A.T.L.S.Primary Secondary SurveyHead InjurySpinal Injury

Primary survey A : Airway B : Breathing C : Circulation D : Disability E : Exposure Goal : recognizing life threatening condition and simultaneously do resuscitation

Airway Cervical Spine Control (Assume injury until proven otherwise) Airway assessment Obstruction? Patient can talk airway clear Look (cyanosis/breathing pattern/uses of accessories muscle/RR/Pox ) Listen (grunting/stridor/ total obstruction silent) Feel (decreased/absent airflow) Airway management Triple airway maneuver only if w/o possible cervical spine injury : Slight neck extension Jaw thrust ( elevation of mandible) Mouth opening Possible cervical injury : without neck extension Adjunctive devices : oropharyngeal airway ( only if no gag reflex) / Nasopharyngeal airway ( KI: susp. Basilar skull fracture/coagulapaty)

Breathing Assesment : Look ( sign of respiratory distress/ equal chest rise /RR/P ox) /Listen ( lung sound ) /Feel ( trachea position /crepitus ,emphysema subcutis) /P Management : Oxygen supplement / Assisted ventilation Manual assisted ventilation Indication : Apneic/Inadequate ventilation Bag valve mask , RR:12 to 16 x/min, 100 % oxygen with max flow ( >10 l/min)

Circulation Assestment : pulse ( carotid/femoral/radial) / BP/HR /evaluate quickly for areas of large hemorrhaging that can easily be stopped with direct pressure Management : 2 Large/short IV bore : 16 or intraosseous needle NS /RL 2-3 L/min or 20 cc/kg bolus in children No response, blood , O negative

Disability (Neuro) AVPU ( Alert / Verbal response/Pain response/Unresponsive) GCS ( Adult/children)

Exposure Undress patient for thorough examination Remember hypothermia

Remember neck/spinal immobilization

Addition on primary survey Vital sign monitor ( BP/P ox/HR or Pulse rate) / Cardiac monitor ECG Urinary catheter Check for possible urethra rupture ( blood OUE/scrotal or perineal hematome/ RT : unpalpable / high prostate) If susp. Urethra rupture, need urethra-systogram X-ray : Cervical ( lateral ) / Thorax (AP) /Pelvic ( AP)

Secondary survey After primary survey / resuscitation and ABC stabilize Examine patient from head to toe Anamnesis : AMPLE ( Allergy / Medication/ Past medical history/ Last meal/ Event , mechanism of injury)

HEENT Examine face for facial fractures Examine eyes for any gross injury, shattered glass should be irrigated then flourescein Examine ears for hemotympanum Examine mouth for jaw fractures/loose teeth

Neck Ask patient if s/he has any neck pain Midline tenderness? Penetrating wound : which zone ? trauma to the arteries/airway?

Chest Palpate entire chest for area of crepitus/tenderness Look for Seat belt sign/bruising /asymmetric Listen to breath sounds, symmetric ? other additional sounds? Listen to heart sound Abdomen Look for distension / bruising / seat belt sign Examine for area of tenderness Pelvic Examine for tenderness AP/Lateral compression Genitourinary/rectal Examine externally for signs of bleeding Rectal exam for blood/position of prostate( male)

Back Log roll Look for bruising / tenderness on bone palpation / penetrating wound Extremities Look for deformity/laceration / bleeding site /abrasion Palpation for area of tenderness/crepitus/pulsation

Neurologic GCS/Mental Status Limited sensory/motor exam

Laboratory test Cervical spine : AP/Lateral/open mouth ( odontoid) Hemoglobin : serial : 3x q 15 min Urinalysis Extremities X-ray USG abdomen /CT

Head InjuryClassification Mild Head Injury : GCS : 13-15 Moderate Head Injury : GCS : 9 12 Severe Head Injury : GCS : 3-8

Goal Discover all moderate/severe head injury Discover mild head injury with intracranial injury especially needing surgery Observation/education : patient that first appear with mild injury may worsen over several hours Risk stratifying Cost effectiveness

