INTRODUCTION
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Trauma is a public health issue and one of the leading causes of morbidity and mortality.
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Trauma mortality has a trimodal distribution.
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Seconds to minutes after injury:
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Major injury to aorta, heart, brain stem, or spinal cord, or acute respiratory distress usually contributes to death during the first mortality peak.
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These patients are unlikely to be salvageable.
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Minutes to the few hours after injury (the so-called golden hour):
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Death during the second peak is likely due to epidural or subdural hematoma, hemopneumothorax, severe liver or spleen injury, pelvic fractures, or injuries involving major hemorrhage.
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The main objective of ATLS protocol is to reduce mortality during this critical period.
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Days to weeks after injury:
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Death during the third peak usually stems from multisystem organ failure and infection. Not infrequently, withdrawal of care is selected because of a poor prognosis such as after severe head trauma.
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INITIAL ASSESSMENT
ATLS outlines the correct prioritization of diagnostic and therapeutic interventions. The surgeon plays a key role in the proper evaluation and resuscitation. The primary survey constitutes the ABCDE of trauma care:
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A irway maintenance with cervical spine precaution
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B reathing
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C irculation
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D isability
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E xposure and environmental control
AIRWAY
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The first priority is establishment of airway patency and air exchange.
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Assessment includes inspecting the oropharynx for foreign body obstruction, observing chest wall movements, and listening for breath sounds at the patient’s nose, mouth, and chest, and palpation.
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Maxillofacial trauma can produce fracture and dislocation, leading to airway obstruction. Neck and laryngeal trauma can cause significant disruption and hemorrhage, thereby compromising the airway.
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Maneuvers such as repositioning the head and mandible (chin lift and jaw thrust), and removing foreign objects from oropharynx can help establish airway patency.
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Cervical spine precaution is critically important. Cervical spine injury is assumed in any patient with multisystem injuries or altered level of consciousness.
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Inline cervical spine immobilization techniques must be used to protect spine and spinal cord.
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Patients with an altered level of consciousness may not be able to protect their airway.
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Should there be any doubt about a patient’s ability to maintain airway patency, establishing definitive airway control is necessary ( Table 54-1 ).
TABLE 54-1 ▪
INDICATIONS FOR ESTABLISHING DEFINITIVE AIRWAY
Need for Airway Patency
Need for Ventilation
Altered mental status (GCS score < 8)
Apnea
Severe maxillofacial injuries
Respiratory distress and inadequate air exchange
Risk for aspiration
Severe orophayngeal bleeding
Vomiting
Severe head injury with need for hyperventilation
Risk for airway obstruction
Expanding neck hematoma
Laryngeal injury
Tracheal injury
GCS, Glasgow Coma Scale.
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Rapid-sequence intubation is a technique of administering fast-acting anesthetic agent, followed by neuromuscular blocker, thereby allowing efficient airway establishment. The combination of etomidate and succinylcholine is frequently used.
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Endotracheal intubation:
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Orotracheal intubation: frequently used technique for airway establishment
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Nasotracheal intubation: contraindicated in the apneic patient
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Surgical airway: indicated in the patient with significant maxillofacial injury, anatomically distorted injury, or in whom endotracheal intubation cannot be performed
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Cricothyroidotomy: the preferred method of surgical airway whereby an endotracheal tube or tracheostomy tube is inserted through the cricothyroid membrane
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Tracheostomy: indicated in patients with severe laryngeal trauma or patients younger than 12 years of age
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BREATHING
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After establishing airway control, adequate gas exchange and ventilation are assessed.
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Evaluation of the patient’s breathing involves three elements:
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Inspection of chest wall movement and chest injuries.
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Auscultation for equal and symmetric breath sounds.
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Palpation to detect chest injuries.
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Plain chest radiograph (CXR), pulse oximetry, and arterial blood gas are useful diagnostic tools.
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Life-threatening thoracic injuries, such as hemopneumothorax or tension pneumothorax, should be recognized and managed immediately on recognition. Refer to Chapter 55 for a detailed discussion of thoracic injuries.
CIRCULATION
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After airway and breathing are evaluated, the circulatory system is assessed. The aim is to evaluate the patient’s hemodynamic status and to control hemorrhage.
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Hypotension is frequently secondary to hypovolemia. Assessment of the patient’s volume status involves several clinical factors.
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Level of consciousness:
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Hypovolemia can lead to impaired cerebral perfusion, resulting in altered level of consciousness.
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Skin color and capillary refill
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Pulse: assess for symmetry, rate, regularity, and quality
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Urinary output: Foley catheter should be placed for accurate assessment of urine output.
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Intravenous lines should be placed to permit fluid resuscitation.
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Placement of at least two large-bore (16-gauge or larger) catheters in peripheral veins is necessary.
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If peripheral lines cannot be established, central lines should be placed. Femoral access is preferred over subclavian vein. Saphenous vein cutdown is an alternate route. In small children, intraosseous infusion is the preferred route.
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Fluid resuscitation begins with 1-liter bolus of lactated Ringer’s or normal saline solution for an adult or 20 ml/kg for a child.
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Blood transfusion should be considered if the patient does not respond to fluid bolus adequately.
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Determine response to bolus therapy by frequent assessment of the above-mentioned clinical factors.
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The patient’s response to bolus therapy and clinical presentation reflect the degree of hemorrhage ( Table 54-2 ).
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