Jason Wolfe's ATLS® Trauma Moulage Page

(Thoughts on the Management of the Multiply Injured Patient)



Aim :    

 To give people a framework for thinking about the management of the traumatised patient and assist them to pass the ATLS trauma moulage.  This webpage was produced as a culmination of the teaching and experiences I gained during a past ATLS course.

ATLS®: 

 The ATLS course itself is an excellent way of practicing the theoretical and practical aspects of trauma management.  I highly recommend anyone involved in management of trauma patients to do it.

Note :

 This is not meant as a short cut which negates the need to read the ATLS course manual.  You are reminded that it is extremely unlikely that you will pass the course if you don't read the ATLS manual.

PS:

 Note that the term 'ATLS' is a registered trade mark of the 'American College of Surgeons'.  This web-page is not affiliated to, nor officially endorsed by them.


General Principles of Trauma Management


1.     There is a need for rapid evaluation of the trauma patient.  Time wasted costs lives.
2. The absence of a definitive diagnosis should never impede the application of essential treatment.
3. The first 'Golden Hour' is crucial to both the short and long term survival of the patient.  It also is also critical in determining the morbidity that the patient will endure.
4. There is a need to establish management priorities:  The things which will kill the patient first are always the things which should be checked and treated first.  Things which will kill the patient later are managed later.  Thus, airway problems are managed and treated before breathing problems, which in turn are treated before circulatory problems.
5. Patients with serious injuries are managed by the 'Trauma Team'. This will normally include ED doctors, an anaesthetist, along with specialists in the particular injury involved.
Eg. Thoracic Surgeons / Orthopaedics / General Surgeons / Neurosurgeons.
6. All treatment modalities should be governed by the abiding principle of 'First do no harm'.




Overview of ATLS Protocol :-

(Stages & Subject Headings)

1.      Preparation
2. Triage
3. Primary Survey (ABCDE)  &  Resuscitation
4. Adjuncts to Primary Survey & Resuscitation
5. Consider need for Patient Transfer
6. Secondary Survey  (with AMPLE History)
7. Continued Post-Resuscitation Monitoring & Re-evaluation
8. Transfer to Definitive Care




1.   Preparation  -  Equipment needed for Practice


You should familiarise yourself with all the following equipment.  You should be able explain each item's use, not only just by physical demonstration but also by verbal description.

GENERAL EQUIPMENT

CERVICAL SPINE EQUIPMENT

AIRWAY EQUIPMENT

BREATHING EQUIPMENT

CIRCULATION EQUIPMENT

DRUGS

MISCELLANEOUS STUFF


2.  Triage.

Triage is the prioritisation or ranking of patients according to both their clinical need and the available resources to provide treatment.  The process is based on the same ABC principles as explained below.

3.  Summary of Primary Survey & Resuscitation :-

(Explained in full detail later)

  A   -   Airway  &  Cervical Spine Control
  B   -   Breathing  &  Oxygenation
  C   -   Circulation  &  Haemorrhage Control
  D   -   Dysfunction  &  Disability of the CNS
  E   -   Exposure  &  Environmental Control


4.  Adjuncts to Primary Survey & Resuscitation :-



These are various useful monitoring or therapeutic modalities which supplement the information already obtained using clinical skills in the Primary Survey.

They include :-


 1.     Pulse Oximeter
 2. Blood Pressure
 3. Cardiac Monitor  /  Electrocardiogram
 4. Arterial Blood Gases  /  End Tidal pCO2
 5. X-Rays - Chest X-Ray  /  Cervical Spine  /  Pelvis  /  Others
 6. FAST Ultrasound (Focused Assessment with Sonography for Trauma)
 7. Nasogastric Tube  &  Urinary Catheter
 8. Core Temperature


5.  Consider the Need for Emergency Patient Transfer.


The particular accident unit or hospital where the patient has arrived is not always the most suitable place for the definitive care of that patient to be managed.  Once the resuscitation is well under way and the patient is stable, consideration should be given to transferring the patient elsewhere.  Transfer may be to another hospital which is more geared to treating the multiply injured patient (eg. a level 1 trauma centre) or to another facility which can adequately deal with the particular set of specialised injuries which are peculiar to your patient (eg. a neurosurgical unit).  Transfer may also be to a different department of the same hospital (eg. theatres / radiology).

