La primera etapa del curso ATLS (Advanced Trauma Life Support) se conoce como "Evaluación Inicial". En esta etapa, los estudiantes de medicina aprenden un enfoque sistemático y estructurado para evaluar a un paciente traumatizado de manera rápida y eficaz. La Evaluación Inicial se centra en identificar y abordar de inmediato las lesiones que amenazan la vida del paciente.

1. Initial Assessment and Management of the
Trauma Patient
Unfolding scenario
Reflective self-assessment
April 2020
© The Royal College of Surgeons of England 2020. All rights reserved

2. Initial Assessment
Learning objectives:
• Identify the correct sequence of priorities for assessment of a multiply
injured patient - the primary survey.
• Consider how the mechanism of injury contribute to the identification of
injuries.
• Recognize patients who will require transfer for definitive management.

3. Initial Assessment

4. Initial Assessment
PPE is needed
● Cap
● Gown
● Gloves
● Mask
● Shoe covers
● Protective eyewear / face shield

5. Clinical Scenario
M 18-year-old male, unrestrained driver in MVC vs. tree.
I None reported.
S Observations not reported.
T Prolonged extrication; transported to ED by ambulance; O2 by mask;
fluids via single IV; spinal motion restricted on long spine board.

6. Initial Assessment
Video: Hospital preparation
Self-assessment questions (suggested responses on next slide):
• How would you prepare for the arrival of this patient?
• What other information would be helpful to know in order to prepare?
• From the history, what are the potential injuries this patient may have suffered?

7. Initial Assessment
• All equipment for an ABC evaluation to be available including oxygen,
airway devices, iv cannulae and warmed isotonic fluids.
• Introduce and brief members of the Trauma Team. As Team Leader,
assess capabilities of team members.
• It would be helpful to have a report of vital signs, interventions and GCS
score from the pre-hospital team.
• Likely injuries include head, spine, chest, abdomen, pelvis and long
bones in this high energy impact.

8. Clinical Scenario
Case progression
Patient arrives at hospital.
Vital signs: HR 120; BP 90/65; RR 20; SpO2 82% on O2, temp 35.5°C.
Video: Handover
Self-assessment questions (suggested responses on next slide):
What are your management priorities?
What are your clinical concerns?

9. Clinical Scenario
• The patient is hypoxic, tachycardic, and hypotensive.
• There may be an airway issue, but there certainly is a breathing issue (e.g.,
pulmonary contusion, haemothorax/pneumothorax, aspiration).
• The patient is in shock (hemorrhagic and/or obstructive).
• Potential sources of bleeding are chest, abdomen, pelvis and femur.
• Ongoing hemodynamic instability leads to the potential for secondary brain
injury.
• Management priorities cover ABCD. The rationale for the order of priority
(airway, breathing, circulation, disability) is to assess and manage problems
in an order that addresses the most life-threatening injuries first – for
example an obstructed airway will usually kill a patient before haemorrhagic
shock.

10. Initial Assessment
• Initial Assessment (Primary Survey) follows a strict
algorithm based on a hierarchy of what injuries and
patient compromises are going to kill the patient most
rapidly.
• Thus
• Compromise of airway (A) will need correction before
• Interventions to correct breathing (B) problems
• And control of bleeding and resuscitation of haemorrhagic
shock (C) is done after A and B
• Assessment of Disability (D) Follows A B and C
• And finally consideration is given to full exposure (E) of the
patient whilst remembering to prevent patient cooling
• If a life-threatening problem is identified it is important to
manage the problem when found before proceeding with
assessment.
• Any intervention should be followed by reassessment
before proceeding with the primary survey to ensure
appropriate response.
• Priorities for all trauma patients are the same.
Video: Initial assessment

11. Clinical Scenario
Case progression
Primary survey reveals:
Vital signs: HR 120; BP 90/65; RR 20; SpO2 82% on O2
A: Obvious facial trauma and mumbling incoherently.
B: Decreased breath sounds in L chest. No visible neck veins.
C: Minimal bleeding from open L femur fracture. Left chest bruising.
Possible pelvic fracture.
D: Localizes to pressure with upper extremities. Moans to pressure
stimuli. Does not open eyes.

