How To Pass Atls Written Exam

---

Jason Wolfe'due south ATLS ^� Trauma Moulage Page

(Thoughts on the Management of the Multiply Injured Patient)

---

Aim :����	To give people a framework for thinking nigh the direction of the traumatised patient and assist them to pass the ATLS trauma moulage.  This webpage was produced every bit a culmination of the educational activity and experiences I gained during a by ATLS course.
ATLS � :	The ATLS course itself is an excellent way of practicing the theoretical and practical aspects of trauma management.  I highly recommend anyone involved in direction of trauma patients to do information technology.
Annotation :	This is not meant as a short cutting which negates the demand to read the ATLS course manual.��Y'all are reminded that information technology is extremely unlikely that you volition pass the course if you don't read the ATLS manual.
PS:	Notation that the term 'ATLS' is a registered trade mark of the 'American College of Surgeons'.��This web-page is not affiliated to, nor officially endorsed past them.

---

Full general Principles of Trauma Direction

1.����	There is a need for rapid evaluation of the trauma patient.��Fourth dimension wasted costs lives.
2.	The absence of a definitive diagnosis should never impede the awarding of essential treatment.
3.	The first 'Golden 60 minutes' is crucial to both the curt and long term survival of the patient.��It as well is as well critical in determining the morbidity that the patient will endure.
4.	At that place is a need to establish direction priorities:��The things which will kill the patient first are always the things which should exist checked and treated offset.��Things which will kill the patient later are managed later.��Thus, airway issues are managed and treated before breathing problems, which in plow are treated earlier circulatory problems.
5.	Patients with serious injuries are managed by the 'Trauma Team'. This will normally include ED doctors, an anaesthetist, along with specialists in the particular injury involved. Eg. Thoracic Surgeons / Orthopaedics / General Surgeons / Neurosurgeons.
six.	All treatment modalities should be governed past the constant principle of 'Commencement do no harm'.

---

Overview of ATLS Protocol :-

(Stages & Subject Headings)

one.�����	Preparation
2.	Triage
iii.	Main Survey (ABCDE)��&��Resuscitation
4.	Adjuncts to Primary Survey & Resuscitation
5.	Consider demand for Patient Transfer
vi.	Secondary Survey��(with AMPLE History)
seven.	Continued Post-Resuscitation Monitoring & Re-evaluation
8.	Transfer to Definitive Care

---

1.���Preparation��-��Equipment needed for Practice

You should familiarise yourself with all the following equipment.��Y'all should exist able explain each item'south utilize, not only only by physical demonstration but also by verbal description.

General EQUIPMENT

• 1 Live Patient��(normally an histrion with copious merely expert make-up to ensure realism)
• One Nurse Assistant��(who usually is an inexperienced pupil)
• One Candidate��(with large amounts of adrenaline in blood stream and suitably fast beating heart)
• I Examiner��(to brand life difficult and generally throw a spanner in the works)
• Universal Precautions
• Toilet +/- Cigarette for afterwards

CERVICAL SPINE EQUIPMENT

• Long Spinal Board
• Hard Collars of various sizes
• Sandbags
• Tape for securing caput

AIRWAY EQUIPMENT

• Suction
• Oxygen
• Ventilator
• Laryngoscopes��(various sizes & shapes)
• Bag and Mask with Reservoir
• Flexible Bougie
• Tongue Depressor
• Oropharyngeal��/��Nasopharyngeal Tubes
• Orotracheal��/��Nasotracheal��/��Endotracheal Tubes
• Needle Cricothyroidotomy Set
• Formal Cricothyroidotomy Set
• Tracheostomy prepare��(for children under 12 yrs)
• Surgical Drapes
• 10ml Syringes
• Scalpel

BREATHING EQUIPMENT

• Stethoscope
• Large Bore Cannula
• Breast Drain Set including :-
  • Antiseptic swap
  • Local Anaesthetic
  • Scalpel
  • Dissecting forceps
  • Chest Drain
  • Tubing
  • Suitable container with underwater seal
  • Stitch Fabric
  • Occlusive dressing

