Jason Wolfe's ATLS® Trauma Moulage Page
(Thoughts on the Management of the Multiply
|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.
|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.
|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.
|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
||There is a need for rapid evaluation of the trauma patient. Time wasted
||The absence of a definitive diagnosis should never impede the application
of essential treatment.
||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.
||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.
||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.
||All treatment modalities should be governed by the abiding principle of
'First do no harm'.
Overview of ATLS Protocol :-
(Stages & Subject Headings)
||Primary Survey (ABCDE) & Resuscitation
||Adjuncts to Primary Survey & Resuscitation
||Consider need for Patient Transfer
||Secondary Survey (with AMPLE History)
||Continued Post-Resuscitation Monitoring & Re-evaluation
||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.
- One Live Patient (usually an actor with copious but expert make-up to
- One Nurse Assistant (who usually is an inexperienced student)
- One Candidate (with large amounts of adrenaline in blood stream and
suitably fast beating heart)
- One Examiner (to make life difficult and generally throw a spanner in
- Universal Precautions
- Toilet +/- Cigarette for afterwards
CERVICAL SPINE EQUIPMENT
- Long Spinal Board
- Hard Collars of various sizes
- Tape for securing head
- Laryngoscopes (various sizes & shapes)
- Bag and Mask with Reservoir
- Flexible Bougie
- Tongue Depressor
- Oropharyngeal / Nasopharyngeal Tubes
- Orotracheal / Nasotracheal / Endotracheal Tubes
- Needle Cricothyroidotomy Set
- Formal Cricothyroidotomy Set
- Tracheostomy set (for children under 12 yrs)
- Surgical Drapes
- 10ml Syringes
- Large Bore Cannula
- Chest Drain Set including :-
- Antiseptic swap
- Local Anaesthetic
- Dissecting forceps
- Chest Drain
- Suitable container with underwater seal
- Stitch Material
- Occlusive dressing
- Pressure Dressings & Swabs
- Antiseptic swaps
- Hypodermic Needles
- Intra-venous Cannulas
- Long-venous Cannulas for use with Seldingers Technique
- Pericardiocentesis over-the-needle cannulas
- Venous Cut-down set
- Peritoneal Dialysis Catheter
- Adhesive Tape
- Giving sets
- Warmed Crystalloid / Colloid / Blood
- PASG : Pneumatic Anti-Shock Garment
- Set of Resuscitation Trolley Drugs
- Lignocaine (+/- Adrenaline) L/A Injection
- Lignocaine Gel for Catheterisation
- Xylocaine Spray for Oro / Nasopharyngeal L/A
- Resuscitation trolley
- Pulse Oximeter
- Blood Pressure Monitor
- Cardiac Monitor
- Normal & Low-Range Thermometers
- Nasogastric Tube
- Urinary Catheter
- Fast Intravenous Infuser / Warmer Device
- Ophthalmoscope & Otoscope
- Fracture Splints
- Glasgow Coma Scale Chart
- Broselow Paediatric Resuscitation Measuring Tape
- X-Ray Viewing Box
- Ultrasound Scanner
- Warming Blanket
- Polaroid Camera
- Hammer & Nails to prevent the paramedics who brought the patient in from
leaving the department before they have given an ample history.
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
They include :-
||Cardiac Monitor / Electrocardiogram
||Arterial Blood Gases / End Tidal pCO2
||X-Rays - Chest X-Ray / Cervical Spine / Pelvis / Others
||FAST Ultrasound (Focused Assessment with Sonography for Trauma)
||Nasogastric Tube & Urinary Catheter
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
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.
- Mechanism (& time) of injury
- Injuries found & suspected
- Symptoms & Signs
- Treatment initiated
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 :-
||Inadequate Airway Protection
||Flail Chest with Hypoxia
||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 :-
||Blunt Cardiac Injury
||Traumatic Aortic Disruption
||Mediastinal Traversing Wounds
||Blunt Oesophageal Trauma
||Sternal / Scapular / Rib Fractures
||Ruptured Liver or Spleen
||Rupture of an abdominal or pelvic viscus
||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
A - AIRWAY & CERVICAL SPINE CONTROL
- Say you are wearing universal precautions.