In any case, patient transfer is often the time of greatest peril for the patient because it is all too easy for the 'level of care' to decline.  The challenge therefore is to ensure that this level of care does not deteriorate at any time.  Transfer should always be as soon a possible after the patient is stabilised.  The acquiring of specialised investigations should not hold up the transfer of the patient as these investigations are often more appropriately performed in the unit where the patient is to be transferred.

6.  Secondary Survey.


A full AMPLE history is taken from anyone who knows the relevant details.   This often includes both the family and the paramedics who brought the patient in.  This is followed by complete head to toe & systems examination.   All clinical, laboratory & radiological information is assimilated and a management plan is formulated for the patient.

During this time there is a process of continued post-resuscitation monitoring & re-evaluation.  Any sudden deterioration in the patient should immediately prompt the doctor to return to the primary survey for a re-assesment of the ABCDE's.

AMPLE History :-

   A  -  Allergies
   M  -  Medicines
   P  -  Past Medical History  /  Pregnancy
   L  -  Last Meal
   E  -  Events  /  Environment leading to the current trauma

7.  Transfer to Definitive Care & Handover

This is governed by the same principles as were mentioned above in the emergency transfer of patients.  The level of care should not deteriorate.

MIST Handover



The Primary Survey & Resuscitation.

(This is the main part which is tested in the practical moulages, so this the part will be covered in the greatest detail)

NOTE FIRST :-

9 Immediately Life Threatening Injuries or Conditions which should be picked up in ABCDE and treated immediately :-

1.     Inadequate Airway Protection
2. Airway Obstruction
3. Tension Pneumothorax
4. Open pneumothorax
5. Flail Chest with Hypoxia
6. Massive Haemothorax
7. Cardiac Tamponade
8. Severe Hypothermia
9. Severe Shock from Haemorrhage Unresponsive to Fluid Resuscitation.

NOTE ALSO :-

13 Potentially Life Threatening "Non-Obvious" Injuries which should be considered in the traumatised patient, but whose management can often wait until after ABCDE until the time of definitive care :-

1.     Simple Pneumothorax
2. Haemothorax
3. Pulmonary Contusion
4. Tracheo-Bronchial Injury
5. Blunt Cardiac Injury
6. Traumatic Aortic Disruption
7. Diaphragmatic Rupture
8. Mediastinal Traversing Wounds
9. Blunt Oesophageal Trauma
10. Sternal / Scapular / Rib Fractures
11. Ruptured Liver or Spleen
12. Rupture of an abdominal or pelvic viscus
13. Any other chest / abdominal / or pelvic injuries which have resulted in organ damage but not in immediate shock




How to approach the Primary Survey and what to do :-

This next section assumes you are in a moulage scenario and goes through your possible actions and reactions in response to what you find with your patient.

A  -  AIRWAY & CERVICAL SPINE CONTROL



B  -  BREATHING & OXYGENATION


C  -  CIRCULATION & HAEMORRHAGE CONTROL






If the patient fails to respond, or initially responds but subsequently deteriorates, you should reflect on the various possible causes of this state of affairs :-

1.     Go back and check Airway & Breathing.
2. The patient could be BLEEDING faster than you are replacing blood.  These patients need to be taken to theatre immediately for surgical repair of the injured organ or vessel. Patients with severe blood loss & shock may be considered suitable for early administration of Tranexamic Acid. Consider activating the 'Massive Transfusion Protocol'.
3. The patient could be HYPOTHERMIC and therefore may be responding more slowly than a normothermic patient.
4. The patient could be in CARDIOGENIC SHOCK: Here the heart pump is failing due to blunt trauma, or sometimes due to penetrating trauma.  Consider again pericardial tamponade and act appropriately if required.  Consider early CVP monitoring.
5. The patient may be PREGNANT.  If moderately or heavily pregnant women are treated in the supine position, the bulky uterus may impede the flow of blood in the Inferior Vena Cava.  Such patients should be bolstered so that they are lying slightly on their left side by placing sand-bags or pillows under the right side of the pelvis and chest.  This manoeuvre should be carried out earlier rather than later in the resuscitation.
6. The patient may be in NEUROGENIC SHOCK: This occurs with spinal cord injuries in which the sympathetic outflow is damaged.  This denervation of the heart and blood vessels results in a clinical picture of hypotension without tachycardia or peripheral vasoconstriction.  Volume resuscitation is still the primary treatment, but consideration should be given to the judicious use of vasopressors.  Early CVP monitoring & Swan-Ganz pulmonary artery catheterisation may also be useful.
7. SEPTIC SHOCK: This is uncommon in the early period following trauma but may occur in penetrating abdominal injuries with a perforated viscus or in other penetrating injuries where the wound has been contaminated with dirty exogenous debris, especially if arrival in A&E has been delayed for hours or days.  It is identified by the presence of hypotension, tachycardia, pyrexia and cutaneous vasodilation.

