Initial

Assessment
and
Management

ATLS 10th Edition

Initial Assessment
– rapidly assess injuries and institute lifepreserving therapy. Because timing is crucial, a
systematic approach that can be rapidly and accurately applied is essential. This approach,
termed the “initial assessment”.
– elements:
• Preparation
• Triage
• Primary survey (ABCDEs) with immediate resuscitation of patients with life-
threatening injuries
• Adjuncts to the 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
Preparation
– Prehospital
The prehospital system ideally is 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, providers emphasize 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
Preparation
– Hospital
The hand-over between prehospital providers and those at the receiving hospital should be a smooth
process, directed by the trauma team leader, ensuring that all important information is available to the
entire team.
Critical aspects of hospital preparation include the following:
• A resuscitation area is available for trauma patients.
• Properly functioning airway equipment (e.g., laryngoscopes and endotracheal tubes) is organized,
tested, and strategically placed to be easily accessible.
• Warmed intravenous crystalloid solutions are immediately available for infusion, as are appropriate
monitoring devices.
• A protocol to summon additional medical assistance is in place, as well as a means to ensure prompt
responses by laboratory and radiology personnel.
• Transfer agreements with verified trauma centers are established and operational
Preparation
Triage
– Triage involves the sorting of patients based on the resources required for
treatment and the resources that are actually available. The order of treatment
is based on the ABC priorities (airway with cervical spine protection, breathing,
and circulation with hemorrhage control)
– Triage also includes the sorting of patients in the field to help determine the
appropriate receiving medical facility. Trauma team activation may be
considered for severely injured patients
Primary Survey with Simultaneous
Resuscitation

– The primary survey encompasses the ABCDEs of trauma care and identifies life-
threatening conditions by adhering to this sequence:
• Airway maintenance with restriction of cervical spine motion
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability(assessment of neurologic status)
• Exposure/Environmental control
Airway Maintenance With RESTRICTION
OF CERVICAL SPINE MO

– first assess the airway to ascertain patency.

– This rapid assessment for signs of airway obstruction includes inspecting for
foreign bodies; identifying facial, mandibular, and/or tracheal/laryngeal
fractures and other injuries that can result in airway obstruction; and suctioning
to clear accumulated blood or secretions that may lead to or be causing airway
obstruction. Begin measures to establish a patent airway while restricting
cervical spine motion. If the patient is able to communicate verbally, the airway
is not likely to be in immediate
Airway Maintenance With Restriction of
Cervical Spine Motion

– first assess the airway to ascertain patency.

– This rapid assessment for signs of airway obstruction includes inspecting for
foreign bodies; identifying facial, mandibular, and/or tracheal/laryngeal
fractures and other injuries that can result in airway obstruction; and suctioning
to clear accumulated blood or secretions that may lead to or be causing airway
obstruction. Begin measures to establish a patent airway while restricting
cervical spine motion. If the patient is able to communicate verbally, the airway
is not likely to be in immediate
– The cervical spine is protected with a cervical collar. When airway
management is necessary, the cervical collar is opened, and a team
member manually restricts motion of the cervical spine
– When airway management is necessary, the cervical collar is
opened, and a team member manually restricts motion of the
cervical spine
Breathing and Ventilation

– Ventilation requires adequate function of the lungs, chest wall, and diaphragm;
therefore, clinicians must rapidly examine and evaluate each component.
– To adequately assess:
 jugular venous distention
 position of the trachea
 chest wall excursion
 expose the patient’s neck and chest.
 Perform auscultation to ensure gas flow in the lungs
 Visual inspection and palpation can detect injuries
 Percussion of the thorax can also identify abnormalities.
Breathing and Ventilation

Every injured patient should receive supplemental oxygen. If the patient is not intubated,
oxygen should be delivered by a mask-reservoir device to achieve optimal oxygenation.
Use a pulse oximeter to monitor adequacy of hemoglobin oxygen saturation.