- Approach patient from head side and stabilise cervical spine using
in-line immobilisation. Try to avoid placing your hands over the patient's
- Introduce yourself and reassure patient.
- Assess preliminary ABC from patients response to this.
- IF THE AIRWAY IS NOT AT LEAST PARTIALLY SECURE, then definitive cervical
spine control will have to wait. Ask the nurse to take over the function of
in-line immobilisation of the cervical spine, and MOVE ONTO AIRWAY MANAGEMENT.
Don't forget to come back to cervical spine management later.
- CERVICAL SPINE MANAGEMENT :-
- Ask for a hard neck collar. Measure the size of collar by measuring
from the angle of mandible to the top of shoulder / trapezius. The collar should be
the same size from the black marker peg to the base of the hard part of the
- Apply Neck Blocks and Tape.
- AIRWAY MANAGEMENT :-
- In the trauma patient, if the patient is likely to need intubation
eventually, then early intubation is preferred, so as to prevent the
patient from tiring and becoming acidotic.
- Suction out the airway or remove foreign bodies if necessary.
- IF - BREATHING IS SPONTANEOUS AND THE PATIENT IS CONSCIOUS, BUT AIRWAY
IS COMPROMISED BY POOR PHARYNGEAL TONE / REDUCED LEVEL OF CONSCIOUSNESS
(GCS 9-13) :-
- Try jaw thrust / chin lift and ask for response.
- If the response is good, insert an oropharyngeal (Guedel) or
- Notes :-
- The oropharyngeal airway is measured from the 'midline of the mouth to the angle of the mandible'. (Also measured as 'edge of mouth to the tragus of ear').
- The nasopharyngeal airway is measured from the 'tip of the nose to the earlobe'. Its diameter is also conveniently estimated by looking at
the patient's little finger.
- Don't attempt to insert a nasopharyngeal airway if the patient has
a head injury with the possibility of a basal skull fracture.
- Assuming the patient responds to this, apply oxygen using a face mask
with attached reservoir bag.
- If you haven't already done so, most patients should now have their neck
immobilised with a hard neck collar, blocks and tape.
- IF - THE SUPPORTIVE MEASURES ABOVE HAVE FAILED, OR IF PATIENT IS
UNCONSCIOUS WITH A GCS OF 8 OR LESS, OR IF THE PATIENT IS APNOEIC :-
- The patient needs a definitive airway.
- Call for an anaesthetist.
- If the patient is COMPLETELY UNRESPONSIVE, it is necessary to
proceed straight to endotracheal intubation.
- Method of ENDOTRACHEAL INTUBATION.
- Pre-oxygenate with bag and mask.
- The neck collar will need to be removed during intubation and during
this time your assistant must provide in-line immobilisation of the neck.
- Standing above the head of the patient, insert a laryngoscope into the
oropharynx, pushing the tongue to the left. Pull the scope upwards and away
from yourself until the vocal chords become visible.
- Slip the endotracheal tube through the vocal chords, if necessary using
a gum elastic bougie. Inflate the tube's balloon seal and connect the tube
to a reservoired 'bag & mask' or ventilator. Some patients may be
suffiently stable with the ET tube in situ to breathe spontaneously without
the need for bag & mask or ventilator.
- Ensure positioning of tube in trachea by listening to the chest (listen
to the lung apices, bases and over the stomach). Final confirmation can be
made by connecting the tube to a capnograph.
- Secure the tube using a commercially available ET tube securing device.
- Once finished, re-establish cervical spine control using the hard neck
collar, blocks and tape.
- See LEMON notes at end for 'Difficult Intubation'.
See 'DOPE' notes for Failed Intubation.
- If the patient is STILL PARTIALLY CONSCIOUS AND RESPONSIVE, then
intubation will need to be carried out by 'RAPID SEQUENCE INDUCTION', using
anaesthetic drugs. The
procedure should only be carried out by practitioners who are quite familiar
with its 'ins and outs' (which usually excludes everyone except experienced
anaesthetists). If you aren't experienced enough to perform RSI, then 'bag
& mask' until the anaesthetist arrives.
