PPT Advance Trauma Life Support edisi 10

Course Overview
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Welcome and Introductions
• Course Director
• Faculty
• Course Coordinator

Course Overview
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Welcome and Introductions
We would like you to introduce yourselves now:
Who are you?
What is your professional background?
What is your experience with trauma?
What do you hope to gain from this course?

Course Overview
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Safe Learning Environment
• Interactive, unfolding case discussions, stimulus questions
• Participation required
• Respect for each other
• Try answering the questions – it’s ok if you get it wrong

Course Overview
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M
43 year old male, driver MVC,
involved in head on collision
with truck
I
Right sided bruising and
abrasions on Chest, deformed
right leg,
S
Non responsive, RR 30, HR 130,
BP 80/60
T
On spine board with C spine
collar
Discussion Question:
What are your concerns with this
patient?

Course Overview
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The ATLS course provides one
acceptable method for the safe,
immediate management of
trauma patients.

Course Overview
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Program Goals
ATLS course provides participants with a safe and reliable method to:
1. Assess a patient’s condition rapidly and accurately.
2. Resuscitate and stabilize patients according to priority.
3. Determine whether a patient’s needs exceed a facility’s resources and/or provider’s
capabilities.
4. Arrange transfer when indicated
A
?⃝
→ Oxygenation flow to cells
⑦ →
eoagulophaty

Course Overview
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Course Objectives
Upon completion of the ATLS student course, you will be able to:
1. Demonstrate the concepts and principles of the primary and secondary
patient assessments.
2. Establish management priorities in the initial management of a trauma
patient.
3. Initiate the primary and secondary management of a simulated trauma
patient in a timely manner.
4. In a given trauma simulation, demonstrate the skills that are often required
in the initial assessment and treatment of patients with multiple injuries.
Airway → 5 ppnypbab → baca
buta
TABCDE

Course Overview
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The Need
• 5.8 million people die every year
from unintentional injury and
violence -- more than nine people
every minute.
• Injury accounts for 18% of the
world’s burden of disease.
• Motor vehicle crashes alone cause
more than 1 million deaths annually
and 20 to 50 million significant
injuries.
Self-inflicted
violence
16%
Interpersonal
violence
10%
Other
17%
Road traffic
injuries
25%
Fires 5%
Poisoning 6%
Falls 6%
War
6%
Drowning
9%

Course Overview
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ATLS provides a
common language

Course Overview
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The Beginning

Course Overview
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“When I can provide better
care in the field with
limited resources than what
my children and I received
at the primary care facility,
there is something wrong
with the system, and the
system has to be changed.”
James Styner, MD, FACS
1977

Course Overview
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Trimodal to Bimodal Distribution
L % Jam → 5 days
death
1 JM → besok
71 Jan → hari in

Course Overview
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ATLS Concept
• Follow ABCDE approach to evaluation and treatment.
• Treat the greatest threat to life first.
• Recognize the definitive diagnosis is not immediately important.
• Understand that time is of the essence.
• Do no further harm.
✗
ray thorax e
pelvis

Course Overview
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ATLS Concept
Airway with restriction of cervical spine motion
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neurological status
Exposure / Environmental control
Bleeding
4) I II IT IV
≤750 ≤ 1500 ≤2000712000

Course Overview
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Initial Assessment and Management

Course Overview
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ATLS Educational Format
• Introductory lecture
• Interactive group discussions
• Interactive skill sessions
• Simulated patient scenarios
• Written examinations
• mATLS online learning modules
• MyATLS mobile app

Course Overview
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International ATLS Program
• 83 countries
• 3,380 courses
• 68,000 students
• MyATLS mobile app 181 countries,
216,000 downloads

Course Overview
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Impact of ATLS Program
• Documented improvement in the care of injured patients after
implementation of program
• Organized trauma care resulting in reduced injury mortality
• Retention of organizational and procedural skills

Course Overview
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Any Questions?
ABC → fangs, wana
Jaknnya Coagulopathy
→ ttoas of
AS/dos's
Death hepotrensi
↳ Korans Imprint → 6 man't
↓ Man blasts
Kamata Kling

Course Overview
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Summary
• ABCDE approach to trauma care
• Do no further harm
• Treat the greatest threat to life first
• One safe way
• A common language

Course Overview
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Video 1

Course Overview
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1 Initial Assessment and Management
The primary survey (ABCD) is the cornerstone of the initial
assessment of the trauma patient. Repeat the primary survey
frequently to identify any deterioration in the patient’s
status that indicates the need for additional intervention.

Course Overview
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Objectives
By the end of this interactive discussion, you will be able to:
1. Explain the importance of preparation prior to trauma patient arrival.
2. Evaluate the mechanism of injury to determine the patient’s potential
injuries.
3. Identify the correct sequence of priorities for the assessment of a multiply
injured patient.
4. Apply the principles of the primary and secondary surveys to the assessment
of a multiply injured patient.
5. Discuss the importance of reevaluating a patient who is not responding
appropriately to initial resuscitation and management.
6. Recognize patients who require transfer to another facility for definitive
management.

Course Overview
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1
Case Scenario
18-year-old male , unrestrained
driver in MVC vs. tree
None reported
Vitals not reported
Prolonged extrication; transported
to ED by ambulance; O2 by mask;
fluids via single IV; spinal motion
restricted on long spine board
M
I
S
T

Course Overview
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1
Discussion Questions:
1. How would you prepare for the arrival
of this patient?
2. What other information would be
helpful to know in order to prepare?
3. From the history, what are the
potential injuries this patient may have
suffered?
Case Details
M
18-year-old male ,
unrestrained driver in MVC
vs. tree
None reported
Vitals not reported
Prolonged extrication;
transported to ED by
ambulance; O2 by mask;
fluids via single IV; spinal
motion restricted on long
spine board
I
S
T

Course Overview
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1
Case Scenario Progression
• EMS report: patient is
lethargic, mumbling
unintelligibly
• Patient has facial injuries
• Vital signs: HR 120; BP 90/40;
RR 24, O2 sat 89%, temp 36°C

Course Overview
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1
1. Based on this information, what
interventions can be done in the
prehospital setting?
2. Which patients should be immediately
transported to the trauma center
based on their field presentation?
Case Details
• EMS report: patient
is lethargic,
mumbling
unintelligibly
• Patient has facial
injuries
• Vital signs: HR 120;
BP 90/40; RR 24, O2
sat 89%, temp 36°C

Course Overview
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1
• Patient arrives at hospital
• Vital signs: HR 120; BP 90/palp;
RR 20; O2 sat 82%, temp 35.5°C.

Course Overview
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1
1. What are your clinical concerns?
2. What are your management priorities?
Case Details
• Patient arrives at
hospital
• Vital signs: HR 120;
BP 90/palp; RR 20;
O2 sat 82%, temp
35.5°C.

Course Overview
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1
Primary survey reveals:
A: Obvious facial trauma and mumbling incoherently.
B: Decreased breath sounds, L chest; no visible neck veins
C: Minimal bleeding; open L femur fracture; L chest bruising;
possible pelvic fracture
D: Localizes to pain with upper extremities; moans to painful
stimuli; does not open eyes
tmpt mpnanpurg - thorax
¢ Caution abdomm
_
retroperitoneal
darah
(Prius
hulas Panjang

Course Overview
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Case Details
A: Obvious facial trauma and
mumbling incoherently.
B: Decreased breath sounds, L
chest; no visible neck veins
C: Minimal bleeding; open L
femur fracture; L chest
bruising; possible pelvic
fracture
D: Localizes to pain with upper
extremities; moans to
painful stimuli; does not
open eyes
1. What are your clinical concerns?
2. What are your management priorities?
-

Course Overview
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1
• Patient intubated
• Femur fracture reduced and immobilized; pelvic stabilizing
device applied
• 500 mL warmed crystalloid and 1 unit unmatched pRBCs IV
• Vital signs: HR 97; BP 110/64; RR 24; O2 sat 96%
• Patient begins to respond to verbal stimuli, opens eyes, and tries
to brush away your hands
ppnunsong yg primary dow - chest ✗
ray
( ppluic ✗-
ray

Course Overview
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1
1. What additional adjuncts and
treatments would you order at this
time?
2. When should the transfer occur and
what tests are necessary before
transferring the patient?
Case Details
• Femur fracture reduced and
immobilized; pelvic stabilizing
device applied
• 500 mL warmed crystalloid
and 1 unit unmatched pRBCs
IV
RR 24; O2 sat 96%
• Patient begins to respond to
verbal stimuli, opens eyes,
and tries to brush away your
hands

Course Overview
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1
• Patient’s LOC decreases
• Patient opens his eyes to
pressure and moves away from
stimulus (normal flexion)
RR 20
• Good breath sounds bilaterally

Course Overview
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Secondary survey:
• Pupils: 5 mm, minimally reactive, L; 6
mm, reactive, R
• Laceration and soft tissue injury, L
temporal-frontal region; no active
bleeding
• L hemotympanum
• Large ecchymosis, L anterior chest
• Abdomen soft, nondistended
f-
Syarat →
☒ stabil → ABC stab
-
→ fast⊕
pprw

Course Overview
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1
What is your first step when a patient’s condition changes?
↳ Reevaluation

Course Overview
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1
When does the secondary survey occur, and how is it conducted?

