ATLS EXAM STUDY GUIDE FULLY SOLVED

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 haemodynamic instability transfuse: platelets, FFP and RBCs in ratio 1:1:1 (warm whole blood has better outcomes but often not available) Disability - Check GCS/AVPU, pupillary reflexes, gross evidence of a lateralizing injury or spinal cord level - Check BM Exposure - Check and maintain body temperature with rewarming methods - Totally undress patient, cutting clothes off if necessary - Examine body for signs of occult injury, including back - Palpate for vertebral tenderness and rectal tone 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? Has My Critical Care Assessed Patient's Priorities Or Next Management Decisions? What does the secondary survey mnemonic stand for? Head/skull Maxillofacial Cervical spine Chest Abdomen Pelvis Perineum Orifices Neurological Musculoskeletal Diagnostic tests/definitive care What is the AMPLE history and when is it used? Used after primary survey to gather important parts of a history Allergies Medications Past pertinent medical history Last oral intake Events leading up to injury/illness What acronym is used for giving a trauma handover? ATMIST