- IF - THE ACTIVE MEASURES ABOVE HAVE FAILED, OR THERE IS PARTIAL UPPER
AIRWAY OBSTRUCTION WITH STRIDOR, OR THE PATIENT IS APNOEIC FROM COMPLETE
AIRWAY OBSTRUCTION :-
- Perform NEEDLE CRICOTHYROIDOTOMY and describe this method.
- A large bore cannula is inserted through the crico-thyroid membrane
and is then connected to high flow oxygen at 15 litres / minute.
Inspiration / Expiration is achieved by intermittently holding ones thumb
over the side of an open Y-connector attached to the cannula - 1 second
inspiration, 4 seconds expiration. The patient can only be adequately
oxygenated using this method for about 30 - 45 minutes.
- Call for an anaesthetist.
- Finally establish definitive airway by formal cricothyroidotomy and
describe this method.
- OTHER INDICATIONS FOR A DEFINITIVE AIRWAY INCLUDE :-
- Severe maxillofacial / laryngeal / neck injuries with impending
obstruction. The patient will almost certainly require a surgical airway.
- Severe Closed Head Injuries with a reduced level of consciousness, a
risk of aspiration, and the need for hyperventilation.
- If you haven't already done so, apply 100% oxygen.
- Ask nurse to apply Pulse Oximeter, Blood Pressure Monitor and Cardiac
Monitor. Ask her to take readings from all these monitors.
B - BREATHING & OXYGENATION
- If patient suddenly deteriorates at any point, move back and check
- Move down neck.
- Assess Carotid pulse for Rate, Character & Volume.
- Check Neck veins for distension.
- Check for Wounds, Laryngeal crepitus & Subcutaneous emphysema.
- Check if Trachea is central.
- Then move onto chest.
- Inspect for Bruising / Asymmetry of expansion.
- Palpate any areas of interest.
- Check for Subcutaneous emphysema and Flail chest.
- Percuss and Auscultate both anterior and lateral chest and ask for results.
- Most people listen to the heart here (even though it is officially 'C' - Circulation).
- IF - PATIENT HAS A SIMPLE PHEUMOTHORAX :-
- Hyper-resonant chest, reduced / absent breath sounds, but neck veins
down and trachea central.
- Ask the nurse to set up formal Chest Drain set.
- Don't insert the chest drain yet, but state that you intend to insert it
- CHEST DRAIN INSERTION :-
- Drape & surgically prepare the chest.
- If there is time, give an injection of lignocaine local anaesthetic.
- Make an incision in the 5th intercostal space just anterior to the
mid-axillary line, and just above the upper border of the 6th rib.
- Blunt dissect down through the intercostal muscles, until the pleura is
punctured. Clear away adhesions, clots or foreign bodies using a finger
- Clamp the proximal end of the chest drain and then advance it into the
chest to the desired length.
- Connect the chest drain to an underwater-seal apparatus and then
- Check the drain is functioning correctly - the water column at the
underwater-seal apparatus should move up on inspiration and bubble during
- Suture the tube in place using a purse-string suture and then apply an
adhesive non-gas-permeable dressing to the site. Apply the dressing
to 3 out of 4 sides of the drain tube.
- Finally re-examine the chest and obtain an early chest x-ray.
- IF - NECK VEINS DILATED, TRACHEA DEVIATED, ABSENT OR REDUCED BREATH
SOUNDS AND CHEST HYPER-RESONANT, THEN THINK 'TENSION PNEUMOTHORAX' :-
- Ask nurse to set up formal Chest Drain set.
- In the meantime, perform Needle Thoracostomy (Thoracentesis) and check for hissing
sound. Leave the needle thoracostomy open.
- Re-examine chest and ask for response.
- If patient stabilises, then leave formal chest drain until later.
- If they don't stabilise, perform another Needle Thoracostomy and proceed
straight to formal Chest Drain insertion.
- Describe this method.