12. Clinical Scenario
Self-assessment questions (suggested responses on next
slide):
What are your priorities and your clinical concerns now?

13. Clinical Scenario
• Establish a patent airway (A) while maintaining restriction of cervical spine
movement.
• Confirm adequate breathing (ventilation) (B).
• Control bleeding and support the circulation (C).
• Evaluate the patient for evidence of brain injury and prevent secondary
brain injury if present (D).
• Undress the patient while preventing hypothermia to fully assess (including
the back) (E).
• AND RE-EVALUATE!

14. Clinical Scenario
• Hemorrhage is the commonest cause of shock in trauma patients.
• This patient likely has class III estimated blood loss (30-40%).
• All other types of shock are secondary (neurogenic, cardiogenic,
obstructive, and septic).
• Signs that indicate shock include tachycardia and hypotension, evidence of
poor organ perfusion (e.g. to the brain - decreased mental status vs. head
injury), pallor, and thready pulse.

15. Clinical Scenario
Case progression
• Chest drain sited in L chest.
• Femur fracture reduced and immobilized; pelvic binder applied.
• 500 mL warmed crystalloid and 1 unit unmatched pRBCs given iv.
• Vital signs: HR 97; BP 110/64; RR 24; SpO2 96%.
• Patient begins to respond to verbal stimuli, opens eyes, and tries to
brush away your hands.

16. Initial Assessment
Self-assessment questions (suggested responses on next
slide):
What additional adjuncts and treatments would you order at this time?
When should a transfer occur and what tests are necessary before transferring
a patient?

17. Initial Assessment
• Additional adjuncts should include chest x-ray, pelvic x-ray, and FAST.
• Insert a gastric tube and a urinary catheter, assuming there is no evidence
of blood at the urethral meatus or perineal bruising.
• If your facility has the capabilities to definitively treat this patient, x-ray of left
femur as well as full trauma CT scan of head, C-spine, chest, abdomen and
pelvis could be performed.
• If transfer needed do not delay for additional investigations.

18. Initial Assessment
• Transfer should occur as soon as possible after you determine that the
patient’s needs exceed the capabilities of your facility.
• Transfer must not be before the patient has been resuscitated and stabilized
to the best of your available capabilities.
• Only perform tests that directly affect your care of the patient (e.g., do not
delay transfer to perform a head CT if a neurosurgeon is not available).
• See Transfer Module for more information.

19. Clinical Scenario
Case progression
• Patient’s conscious level decreases.
• Patient opens his eyes to pressure and withdraws.
• Vital signs: HR 100; BP 100/60; RR 20.
• Good breath sounds bilaterally.

20. Clinical Scenario
Case progression:
Re-evaluation reveals:
• Pupils: LEFT 5 mm, minimally reactive; RIGHT 6 mm, reactive.
• Laceration and soft tissue injury L temporal-frontal region; no active
bleeding.
• Bruising L anterior chest.
• Abdomen soft, non-distended.

21. Clinical Scenario
Self-assessment questions (suggested responses on next
slide):
What do you think has happened to the patient?
What should be done?

22. Clinical Scenario
• The patient has developed an
intracranial bleed.
• If your hospital does not have
neurosurgical capability the patient must be transferred to one that
does AFTER all primary survey problems have been addressed and the
patient is stabilized.
• This patient will need intubation prior to transfer.

23. Clinical Scenario
Case progression
The patient is transferred to a trauma center via air, and goes to surgery for
evacuation of an intracranial hematoma.

24. Initial Assessment
You have learned:
• The initial management of the injured patient requires:
• Coordination with prehospital providers
• Preparation for receiving the patient
• Anticipation of injuries based on the mechanism of injury
• The evaluation of all trauma patients follows a precise algorithm.
• Patients who exceed the capability of the institution should be identified
rapidly and process for transfer begun.
• Evaluate the patient according to priority using the ABCDEs.