Case 6: Myles Downie - ATLS

Advanced Trauma Life Support (ATLS): Primary Survey

XABCDE

• X: X (stop) bleeding

• A: Airway

• B: Breathing

• C: Circulation

• D: Disability

• E: Exposure

ATLS: X Bleeding

Pressure

Torniquet

ATLS: Airway

Assess airway

• Compromised airway

• Respiratory distress

Stabilize C-spine

Initial Interventions: 

• Suction airway

• Intubation

  • Indications:

    • Airway obstruction

    • Respiratory failure

    • GCS ≤ 8

ATLS: Breathing

Assess SpO2

Assess ventilation

• Vitals

• Neck:

  • Jugular venous distension

  • Tracheal deviation

• Chest:

  • Auscultate

  • Chest wall injuries

Initial Interventions:

• O2

• Tension pneumothorax → Chest decompression

• Chest wounds → Dressing

• Respiratory failure → Mechanical ventilation

ATLS: Circulation

Assess hemodynamic status

• Central pulses

• LOC

• Cap refill

• Vitals

Identify hemorrhage

• FAST

• Deformities

Initial Interventions:

• 2 large-bore IVs (18-guage)

  • No IV access = IO access

• 1L warmed isotonic crystalloid bolus

  • No response = Blood transfusion

• Treat shock

  • Transfusion

  • Reverse anticoagulation

    • Tranexamic acid

ATLS: Disability

Neurological exam

• GCS

• Pupillary light response

• Motor + sensation

ATLS: Exposure

Assess for injuries

• Undress patient

• Examine axilla, groin, back

Warm blankets + fluids

ATLS: Secondary Survery

After stabilization

• AMPLE history

• Mechanism of injury

• Physical exam

• Interventions

ATLS: AMPLE History

Rapid evaluation

• A: Allergies

• M: Medications

• P: PMHx + Pregnancy

• L: Last meal

• E: Events + environment

ATLS: Interventions

Open wounds → Tetanus immunization

Intraperitoneal injury → Empiric antibodies

ATLS: Tertiary Survey

Ensure patient safety + identify undetected injuries

• PMHx

• MSK + neuro exam

Polytrauma: Description

Severe injuries in 1+ anatomic injury → Systemic physiological disturbances

Polytrauma: Investigations

Lab tests

Imaging

Diagnostic peritoneal lavage

Polytrauma Investigations: Lab Tests

Blood tests

• CBC

• BMP

• LFTs

• Lactate

• Coagulation studies

• POC glucose

• Serum ethanol

Urinalysis

Toxin panel

• Indications:

  • Altered mental status

  • Suicide

Polytrauma Investigations: Imaging

ECG

POCUS

XR

CT

Polytrauma: POCUS

FAST: Thoracoabdomen

eFAST: Lung sliding

Findings:

• Hemorrhage

  • Pericardial

  • Pleural

  • Hepatorenal

  • Splenorenal

  • Pelvic

• Pneumothorax

  • No lung sliding

Polytrauma: XR

Primary Survey:

• Chest

• Pelvis

Secondary Survey:

• Long bone

• Spine

Chest XR

Indications: Chest + abdomen trauma

Findings:

• Pneumothorax

• Hemotheorax

• Pneumoperitoneum

Pelvis XR

Indications:

• Abdomen trauma

• Unstable pelvis

Findings: Pelvic fracture

Long Bone XR

Indications:

• Pain

• Erythema

• Swelling

• Deformity

Findings:

• Fracture

• Dislocation

Spine XR

Indications:

• Tenderness

• Deformity

• Neurological deficits (numbness, tingling, weakness)

• Neurogenic shock

Findings:

• Fracture

• Spondylolisthesis

Polytrauma Imaging: CT

Secondary survey

• Whole body

• Head + spine

• Chest

• Abdomen + pelvis

Polytrauma Investigations: Diagnostic Peritoneal Lavage

Assess hemoperitoneum or perforation in trauma

Indications: Primary survey

• Hemoperitoneum

• No FAST

Procedure: 

• Catheter aspiration in abdomen to detect blood/fecal matter

• Flush with saline + analyze

Polytrauma: Treatment

Treat…

• Fractures

• Pneumothorax

Provide…

• DVT/VTE prophylaxis

• Tetanus shot

• Antibiotics

Closed Fracture: Treatment

Closed reduction

• Realign displaced fracture/dislocation

Immobilization (cast/splint)

• Lower limbs: VTE prophylaxis

Elevation above heart

Ice

Analgesics

• Non-opioid 

  • Acetaminophen

  • NSAIDs

  • Gabapentin (Inhibit Ca2+ channels = Reduce neuropathic pain)