Glasgow Comatose Scale

Adult /Children ( check in PDA : epocrates / table/ GCS ) Serial check Mild Head Injury Clinical predictor : GCS / Loss of consciousness GCS 15 / LOC (+) : 10 % Intracranial injury (+) , 1% need surgery GCS 13/ LOC (+) : 38 % Intracranial injury (+) , 8 % need surgery Location of injury : temporo-parietal , increased risk of epidural bleeding Significant retrograde amnesia Older patient Preexisting condition : on anticoagulant / hemophiliac Difficulty to determine Level of Consciousness in intoxicated patient ( alcohol / drugs) Sign of basilar fracture ( battles sign / raccoon eyes/ CSF leakage from nose ,ear / hemotympanum )

Head X-ray Only if patient stable otherwise dont waste time For facial fracture

CT scan Infant < 12 months , all unless : Fall less than 1metres ( 3 feet) Normal neuro exam No evidence of scalp trauma ( bruising/hematoma etc) Older children and adult AbN neuro exam/GCS < 15 Prolonged LOC ( > 15 min) Retrograde amnesia > 30 min Repeated vomiting Worsened/severe headache Depressed skull fracture/basilar skull fracture

Special consideration : ( anticoagulation / older patient with LOC/Intoxicated ) Not sure / concerning mechanism of injury : CT Scan CT scan (-) but abN neuro exam , plan for another CT in 24/48 hours or significant worsening of symptoms.

Disposition Mild Head Injury , No neurological deficit , GCS : 15 . low risk stratification No Intra cranial injury on Head CT , normal neuro exam Observation for 24 hours , including neuro checks q 2-4 hours by responsible adult ( Head Injury patient leaflet) Follow up the next day

Admission Intra cranial injury (+) on Head CT All abN Neuro exam / GCS < 15

Other consideration Second Impact syndrome Head Injury in sports , Can I return to the game?

Post concussive syndrome Headache / dizziness / poor concentration / memory problems/ emotional problems. Most resolves after few weeks , 90 % resolves in 1 year , 10 % became chronic If worsening , Neuro evaluation / Head CT

Moderate / Severe Head Injury ABC Cervical immobilization Maintain good oxygenation /perfusion ( avoid hypotension from shock) Prophylaxis anti seizures ( phenytoin) /Manitol Head CT Referral hospital / Neurosurgeon / Neurologist

Spine Injury ABCDE / Primary survey / A with cervical immobilization /Spine immobilization with long spine board/back board. Maintain in line immobilization , i.e. hold the head with your hands/ Log roll during examination Usage of back board : for transportation , > 2 hours can cause decubitus ulcer , if > 2 hours need to log roll q 2 hourly

Neurological exam : Sensory exam , check level Motor exam , score 0 5 , check level Proprioseptive / vibratory function ( posterior column) Deep tendon reflex Anogenital ( sacral sparing) : Bulbocavernosus /cremaster /TSA

Classification Level Lowest segment ( caudal) of the spinal cord that still have motoric ( 3/5) /normal sensoric function bilaterally Partial preservation Spinal injury level not the same with Level of bone fracture

Neurologic Deficit Complete /Incomplete Spinal Cord syndrome Anterior cord Central cord Brown Sequard Cauda Equina Spinal shock Morfology Fracture Fracture/Dislocation SCIWORA Penetration injury e.g gun shot

Cervical spine injury Cervical collar ? If you are worried or unsure assume theres cervical injury until proven otherwise . Immobilize /X-ray Ruled out C-spine injury, Low risk if following guidelines : No midline tenderness Alert / no neurological deficit Not intoxicated No other distracting injury

Physical exam Sensory exam Motor exam C2 Top of head -C3 Ear -C4 Neck C3/4/5 diaphragmC5 Shoulder Shoulder shrugC6 Thumb Biceps ( elbow flexion) C7 Middle finger Triceps ( elbow extension)C8 Little finger Finger muscle

Posterior column sensation proprioception ( finger up/down) Imaging Studies X-ray : Lateral / Open Mouth Odontoid (OMO) /AP ( check proc. spinosus) CT Scan : To illustrate detail of fracture If fracture is suspected but no adequate X-ray MRI : Ligament /spinal cord

Management : Methyl prednisolone, initial dose : 30 mg / kg IV over 1 hour followed by 5.4mg

/kg/hour for the next 23 hours ( total 24 hours)

Exclusion criteria : To be given within 8 hours > 13 years old No serious injury Not pregnant Not already taking other steroids Not given naloxone recently

Neurogenic Shock :

Not common . Cause by spinal cord injury . Decreased vascular tone and relative bradycardia. ( symphatic enervation of the heart) Spinal shock After spinal cord injury . Flacid / loss of reflexes. Temporary .