A simple pneumothorax can be converted to a tension pneumothorax when a patient is

intubated and positive pressure ventilation is provided before decompressing the
pneumothorax with a chest tube.
Cirulation with Hemorrhage Control
1. Blood Volume and Cardiac Output
Identifying, quickly controlling hemorrhage, and initiating resuscitation are therefore crucial steps in
assessing and managing such patients.
The elements of clinical observation that yield important information within seconds are level of
consciousness, skin perfusion, and pulse.
 Level of consciousness
When circulating blood volume is reduced, cerebral perfusion may be critically impaired, resulting in an
altered level of consciousness.
 Skin Perfusion
This sign can be helpful in evaluating injured hypovolemic patients. A patient with pink skin, especially in
the face and extremities, rarely has critical hypovolemia after injury. Conversely, a patient with
hypovolemia may have ashen, gray facial skin and pale extremities
 Pulse
A rapid, thready pulse is typically a sign of hypovolemia. Assess a central pulse (e.g., femoral or carotid
artery) bilaterally for quality, rate, and regularity. Absent central pulses that cannot be attributed to
local factors signify the need for immediate resuscitative action.
Cirulation with Hemorrhage Control
2. Bleeding
Identify the source of bleeding as external or internal. External hemorrhage is identified and controlled
during the primary survey. Rapid, external blood loss is managed by direct manual pressure on the
wound.
Tourniquets are effective in massive exsanguination from an extremity but carry a risk of ischemic injury
to that extremity. Use a tourniquet only when direct pressure is not effective and the patient’s life is
threatened.
The major areas of internal hemorrhage are the chest, abdomen, retroperitoneum, pelvis, and long
bones. The source of bleeding is usually identified by physical examination and imaging (e.g., chest x-ray,
pelvic x-ray, focused assessment with sonography for trauma [FAST], or diagnostic peritoneal lavage
[DPL]).
- Immidiate management may include chest decompression, and application of a pelvic stabilizing
device and/ or extremity splints.
- Definitive management may require surgical or interventional radiologic treatment and pelvic and
long-bone stabilization.
Cirulation with Hemorrhage
Control
Aggressive and continued volume resuscitation is not a substitute for definitive
control of hemorrhage.

Shock associated with injury is most often hypovolemic in origin. In such cases,
initiate IV fluid therapy with crystalloids. All IV solutions should be warmed either
by storage in a warm environment (i.e., 37°C to 40°C, or 98.6°F to 104°F) or
administered through fluidwarming devices.
A bolus of 1 L of an isotonic solution may be required to achieve an appropriate
response in an adult patient. If a patient is unresponsive to initial crystalloid
therapy, he or she should receive a blood transfusion.
Disability (Neurologic Evaluation)

A rapid neurologic evaluation establishes the patient’s level of consciousness and pupillary size and
reaction; identifies the presence of lateralizing signs; and determines spinal cord injury level, if present.

The GCS is a quick, simple, and objective method of determining the level of consciousness. The motor
score of the GCS correlates with outcome.
- A decrease in a patient’s level of consciousness may indicate decreased cerebral oxygenation and/or
perfusion, or it may be caused by direct cerebral injury.
- An altered level of consciousness indicates the need to immediately reevaluate the patient’s
oxygenation, ventilation, and perfusion status.
- Hypoglycemia, alcohol, narcotics, and other drugs can also alter a patient’s level of consciousness.
Until proven otherwise, always presume that changes in level of consciousness are a result of
central nervous system injury.
Exposure and Environmental
Control
– During the primary survey, completely undress the patient, usually by cutting
off his or her garments to facilitate a thorough examination and assessment.
After completing the assessment, cover the patient with warm blankets or an
external warming device to prevent him or her from developing hypothermia in
the trauma receiving area. Warm intravenous fluids before infusing them, and
maintain a warm environment.
– Hypothermia can be present when the patient arrives, or it may develop quickly
in the ED if the patient is uncovered and undergoes rapid administration of
room-temperature fluids or refrigerated blood. Because hypothermia is a
potentially lethal complication in injured patients, take aggressive measures to
prevent the loss of body heat and restore body temperature to normal.
Exposure and Environmental
Control
Adjuncts to the Primary Survey
with Resuscitation
1. Electrocardiographic (ECG) monitoring of all trauma patients is important.
– Dysrhythmias—including unexplained tachycardia, atrial fibrillation, premature
ventricular contractions, and extreme hypothermia
– ST segment changes—can indicate blunt cardiac injury.
– Pulseless electrical activity (PEA) can indicate cardiac tamponade, tension
pneumothorax, and/or profound hypovolemia.
– When bradycardia, aberrant conduction, and premature beats are present,
hypoxia and hypoperfusion should be suspected immediately
2. Pulse Oxymetri
Adjuncts to the Primary Survey
with Resuscitation
3. Ventilatory rate, capnography, and ABG
Ventilatory rate, capnography, and ABG measurements are used to monitor the
adequacy of the patient’s respirations. Ventilation can be monitored using end
tidal carbon dioxide levels. End tidal CO2 can be detected using colorimetry,
capnometry, or capnography

