSE MANUAL.
Often contradictory recommendations no positive pressure ventilation if there is a PTx but still airway comes first. No recommendations for massive transfusion or reversal of anticoagulation. No mention of albumin usage in severe burn patients. No mention of risks of over-resuscitation of burn patients and subsequent high risk for compartment physiology. Apr 16, Annisa MoeL rated it it was amazing. Great guideline book! Feb 13, Gustaf Hultman rated it liked it. Now, time to reread it and see how much I remember.
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Subscribe to eTOC. Toggle navigation. Subscribe Register Login. Advanced Search. Other types of injuries for which historical information is impor- tant include thermal injuries and those caused by haz- ardous environments. Blunt Trauma Blunt trauma often results from automobile collisions, falls, and other injuries related to transportation, rec- reation, and occupations.
Important information to obtain about automobile collisions includes seat-belt use, steering wheel defor- mation, direction of impact, damage to the automo- bile in terms of major deformation or intrusion into the passenger compartment, and whether the patient was ejected from the vehicle. Ejection from the vehicle greatly increases the possibility of major injury.
Injury patterns can often be predicted by the mechanism of injury. Such injury patterns also are influenced by age groups and activities Table 1. Penetrating Trauma The incidence of penetrating trauma e. Factors that determine the type and extent of injury and subsequent management include the re- gion of the body that was injured, the organs in the path of the penetrating object, and the velocity of the missile. Therefore, in gunshot victims, the velocity, caliber, presumed path of the bullet, and distance from the weapon to the wound can provide important clues regarding the extent of injury.
See Biomechanics of Injury electronic version only. Inhalation injury and carbon monoxide poisoning often complicate burn injuries. Therefore, it is important to know the circumstances of the burn injury, such as the environment in which the burn in- jury occurred open or closed space , the substances consumed by the flames e.
These factors are critical for patient management. Acute or chronic hypothermia without adequate protection against heat loss produces either local or generalized cold injuries. Such historical information can be obtained from prehospital person- nel. Thermal injuries are addressed in more detail in Chapter 9: Thermal Injuries. Hazardous Environment A history of exposure to chemicals, toxins, and radia- tion is important to obtain for two main reasons: Second, these same agents may also present a hazard to healthcare providers.
Head The secondary survey begins with evaluating the head and identifying all related neurologic injuries and other significant injuries. The entire scalp and head should be examined for lacerations, contusions, and evidence of fractures.
Head Trauma. Because edema around the eyes can later preclude an in-depth examination, the eyes should be reevalu- ated for: Ocular mobility should be evaluated to exclude entrapment of extraoc- ular muscles due to orbital fractures.
These proce- dures frequently identify ocular injuries that are not otherwise apparent. See Appendix A: Ocular Trauma. Maxillofacial Structures Examination of the face should include palpation of all bony structures, assessment of occlusion, intraoral ex- amination, and assessment of soft tissues. Maxillofacial trauma that is not associated with airway obstruction or major bleeding should be treated only after the patient is stabilized completely and n TABLE 1.
At the discretion of appropriate specialists, definitive man- agement may be safely delayed without compromis- ing care. Patients with fractures of the midface may also have a fracture of the cribriform plate. For these patients, gastric intubation should be performed via the oral route. Assessment and Management. Cervical Spine and Neck Patients with maxillofacial or head trauma should be presumed to have an unstable cervical spine injury e.
The absence of neurologic deficit does not exclude in- jury to the cervical spine, and such injury should be presumed until a complete cervical spine radiographic series and CT are reviewed by a doctor experienced in detecting cervical spine fractures radiographically. Examination of the neck includes inspection, pal- pation, and auscultation. Cervical spine tenderness, subcutaneous emphysema, tracheal deviation, and laryngeal fracture can be discovered on a detailed exam- ination.
The carotid arteries should be palpated and auscultated for bruits. Evidence of blunt injury over these vessels should be noted and, if present, should arouse a high index of suspicion for carotid artery injury.
