ATLS Latest 2023 Already Passed

ATLS Latest 2023 Already Passed A = E in ATLS *Airway* (and c-spine and catastrophic haemorrhage) *-* If answering questions that airway is patent *-* Use jaw thrust to protect c-spine *-* Give 100% oxygen *-* Assume c-spine injury in blunt trauma until proven otherwise (x-ray or satisfies Canadian c-spine rules) *Breathing* *-* Assess oxygenation with pulse oximetry *-* Check air entry with auscultation (also auscultate heart) *-* Inspect, palpate and percuss chest wall *-* Check RR and chest trauma *Circulation* (and haemorrhage control) *-* Assess central and peripheral pulses *-* BP *-* Place two large (at least 16 gauge) cannulae *-* Take bloods: *crossmatch*, FBC, U&E, clotting, VBG, ABG *-* Control any visible haemorrhage with pressure and consider possible sources of occult haemorrhage if no source identified but the patient is shocked *-* If low BP consider fluids (ATLS dictates 1L warmed Hartmann's/0.9% saline although growing evidence for hypotensive resuscitation) *-* If significant haemorrhage and persistent haemody Why are crystalloid fluids tending to be avoided in modern trauma resuscitation? Contributes to *hypothermia and haemodilution of clotting factors and Hb*, thus worsening coagulopathy in trauma already exacerbated by haemorrhage and the looming lethal triad Increased *hydrostatic forces from fluids can also disrupt clots* *Penetrating trauma*: aim for 70-80mmHg *Blunt trauma*: aim for 90mmHg Where can patients lose a significant portion of their blood volume? *On the floor and 4 more* *Chest* *Long bones* *Abdomen* *Pelvis* What is the lethal triad in trauma? *Hypothermia* *Acidosis* *Coagulopathy* Pathophysiology of the lethal triad *Hypothermia*: occurs as a result of hypovolaemia and exposure. The elderly, intoxicated, burnt and exposed patients are esp. at risk. Hypothermia dampens the CVS compensatory mechanisms against hypovolaemic shock thus worsening tissue hypoxia *Acidosis*: arises from tissue hypoperfusion and subsequent lactic acid production, further exacerbated by respiratory hypoventilation causing acidosis. Temperature and pH heavily influence clotting and platelet function leading to potential coagulopathy *Coagulopathy*: develops in ~25% severely injured patients and is associated with 4x mortality. Thought to arise mainly from haemorrhage and haemodilution from excessive fluid resusc but has been noted to develop within minutes of injury causing reduced tissue perfusion. Note pre-existing medical conditions that alter clotting (liver failure) or oral anti-coagulants (warfarin, DOACs) How is hypothermia defined? Traditionally defined as *T 35°C* but in trauma it is *T 36°C* as it is associated with especially poor outcomes What is the best and quickest method to determine the presence of internal haemorrhage? *FAST scan* (focused assessment with sonography for trauma) Can detect ~200mL intraperitoneal fluid with 90% sensitivity It is not sensitive at detecting liver and spleen tears or hollow viscous injuries What else might free fluid in the abdomen or pelvis be? *-* Urine from bladder rupture *-* Ascites *-* Peritoneal dialysis When is a FAST scan typically performed? Immediately after primary survey is complete (resuscitation can be ongoing throughout) What is a secondary survey? *Thorough head-to-toe examination* following completion of ABCDE once the patient is responding to initial resuscitation It includes a *more complete history and further imaging* (US, angiography etc) Continuous reassessment of A=E is still expected It is especially important in the unconscious patient who is unable to report a finger fracture or testicular rupture for example What is the mnenomic to help remember components of a secondary survey? *H*as *M*y *C*ritical *C*are *A*ssessed *P*atient's *P*riorities *O*r *N*ext *M*anagement *D*ecisions? What does the secondary survey mnemonic stand for? *H*ead/skull *M*axillofacial *C*ervical spine *C*hest *A*bdomen *P*elvis *P*erineum *O*rifices *N*eurological *M*usculoskeletal *D*iagnostic tests/definitive care What is the AMPLE history and when is it used? Used after primary survey to gather important parts of a history *A*llergies *M*edications *P*ast pertinent medical history *L*ast oral intake *E*vents leading up to injury/illness What acronym is used for giving a trauma handover? *ATMIST* What is included in ATMIST?