THORACIC TRAUMALife threatening condition that need to be identified and treated immediately on Primary Survey

Airway Laryngeal Injury

Sign of upper airway obstruction ( stridor) Hoarseness/emphysema subcutaneous emphysema/palpable fracture of

the larynx Humidified Oxygen/IV access/Prepare for early intubation or surgical

airway/ ENT consult If edema larynx : Dexamethasone, adult 4 mg IV, ped: 0.25 mg 0.5

mg/kg IV

Fracture /Dislocation of Sternoclavicular joint Obvious sign of trauma on the base of the neck with palpable defect on

the sternoclav. Joint Closed reduction of the sternoclavicular joint in supine position

Breathing Tension Pneumothorax

Clinical diagnosis : Chest pain / respiratory distress/tachycardia/ hypotension/ tracheal deviation/unilateral absence of breath/JVD/cyanosis

Needle thoracocentesis ( large bore needle , 14-16 G, 2nd intercostal space, midclav) followed by insertion of chest tube

Open Pneumothorax Large defects of chest wall which remain open or sucking chest wound Close the defect with sterile occlusive dressing, large enough to overlap

the wound, tapes securely on 3 sides

Flail chest Multiple ribs fractures ie, two or more ribs fractured in two or more places Paradoxical movement of the chest wall ( inspiration/expiration) Main problem is the underlying lung disease : Pulmonary contusion Humidified oxygen/fluid resuscitation/analgesic Asses adequate ventilation for the need for assisted ventilation /intubation

Circulation Massive Hemothorax

> 1500 ml blood in the chest cavity or blood loss > 200 ml/hour for 2 to 4 hours

shock associated with the absence of breath sound and or dullness on percussion on one side of the chest

Management : Fluid resuscitation/blood transfusion simultaneously with decompression of chest cavity ( chest tube)

Cardiac Tamponade Commonly associated with penetrating injury Becks triad : JVD/hypotension/muffled heart sounds, not always present PEA in the absence of hypovolemia/tension pneumothorax Pericardiocentesis

Secondary Survey Further physical examination CXR P ox /Blood Gas Analysis ECG

Simple Pneumothorax Decreased breath sounds / hyperresonance /CXR If pneumothorax < 15 %, no cardiovascular or respiratory compromise :

observe for 4 to 6 hours and repeat CXR , if no change : discharge otherwise chest tube insertion

Hemothorax Shown in CXR , needed to be evacuated with chest tube

Pulmonary contusion Cause respiratory failure Intubation

Blunt Cardiac Injury

Traumatic Aortic Disruption Persistent hypotension CXR: widened mediastinum

Subcutaneous emphysema Not require treatment Underlying injury If needed to assist ventilation with positive pressure, anticipate possible

pneumothorax

Rib fractures Upper ribs : 1-3 : severe injury , associated with other serious injury

( major blood vessels) Lower ribs : 10 -12 : considered hepatosplenic injury Common associated injury : pneumohemato thorax Treatment : adequate pain management to improve ventilation. Risk of

infection esp. in elderly

Traumatic Diaphragmatic injury More common in the left side

Sternum/scapular fractures Generally results of direct pressure Sternum fracture can accompanied by lung contusion/blunt cardiac injury

ABDOMINAL TRAUMA Primary survey : ABCDE , Hypotension? Obvious sign of trauma on the abdomen : blunt/penetrating injury Internal organ injury : Liver/spleen/pancreas/hollow viscus/kidney Sign of peritonitis ( distension /tenderness/muscle guarding/ rebound) Serial Hb/urinalysis/pregnancy test Abdominal series /USG Pelvic Injury , associated with major blood vessel Genito-urinary trauma : blood OUE/scrotal-perineal hematoma/high riding

prostate or blood on the rectal exam , precaution for urinary catheter. Penetrating injury : closed wound with gauze soaked with NS