A common sign of potential injury is a seat- belt mark. Occlusion or dissection of the carotid artery can occur late in the injury process without anteced- ent signs or symptoms. Angiography or duplex ultra- sonography may be required to exclude the possibility of major cervical vascular injury when the mechanism of injury suggests this possibility. Most major cervical vascular injuries are the result of penetrating injury; however, blunt force to the neck or a traction injury from a shoulder-harness restraint can result in intimal disruption, dissection, and thrombosis.
Protection of a potentially unstable cervical spine injury is imperative for patients who are wearing any type of protective helmet, and extreme care must be taken when removing the helmet.
Helmet removal is described in Chapter 2: Penetrating injuries to the neck can potentially injure several organ systems. Wounds that extend through the platysma should not be explored manu- ally, probed with instruments, or treated by individu- als in the ED who are not trained to manage such injuries. EDs are not typically equipped to deal with the problems that may arise with these injuries; they require evaluation by a surgeon operatively or with specialized diagnostic procedures under the direct supervision of a surgeon.
The finding of active arterial bleeding, an expanding hematoma, arterial bruit, or airway compromise usually requires opera- tive evaluation. Unexplained or isolated paralysis of an upper extremity should raise the suspicion of a cervical nerve root injury and should be accurately documented.
A complete evaluation of the chest wall requires palpation of the entire chest cage, including the clavicles, ribs, and sternum. Ster- nal pressure can be painful if the sternum is fractured or costochondral separations exist.
Contusions and he- matomas of the chest wall should alert the clinician to the possibility of occult injury. Such difficulties should not deter the clinician from performing the components of the ocular examination that are possible. Therefore, frequent reassess- ment is crucial.
Injury to the intima of the carotid arteries is an example. Ef- forts to exclude the possibility of spinal injury should be initiated as soon as is practical, and these devices should be removed. However, resuscitation and ef- forts to identify life-threatening or potentially life- threatening injuries should not be deferred. Evaluation includes auscultation of the chest and a chest x-ray. Auscultation is conducted high on the anterior chest wall for pneumothorax and at the posterior bases for hemothorax.
Although aus- cultatory findings can be difficult to evaluate in a noisy environment, they may be extremely helpful. Distant heart sounds and decreased pulse pressure can indicate cardiac tamponade. In addition, cardiac tamponade and tension pneumothorax are suggested by the presence of distended neck veins, although associated hypovo- lemia can minimize or eliminate this finding.
A chest x-ray may confirm the presence of a hemot- horax or simple pneumothorax. Rib fractures may be present, but they may not be visible on the x-ray. A widened mediastinum or other radiographic signs can suggest an aortic rupture. See Chapter 4: Thoracic Trauma. Abdomen Abdominal injuries must be identified and treated ag- gressively.
The specific diagnosis is not as important as recognizing that an injury exists that requires surgical intervention. A normal initial examination of the ab- domen does not exclude a significant intraabdominal injury. Early involvement of a surgeon is essential.
Fractures of the pelvis or lower rib cage also can hinder accurate diag- nostic examination of the abdomen, because palpat- ing the abdomen can elicit pain from these areas.
See Chapter 5: Abdominal and Pelvic Trauma. Perineum, Rectum, and Vagina The perineum should be examined for contusions, hematomas, lacerations, and urethral bleeding.
A rectal examination may be performed before placing a urinary catheter. If a rectal examination is required, the clinician should assess for the presence of blood within the bowel lumen, a high-riding prostate, the presence of pelvic fractures, the integrity of the rectal wall, and the quality of sphincter tone. Vaginal examination should be performed in patients who are at risk of vaginal injury, including all women with a pelvic fracture. The clinician should assess for the presence of blood in the vaginal vault and vaginal lac- erations.
In addition, pregnancy tests should be per- formed on all females of childbearing age. Musculoskeletal System The extremities should be inspected for contusions and deformities.