- IF - PATIENT HAS EVIDENCE OF CHEST TRAUMA, DILATED NECK VEINS, MUFFLED
HEART SOUNDS, AND DECREASED ARTERIAL BLOOD PRESSURE (POSSIBLY EVEN PULSELESS
ELECTRICAL ACTIVITY) (BECK's TRIAD), THEN THINK 'PERICARDIAL TAMPONADE' :-
- Proceed straight to Needle Pericardiocentesis.
- Describe this method and check for response.
- NEEDLE PERICARDIOCENTESIS :-
- Monitor the patient's vital signs and ECG before, during & after the
- Drape & surgically prepare the xiphoid area.
- Use a #16 gauge 15cm needle, 3 way tap, and a 20cm syringe.
- Puncture the skin 1 - 2cm below and lateral to the left xiphi-chondral
junction, pointing the needle at an angle 45° to the skin and aiming for the
tip of the left scapula.
- Advance the needle until there is a flush-back of blood, and at this
point withdraw as much blood as possible.
- If the needle is advanced so that it penetrates the myocardium, the
ECG pattern will change, producing wild ST-T segment variation and widened /
enlarged QRS complexes. If this occurs, the needle should be withdrawn
slightly until the ECG pattern returns to normal.
- It is sometimes necessary to leave a cannula in situ for repeat
aspirations, and so here the needle may be changed to a plastic cannula using
the Seldinger technique.
- IF - PATIENT IS HYPOXIC, SHOCKED, HAS A STONY DULL CHEST, ABSENT
BREATH SOUNDS AND A TRACHEA DEVIATED AWAY FROM THIS SIDE, THEN THINK
'MASSIVE HAEMOTHORAX' :-
- Establish intravenous access using two large bore cannulas.
- Urgently call Cardiothoracic Surgeons, and in the meantime proceed to chest drain insertion.
- IF - PATIENT HAS A FLAIL CHEST AND IS HYPOXIC :-
- Early intubation is essential.
- Perform Orotracheal intubation yourself preferably by 'Rapid Sequence
Induction' or call for an anaesthetist to do it.
- IF - PATIENT HAS AN OPEN PNEUMOTHORAX :-
- Cover this opening with an occlusive dressing with one-way valve (to allow outgoing air leak).
- Secure the dressing well so as to prevent air-leaks through the adhesive.
- Proceed straight to Chest Drain, placing the drain well away from the
wound of the original open pneumothorax.
C - CIRCULATION & HAEMORRHAGE CONTROL
- Ask nurse to repeat measurements of Oxygen Saturation, Blood Pressure &
- Palpate the patients head and hands looking for signs of 'shock'. This
is defined as insufficient organ perfusion and oxygenation. It is suspected
in a patient with cold, clammy, pale, peripherally shut down extremities.
- Move onto Abdomen & Pelvis.
- ABDOMEN :-
- Inspect abdomen for injuries or distension.
- Palpate abdomen for any masses or signs of peritonism.
- Consider abdominal percussion & auscultation.
- If there are signs of abdominal bleeding, ask the nurse to fast bleep
the on-call surgeon and ask them to come to casualty.
- Ask the nurse to state that you have a clinically shocked patient in
casualty who you suspect has abdominal bleeding, who you are in the process
of resuscitating, but who may urgently need to be taken to theatre for
- PELVIS :-
- Palpate the Pelvis.
- Apply both lateral and antero-posterior springing forces onto the
anterior superior iliac spines and feel for abnormal mobility or
crepitus. This examination should be performed once by an experienced practitioner.
- Ask examiner whether the pelvis is stable or unstable.
- If there are signs of a fractured pelvis, apply a 'Pelvic Binder' to temporarily stabilise the pelvis (close an open-book pelvic fracture) and reduce bleeding.
- Ask the nurse to fast bleep
the orthopaedic surgeon on call and tell them that you have a clinically shocked patient in
casualty who you suspect has an unstable fracture of the pelvis, who you are
in the process of resuscitating, who requires urgent stabilisation with
a pelvic external fixator.
- Try to get a pelvis x-ray before the orthopaedic surgeon arrives,
provided this doesn't interfere with the rest of your resuscitation.