Course Overview
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1
• No neurosurgery on site
• Decision: transfer patient to
another facility for definitive care
• Contact the family to give update
and obtain consent for transfer

Course Overview
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1
1. The family insists on obtaining a CT of
the head, even though this will
significantly delay transport (the team
is ready). Do you agree and why?
2. What information should you provide
to the receiving facility?
Case Details
• Femur fracture reduced
and immobilized; pelvic
stabilizing device applied
• 500 mL warmed crystalloid
and 1 unit unmatched
pRBCs IV
• Vital signs: HR 97; BP
110/64; RR 24; O2 sat 96%
• Patient begins to respond
to verbal stimuli, opens
eyes, and tries to brush
away your hands
fdrnhtas → Mist -
Mtkhonism
spring
treatment →tovaoasl tvrdakcn

Course Overview
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1
Case Scenario Conclusion
The patient is transferred to a
trauma center via air, and goes to
surgery for evacuation of an
intracranial hematoma.

Course Overview
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1
Any Questions?

Course Overview
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1
Review Objectives
1. Explain the importance of preparation prior to trauma patient arrival.
2. Evaluate the mechanism of injury to determine the patient’s potential
injuries.
3. Identify the correct sequence of priorities for the assessment of a multiply
injured patient.
4. Apply the principles of the primary and secondary surveys to the assessment
of a multiply injured patient.
5. Discuss the importance of reevaluating a patient who is not responding
appropriately to initial resuscitation and management.
6. Recognize patients who require transfer to another facility for definitive
management.

Course Overview
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Key Learning Points
1. 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
2. The evaluation of all trauma patients follows a precise algorithm.
3. Patients who exceed the capability of the institution should be
identified rapidly and process for transfer begun.
4. Evaluate the patient according to priority using the ABCDEs.

Course Overview
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Video 2

Course Overview
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Video 3

2 Airway and Ventilatory Management
The earliest priorities in managing the injured patient are to
ensure an intact airway and recognize a compromised airway.
pg
[
Korma
balk
→ obspruasi
]
Rppvaluasi
↓
[ Suara Sevak
{⊕¥%Éah momaxai dat bantu nafas protrusion
"
"'
Sam poi
to -both
④ ada Cpdera

Objectives
1. Identify different clinical situations in which airway compromise is likely to occur.
2. Recognize the signs and symptoms of acute airway compromise in a trauma case
scenario.
3. Determine factors that may lead to a difficult airway.
4. Apply the ATLS airway algorithm to a case scenario involving a patient with a difficult
airway.
5. Define the term definitive airway.
→ tubp dalam trachea dgn baton
dlkoimbongkan

Case Scenario
43-year-old obese- restrained driver lost
control of his small vehicle while traveling at
a high speed on an icy road; crashed driver’s
side into a large tree.
None reported
Patient combative during extrication
Spinal motion restricted on long spine
board; C collar; bag-mask ventilation
M
I
S
T

1. What aspects of the reported mechanism
of injury present a risk of airway
compromise?
2. Which clinical findings suggest(s) potential
airway compromise?
Case Details
M
43-year-old obese- restrained
driver lost control of his small
vehicle while traveling at high
speed on an icy road;
crashed driver’s side into a
large tree.
None reported
Patient combative during
extrication
Spinal motion restricted on
long spine board; C collar;
bag- mask ventilation
I
S
T
Multitrauma → maxi/ofaaal ,
caracal trauma ,
alcohol
combative Cmplawon )

3. How do you know if the patient’s airway is
patent?
4. What are some patient factors that may
contribute to a difficult airway in this
patient?
Case Details
M
large tree.
None reported
extrication
Spinal motion restrictedon
I
S
T
Komunikass dgn balk → ✗ blsa → 19 mungklna airway④
Stahl
Obpshtas & trauma

5. Are there additional factors that may be
present in other trauma patients?
6. How might we predict a difficult airway?
Case Details
M
large tree.
None reported
extrication
Spinal motion restricted on
I
S
T
Extreme agp ,
☆ Pdcatric i
Brosnanf
↳mon
~

On arrival:
• Patient lethargic
• Asymmetric chest expansion
• Shallow breathing, O2 sat 82%
• Significant facial injuries, L chest bruising
You are attempting to assist his ventilation with bag-mask ventilation.

1. What are the symptoms of inadequate
ventilation?
2. What are the signs of inadequate
ventilation?
3. What are your next steps in
management?
4. What equipment is required?
• Patient lethargic
• Asymmetric chest expansion
• Shallow breathing, O2 sat 82%
• Significant facial injuries, L chest
bruising
• You are attempting to assist his
ventilation with bag-mask
ventilation.
Case Details
bpbaslcan salon natas → A da -
haha →
mug,
f

• Patient now unconscious
• Vital signs: systolic BP 100; HR 120
• Upper airway suctioned, some bloody sputum cleared
• Teeth and facial bones intact
• Oral airway inserted and bag-mask ventilation continued with 100%
oxygen. O2 sat improves to 93%
• You decide to intubate the patient

1. What constitutes a definitive airway?
2. How do you prepare for this
intubation?
3. What adjuncts might be used during
intubation?
Case Details
• Patient now unconscious
• Vital signs: systolic BP 100; HR 120
• Upper airway suctioned, some bloody
sputum cleared
• Teeth and facial bones intact
• Oral airway inserted and bag-mask
ventilation continued with 100%
oxygen. O2 sat improves to 93%
• You decide to intubate the patient

• You have difficulty intubating the patient.
• LMA is inserted, but it is difficult to get an adequate seal.
• An attempt with a gum elastic bougie is successful.
• The patient oxygenation improves.

1. When is a surgical airway indicated? Should
one have been performed now
2. Is there anything that may have been
considered for intubation prior to the
patient’s decompensation?
Case Details
• You have difficulty intubating
the patient.
• LMA is inserted, but it is
difficult to get an adequate
seal.
• Successful drug-assisted
intubation performed using a
gum elastic bougie.
• The patient oxygenation
improves.
extreme trauma meal Cofaacal

• Following successful drug-assisted intubation:
• Vital signs a few minutes following intubation: HR 130; BP 90/30; O2
sat 70%.
• Breath sounds are diminished on the L side.
- Evalbass Ett → false
-
trauma - homothorax
l
pneumothorax

1. What are the possible causes of this
patient’s deterioration?
2. How can you diagnose and treat these
possible causes?
Case Details
• Successful drug-assisted
intubation performed
• Vital signs a few minutes
following intubation: HR 130;
BP 90/30; O2 sat 70%.
• Breath sounds are diminished
on the L side.
Somnath
?
M
{
look 5
Mkt hiding
Phngnmbangon dada
gurgling
Menial airway {
""m →
Suara haters abnormal
✗snoomg
stridor
HM
% hcembusan
ragas

• Right mainstem intubation is discovered and readjusted.
• Patient’s vital signs return to normal.
• Primary survey is completed.

Any Questions?

Objectives
1. Identify different clinical situations in which airway compromise is likely to occur.
2. Recognize the signs and symptoms of acute airway compromise in a trauma case
scenario.
3. Determine factors that may lead to a difficult airway.
4. Apply the ATLS airway algorithm to a case scenario involving a patient with a difficult
airway.
5. Define the term definitive airway.
Timon

Key Learning Points
1. One of earliest priorities is recognizing a compromised airway.
2. All trauma patients should receive supplemental oxygen.
3. Risk of airway compromise and difficult airway management can be
predicted.
4. Alterations in mental status (agitation, combativeness, confusion, or
obtundation) may indicate the need for airway management.
5. A definitive airway (cuffed tube in trachea below vocal cords) should be
obtained in cases of airway compromise.

Skill Station :
Basic and Advanced Airway Management

Nasopharyngeal Airway
Airway Video 1

Oropharyngeal Airway
Airway Video 2

Bag-Mask Ventilation
Airway Video 3

Laryngeal Mask Airway
Airway Video 4

Oral Endotracheal Intubation
Airway Video 5

Gum Elastic Bougie
Airway Video 6

Needle Cricothyrotomy
Airway Video 7

Surgical Cricothyrotomy
Airway Video 8

Infant Endotracheal Intubation
Airway Video 9

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Shock
3
The first step in the initial management of shock is to recognize its presence.
The diagnosis of shock is based on clinical recognition of the presence of
inadequate tissue perfusion and oxygenation.

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Shock
3
Objectives
1. Apply the ATLS principles to the management of a trauma patient with shock.
2. Recognize the signs and symptoms of shock.
3. Evaluate a patient case scenario to determine the possible causes of shock.
4. Discuss the changes that may be seen on initial investigations of a patient with shock.
5. Evaluate the efficacy of initial fluid management of a patient in shock.
6. Discuss the impact of special patient factors on the management of shock.