Palpation of the bones and examina- tion for tenderness and abnormal movement aids in the identification of occult fractures. Pelvic fractures can be suspected by the iden- tification of ecchymosis over the iliac wings, pubis, labia, or scrotum.
Pain on palpation of the pelvic ring is an important finding in alert patients. Mobility of the pelvis in response to gentle anterior-to-posterior pressure with the heels of the hands on both anterior iliac spines and the symphysis pubis can suggest pel- vic ring disruption in unconscious patients. Progression to acute respira- tory insufficiency must be anticipated, and support should be instituted before collapse occurs.
The AP pelvic x-ray examination, per- formed as an adjunct to the primary survey and resuscitation, can provide valuable information re- garding the presence of pelvic fractures, which are potentially associated with significant blood loss. Classic examples include duodenal and pancreatic injuries. When present, such injuries are difficult to detect. In addition, assessment of peripheral pulses can identify vascular injuries. Significant extremity injuries can exist without frac- tures being evident on examination or x-rays.
Ligament ruptures produce joint instability. Muscle-tendon unit injuries interfere with active motion of the affected struc- tures. Other injuries can mask the physical findings of spinal injuries, and they can remain undetected unless the clinician obtains the appropriate x-rays. Spine and Spinal Cord Trauma, and Chapter 8: Musculoskeletal Trauma. The GCS score facilitates detection of early changes and trends in the neurologic status. Revised and Pe- diatric electronic version only. Early consultation with a neurosurgeon is required for patients with head injury.
Patients should be moni- tored frequently for deterioration in level of conscious- ness and changes in the neurologic examination, as these findings can reflect worsening of the intracra- nial injury.
If a patient with a head injury deterio- rates neurologically, oxygenation and perfusion of the brain and adequacy of ventilation i. Intracranial surgical intervention or measures for reducing intracranial pressure may be necessary. The neurosurgeon will decide whether conditions such as epidural and subdural hemato- mas require evacuation, and whether depressed skull fractures need operative intervention.
Head Trauma, and Chapter 7: Any evidence of loss of sensation, paralysis, or weakness suggests major injury to the spinal column or peripheral nervous system. Neurologic deficits should be documented when identified, even when transfer to another facility or doctor for specialty care is neces- sary. Protection of the spinal cord is required at all times until a spine injury is excluded. Early consultation with a neurosurgeon or orthopedic surgeon is necessary if a spinal injury is detected.
Adjuncts to the Secondary Survey? How can I minimize missed injuries? Specialized diagnostic tests may be performed during the secondary survey to identify specific injuries. A sense of urgency should accom- pany the management of these injuries.
Therefore, frequent reevaluation is essential. Most of the diagnostic and therapeutic maneuvers necessary for the evaluation and care of patients with brain injury will increase ICP. Tracheal intubation is a classic example; in patients with brain injury, it should be performed expeditiously and as smoothly as possible.
Rapid neurologic deterioration of patients with brain injury can occur despite the application of all measures to control ICP and main- tain appropriate support of the central nervous sys- tem.
The common mis- take of immobilizing the head but freeing the torso allows the cervical spine to flex with the body as a fulcrum.
In a patient with obtun- dation who requires CT of the brain, CT of the spine may be used as the method of radiographic assess- ment. Many trauma centers forego plain films and use CT instead for detecting spine injury. Spinal cord pro- tection that was established during the primary survey should be maintained. An AP chest film and additional films pertinent to the site s of suspected injury should be obtained.
Often these procedures require transportation of the patient to other areas of the hospital, where equip- ment and personnel to manage life-threatening contin- gencies may not be immediately available. Therefore, these specialized tests should not be performed until the patient has been carefully examined and his or her hemodynamic status has been normalized. Reevaluation Trauma patients must be reevaluated constantly to ensure that new findings are not overlooked and to discover deterio- ration in previously noted findings.