- LIMBS :-
- Quickly move onto the limbs, cutting off clothes as necessary, and
examining for the presence of obvious deformity or soft tissue haematoma.
- Any sources of external haemorrhage should immediately be stemmed by
applying direct pressure and wrapping in a bandage.
- If there are Open (Compound) Fractures, then these should be
photographed, and then immediately packed with a Betadine soaked bandage and
direct pressure applied. Long bone fractures should be stabilised in Traction Splints.
- Ask the nurse to stand by with intravenous
morphine, a tetanus injection and intravenous antibiotics (usually
cefuroxime & metronidazole). The orthopaedic team should be informed and
asked to attend the A&E department.
- FLUID RESUSCITATION :-
- Having examined the body for potential sources of haemorrhage as well as
stemming any areas of overt haemorrhage, fluid resuscitation should begin in
- You need to place two large bore (#14 gauge) intravenous cannulas, one in
each cubital fossa.
- Blood should be aspirated into a syringe for FBC, U&E, and
Cross-Match. Ask the nurse to ensure that the sample is rushed to the
lab. Ask for 2 - 4 units of O Negative Blood, 2 - 4 units of Type Specific
Blood, and 2 - 4 units of Crossmatched Blood, depending on the individual
- If cannulation is unsuccessful, then alternatives include the other
cubital fossa, the femoral vein, the subclavian vein, the external jugular
vein, the internal jugular vein, or a venous cut-down for the great
Intraosseous Infusion is increasingly being used in both children & adults.
- Immediately set up 1 litre of warmed Hartmanns or Ringer's Lactate for each of the two
cannulas and run as a bolus through using a fast infuser. This can take 1 - 2 minutes
to run in.
- In children under 6 years, intra-osseous infusion is the preferred
method of access after 2 unsuccessful attempts at cannulation. In infants,
scalp veins may be tried, and in neonates the umbilical vein often provides
excellent access. The volume of the infusion bolus in children is 20mls / kg
and this can be repeated 2 or 3 times depending on response.
- Ask the nurse to repeat Oxygen Saturation, Blood Pressure, Pulse &
Respiratory Rate. Check also the Temperature.
- According to response, 2 units of O Negative blood (which have just arrived from the lab) should be
given using the fast infuser. If the patient can wait 10 minutes for type
specific blood, then this is preferable.
Colloids are no longer used as standard.
- The aim is 'balanced fluid resuscitation', possibly with mild permissible hypotension.
Avoid aggressive over-zealous fluid infusions, which can re-precipitate bleeding which had previously stopped.
- Burns have fluid resuscitation according to the Modified Parkland Formula.
- Check for Clinical Response.
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 :-
||Go back and check Airway & Breathing.
||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'. |
||The patient could be HYPOTHERMIC and therefore may be responding more
slowly than a normothermic patient. |
||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. |
||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. |
||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. |
||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.
||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.
||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.
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.
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.
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.
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
- An AVPU or GCS assessment is carried out.
- The patient's pupils are examined for size, symmetry & reaction to light.
- The consensual pupillary reflex can also be tested here.
AVPU Assessment :-
A - Alert
V - Responding to Voice
P - Responding to Pain
U - Unresponsive
Glasgow Coma Scale (GCS) :-
- Eye Opening
4 - Spontaneous
3 - To Speech
2 - To Pain
1 - No Eye Opening
- Best Verbal Response
5 - Orientated
4 - Confused Conversation
3 - Inappropriate Words
2 - Incomprehensible Sounds
1 - No Response
- Best Motor Response
6 - Obeys commands
5 - Appropriate localising response to pain
4 - Withdrawal response
3 - Abnormal flexion response (Decorticate Rigidity)
2 - Extension response (Decerebrate rigidity)
1 - No Response
E - EXPOSURE & ENVIRONMENTAL CONTROL
- Here, any clothes which haven't already gone are removed.
- Care is still taken to protect all areas of the spine from undue movement.
- Log Roll is sometimes done at 'E'.
- Finally, the patient is covered with a blanket or other suitable warm
covering to prevent hypothermia.
Here endeth the lesson !!
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Last Modified : 12th January 2019