MUSCULOSKELETAL TRAUMA AB C DE IV/O2 /Monitor Hipovolemic shock Femur fr. Pain management . Narcotic pain relief ( Pethidine/Morphine) Asses N V D ( Neurovascular distal) . Always check

colour/pulsation/capillary refill / sensation, compare bilaterally, and documented prior and after every manipulation /splint

Open wound Open fractures ? , cover with sterile dressing Splint , immobilized one joint above and one joint below the injury site Mal-aligned/ compromise NVD : attempt to realign by gentle traction. If

after traction NVD compromise worsened back to position before and splint in that position

Do not forced re-alignment if difficult splint in that position Tetanus prophylaxis : vaccine/Ig Antibiotic : Cefazolin ( gr I ) , + gentamycine ( gr II / III ) , dose check on

5MEC Orthopedic consult Compartment syndrome

o Pain is the earliest symptoms esp. with passive stretching of the involved groups of muscle

o Other ischemic sign: 5 P :pain /pressure/paresis/paresthesia/pulse o Unconscious patient is at increased risk

NEAR DROWNING

Near Drowning : survival at least a day after submersion

Secondary drowning : Complication of near drowning after initially successful resuscitation ( may be delayed by up to 12 hours in otherwise normal appearing patient)

In near drowning, aspiration as little as 2 cc/kg may cause lung damage/hypoxia :

Surfactant loss/alveolar dysfunction Direct tissue toxicity , pulmonary edema V/Q mismatch , vasoconstriction

Even without aspiration, life threatening pulmonary edema may occur due to cerebral hypoxia or cardiac failure ( dry drowning)

Management Prehospital

ABCDE with neck/spinal injury and hypothermia ( especially in children) precaution

Begin CPR immediately with max Oxygen IV/ Monitor No role for trying to evacuate water by Heimlich or other maneuvers Asymptomatic patient still need to be observe for possible secondary drowning

Patient with Cardio pulmonary arrest /.P ox < 90 % with max Oxygen, should be transported to hospital with facility of Intubation

Emergency Department Consider other associated injuries ( spine/head/other trauma) and medical condition ( AMI/Disrythmia/ stroke)

Patient who arrived awake but with respiratory distress or hypoxia IV /O2 max with NRB/Monitor CXR PA/Lat and other X-ray if needed ECG / ABG / electrolyte/BUN /Creatinin/CBC/ Glucose If unable to maintain P ox > 90 % with max O2, need to intubate Antibiotic : Levofloxacine 500 mg QD Observation for 12-24 hours Repeat CXR/lab test every 6 to 12 hours

Patient who arrived without any symptoms If physical exam/CXR and Pox normal , patient may be discharged after 6 hours

of observation ( repeat CXR/lab test)

High risk patient Loss of consciousness Cardiopulmonary arrest Cyanotic /tachypnoe / respiratory distress Seizures Prolonged time under water /water ingestion Preexisting medical condition /elderly/young children

A.T.L.S.Primary Secondary SurveyHead InjurySpinal Injury

Primary surveyA : AirwayB : BreathingC : CirculationD : DisabilityE : ExposureGoal : recognizing life threatening condition and simultaneously do resuscitation

AirwayCervical Spine Control (Assume injury until proven otherwise)Airway assessmentObstruction? Patient can talk airway clearLook (cyanosis/breathing pattern/uses of accessories muscle/RR/Pox )Listen (grunting/stridor/ total obstruction silent)Feel (decreased/absent airflow)

Airway managementTriple airway maneuver only if w/o possible cervical spine injury :Slight neck extensionJaw thrust ( elevation of mandible)Mouth opening

Possible cervical injury : without neck extensionAdjunctive devices : oropharyngeal airway ( only if no gag reflex) / Nasopharyngeal airway ( KI: susp. Basilar skull fracture/coagulapaty)