• Opioids: Severe pain

  • Tramadol

  • Hydrocodone

Open Fracture: Treatment

Open/closed reduction

Immobilization

• External Fixation: Pins/screws outside skin

• Internal: Implants (plates, screws, wires)

Compound Fractures: STAND

• S: Stabilize + immobilize

• T: Tetanus shot

• A: Antibiotic prophylaxis (Ancef)

• N: Neurovascular exam

• D: Dressing 

  • Acute wound management

    • Remove foreign bodies + debris

    • Irrigate wound

    • Cover with dressing

  • Operative irrigation + debridement (remove dead tissue)

    • ≤ 24h

Unstable Pneumothorax: Treatment

Occlude open wounds

Decompression

• Needle/finger thoracostomy

• Chest tube

Treat obstructive shock

Stable Pneumothorax: Treatment

Conservative

Chest tube

High-flow O2

Mechanical ventilation

Polytrauma Treatment: DVT/VTE Prophylaxis

Risk Factors:

• Older

• Obesity

• Male

• Fractures

• Spinal injuries

• Surgery

• Tranexamic acid use

Contraindications:

• Active hemorrhage

• Hematomas

Agents:

• LMWH: Preferred

  • Enoxaparin

• Unfractionated heparin

• ASA

• DOACs

Polytrauma Treatment: Tetanus Shot

Open wounds

Polytrauma Treatment: Antibiotics

Indications:

• Open fracture

• Open wound

Agents:

• 1st gen cephalosporin

  • Cefazolin

• Aminoglycoside

Polytrauma: Complications

Tetanus

Tetanus: Etiology

Neurotoxins from Clostridium tetani

Tetanus: Pathophysiology

Neurotoxins penetrating body through wound = Activate alpha motor neurons = Muscle rigidity + spasms

Tetanus: Clinical Presentation

Trismus: Decreased jaw opening

Risus sardonicus: Raised eyebrows + grin

Opisthotonus: Head + lower limbs hyperextend + trunk arch forward

Tetanus: Treatment/Management

Mechanical ventilation

Antibiotics:

• Metronidazole: First-line

• Penicillin G

Immunization:

• Passive: Human tetanus IG

• Active: Tetanus vaccine

Indigenous Patients: Health Services

Non-Insured Health Benefits (NIHB) program: Cover supplemental benefits not under Medicare

Community health centres

Aboriginal health access centres

Suicide: Management

Form 1

Treat psychiatric disorders

• Depression: SSRIs, TCAs

• Bipolar: Mood stabilizers

• Schizophrenia: Antipsychotics

Psychotherapy

• CBT

• DBT

• Mindfulness-based cognitive therapy

Counselling

Form 1: Indications

• Mental disorder/disorientation

• Threat to self or others

• No capacity

Alcohol Withdrawal: Clinical Presentation

Assess with CIWA (clinical institute of withdrawal assessment)

Score symptom severity

• Nausea/vomiting

• Tremor

• Sweat

• Anxiety

• Agitation

• Hallucinations (tactile, auditory, visual)

• Headache

• Disorientation/confusion

• Seizures

Alcohol Withdrawal: Risk Factors

Family history

Psychiatric disorders

Men

Alcohol Withdrawal: Treatment/Management

Benzodiazepines: First-line

Anticonvulsants: Second-line

Alcohol Withdrawal Treatment: Benzodiazepines

Slow-Metabolism: Oxazepam, lorazepam

• Older adults

• Liver failure

All Patients: Chlordiazepoxide, diazepam

Alcohol Withdrawal: Complications

Alcoholic ketoacidosis

Wernicke encephalopathy + Korsakoff syndrome

Alcoholic Ketoacidosis: Pathophysiology

Alcohol use disrupt glucose metabolism + starvation = Increase ketone bodies + normal/low glucose = HAGMA

Alcoholic Ketoacidosis: Treatment/Management

Acute

• Thiamine: Prevent Wernicke encephalopathy

• IV dextrose

• Correct electrolyte imbalances

Wernicke Encephalopathy + Korsakoff Syndrome: Pathophysiology

Severe thiamine/B1 deficiency = Decreased cerebral glucose metabolism + mitochondrial dysfunction = Neuronal injury

• Prolonged = Korsakoff syndrome (irreversible)

Wernicke Encephalopathy: Clinical Presentation

Confusion

Oculomotor dysfunction

Gait ataxia: Wide base + small steps

Korsakoff Syndrome: Clinical Presentation

Confabulation: Producing false memories to fill in gaps

Amnesia

Personality changes

Disorientation

Wernicke Encephalopathy + Korsakoff Syndrome: Treatment/Management

Acute: IV thiamine

• BEFORE IV dextrose/glucose (worsen encephalopathy)

Oral vitamins

Alcohol abstinence