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Shock
3
Case Scenario
80-year-old male, unrestrained
passenger in a low-speed MVC
None reported
Patient confused
Brought to ED by paramedics
M
I
S
T

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Shock
3
1. What are the possible reasons for the
patient’s confusion?
2. What additional scene information would
be helpful to obtain from the prehospital
providers that could help you differentiate
the causes of his confusion?
Case Details
M
80-year-old male,
unrestrained
passenger in a low-
speed MVC
None reported
Patient confused
Brought to ED by
paramedics
I
S
T

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Shock
3
• Vital signs: BP 100/70; HR 100; RR 20
• Patient on a stretcher, receiving IV fluids

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Shock
3
1. Based on the information given, is this
patient in shock? What additional
information is needed to help
determine this?
2. What vital signs and laboratory studies
support the diagnosis of shock?
3. Can a single vital sign or laboratory
result diagnose shock?
• Vital signs: BP 100/70;
HR 100; RR 20
• Patient on a stretcher,
receiving IV fluids
Case Details

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Shock
3
4. What is the most common
cause of shock in a trauma
patient?
5. What types of soft tissue or
bony injuries might result in
shock?
• Vital signs: BP 100/70;
HR 100; RR 20
• Patient on a stretcher,
receiving IV fluids
Case Details

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Shock
3
• Two large-bore IVs placed, 1 L crystalloid bolus given
• Vital signs post treatment: BP 98/77; HR 80
• The patient remains confused and unable to give his medical history

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Shock
3
1. What adjuncts should be considered to
determine the cause of shock (if not
already done)?
2. How should further resuscitation
proceed?
3. How will you continue to monitor this
patient’s ongoing response to fluid
resuscitation?
Case Details
• Two large-bore IVs placed,
1 L crystalloid bolus given
• Vital signs post treatment:
BP 98/77; HR 80
• The patient remains
confused and unable to
give his medical history

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Shock
3
• Chest x-ray shows multiple rib fractures, large R hemothorax
• The patient’s family arrives and provides history:
o coronary artery disease
o coronary artery stenting 1 year ago
o Meds: beta blocker, clopidogrel (Plavix), and aspirin

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Shock
3
1. How do the beta blockers affect this
patient’s presentation and response to
interventions?
2. What management concerns are presented
by the antiplatelet agents the patient is
taking?
3. What medical condition could further
impact the patient’s response to shock?
Case Details
• Chest x-ray shows multiple
rib fractures, large R
hemothorax
• Patient history:
o coronary artery disease
o coronary artery stenting
1 year ago
o Meds: beta blocker,
clopidogrel (Plavix), and
aspirin

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Shock
3
• Platelet transfusion initiated.
• R chest tube is placed 750 mL of blood obtained
• Subsequent chest tube output is 50 mL/2 hours

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Shock
3
Any Questions?

92 of 17
Shock
3
Review Objectives
1. Apply the ATLS principles to the management of a trauma patient with shock.
2. Recognize the signs and symptoms of a trauma patient in shock.
3. Evaluate a patient case scenario to determine the possible causes of shock.
4. Discuss the changes that may be seen on initial investigations of a patient with shock.
5. Evaluate the efficacy of initial fluid management of a patient in shock.
6. Discuss the impact of special patient factors on the management of shock.

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Shock
3
Key Learning Points
1. Hemorrhage is the most common cause of shock after injury.
2. No single laboratory test and no single vital sign on its own can diagnose shock.
3. Massive blood loss may produce only minimal acute decrease in hemoglobin or
hematocrit.
4. Major soft tissue injuries and fractures can be associated with significant hemorrhage.
5. The patient’s response to initial fluid therapy will help guide subsequent therapy.
6. A variety of special conditions may affect the patient’s response to shock and the
management of it (e.g., age, medication use).

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Shock
3
Thoracic injury is common in polytrauma patients and can be life-threatening,
especially if not promptly identified and treated during the primary survey.
4 Thoracic Trauma

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Shock
3
Objectives
1. Apply the ATLS principles to the management of a patient with thoracic trauma.
2. Recognize the important life-threatening injuries in a patient with thoracic trauma.
3. Evaluate the case scenario of a patient with thoracic trauma to identify immediate life-
threatening injuries.
4. Discuss the clinical findings and adjunctive studies that may be useful during the
secondary survey in a patient with thoracic trauma.
4 Thoracic Trauma

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Shock
3
Case Scenario
27-year-old male unrestrained driver in
high-speed, frontal-impact MVC
Airway patent, obvious respiratory
distress
BP 90/50; HR 110; RR 36; and GCS 14
None reported
M
I
S
T
4 Thoracic Trauma

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Shock
3
1. What life-threatening injuries might one
discover in the primary survey that could
account for the patient’s clinical status?
2. What are the next steps in the evaluation
and treatment of this patient?
Case Details
M
27-year-old male
unrestrained driver in
high-speed, frontal-impact
MVC
Airway patent, obvious
respiratory distress
BP 90/50; HR 110; RR 36;
and GCS 14
None reported
I
S
T
4 Thoracic Trauma

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Shock
3
1. What are the immediately life-threatening
thoracic injuries involving:
• Airway
• Breathing
• Circulation
Case Details
M
27-year-old male
unrestrained driver in
high-speed, frontal-impact
MVC
Airway patent, obvious
respiratory distress
BP 90/50; HR 110; RR 36;
and GCS 14
None reported
I
S
T
4 Thoracic Trauma

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Shock
3
On arrival to ED:
• Patient complains of profound shortness of breath, asking to sit up
• O2 sat 89%.
• Cervical collar in place
• Trachea deviated to left
• Breath sounds absent on left
• Heart sounds normal
• Left chest wall crepitus
4 Thoracic Trauma

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Shock
3
1. What is this patient’s most likely
diagnosis?
2. What is the appropriate
technique to alleviate this
patient’s condition?
• Patient complains of profound
shortness of breath, asking to sit
up
• O2 sat 89%.
• Cervical collar in place
• Trachea deviated to left
• Breath sounds absent on left
• Heart sounds normal
• Left chest wall crepitus
Case Details
4 Thoracic Trauma

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Shock
3
• Needle decompression performed, no rush of air
• Vital signs unchanged
4 Thoracic Trauma

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Shock
3
What alternative management strategy
can you use?
Case Details
• Needle decompression
performed, no rush of air
• Vital signs unchanged
4 Thoracic Trauma

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Shock
3
What are the differences in clinical
presentation between a tension
pneumothorax and an open pneumothorax?
4 Thoracic Trauma

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Shock
3
• Finger thoracostomy performed
• Vital signs: RR 28; HR 110; BP 100/60
• Thoracostomy tube placed, 600 mL dark blood drained
• Two large-bore IV lines established, isotonic fluid given
• Type and crossmatch requested
• Chest x-ray shows:
o obscured L diaphragm
o multiple L rib fractures
o wide mediastinum
o pulmonary contusion
4 Thoracic Trauma

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Shock
3
1. What are the indications for operation in
a patient with traumatic hemothorax?
2. What resuscitative measures should be
undertaken in a patient with massive
hemothorax?
4 Thoracic Trauma

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Shock
3
3. What other potential life threats
might exist in a patient with this
mechanism? For each, what would
the clinical presentation/findings
and the appropriate treatment be?
4. What test would you perform to
make the diagnosis during the
secondary survey?
• Finger thoracostomy performed
• Vital signs: RR 28; HR 110; BP 100/60
• Thoracostomy tube placed, 600 mL dark
blood drained
• Two large-bore IV lines established,
isotonic fluid given
• Type and crossmatch requested
• Chest x-ray shows:
• obscured L diaphragm
• multiple L rib fractures
• wide mediastinum
• pulmonary contusion
Case Details
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Potential Life Threat Clinical
Presentation/Findings
Treatment Pitfalls
Simple Pneumothorax +/- shortness of breath No
hypotension
Diagnosis by chest x-ray
Chest tube drainage Could become tension
pneumothorax if untreated
Hemothorax Dullness to percussion
Diagnosis by chest x-ray
Chest tube drainage Could become massive
hemothorax
Flail Chest and Pulmonary
Contusion
May see paradoxical movement
of chest wall More commonly
presents with pain and poor
respiratory excursions
Oxygen
Analgesia
Intubation if necessary
Progressive respiratory failure
Blunt Cardiac Injury ECG changes Cardiac monitoring
Therapy based on clinical
status
At risk for clinically significant
dysrhythmias
Traumatic Aortic Disruption May be asymptomatic
Multiple possible radiographic
findings
Endovascular or open surgical
repair
Blood pressure control
important prior to definitive
therapy
Traumatic Diaphragm Injury Respiratory distress
Obscured left diaphragm
border
Evidence of abdominal viscera
in chest
Operative repair Concomitant pulmonary
contusion may mask diaphragm
injury
Esophageal injury Chest pain; mediastinal air on
imaging; crepitus
delayed fever
Operative repair Delayed diagnosis
4 Thoracic Trauma

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• 250 mL of IV fluids given
• O2 sat 91% on nonrebreather mask
4 Thoracic Trauma

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Which of the following treatments is best for pulmonary
contusion/flail chest?
A. Beta blockers
B. Massive fluid resuscitation
C. Immediate nebulizer treatment
D. Supplemental oxygen, pain control, and recognition of the
potential for respiratory failure
4 Thoracic Trauma

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Your institution has the capability to care for this patient, and you order
a CT scan for further evaluation.
4 Thoracic Trauma

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Case Scenario #2
25-year-old male, high-speed MVC
Awake and responds to questions, complaining of chest pain and
shortness of breath, gurgling sounds L lung base.
BP 102/76; HR 134; O2 sat 93% on oxygen by face mask
Chest x-ray
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4 Thoracic Trauma