BreathingAssesment : Look ( sign of respiratory distress/ equal chest rise /RR/P ox) /Listen ( lung sound ) /Feel ( trachea position /crepitus ,emphysema subcutis) /PManagement : Oxygen supplement / Assisted ventilationManual assisted ventilationIndication : Apneic/Inadequate ventilationBag valve mask , RR:12 to 16 x/min, 100 % oxygen with max flow ( >10 l/min)

CirculationAssestment : pulse ( carotid/femoral/radial) / BP/HR /evaluate quickly for areas of large hemorrhaging that can easily be stopped with direct pressureManagement :2 Large/short IV bore : 16 or intraosseous needleNS /RL 2-3 L/min or 20 cc/kg bolus in childrenNo response, blood , O negative

Disability (Neuro)AVPU ( Alert / Verbal response/Pain response/Unresponsive)GCS ( Adult/children)

ExposureUndress patient for thorough examinationRemember hypothermiaRemember neck/spinal immobilization

Addition on primary surveyVital sign monitor ( BP/P ox/HR or Pulse rate) / Cardiac monitorECGUrinary catheterCheck for possible urethra rupture ( blood OUE/scrotal or perineal hematome/ RT : unpalpable / high prostate)If susp. Urethra rupture, need urethra-systogram

X-ray : Cervical ( lateral ) / Thorax (AP) /Pelvic ( AP)

Secondary surveyAfter primary survey / resuscitation and ABC stabilizeExamine patient from head to toeAnamnesis : AMPLE ( Allergy / Medication/ Past medical history/ Last meal/ Event , mechanism of injury)HEENTExamine face for facial fracturesExamine eyes for any gross injury, shattered glass should be irrigated then flouresceinExamine ears for hemotympanumExamine mouth for jaw fractures/loose teethNeckAsk patient if s/he has any neck painMidline tenderness?Penetrating wound : which zone ? trauma to the arteries/airway?

ChestPalpate entire chest for area of crepitus/tendernessLook for Seat belt sign/bruising /asymmetricListen to breath sounds, symmetric ? other additional sounds?Listen to heart sound

AbdomenLook for distension / bruising / seat belt signExamine for area of tendernessPelvicExamine for tenderness AP/Lateral compressionGenitourinary/rectalExamine externally for signs of bleedingRectal exam for blood/position of prostate( male)

BackLog rollLook for bruising / tenderness on bone palpation / penetrating woundExtremitiesLook for deformity/laceration / bleeding site /abrasionPalpation for area of tenderness/crepitus/pulsation

NeurologicGCS/Mental StatusLimited sensory/motor exam

Laboratory testCervical spine : AP/Lateral/open mouth ( odontoid)Hemoglobin : serial : 3x q 15 minUrinalysisExtremities X-rayUSG abdomen /CT

Head InjuryClassificationMild Head Injury : GCS : 13-15Moderate Head Injury : GCS : 9 12Severe Head Injury : GCS : 3-8

GoalDiscover all moderate/severe head injuryDiscover mild head injury with intracranial injury especially needing surgeryObservation/education : patient that first appear with mild injury may worsen over several hoursRisk stratifyingCost effectiveness

Glasgow Comatose ScaleAdult /Children ( check in PDA : epocrates / table/ GCS )Serial check

Mild Head InjuryClinical predictor :GCS / Loss of consciousnessGCS 15 / LOC (+) : 10 % Intracranial injury (+) , 1% need surgeryGCS 13/ LOC (+) : 38 % Intracranial injury (+) , 8 % need surgery

Location of injury : temporo-parietal , increased risk of epidural bleedingSignificant retrograde amnesiaOlder patientPreexisting condition : on anticoagulant / hemophiliacDifficulty to determine Level of Consciousness in intoxicated patient ( alcohol / drugs)Sign of basilar fracture ( battles sign / raccoon eyes/ CSF leakage from nose ,ear / hemotympanum )

Head X-rayOnly if patient stable otherwise dont waste timeFor facial fracture

CT scanInfant < 12 months , all unless :Fall less than 1metres ( 3 feet)Normal neuro examNo evidence of scalp trauma ( bruising/hematoma etc)

Older children and adultAbN neuro exam/GCS < 15Prolonged LOC ( > 15 min)Retrograde amnesia > 30 minRepeated vomitingWorsened/severe headacheDepressed skull fracture/basilar skull fractureSpecial consideration : ( anticoagulation / older patient with LOC/Intoxicated )

Not sure / concerning mechanism of injury : CT ScanCT scan (-) but abN neuro exam , plan for another CT in 24/48 hours or significant worsening of symptoms.