As initial life-threaten- ing injuries are managed, other equally life-threatening problems and less severe injuries may become apparent. Underlying medical problems that can significantly af- fect the ultimate prognosis of the patient may become evident.
A high index of suspicion facilitates early diag- nosis and management. Continuous monitoring of vital signs and urinary output is essential.
For adult patients, maintenance of urinary output at 0. ABG analyses and cardiac monitoring devices should be used. Pulse oximetry on critically injured patients and end-tidal carbon dioxide monitoring on intubated patients should be initiated. The relief of severe pain is an important part of the treatment of trauma patients.
Many injuries, espe- cially musculoskeletal injuries, produce pain and anxi- ety in conscious patients. Effective analgesia usually requires the administration of opiates or anxiolytics intravenously intramuscular injections should be avoided.
Definitive Care? Which patients do I transfer to a higher level of care? When should the transfer occur? Interhospital triage criteria will help determine the level, pace, and intensity of initial treatment of the multiply injured patient.
What do you do? The closest appropri- ate local facility should be chosen based on its overall capabilities to care for the injured patient.
Transfer to Definitive Care and Figure Disaster Disasters frequently overwhelm local and regional resources. Plans for management of such conditions must be developed, reevaluated, and rehearsed fre- quently to enhance the possibility of saving the maxi- mum number of injured patients. ATLS providers should understand their role in disaster management within their healthcare institutions and remember the principles of ATLS relevant to patient care. Records and Legal Considerations Specific legal considerations, including records, con- sent for treatment, and forensic evidence, are relevant to ATLS providers.
RECORDS Meticulous record keeping during patient assessment and management, including documenting the time for all events, is very important. Accu- rate record keeping during resuscitation can be facili- tated by a member of the nursing staff whose primary responsibility is to record and collate all patient care information.
Medicolegal problems arise frequently, and pre- cise records are helpful for all individuals concerned. Transfer to Definitive Care, in this textbook. In life- threatening emergencies, it is often not possible to ob- tain such consent. In these cases, treatment should be provided first, with formal consent obtained later. All items, such as cloth- ing and bullets, must be saved for law enforcement personnel. Laboratory determinations of blood alcohol concentrations and other drugs may be particularly pertinent and have substantial legal implications.
Teamwork In many centers, trauma patients are assessed by a team, the size and composition of which varies from institution to institution. In order to perform effectively, one team member should assume the role of team leader. The team leader is not neces- sarily the most senior person present. The team leader supervises and checks the prepa- ration stage to ensure a smooth transition from the prehospital to hospital environment, assigning tasks to the other members of the team.
Team function is related to team training; during training, duties are assigned to a particular role, which is reviewed with individual team members by the team leader as the team prepares for a specific patient. Depending on the size and composition of the team, it is helpful to have team members assigned to the following roles: A useful format is the MIST acronym: This is facilitated by verbalizing each action and each finding out loud without more than one member speaking at the same time.
Requests and orders should not be stat- ed in general terms, but instead should be directed to During the entire process, all team members are expected to make remarks, ask questions and make suggestions, when appropriate.
In that case, all other team members should pay attention and then act as directed by the team leader. He was intu- bated on arrival at the hospital and a chest tube placed for a left pneumothorax. Correct position of the tube was confirmed with chest x-ray, and a pelvic fracture was identified on pelvic x-ray. The patient received 2 units of blood for tachycardia and hypotension, and is now normotensive.
His GCS is 6T. A cervical collar remains in place. He will need further evaluation for possible head injury and abdominal injury. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. Chi- cago, IL: American College of Surgeons Committee on Trauma; Battistella FD. Emergency department evaluation of the patient with multiple injuries. Scientific American Surgery.
New York, NY: Scientific American; — Video registration of trauma team performance in the emer- gency department: J Trauma. The tertiary trauma survey: J Trauma ; Reasons to omit digital rectal exam in trauma patients: J Trauma ;59 6: