This document discusses the assessment and management of multiply injured patients. It describes the ATLS protocol, including the primary survey to address the ABCDEs (airway, breathing, circulation, disability, exposure). Special considerations are given to head injuries, chest injuries, and the elderly. The stages of assessment and resuscitation are outlined to structure the initial approach to trauma patients.

1. Assessment of theAssessment of the
MultiplyMultiply InjuredInjured
PatientPatient
Dr. Michael O’ConnorDr. Michael O’Connor
Professor, Dept. of EmergencyProfessor, Dept. of Emergency
Medicine, Queen’s University,Medicine, Queen’s University,
CANADACANADA

2. The ATLS ProgramThe ATLS Program
““Advanced Trauma Life Support”Advanced Trauma Life Support”
 Originated in the USA- ~1980-Originated in the USA- ~1980-
Trauma- “The Neglected Disease ofTrauma- “The Neglected Disease of
Modern Society”Modern Society”
 Intended for the Primary CareIntended for the Primary Care
PhysicianPhysician
 Addressing early Assessment andAddressing early Assessment and
RecognitionRecognition
 Standardized in 32 countriesStandardized in 32 countries

3. Regrettably, War and ConflictRegrettably, War and Conflict
have consistently lead tohave consistently lead to
improved care of the Injured.improved care of the Injured.

4. Death Following TraumaDeath Following Trauma
0%
5%
10%
15%
20%
25%
30%
35%
40%
< 30 min. Hours Days-Weeks

5. The Stages…..The Stages…..
 Preparation- Prior to HospitalPreparation- Prior to Hospital
 Primary SurveyPrimary Survey
 ResuscitationResuscitation

6. Preparation - Prior to HospitalPreparation - Prior to Hospital
Vital SignsVital Signs
Pulse and Blood PressurePulse and Blood Pressure
Level of ConsciousnessLevel of Consciousness
Glasgow Coma ScaleGlasgow Coma Scale
 MotorMotor
 VerbalVerbal
 Eyes OpeningEyes Opening
MechanismMechanism
High VelocityHigh Velocity
Outside conditionsOutside conditions
(cold)(cold)
Patient FactorsPatient Factors
 AgeAge
 Medical conditionMedical condition
 PregnancyPregnancy

7. Primary SurveyPrimary Survey
A-A- AAirway maintenance (C-spine)irway maintenance (C-spine)
B-B- BBreathing and Ventilationreathing and Ventilation
C-C- CCirculation and Hemorrhage Controlirculation and Hemorrhage Control
D-D- DDisability- Neurological Statusisability- Neurological Status
E-E- EExposure, Environmental Controlxposure, Environmental Control

8. AIRWAYAIRWAY
 Relieve AirwayRelieve Airway
ObstructionObstruction
 Head Injury, Blood, Teeth,Head Injury, Blood, Teeth,
VomitusVomitus
 OxygenationOxygenation
 Simple AirwaySimple Airway
maneuversmaneuvers

9. BREATHINGBREATHING
 Look ForLook For……
 Equal Rise and Fall of the ChestEqual Rise and Fall of the Chest
 ListenListen For...For...
 Air entry on both sides of chestAir entry on both sides of chest
 Feel For…Feel For…
 Rib Fractures (Elderly Patient)Rib Fractures (Elderly Patient)
 Subcutaneous emphysemaSubcutaneous emphysema
Continuous Pulse Oximeter to monitor oxygenContinuous Pulse Oximeter to monitor oxygen

10. CIRCULATIONCIRCULATION
SHOCKSHOCK
 Hemorrhage most common,Hemorrhage most common, notnot isolatedisolated
Brain Injury- expectBrain Injury- expect Tachycardia andTachycardia and
Cutaneous VasoconstrictionCutaneous Vasoconstriction
 Other Causes-Other Causes-
 Cardiac- Direct InjuryCardiac- Direct Injury
 Tension PneumothoraxTension Pneumothorax
 Neurogenic- Spinal Cord InjuryNeurogenic- Spinal Cord Injury

11. DISABILITYDISABILITY
NeurologicalNeurological
ExaminationExamination
EXPOSUREEXPOSURE
Undress the PatientUndress the Patient
PreventPrevent
HypothermiaHypothermia

12. Elderly PatientElderly Patient
Conditions that correlate withConditions that correlate with
High Mortality:High Mortality:
 Head TraumaHead Trauma
 ShockShock
 HypoxiaHypoxia
 Sepsis-Multisystem Organ FailureSepsis-Multisystem Organ Failure
 Prolonged ventilationProlonged ventilation

13. Specific OrganSpecific Organ
SystemsSystems
Head InjuryHead Injury
 High primary Mortality, Poor functionalHigh primary Mortality, Poor functional
outcome post discharge.outcome post discharge.
 High predisposition to subdural withHigh predisposition to subdural with
subtle presentation-- (subtle presentation-- (CT Scans)CT Scans)
 Airway, Cautious hyperventilation,Airway, Cautious hyperventilation,
Definitive care and decisionsDefinitive care and decisions

14. Specific Organ SystemsSpecific Organ Systems
Chest InjuriesChest Injuries
 Rib and Sternal InjuriesRib and Sternal InjuriesFlail segment,Flail segment,
splinting, hypoventilation and pneumoniasplinting, hypoventilation and pneumonia
  Chest compliance & pulmonary reserveChest compliance & pulmonary reserve
 Cardiac Arrhythmia- Premorbid vs ? DirectCardiac Arrhythmia- Premorbid vs ? Direct
injuryinjury

15. SUMMARYSUMMARY
 Anticipate the ProblemAnticipate the Problem
 Primary SurveyPrimary Survey
 Resuscitation PhaseResuscitation Phase
 Know when to ask for AssistanceKnow when to ask for Assistance
 Elderly patients pose specialElderly patients pose special
problemsproblems