DispositionMild Head Injury , No neurological deficit , GCS : 15 . low risk stratificationNo Intra cranial injury on Head CT , normal neuro examObservation for 24 hours , including neuro checks q 2-4 hours by responsible adult ( Head Injury patient leaflet)Follow up the next day

AdmissionIntra cranial injury (+) on Head CTAll abN Neuro exam / GCS < 15

Other considerationSecond Impact syndromeHead Injury in sports , Can I return to the game?

Post concussive syndromeHeadache / dizziness / poor concentration / memory problems/ emotional problems.Most resolves after few weeks , 90 % resolves in 1 year , 10 % became chronicIf worsening , Neuro evaluation / Head CT

Moderate / Severe Head InjuryABCCervical immobilizationMaintain good oxygenation /perfusion ( avoid hypotension from shock)Prophylaxis anti seizures ( phenytoin) /ManitolHead CTReferral hospital / Neurosurgeon / Neurologist

Spine InjuryABCDE / Primary survey / A with cervical immobilization /Spine immobilization with long spine board/back board.Maintain in line immobilization , i.e. hold the head with your hands/ Log roll during examinationUsage of back board : for transportation , > 2 hours can cause decubitus ulcer , if > 2 hours need to log roll q 2 hourly

Neurological exam :Sensory exam , check levelMotor exam , score 0 5 , check levelProprioseptive / vibratory function ( posterior column)Deep tendon reflexAnogenital ( sacral sparing) : Bulbocavernosus /cremaster /TSA

ClassificationLevelLowest segment ( caudal) of the spinal cord that still have motoric ( 3/5) /normal sensoric function bilaterallyPartial preservationSpinal injury level not the same with Level of bone fracture

Neurologic DeficitComplete /Incomplete

Spinal Cord syndromeAnterior cordCentral cordBrown SequardCauda EquinaSpinal shock

MorfologyFractureFracture/DislocationSCIWORAPenetration injury e.g gun shot

Cervical spine injuryCervical collar ? If you are worried or unsure assume theres cervical injury until proven otherwise . Immobilize /X-rayRuled out C-spine injury, Low risk if following guidelines :No midline tendernessAlert / no neurological deficitNot intoxicatedNo other distracting injury

Physical examSensory exam Motor examC2 Top of head -C3 Ear -C4 Neck C3/4/5 diaphragmC5 Shoulder Shoulder shrugC6 Thumb Biceps ( elbow flexion)C7 Middle finger Triceps ( elbow extension)C8 Little finger Finger musclePosterior column sensation proprioception ( finger up/down)

Imaging StudiesX-ray : Lateral / Open Mouth Odontoid (OMO) /AP ( check proc. spinosus)CT Scan :To illustrate detail of fractureIf fracture is suspected but no adequate X-ray

MRI :Ligament /spinal cord

Management :Methyl prednisolone, initial dose : 30 mg / kg IV over 1 hour followed by 5.4mg /kg/hour for the next 23 hours ( total 24 hours)Exclusion criteria :To be given within 8 hours> 13 years oldNo serious injuryNot pregnantNot already taking other steroidsNot given naloxone recentlyNeurogenic Shock :Not common . Cause by spinal cord injury . Decreased vascular tone and relative bradycardia. ( symphatic enervation of the heart)Spinal shockAfter spinal cord injury . Flacid / loss of reflexes. Temporary .THORACIC TRAUMAAirwayBreathingCirculation

ABDOMINAL TRAUMAMUSCULOSKELETAL TRAUMANEAR DROWNINGManagementPrehospitalEmergency Department