4. Urinary and Gastric Catheters

Urinary output is a sensitive indicator of the patient’s volume status and reflects
renal perfusion. do not insert a urinary catheter before examining the perineum
and genitalia. When urethral injury is suspected, confirm urethral integrity by
performing a retrograde urethrogram before the catheter is inserted.
Adjuncts to the Primary Survey
with Resuscitation
4. Urinary and Gastric Catheters
A gastric tube is indicated to decompress stomach distention, decrease the risk of
aspiration, and check for upper gastrointestinal hemorrhage from trauma.
Adjuncts to the Primary Survey
with Resuscitation
5. X-ray Examinations and Diagnostic Studies
- Anteroposterior (AP) chest and AP pelvic films often provide information to guide
resuscitation efforts of patients with blunt trauma. Chest x-rays can show
potentially life-threatening injuries
- FAST, eFAST, and DPL are useful tools for quick detection of intraabdominal blood,
pneumothorax, and hemothorax.
Consider need for patient transfer
– It is important not to delay transfer to perform an indepth diagnostic
evaluation. Only undertake testing that enhances the ability to resuscitate,
stabilize, and ensure the patient’s safe transfer.

Special Population
– Patient populations that warrant special consideration during initial assessment
are children, pregnant women, older adults, obese patients, and athletes.
Priorities for the care of these patients are the same as for all trauma patients,
but these individuals may have physiologic responses that do not follow
expected patterns and anatomic differences that require special equipment or
consideration.
Secondary Survey
The secondary survey does not begin until the primary survey (ABCDE) is completed,
resuscitative efforts are under way, and improvement of the patient’s vital functions
has been demonstrated.
The secondary survey is a head-to-toe evaluation of the trauma patient—that is, a
complete history and physical examination, including reassessment of all vital signs.
Each region of the body is completely examined. The potential for missing an injury or
failing to appreciate the significance of an injury is great, especially in an unresponsive
or unstable patient.
The AMPLE history is a useful mnemonic for this purpose:
• Allergies
• Medications currently used
• Past illnesses/Pregnancy
• Last meal
• Events/Environment related to the injury
Injuries are divided into two broad categories:
– blunt and penetrating trauma