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1. What abnormalities do you note
on the chest film?
4 Thoracic Trauma

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2. What is the treatment for a
traumatic diaphragm injury?
3. Aside from the tracheal deviation to
the right seen on the chest film,
what other signs and x-ray findings
might one see in a patient with
traumatic aortic disruption?
Case Details
M
25-year-old male, high-speed
MVC
Awake and responds to questions,
complaining of chest pain and
shortness of breath, gurgling
sounds L lung base.
BP 102/76; HR 134; O2 sat 93% on
oxygen by face mask
Chest x-ray
I
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4 Thoracic Trauma

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CT scan shows blunt aortic injury
4 Thoracic Trauma

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1. What is the expected hemodynamic impact of
a contained aortic disruption from blunt
trauma?
2. If a patient with a known contained aortic
disruption from blunt trauma becomes
hypotensive, what should you consider?
3. What therapeutic steps should a clinician
consider when managing a traumatic aortic
disruption?
Case Details
• CT scan shows blunt aortic
injury
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• Discussion with anesthesiology re: management of the patient’s
aortic injury
• Patient undergoes repair of his diaphragmatic injury via laparotomy
• The following day, he undergoes endovascular repair of his aortic
injury
• He does well after 2 weeks in the ICU and is discharged home
4 Thoracic Trauma

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Any Questions?
4 Thoracic Trauma

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Review Objectives
1. Apply the ATLS principles to the management of a patient with thoracic trauma.
2. Recognize the important life-threatening injuries in a patient with thoracic trauma.
3. Evaluate the case scenario of a patient with thoracic trauma to identify immediate life-
threatening injuries.
4. Discuss the clinical findings and adjunctive studies that may be useful during the
secondary survey in a patient with thoracic trauma.
4 Thoracic Trauma

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Key Learning Points
1. It is important to recognize thoracic life-threatening problems in polytrauma
patients.
2. Most immediate thoracic life-threatening problems can be recognized without
special testing and may be treated with:
• airway control
• decompression and/or
• fluid resuscitation
3. Potential life-threatening problems can become immediate life-threatening
problems if untreated (e.g., a simple pneumothorax can become a tension
pneumothorax).
4 Thoracic Trauma

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Breathing Video 1 (paradoxical chest wall movement)
Respiratory Distress

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Breathing Video 2
Chest Tube

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Breathing Video 3
Respiratory Distress (Child)

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3 Chest Tube (Child)
Breathing Video 4

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3 Chest Tube (Child)
Breathing Video 5

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Breathing Video 6
Dressing on a Sucking Chest Wound

5 Abdominal and Pelvic Trauma Tenth Edition

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When uncontrolled or unrecognized, blood loss from abdominal
and pelvic injuries can result in preventable death.
5 Abdominal and Pelvic Trauma

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Objectives
1. Identify the anatomic regions of the abdomen that are critical in assessing and managing trauma
patients.
2. Discuss the risk for abdominal and pelvic injuries based on the mechanism of injury.
3. Identify patients who require surgical consultation and possible surgical and/or catheter-based
intervention.
4. Determine appropriate diagnostic procedures to ascertain if a patient has ongoing hemorrhage and/or
other injuries that can cause delayed morbidity and mortality.
5. Formulate an acute management plan for abdominal and pelvic injuries utilizing a case scenario.
6. Discuss the importance of early identification and emergent management of pelvic hemorrhage.

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Case Scenario
28-year-old male, helmeted motorcyclist,
high-speed collision, head-on into the side
of a vehicle that pulled out in front of him
Patient reports brief loss of consciousness,
complains of pain in chest, abdomen, and
pelvis
BP 100/75; HR 115; RR 20, and GCS 15
Backboard and c-collar
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1. What are your priorities for
management of this patient?
2. What is your interpretation of
the vital signs?
3. What is your initial therapy for
this patient?
Case Details
M
28-year-old male, helmeted
motorcyclist, high-speed collision,
head-on into the side of a vehicle that
pulled out in front of him
Patient reports brief loss of
consciousness, complains of pain in
chest, abdomen, and pelvis
BP 100/75; HR 115; RR 20, and GCS
15
Backboard and c-collar
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• EMS reports:
o Patient found 10 feet (3 meters) from his motorcycle
o Patient lying on R side, wearing a helmet
o Had been travelling at 45 mph (70 kph)
• Patient reports:
o Hard R sided landing, brief LOC
o No allergies, no previous medical history or current medications

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1. Based on the reported mechanism
of injury, what intra-abdominal
and/or pelvic injury is the patient
likely to have sustained?
• Patient found 10 feet (3 meters) from his
motorcycle
• Patient lying on R side, wearing a helmet
• Had been travelling at 45 mph (70 kph)
• Hard R sided landing, brief LOC
• No allergies, no previous medical history
or current medications
Case Details

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1. How would the risk of intra-
abdominal injury change if the
patient described striking the
handlebar into the epigastrium?
2. How would the risk of intra-
abdominal injury change if a
penetrating injury was observed?
• Patient found 10 feet (3 meters) from his
motorcycle
• Patient lying on R side, wearing a helmet
• Had been travelling at 45 mph (70 kph)
• Hard R sided landing, brief LOC
• No allergies, no previous medical history
or current medications
Case Details

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On examination:
• Right-sided lower chest tenderness
• Contusions, R chest, abdomen, and flank
• Tender R upper quadrant, R flank, and suprapubic region
• Pain on palpation of the anterior pelvis
• No blood at the urethral meatus
• Rectal examination is normal.
• Vital signs following 500 ml of crystalloid solution: BP 110/75; HR 100; RR 20;
GCS 15

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1. How should you assess the abdomen
and pelvis for injury and as potential
sources of bleeding?
2. Based on your knowledge of anatomy,
the mechanism of injury, and this
patient’s physical examination, what
abdominal and/or pelvic injuries are
most likely?
3. Is a FAST exam indicated at this stage?
• Tender R upper quadrant, R flank, and
suprapubic region
• Vital signs following 500 ml of crystalloid
solution: BP 110/75; HR 100; RR 20; GCS 15
Case Details

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4. If this patient were female, what other
examination would be relevant?
5. What radiological investigations would
be appropriate to arrange now?
• Tender R upper quadrant, R flank, and
suprapubic region
• Vital signs following 500 ml of crystalloid
solution: BP 110/75; HR 100; RR 20; GCS 15
Case Details

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• Your institution has full surgical and radiological capabilities
• Abdominal CT: grade III liver injury, R rib fractures, bilateral pelvic
rami fractures
• Surgical consultation obtained
• Vital signs: BP normal; HR 100
• A total of 1.0 L of crystalloid solution given

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1. Is emergent laparotomy warranted in
this patient?
2. What clinical changes in this patient
would indicate the need for operation,
other therapies, or additional
investigations regarding the abdominal
and pelvic injuries?
3. How would your management change if
the CT scan identified contrast
extravasation suggesting bleeding in the
pelvis?
• Your institution has full surgical and
radiological capabilities
• Abdominal CT: grade III liver injury,
R rib fractures, bilateral pelvic rami
fractures
• Surgical consultation obtained
• Vital signs: BP normal; HR 100
• A total of 1.0 L of crystalloid
solution given
Case Details

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• Emergent laparotomy not required; nonoperative management
undertaken
• Patient admitted to ICU for monitoring, pain control, and respiratory
care
• Hemodynamics normal over 24 hours, transferred to the ward
• Physical therapy for the pelvic fractures
• Patient discharged home on day 6

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Any Questions?

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Review Objectives
1. Identify the anatomic regions of the abdomen that are critical in assessing and managing trauma
patients.
2. Discuss the risk for abdominal and pelvic injuries based on the mechanism of injury.
3. Identify patients who require surgical consultation and possible surgical and/or catheter-based
intervention.
4. Determine appropriate diagnostic procedures to ascertain if a patient has ongoing hemorrhage and/or
other injuries that can cause delayed morbidity and mortality.
5. Formulate an acute management plan for abdominal and pelvic injuries utilizing a case scenario.
6. Discuss the importance of early identification and emergent management of pelvic hemorrhage.

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Key Learning Points
1. Mechanism of injury is critical when considering abdominal and/or pelvic injury.
2. Thorough examinations of the chest, abdomen, and pelvis (anterior, lateral, posterior,
and perineum) are required to avoid missing significant injuries.
3. Appropriate diagnostic procedures should be employed.
4. Surgical intervention is assessed via clinical findings and the patient’s response to
management.
5. Early identification and emergent management of pelvic hemorrhage can be
lifesaving.