All the above are treated by generous volume replacement along with definitive treatment of the cause of the shock.



Other Considerations in the Diagnosis & Treatment of Shock.


1.     OLD AGE - Elderly patients have less 'physiological reserve':  They are less able to increase heart rate and stroke volume in response to shock.  Vital organs are more sensitive to the decreased blood flow and hypoxia associated with shock.  The lungs are less efficient at the gaseous exchange of oxygen.   The kidney is less able to respond to the volume preserving stimulus of the stress hormones Aldosterone, Anti-Diuretic Hormone & Cortisol.  All these facts contribute to its increased morbidity and mortality.  It is thus even more crucial in the elderly patient to pay meticulous attention to volume resuscitation, and the placement of arterial and CVP invasive monitoring devices will greatly assist in its assessment.   These devices should be placed earlier rather than later.
2. YOUNG AGE - Children and babies have an especially high physiological reserve.  Homeostatic mechanisms maintain blood pressure and cardiac output despite the loss of large percentages of their blood volume.  However when the percentage of blood loss gets to about 40% (Class IV haemorrhage), the blood pressure and cardiac output drop precipitously.  The lesson here is that children may still have normal vital observations despite being in a high level of shock.  Always take advice from a paediatrician early.
3. ATHLETES - Althletes may have an increased blood volume of up to 15 - 20%, stroke volume can increase by 50%, cardiac output can increase by 600% and resting pulse is generally lower than unfit individuals.  These facts mean that the usual clinical signs of hypovolaemia may not be manifested in athletes, even though significant blood loss may have occurred.
4. PREGNANCY - Women have a higher plasma volume during pregnancy.  Cardiac output increases by 1.0 - 1.5 litres / minute, and heart rate increases by 10 - 15 beats / minute.  Minute ventilation increases also (primarily due to an increase in the respiratory tidal volume), and the Renal Glomerular Filtration Rate also increases.  All these things increase the physiological reserve of the mother and mean that signs of hypovolaemia appear later.  The physiological responses to shock will always favour the mother, and whereas even in moderate shock, the mother may be quite well, the foetus may actually be in severe shock, deprived of the majority of its perfusion.   Invasive maternal monitoring and foetal cardiotocographic monitoring are often required at an early stage to minimise complications to both mother and foetus.  Always take advice from an obstetrician early.
5. DRUGS - Various drugs can affect the body's response to stress.  Beta- blockers prevent the tachycardia and increased sympathetic responses to shock and may confuse the clinical picture.  Diuretic use causes a relative hypovolaemia which may impair the body's reserve to respond to stress.
6. HEAD INJURIES - The brain has a very high demand for oxygen and so secondary brain damage will occur very quickly if the brain is deprived of its supply of oxygenated blood.  The Cerebral Perfusion Pressure is equal to the Mean Arterial Blood Pressure minus the Intra-Cranial Pressure.  Thus, brain perfusion is reduced either by a decrease in blood pressure, or by an increase in intra-cranial pressure.  Head injuries may increase intra-cranial pressure by the presence of mass-lesions (haematoma) preventing the free circulation of cerebro-spinal fluid.  Sub-arachnoid haemorrhage increases intra-cranial pressure because the blood in the cerebro-spinal fluid blocks the arachnoid granulations and thereby stops the CSF from being reabsorbed back into the venous system.

There are a number of conflicting processes in the head injured patient that make it essential to treat shock and hypovolaemia in a very precise manner.   Over cautious volume resuscitation will result in hypotension wheras over enthusiastic volume resuscitation will result in volume overload which may exacerbate an already precarious intra-cranial pressure.  The key aspects in the optimal management of the head injured patient include : early invasive monitoring to assist in accurate volume resuscitation, early endotracheal intubation to assist with hyperventilation (aim low end of normal pCO2), and early consultation with an experienced neurosurgeon.


D  -  DYSFUNCTION & DISABILITY OF THE CNS



AVPU Assessment :-

       A  -  Alert
       V  -  Responding to Voice
       P  -  Responding to Pain
       U  -  Unresponsive

Glasgow Coma Scale (GCS) :-


E  -  EXPOSURE  &  ENVIRONMENTAL CONTROL


Here endeth the lesson !!

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   Last Modified : 12th January 2019