Other types of injuries for which historical information is

important include:
– thermal injuries and those caused by hazardous
environments
Physical Examination
1. Head
The entire scalp and head should be examined for lacerations,
contusions, and evidence of fractures. The eyes should be
reevaluated for: • Visual acuity • Pupillary size • Hemorrhage of the
conjunctiva and/or fundi • Penetrating injury • Contact lenses
(remove before edema occurs) • Dislocation of the lens • Ocular
entrapment
2. Maxillofacial Structures
Examination of the face should include palpation of all bony
structures, assessment of occlusion, intraoral examination, and
assessment of soft tissues. 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.
Physical examination
3. Cervical Spine and Neck
Patients with maxillofacial or head trauma should be presumed to have a cervical
spine injury (e.g., fracture and/or ligament injury), and cervical spine motion must
be restricted
Examination of the neck includes inspection, palpation, and auscultation. Cervical
spine tenderness, subcutaneous emphysema, tracheal deviation, and laryngeal
fracture can be discovered on a detailed examination. The carotid arteries should
be palpated and auscultated for bruits. A common sign of potential injury is a
seatbelt mark
Physical examination
3. Chest
– Significant chest injury can manifest with pain, dyspnea, and hypoxia. Evaluation
includes inspection, palpation, auscultation and percussion, 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
auscultatory findings can be difficult to evaluate in a noisy environment, they
can be extremely helpful. Distant heart sounds and decreased pulse pressure
can indicate cardiac tamponade.
Physical examination
4. Abdomen and Pelvis
Abdominal injuries must be identified and treated aggressively
A normal initial examination of the abdomen does not exclude a significant intraabdominal injury.
Close observation and frequent reevaluation of the abdomen, preferably by the same observer,
are important in managing blunt abdominal trauma, because over time, the patient’s abdominal
findings can change.
Pelvic fractures can be suspected by the identification of ecchymosis over the iliac wings, pubis,
labia, or scrotum. Pain on palpation of the pelvic ring is an important finding in alert patients.
In addition, assessment of peripheral pulses can identify vascular injuries. Patients with a history
of unexplained hypotension, neurologic injury, impaired sensorium secondary to alcohol and/or
other drugs, and equivocal abdominal findings should be considered candidates for DPL,
abdominal ultrasonography, or, if hemodynamic findings are normal, CT of the abdomen
Physical examination
5. Perineum, Rectum and Vagina
The perineum should be examined for contusions, hematomas, lacerations, and urethral
bleeding.
A rectal examination may be performed to assess for the presence of blood within the
bowel lumen, integrity of the rectal wall, and quality of sphincter tone.
Vaginal examination should be performed in patients who are at risk of vaginal injury

6. Musculoskeletal System
The extremities should be inspected for contusions and deformities. Palpation of the bones
and examination for tenderness and abnormal movement aids in the identification of occult
fractures.
Physical examination
5. Neurological System
A comprehensive neurologic examination includes motor and sensory evaluation of the
extremities, as well as reevaluation of the patient’s level of consciousness and pupillary size
and response. The GCS score facilitates detection of early changes and trends in the
patient’s neurological status.
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.
Reevaluation
– Trauma patients must be reevaluated constantly to ensure that new findings are
not overlooked and to discover any deterioration in previously noted findings.
– Continuous monitoring of vital signs, oxygen saturation, and urinary output is
essential. For adult patients, maintenance of urinary output at 0.5 mL/kg/h is
desirable. In pediatric patients who are older than 1 year, an output of 1
mL/kg/h is typically adequate. Periodic ABG analyses and end-tidal CO2
monitoring are useful in some patients.
Definitive Care
– Whenever the patient’s treatment needs exceed the capability of the receiving
institution, transfer is considered. This decision requires a detailed assessment
of the patient’s injuries and knowledge of the capabilities of the institution,
including equipment, resources, and personnel. Interhospital
Teamwork

– includes a team leader, airway manager, trauma nurse, and trauma technician,
as well as various residents and medical students. The specialty of the trauma
team leader and airway manager are dependent on local practice, but they
should have a strong working knowledge of ATLS principles. To perform
effectively, each trauma team should have one member serving as the team
leader
– The following are some of the possible roles, depending on the size and
composition of the team: • Assessing the patient, including airway assessment
and management • Undressing and exposing the patient • Applying monitoring
equipment • Obtaining intravenous access and drawing blood • Serving as
scribe or recorder of resuscitation activity
Teamwork
– includes a team leader, airway manager, trauma nurse, and trauma technician, as
well as various residents and medical students. The specialty of the trauma team
leader and airway manager are dependent on local practice, but they should have a
strong working knowledge of ATLS principles. To perform effectively, each trauma
team should have one member serving as the team leader
– The following are some of the possible roles, depending on the size and composition
of the team:
• Assessing the patient, including airway assessment and management
• Undressing and exposing the patient
• Applying monitoring equipment
• Obtaining intravenous access and drawing blood
• Serving as scribe or recorder of resuscitation activity
Teamwork

– the team leader supervises the hand-over by EMS personnel, ensuring that no
team member begins working on the patient unless immediate life-threatening
conditions are obvious (i.e., a “hands-off hand-over”). A useful acronym to
manage this step is MIST:
• Mechanism (and time) of injury
• Injuries found and suspected
• Symptoms and Signs
• Treatment initiated