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Circulation Video 1
Packing an Open Wound

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Circulation Video 2
Tourniquet

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Circulation Video 3
Splint Traction

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3 Splint Traction
before traction after traction

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Circulation Video 4
Intraosseous

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Circulation Video 5
Pelvic Binder

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3 Pelvic Binder
before binder after binder
Foto : pelvic diasthesis

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Circulation Video 6
Central Venous Catheter

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Circulation Video 7
FAST

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Circulation Video 9
Pericardiocentesis

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The primary goal of treatment for patients with suspected
traumatic brain injury is to prevent secondary brain injury.
6 Head Trauma

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Objectives
1. Recognize the GCS score that corresponds to a severe head injury and indicates a comatose
patient.
2. Identify the different types of intracranial bleeding seen on CT that are associated with
traumatic brain injury.
3. Discuss the role of supplemental oxygen and systolic blood pressure maintenance in limiting
secondary brain injury.
4. Describe the management of intracranial hypertension associated with the mass effect of
blood or brain swelling.
5. Discuss the indications for early, rapid transfer to a center equipped to manage a patient with
brain injury.
6 Head Trauma

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Case Scenario
23-year-old male, fell from bicycle, hitting head on curb; no helmet
10 cm laceration to the L temporal-parietal region
Initially able to say his name. HR 115; BP 100/60; O2 sat 88%; GCS 12 (E3V3M6)
Two hours after transport to local hospital, patient has sonorous respirations; HR 120;
BP 100/70; GCS 6 (E2V1M3)
IV cannulas in situ, O2 via nasal prongs, 200mLs crystalloid infused
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1. What are the initial
priorities in the
management of this
patient?
2. What are the signs that
the patient’s injury is
progressing?
Case Details
M
23-year-old male, fell from bicycle, hitting head on
curb; no helmet
10 cm laceration to the L temporal-parietal region
Initially able to say his name. HR 115; BP 100/60;
O2 sat 88%; GCS 12 (E3V3M6)
Two hours after transport to local hospital, patient
has sonorous respirations; HR 120; BP 100/70; GCS
6 (E2V1M3)
IV cannulas in situ, O2 via nasal prongs, 200mLs
crystalloid infused
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• Given 1 L normal saline
• Vital signs: HR 100; BP 100/70; O2
Sat 94%
6 Head Trauma

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1. How do you monitor this patient’s
neurological status?
2. What other injuries and physical exam
findings may suggest cranial and
intracranial injury?
• Given 1 L normal saline
• Vital signs: HR 100;BP 100/70;
O2 Sat 94%
Case Details
6 Head Trauma

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• Head, c-spine and abdominal CTs performed.
• Head CT: temporal bone fracture, epidural hematoma, 1 cm of midline shift
• C-spine normal
6 Head Trauma

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1. What types of intracranial
hemorrhage can be identified on
CT scan?
6 Head Trauma

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2. What CT scan findings are indicative
of severe head injury that may require
intervention?
• Head, c-spine and abdominal
CTs performed.
• Head CT: temporal bone
fracture, epidural hematoma,
1 cm of midline shift
• C-spine normal
Case Details
6 Head Trauma

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• Thoracoabdominal CT scan normal
• Initial management includes:
o elevating the head of bed
o sedation with short-acting medications
o frequent neurological examinations
6 Head Trauma

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1. What are the initial management
options for this patient with
severe brain injury and how do
these differ from mild and
moderate brain injury?
2. What are the indications for
transferring a patient with a head
injury to a center with a higher
level of care?
• Thoracoabdominal CT scan normal
• Initial management includes:
• elevating the head of bed
• sedation with short-acting
medications
• frequent neurological
examinations
Case Details
6 Head Trauma

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• Neuro exam shows progression to extensor
posturing.
• Repeat CT scan shows new subdural hematoma
with associated mass effect and midline shift.
• Herniation appears imminent without treatment.
• Patient requires a higher level of care and rapid
transfer to neurosurgeon.
6 Head Trauma

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What are the initial treatment
options that may protect the
brain from ongoing swelling?
• Neuro exam shows progression to
extensor posturing.
• Repeat CT scan shows new subdural
hematoma with associated mass effect
and midline shift.
• Herniation appears imminent without
treatment.
• Patient requires a higher level of care
and rapid transfer to neurosurgeon.
Case Details
6 Head Trauma

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• Neurosurgeon recommends 0.5 g/kg mannitol and adjusting PaCO2 to 30
to 35 mm Hg.
• Patient is immediately transported for emergency craniotomy.
• Patient underwent successful evacuation of his intracranial hematoma.
• He was discharged to a rehabilitation center for ongoing therapy.
6 Head Trauma

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Any Questions?
6 Head Trauma

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Review Objectives
1. Recognize the GCS score that corresponds to a severe head injury and indicates a comatose
patient.
2. Identify the different types of intracranial bleeding seen on CT that are associated with
traumatic brain injury.
3. Discuss the role of supplemental oxygen and systolic blood pressure maintenance in limiting
secondary brain injury.
4. Describe the management of intracranial hypertension associated with the mass effect of
blood or brain swelling.
5. Discuss the indications for early, rapid transfer to a center equipped to manage a patient with
brain injury.
6 Head Trauma

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Key Learning Points
• GCS score is an objective, reproducible measurement of brain injury severity.
• GCS of 8 or less is considered severe and indicative of a comatose patient.
• Consider a CT scan of the head for any trauma patient with suspected traumatic brain
injury.
• Initial management of intracranial hypertension includes:
• elevation of the head of bed
• sedation
• selective administration of mannitol and hypertonic saline
6 Head Trauma

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Key Learning Points
• Minimize secondary brain injury by:
• adequate oxygenation (supplemental oxygen)
• ensuring brain perfusion: SBP > 100 mm Hg (age 50-69) or > 110 mm Hg (15 – 49 and
older than 70)
• If no neurosurgical capability, consider early, rapid transfer
6 Head Trauma

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Because spine injury can occur with both blunt and penetrating
trauma, and with or without neurological deficits, it must be
considered in all patients with multiple injuries. These patients require
restriction of spinal motion to protect the spine from further damage
until spine injury has been ruled out.
7 Spine and Spinal Cord Trauma

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Objectives
1. Apply the ABC principles of ATLS when assessing a patient for spine injury.
2. Identify a common mechanism and type of spinal injury.
3. Describe the typical signs and symptoms of a patient with a spinal cord injury.
4. Describe the technique and importance of documentation of a potential spinal injury.
5. Describe the appropriate initial treatment of patients with spinal injuries.
6. Determine the appropriate disposition of patients with spine trauma.

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Case Scenario
28-year-old male fell 5 meters (16 feet)
from scaffolding, wearing hard hat;
bystander reports patient landed head-first,
with neck hyperextended
None reported
Skin warm; breathing shallow; not moving
arms or legs; Vital signs: BP 80/62; HR 58;
RR 28; GCS 15
None Reported
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1. What injuries has the patient
likely sustained?
2. What other mechanisms of
injury are associated with spinal
cord trauma?
3. What types of shock are
potentially present in this
patient?
Case Details
M
bystander reports patient landed head-
first, with neck hyperextended
None reported
Skin warm; breathing shallow; not
moving arms or legs; Vital signs:
BP 80/62; HR 58; RR 28; GCS 15
None Reported
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4. How should you initially manage
this patient?
5. What would you do if the
patient was not breathing?
Case Details
M
None reported
BP 80/62; HR 58; RR 28; GCS 15
None Reported
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6. Which signs and symptoms are
concerning for a spinal injury in
this patient?
7. What other signs and symptoms
not previously mentioned may
be associated with the presence
of a spinal cord injury?
Case Details
M
None reported
BP 80/62; HR 58; RR 28; GCS 15
None Reported
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Peripheral neurologic exam:
• Patient unable to move or feel legs
• Patient can move fingers and wrists bilaterally
• Weak L triceps extension
• Patient unable to move R elbow
• Patient able to feel fingers and thumbs bilaterally
• Patient unable to feel inner arms above the elbows

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1. At what level is the suspected spinal
lesion?
2. What resources are available to assist
with determining the level of spinal
injury?
3. Why is the exam different between
the right and left upper extremities?
• Patient unable to move or feel legs
• Patient can move fingers and
wrists bilaterally
• Weak L triceps extension
• Patient unable to move R elbow
• Patient able to feel fingers and
thumbs bilaterally
• Patient unable to feel inner arms
above the elbows
Case Details

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4. What are important aspects of
documenting the neurologic
examination?
5. Why is it important to accurately and
thoroughly document the neurologic
examination findings?

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• Patient is spinal motion restricted
• 1 L of crystalloid fluid is given
• Vital signs: BP 100/64; HR 62; RR 28; GCS 15

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1. What imaging would you request for
this patient?
2. What tools are available to assist with
decisions regarding spine imaging?
• Patient is spinal motion
restricted
• 1 L of crystalloid fluid is given
• Vital signs: BP 100/64; HR 62;
RR 28; GCS 15
Case Details

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• Negative chest x-ray, pelvic x-ray, and FAST exam
• CT scan unavailable.
• Lateral c-spine x-ray: C6 fracture with anterior displacement.
• Patient placed in c-collar with mobility restrictions
• Vital signs: BP 80/62; HR 58; RR 28; GCS 15

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How do you manage the patient’s
ABCs at this point?
• Negative chest x-ray, pelvic x-ray,
and FAST exam
• CT scan unavailable.
• Lateral c-spine x-ray: C6 fracture
with anterior displacement.
• Patient placed in c-collar with
mobility restrictions
• Vital signs: BP 80/62; HR 58; RR
28; GCS 15
Case Details

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• Following additional 1 L of IV crystalloid, BP remains 80/50, HR 45
• RR increased to 30
• Patient complains of shortness of breath
• ABGs: PCO2 50 mm Hg

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1. What interventions are indicated
at this facility?
2. Does this patient require transfer?
What is the rationale for this
decision?
• Following additional 1 L of
IV crystalloid, BP remains
80/50, HR 45
• RR increased to 30
• Patient complains of
shortness of breath
• ABGs: PCO2 50 mm Hg
Case Details

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• Systolic BP improves to 110/65 with vasopressor support
• O2 sat 98% on 30% oxygen
• Repeat FAST negative
• Transferred to definitive care, where C6 and T6 fractures identified
• Admitted to ICU
• Surgery for C6 fracture, nonoperative management of T6 fracture
• Transferred to a spinal cord rehabilitation center

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Any Questions?

