Podcast #209 - ATLS Episode 1: Initial Assessment and Management (Chapter 1)

It is time to dive into some core Advanced Trauma Life Support (ATLS) content.  Mike Sharma is back to co-host the podcast and help us cover the first chapter of ATLS which discusses the initial assessment and management of trauma patients.

There are a series of steps we need to take during the initial assessment.  Keep in mind, this is dynamic and with each intervention, the patient should be re-evaluated for changes (both good and bad).

• Preparation
  • Identify what resources may be needed based on known information.
  • Mobilize resources as soon as possible (lab, x-ray, blood bank, respiratory therapy, etc).
  • Assign roles and declare team leader.
• Triage
  • In mass casualty situations, need to quickly identify who needs emergent resources.
  • Recognize who may or may not be able to be saved depending on resources and condition.
  • This is also applicable for simply a quick "foot of the bed" assessment to judge the patient's condition (how quickly patient needs intervention).
• Primary Survey (Each Section Discussed More in Upcoming Chapters)
  • A - Airway
    • Establish a definitive airway early if there is any doubt in the patient's ability to manage their airway.
    • Limit attempts and consider algorithms such as the Shock Trauma Center Failed Airway Algorithm.
    • Be prepared for the surgical airway (cricothyrotomy or tracheotomy) if an endotracheal tube can not be readily placed.
  • B - Breathing
    • A tension pneumothorax is a rapid killer and must be identified early.
    • Perform needle decompression of finger thoracostomy as soon as possible.
  • C - Circulation
    • Massive hemorrhage should be managed first (even before airway and breathing).
    • Junctional bleeds (axilla, groin, and neck) are very challenging because they are difficult to compress.
    • Tourniquets should be used early on especially with massive hemorrhage.
    • If a patient needs blood products, give it early (avoid IV fluids such as normal saline)!
    • Do not be afraid to active the a massive transfusion protocol.
  • D - Disability (Think Glasgow Coma Scale)
    • Motor - 6 (six cylinder engine).
    • Verbal - 5 (Roman numeral "V").
    • Eye - 4 ("four eyes").
  • E - Environment/Exposure
    • Hypothermia is part of the Trauma Triangle that can lead to death (in addition to coagulopathy and metabolic acidosis).
    • Keep the patient warm including when giving blood (or IV fluids).
    • Undress the patient to identify wounds that would otherwise be missed.
• Adjuncts and Resuscitation
  • Physiologic parameters such as pulse rate, blood pressure, pulse pressure, ventilatory rate, ABG levels, body temperature, and urinary output are assessable measures that reflect the adequacy of resuscitation. 
  • Values for these parameters should be obtained as soon as is practical during or after completing the primary survey, and re-evaluated periodically.
  • Do not delay definitive care and perform only the interventions necessary to resuscitate the patient and facilitate transfer.
• Secondary Survey (Head to Toe Assessment)
  • D - Deformities
  • C - Contusions
  • A - Abrasions
  • P - Punctures/Penetrations
  • B - Burns
  • T - Tenderness
  • L - Lacerations
  • S - Swelling
• Monitoring and Re-evaluation
  • Until the patient has been transferred, the goal is to keep the patient stable.
  • Remember to factor in special populations that may need additional support such as children, the elderly, and those women that are pregnant.
• Transfer to Definitive Care
  • Initiate transfer as soon as it is recognized the patient can not be managed at your facility.
• Post Event (Patient Left Department)
  • Perform right away a"hot offload" to discuss case.
  • Later perform an after action review (AAR).

​Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

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