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3
Review Objectives
1. Apply the ABC principles of ATLS when assessing a patient for spine injury.
2. Identify a common mechanism and type of spinal injury.
3. Describe the typical signs and symptoms of a patient with a spinal cord injury.
4. Describe the technique and importance of documentation of a potential spinal injury.
5. Describe the appropriate initial treatment of patients with spinal injuries.
6. Determine the appropriate disposition of patients with spine trauma.

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Key Learning Points
1. Attend to the life-threatening injuries identified in the primary survey while minimizing
movement of the spine.
2. Assume possible spinal injury until clinical and/or radiographic evaluation can be completed
(decision tools such as Canadian C-Spine Rules or NEXUS may be used).
3. Be as specific and accurate as possible when describing and documenting the level of neurologic
injury (ASIA tool is extremely useful).
4. High spinal cord injuries may be associated with respiratory failure and/or neurogenic shock,
which must be addressed prior to transfer.
5. Consider obtaining early consultation with a spine surgeon when a spinal injury is suspected
and/or detected.

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Case Scenario #1
A 65-year-old male is transported to the emergency department by EMS after a motor
vehicle collision while driving home at 50 km/hr (30 mph) from a tavern. He is currently
being treated for a recent deep vein thrombosis.
He has a left scalp contusion. He has a strong odor of alcohol on his breath. He is thought
to have suffered a concussion and to have alcohol intoxication.
His airway is clear, he is breathing spontaneously without difficulty, and he has no
hemodynamic abnormalities. His eyes are open. He appears confused and pushes away the
examiner’s hands when assessed for response to fingertip pressure.
He has a cervical collar in place, and motion is restricted on a long spine board.
M
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GCS ?

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Case Scenario #1
A 65-year-old male is transported to the emergency department by EMS after a motor
vehicle collision while driving home at 50 km/hr (30 mph) from a tavern. He is currently
being treated for a recent deep vein thrombosis.
He has a left scalp contusion. He has a strong odor of alcohol on his breath. He is thought
to have suffered a concussion and to have alcohol intoxication.
His airway is clear, he is breathing spontaneously without difficulty, and he has no
hemodynamic abnormalities. His eyes are open. He appears confused and pushes away the
examiner’s hands when assessed for response to fingertip pressure.
He has a cervical collar in place, and motion is restricted on a long spine board.
M
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GCS ?
E : 4
V : 4 (?)
M : 4
GCS 12 (?)

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Case Scenario #3
A 75-year-old male is brought to a rural emergency department by his family after a
ground-level fall after slipping on a water puddle.
According to his family, he had an approximate 30-second loss of consciousness. The
patient does not remember the injury event and only complains of a headache. His past
medical history is only significant for hypertension. Other than a small left frontoparietal
soft tissue contusion, there are no other gross injuries.
His vital signs are: BP 140/85, HR 70, and RR 16. Other than a small left frontoparietal soft
tissue contusion, there are no other gross injuries. He is awake, opens his eyes
spontaneously, follows commands, communicates appropriately, and does not have any
focal neurological deficits.
Triage personnel put patient in cervical collar.
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GCS ?

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Case Scenario #3
A 75-year-old male is brought to a rural emergency department by his family after a
ground-level fall after slipping on a water puddle.
According to his family, he had an approximate 30-second loss of consciousness. The
patient does not remember the injury event and only complains of a headache. His past
medical history is only significant for hypertension. Other than a small left frontoparietal
soft tissue contusion, there are no other gross injuries.
His vital signs are: BP 140/85, HR 70, and RR 16. Other than a small left frontoparietal soft
tissue contusion, there are no other gross injuries. He is awake, opens his eyes
spontaneously, follows commands, communicates appropriately, and does not have any
focal neurological deficits.
Triage personnel put patient in cervical collar.
I
S
T
GCS ?
E : 4
V : 5
M : 6
GCS 15
M

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Disability Video 1
Helmet Removal

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Disability Video 2
Logrolling Technique

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CT of head : epidural hematoma
Epidural Hematoma

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CT of head : subdural hematoma
Subdural Hematoma

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CT of head : subarachnoid hemorrhage and hemorrhage on the left frontoparietal area
Subarachnoid Hemorrhage

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CT of head : intracerebral hematoma
Intracerebral Hematoma

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Injuries to the musculoskeletal system are common in trauma patients.
The delayed recognition and treatment of these injuries can result in
life-threatening hemorrhage or limb loss.
8 Musculoskeletal Trauma

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Objectives
1. Explain the significance of musculoskeletal injuries in patients with multiple injuries.
2. Outline the priorities of the primary survey, resuscitation and secondary survey of
patients with extremity injuries.
3. Identify the adjuncts needed in the immediate treatment of life-threatening extremity
hemorrhage.
4. Explain the principles of the initial management of limb-threatening musculoskeletal
injuries.

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Case Scenario
38-year-old female (102 kg), restrained driver,
high-speed, head-on collision with large truck
Prolonged extrication, marked deformity R
thigh, open fracture R lower leg.
Awake and alert, in severe pain; Vital
signs: HR 120; BP 90/50; RR 22; GCS 15
Two large-bore IVs in upper extremities,
resuscitation with isotonic fluids
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• Airway and breathing are OK
• Lower limb actively bleeding,
dressing applied
• Vital signs after fluids: HR 130;
BP 80/40; RR 24; GCS 14
• Chest x-ray, pelvic x-ray, and FAST
exam negative

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1. What are the priorities for this
patient during the primary
survey and resuscitation?
2. How will you assess the injured
extremities at this point?
Case Details
• Lower limb bleeding, dressing
applied
BP 80/40; RR 24; GCS 14
• Chest x-ray, pelvic x-ray, and
FAST exam negative

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3. How much blood loss would you
expect from this patient’s
extremity injuries, and what is
the best way to control it?
4. How should femur and tibial
shaft fractures be stabilized?
Case Details
• Lower limb bleeding, dressing
applied
BP 80/40; RR 24; GCS 14
• Chest x-ray, pelvic x-ray, and
FAST exam negative

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• Right dorsalis pedis and posterior tibial pulses absent
• Pulses remain absent after splinting.
• Blood soaking through dressings, R lower leg
• Dressing taken down, pulsatile bleeding noted
• Direct pressure applied to wound, followed by gauze packing
• Dressing quickly becomes saturated with blood again

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What is the next step in the
management of this patient’s
uncontrolled extremity
hemorrhage?
Case Details
• Right dorsalis pedis and posterior tibial
pulses absent
• Pulses remain absent after splinting.
• Blood soaking through dressings, R lower
leg
• Dressing taken down, pulsatile bleeding
noted
• Direct pressure applied to wound,
followed by gauze packing
• Dressing quickly becomes saturated with
blood again

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• Tourniquet applied and time of placement documented
• Bleeding controlled
• Distal pulses not palpable

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How would you manage the patient now?
• Tourniquet applied and
time of placement
documented
• Bleeding controlled
• Distal pulses not
palpable
Case Details

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• Patient’s hemodynamics improve with IV fluids
• Secondary survey begins
• Awaiting transfer due to no surgical capabilities at this facility

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1. How would you identify any limb-
threatening injuries or other
extremity injuries during the
secondary survey?
2. What x-rays should be ordered for this
patient prior to transfer?
• Patient’s hemodynamics
improve
• Secondary survey begins
• Awaiting transfer due to
no surgical capabilities at
this facility
Case Details

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• X-rays of the patient’s extremities are obtained.
• Radiographs do not cause a delay in transfer.

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• Vital signs: HR 105; BP 110/70; RR 24; GCS 15.
• Bleeding is controlled with tourniquet.
• Urgent transfer already initiated.
• No known drug allergies.

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1. What else should be done prior
to transfer
2. What antibiotics would you give
and at what dose?
3. How can you decrease the
patient’s discomfort and pain?
Case Details
• Vital signs: HR 105; BP 110/70; RR
24; GCS 15.
• Bleeding is controlled with
tourniquet.
• Your facility does not have the
resources to manage the patient’s
injuries, so urgent transfer
initiated.

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• The patient is transferred to the nearest trauma center, where a trauma
surgeon and an orthopedic surgeon are available to take the patient to
the operating room immediately
• Vital signs: HR 105; BP 110/70; RR 24; GCS 15
• Bleeding is controlled with tourniquet
• Patient received antibiotics prior to transfer

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1. What measures need to be
taken at the receiving hospital?
2. How can you make an early
diagnosis of compartment
syndrome?
3. What is the treatment for
compartment syndrome?
Case Details
• Patient is transferred to the nearest
trauma center, where a trauma surgeon
and an orthopedic surgeon are available
to take the patient to the operating room
immediately.
• Vital signs: HR 105; BP 110/70; RR 24;
GCS 15.
• Bleeding is controlled with tourniquet.
• Patient received antibiotics prior to
transfer.

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Patient taken to the operating room for urgent evaluation of
vascular injury, wound washout and external fixation of fracture.

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Any Questions?

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Review Objectives
1. Explain the significance of musculoskeletal injuries in patients with multiple injuries.
2. Outline the priorities of the primary survey and resuscitation of patients with
extremity injuries.
3. Identify the adjuncts needed in the immediate treatment of life-threatening extremity
hemorrhage.
4. Describe key elements of the secondary survey of patients with musculoskeletal
trauma.
5. Explain the principles of the initial management of limb-threatening musculoskeletal
injuries.

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Key Learning Points
• Hemorrhage from long bone fractures can be significant
• Early splinting helps to control blood loss, reduce pain, and prevent further
neurovascular compromise and soft tissue injury
• Early weight-based dosing of antibiotics for patients with open fractures
• Compartment syndrome is a clinical diagnosis, and the treatment is
fasciotomy.

Normal Chest X-ray
- Patient identity
- Density
- Centration

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3 Chest X-ray
Massive left hematothorax

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3 Chest X-ray
- Right pneumothorax
(collaps of right lung)
- Left pulmonary contusion

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3 Chest X-ray
- Left pneumothorax
(chest tube inserted)
- Multiple rib fractures
- Left subcutaneous air

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CXR
Chest X-ray
- Multiple rib fractures
(flail chest)
- Left subcutaneous air
- Fractures of :
-clavicle
-humeral neck
-scapula

Chest X-ray
- Abnormal gas left chest
(herniation of intraabdominal
organ, bowel)
- Diaphragm not visualized
(rupture of left diaphragma)

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3 Chest X-ray
Widened mediastinum on CXR

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3 Chest CT-scan
- Widened mediastinum
- Periaortic hematoma
(aortic injury)

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3 Normal Pelvic X-ray

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3 Pelvic X-ray
- Extensive widening of the
sacroiliac joints
- Pelvic diastasis

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3 Pelvic X-ray
Bilateral inferior and superior
pelvic rami fractures

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3 Pelvic Binder
before binder after binder
Foto : pelvic diasthesis

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3 Pelvic X-ray
Unconscious and hypotensive
Foto : vertical shear fracture
1. vertical translation of the pelvis
and widened pubis
2. extensive widening of the
sacroiliac joints
3. inferior and superior pelvic rami
fractures
4. left acetabular fractures

Urethrogram
Foto :
No extravasation of contrast
material

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3 Urethro-cyctogram
Clinical :
- Hypotension
- obvious unstable pelvis
- gross hematuria
- perineal ecchymosis
Foto :
No extravasation of contrast
material

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3 Urethro-cyctogram
Clinical :
Gross hematuria
Foto :
Extravasation of contrast
material outsite bladder,
but confined to pelvis
(retroperitoneal bladder
rupture)

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3 Urethro-cyctogram
Clinical :
- lower abdominal pain
- gross hematuria
Foto :
- diffuse contrast
extravasation
- not confined to the pelvis
(intraperitoneal bladder
rupture)

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A Alignment and adequacy
A. Anterior vertebral line
B. Anterior spinal line
C. Posterior spinal line
D. Spinous process
Cervical Spine Anatomy

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B Bone
C1 Atlas
C2 Odontoid
C3-C7
C2
C1
C7

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C Cartilage
D Dens
E Extra axial soft tissues
F Facets

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normal subluxation of C2-C3

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CT
Cervical Spine
normal

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3 Cervical Spine
odontoid fracture, comminution and depression at the C1-C2 interfacet joint

Open Mouth and Lateral View
C-1 burst (Jefferson fracture)

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3 Cervical Spine
complete subluxation of C7-T1
subluxation of C6-C7

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3 Thoraco-lumbal Spine
fracture dislocation of T3-T4 fracture of L2 fracture of L3

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The most significant difference between burns and other injuries is
that the consequences of burn injury are directly linked to the extent
of the inflammatory response to the injury.
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Objectives
1. Discuss the potential risks to the airway of patients with burn injuries.
2. Discuss resuscitation strategies for patients with burns.
3. Estimate the extent of a simulated patient’s burn injury.
4. Describe the appropriate management of burn injuries, including circumferential
burns.
5. Discuss the proper handover method for patients with burns.
6. Describe management of patients with hypothermia, including rewarming risks.
7. Describe the tissue effects of cold injury.
8. Describe the initial treatment of patients with tissue injury from cold exposure.
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Case Scenario
29-year-old male jumps from first story of a
burning house; clothes on fire; bystanders
extinguish fire and summon EMS
Conscious, agitated, voice normal, complaining of
abdominal and leg pain; head and upper body
extensively burned
None reported
None reported
M
I
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1. What are your immediate
priorities?
2. Is this patient’s airway at risk?
Why, or why not?
3. What are some physical
examination findings that
suggest the airway is injured?
Case Details
M
29-year-old male jumps from first story
of a burning house; clothes on fire;
bystanders extinguish fire and summon
EMS
Conscious, agitated, voice normal,
complaining of abdominal and leg pain;
head and upper body extensively burned
None reported
None reported
I
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4. How can you decrease injury
progression from the burn?
5. What are ways to control this
patient’s pain?
Case Details
M
EMS
None reported
None reported
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6. What other potential injuries do
you need to consider in this
patient?
7. What other thermal injury
consequences do you need to
consider?
Case Details
M
EMS
None reported
None reported
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• Patient is intubated
• IV access obtained in the antecubital fossa through burned skin
• Patient exposed fully: face, anterior torso, and bilateral lower
extremities nearly completely burned circumferentially
• Foley catheter placed, minimal dark urine
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1. What is estimated size of the
burn in this patient?
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2. What is the significance of the
dark urine?
Case Details
• Patient is intubated
• IV access obtained in the antecubital
fossa through burned skin
• Patient exposed fully: face, anterior
torso, and bilateral lower extremities
nearly completely burned
circumferentially
• Foley catheter placed, minimal dark urine
9 Thermal Injuries

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• Initial ABCDEs addressed
• Estimated TBSA burned calculated
• Second- and third-degree burn wounds throughout
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How will you manage this patient’s
burns to prevent further morbidity
and mortality?
• Initial ABCDEs addressed
• Estimated TBSA burned
calculated
• Second- and third-
degree burn wounds
throughout
Case Details
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• Fluid resuscitation begun
• Urine output < 30 mL/hr
• Fluid rate increased
• Chest and extremity x-rays ordered
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How do resuscitation strategies differ
in burn resuscitation from other types
of trauma resuscitation?
• Fluid resuscitation begun
• Urine output < 30 mL/hr
• Fluid rate increased
• Chest and extremity x-
rays ordered
Case Details
9 Thermal Injuries
9 Thermal Injuries

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• Secondary survey: calves of both legs firm and edematous
9 Thermal Injuries

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What is the significance of finding
swelling and firm compartments on
the secondary survey?
• Calves of both legs firm and
edematous
Case Details
9 Thermal Injuries

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• Transfer arrangements made
• Decision to perform escharotomies prior to transfer
9 Thermal Injuries

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As the team prepares for transfer and
to carry out the hand-off to the
receiving facility, what are some
important elements that should be
communicated, and where should
they be documented?
• Transfer arrangements
made
• Decision to perform
escharotomies prior to
transfer
Case Details
9 Thermal Injuries

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Case Scenario #2
35-year-old female brought to hospital after
being lost for two days, snowmobiling in -30° C
(-22° F) weather
None reported
Core body temperature 30° C (86° F)
None reported
M
I
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1. How would you initially treat
this patient?
2. How and why would you
monitor this patient during the
rewarming?
Case Details
M
35-year-old female brought to
hospital after being lost for two
days, snowmobiling in -30° C
weather
None reported
Core body temperature 30° C
None reported
I
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Any Questions?
9 Thermal Injuries

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Objectives
1. Discuss the potential risks to the airway of patients with burn injuries.
2. Discuss resuscitation strategies for patients with burns.
3. Estimate the extent of a simulated patient’s burn injury.
4. Describe the appropriate management of burn injuries, including circumferential
burns.
5. Discuss the proper handover method for patients with burns.
6. Describe management of patients with hypothermia, including rewarming risks.
7. Describe the tissue effects of cold injury.
8. Describe the initial treatment of patients with tissue injury from cold exposure.
9 Thermal Injuries

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Key Learning Points
1. The most significant difference between burns and other injuries is that the
consequences of burn injury are directly linked to the extent of the inflammatory
response to the injury. This drives the rate and amount of edema formation.
2. The airway can become obstructed not only from direct injury (e.g., inhalation injury),
but also from the massive edema resulting from the burn injury. Edema is typically not
present immediately, and signs of obstruction may initially be subtle until the patient is
in crisis.
3. In contrast to resuscitation for other types of trauma in which fluid deficit is typically
secondary to hemorrhagic losses, burn resuscitation is required to replace the ongoing
losses from capillary leak due to inflammation.
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Key Learning Points
4. A fresh burn is a clean area that must be protected from contamination.
5. Ensure that there are flow sheets documenting the patient history, injury, IV fluids given,
and urinary output. The flow sheet should be sent with the patient on transfer.
6. Although rapid rewarming is essential for management of frostbite and hypothermia,
reperfusion can cause physiologic changes that need to be managed.
9 Thermal Injuries

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Injury remains the most common cause of death and disability in
childhood. Injury morbidity and mortality surpass all major diseases in
children and young adults, making trauma the most serious public
health and health care problem in this population.
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Objectives
1. Identify the initial priorities of trauma assessment and management for children.
2. Describe the most appropriate interventions for managing difficult airways in pediatric
trauma patients.
3. Recognize the most common causes of cardiac arrest in children.
4. Identify methods for obtaining venous access in children.
5. Discuss how to determine drug and fluid dosages in children.
6. Evaluate for nonaccidental trauma in a pediatric trauma case.
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Case Scenario
3-year-old boy falls 10 meters (32 feet) out of an
apartment window onto pavement
Patient does not open eyes, moans incomprehensibly,
extends abnormally when stimulated
Unresponsive on arrival to ED at a small rural hospital,
pupils unequal, blood coming from R ear, breathing
rapidly, pale, mottled extremities Vital signs: BP 74/57;
HR 156; RR 49
None reported
M
I
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What are the priorities in
evaluating a small child with
multisystem trauma?
Case Details
M
3-year-old boy falls 10 meters (32 ft) out
of an apartment window onto pavement
Patient does not open eyes, moans
incomprehensibly, extends abnormally
when stimulated
Unresponsive on arrival to ED at a small
rural hospital, pupils unequal, blood
coming from R ear, breathing rapidly, pale,
mottled extremities Vital signs: BP 74/57;
HR 156; RR 49
None reported
I
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• Vital signs: BP 74/57; HR 156; RR 49; O2 sat 85%
• Breath sounds symmetrical
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1. What is the most common cause of cardiac arrest in
children?
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2. What steps and maneuvers
would you use to manage this
patient’s airway?
3. Based on the information given,
is this child in shock? If so, what
type of shock is exhibited?
Case Details
• Vital signs: BP 74/57; HR 156; RR
49; O2 sat 85%
• Breath sounds symmetrical
10 Pediatric Trauma

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• Two failed attempts at intubation
• Attempt to position laryngeal mask unsuccessful
10 Pediatric Trauma

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What would your next step be in securing an airway for this
patient?
10 Pediatric Trauma

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• Needle cricothryroidotomy performed, airway secured
• Several failed attempts at peripheral IV access in both antecubital
fossae
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1. How would you secure vascular
access to give fluids?
2. How would you manage this
patient’s hypotension and
determine the appropriate fluid
regime?
• Needle cricothryroidotomy
performed, airway secured
• Vital signs: BP 74/57; HR
156; RR 49
• Several failed attempts at
peripheral IV access in both
antecubital fossae
Case Details
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• Isotonic crystalloid and O-negative blood given with good response
• Vital signs: HR 110; BP 90/60
• Chest x-ray: pulmonary contusions
10 Pediatric Trauma

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Why do children commonly develop pulmonary contusions following
trauma, even in the absence of rib fractures?
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• Pelvic x-ray: normal
• Inconsistencies noted in family’s explanation of fall
• Skeletal survey: healed transphyseal distal L humerus fracture; healing
classic L femur metaphyseal lesion, with periostitis extending into the
femoral diaphysis
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1. Do the x-ray findings raise the
suspicion of child maltreatment?
If so, why?
2. What are the appropriate steps
to take if child maltreatment is
suspected?
• Pelvic x-ray: normal
• Inconsistencies noted in family’s
explanation of fall
• Skeletal survey: healed
transphyseal distal L humerus
fracture; healing classic L femur
metaphyseal lesion, with
periostitis extending into the
femoral diaphysis
Case Details
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• Transfer to nearest pediatric trauma center after intubation and normalization of
hemodynamics
• CT of head and abdomen at receiving facility: intracerebral contusions, moderate
splenic contusion, and subscapular hematoma
• Managed in ICU until gas exchange normalized, extubated
• Splenic injury does not require surgery
• Case reported to the appropriate social and legal services
• Outpatient brain injury follow up for 6 months
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Any Questions?
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Review Objectives
1. Identify the initial priorities of trauma assessment and management for children.
2. Describe the most appropriate interventions for managing difficult airways in pediatric
trauma patients.
3. Recognize the most common causes of cardiac arrest in children.
4. Identify methods for obtaining venous access in children.
5. Discuss how to determine drug and fluid dosages in children.
6. Evaluate for nonaccidental trauma in a pediatric trauma case.
10 Pediatric Trauma

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Key Learning Points
1. The initial priorities of trauma assessment and management are the same for children
and adults.
2. Surgical cricothyroidotomy is generally considered to be unsafe in small children (<12)
due to the small size of the cricothyroid membrane and proximity to vocal cords. Needle
cricothyroidotomy is preferred as a temporizing solution until other preparations are
made.
3. Hypoxia and respiratory compromise are the most common causes of cardiac arrest in
children.
4. Emergent venous access in children can be difficult. If unable to obtain peripheral
access, intraosseous access should be obtained immediately.
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Key Learning Points
5. Determination of weight is essential to pediatric trauma care in order to dose drugs and
guide fluid and blood resuscitation. This can be accomplished by history, length-based
resuscitation tape, or specialty stretchers with integrated scales.
6. Blunt solid organ injury in pediatric patients is usually managed non-operatively by a
surgeon unless the patient is hemodynamically unstable or there are other indications
for surgery.
7. Non-accidental trauma is a significant source of injury in children and has a higher
mortality rate than corresponding accidental injuries. Specific injury patterns exist that
should heighten concerns. Clinicians must have a high index of suspicion and report
these cases appropriately.
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When managing geriatric patients with trauma, the effects of aging on
physiological function and the impact of preexisting conditions and
medications cannot be overemphasized.
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Objectives
1. Describe common mechanisms of injury seen in older adults.
2. Apply the ATLS principles to the management of an elderly trauma
patient.
3. Understand the physiologic changes that occur with aging and how they
affect the geriatric patient’s injury and response to trauma.
4. Understand the common signs and causes of elder maltreatment.
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Case Scenario
82-year-old female fell down 6 stairs;
husband called ambulance,
transported to your rural ED
None reported
Vital signs: RR 22; HR 64; BP 160/80;
GCS 13
None reported
M
I
S
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1. What injuries would you suspect
in this elderly patient?
2. What unique elements of the
AMPLE history should you be
alert to?
3. What are the key aspects of the
initial assessment and
management of this patient?
Case Details
M
82-year-old female fell down 6
stairs; husband called
ambulance, transported to your
rural ED
None reported
Vital signs: RR 22; HR 64; BP
160/80; GCS 13
None reported
I
S
T
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• Examination
• Vital signs unchanged on ED arrival
• Patient confused, localizes to pressure
• Multiple bruises
• Less movement upper compared with lower extremities
• AMPLE: taking a direct thrombin inhibitor, beta blocker for hypertension
• Investigations:
• Chest x-ray: multiple rib fractures
• Head CT: subdural hematoma with shift, few small intracerebral contusions
• Pelvic x-ray: pubic rami fractures
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1. What challenges and pitfalls
might you encounter if you
need to intubate the patient?
2. With respect to her rib
fractures, why is this patient at
higher risk for mortality than a
younger individual?
Case Details
• Vital signs unchanged on ED arrival
• Patient confused, localizes to pressure
• Multiple bruises
• Less movement upper compared with lower
extremities
• AMPLE: taking a direct thrombin inhibitor,
beta blocker for hypertension
• Chest x-ray: multiple rib fractures
• Head CT: subdural hematoma with shift, few
small intracerebral contusions
• Pelvic x-ray: pubic rami fractures
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• Transfer not possible due to severe weather
• Admitted to ICU for monitoring
• Rib fracture pain controlled with narcotics
• Respiratory status and level of consciousness continue to decline
• Repeat head CT: progression of subdural hematoma
• Neurosurgeon by telemedicine recommends craniotomy for
evacuation of the hematoma when transfer is available
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1. What are the potential causes
of declining mental status in
this patient? What are the most
likely?
2. What is the impact of a
prolonged ICU admission and
hospital stay on this elderly
patient’s likelihood of returning
to independent living?
Case Details
• Transfer not possible due to severe weather
• Admitted to ICU for monitoring
• Rib fracture pain controlled with narcotics
• Respiratory status and level of consciousness
continue to decline
• Repeat head CT: progression of subdural
hematoma
• Neurosurgeon by telemedicine recommends
craniotomy for evacuation of the hematoma
when transfer is available
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3. Does the patient’s injury pattern
raise suspicion about elder
maltreatment?
4. What type of injuries would
raise your suspicion about elder
maltreatment?
Case Details
M
82-year-old female fell down 6
stairs; husband called
ambulance, transported to your
rural ED
None reported
Vital signs: RR 22; HR 64; BP
160/80; GCS 13
None reported
I
S
T
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• Husband states that the patient would not want intubation nor life-
sustaining interventions if there is no chance of living independently
again.
• He provides advance directive and living will documenting her wishes
and his status as health care power of attorney.
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Any Questions?
11 Geriatric Trauma

PPT Advance Trauma Life Support edisi 10

PPT Advance Trauma Life Support edisi 10

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PPT Advance Trauma Life Support edisi 10