CIRCULATION EQUIPMENT

• Pressure level Dressings & Swabs
• Antiseptic swaps
• Hypodermic Needles
• Intra-venous Cannulas
• Long-venous Cannulas for apply with Seldingers Technique
• Pericardiocentesis over-the-needle cannulas
• Venous Cut-down set
• Peritoneal Dialysis Catheter
• Adhesive Tape
• Giving sets
• Syringes
• Warmed Crystalloid / Colloid / Blood
• PASG : Pneumatic Anti-Stupor Garment

DRUGS

• Fix of Resuscitation Trolley Drugs
• Lignocaine (+/- Adrenaline) L/A Injection
• Lignocaine Gel for Catheterisation
• Xylocaine Spray for Oro / Nasopharyngeal L/A
• Heparin

MISCELLANEOUS STUFF

• Resuscitation trolley
• Defibrillator
• Pulse Oximeter
• Claret Pressure Monitor
• Cardiac Monitor
• Capnograph
• Normal & Low-Range Thermometers
• Nasogastric Tube
• Urinary Catheter
• Fast Intravenous Infuser / Warmer Device
• Ophthalmoscope & Otoscope
• Fracture Splints
• Glasgow Coma Scale Chart
• Broselow Paediatric Resuscitation Measuring Tape
• Ten-Ray Viewing Box
• Ultrasound Scanner
• Warming Blanket
• Polaroid Photographic camera
• Hammer & Nails to prevent the paramedics who brought the patient in from leaving the department earlier they have given an ample history.

2.��Triage.

Triage is the prioritisation or ranking of patients according to both their clinical need and the available resource to provide treatment.��The process is based on the same ABC principles every bit explained below.

3.��Summary of Principal Survey & Resuscitation :-

(Explained in full particular later on)

��A���-���Airway��&��Cervical Spine Command
��B���-���Breathing��&��Oxygenation
��C���-���Apportionment��&��Haemorrhage Control
��D���-���Dysfunction��&��Disability of the CNS
��Eastward���-���Exposure��&��Environmental Control

4.��Adjuncts to Master Survey & Resuscitation :-

These are various useful monitoring or therapeutic modalities which supplement the information already obtained using clinical skills in the Primary Survey.

They include :-

�1.����	Pulse Oximeter
�ii.	Blood Pressure level
�3.	Cardiac Monitor��/��Electrocardiogram
�4.	Arterial Blood Gases��/��End Tidal pCO2
�v.	X-Rays - Breast X-Ray��/��Cervical Spine��/��Pelvis��/��Others
�half-dozen.	FAST Ultrasound (Focused Cess with Sonography for Trauma)
�vii.	Nasogastric Tube��&��Urinary Catheter
�8.	Core Temperature

5.��Consider the Need for Emergency Patient Transfer.

The particular blow unit or hospital where the patient has arrived is non ever the most suitable place for the definitive intendance of that patient to be managed.��Once the resuscitation is well under style and the patient is stable, consideration should be given to transferring the patient elsewhere.��Transfer may be to another infirmary which is more geared to treating the multiply injured patient (eg. a level ane trauma centre) or to another facility which can fairly deal with the particular set up of specialised injuries which are peculiar to your patient (eg. a neurosurgical unit).��Transfer may also be to a dissimilar department of the aforementioned infirmary (eg. theatres / radiology).

In any instance, patient transfer is often the time of greatest peril for the patient considering it is all too easy for the 'level of care' to refuse.��The claiming therefore is to ensure that this level of care does not deteriorate at any time.��Transfer should always be as soon a possible after the patient is stabilised.��The acquiring of specialised investigations should not concur up the transfer of the patient as these investigations are often more appropriately performed in the unit where the patient is to be transferred.

6.��Secondary Survey.

A total AMPLE history is taken from anyone who knows the relevant details.�� This often includes both the family and the paramedics who brought the patient in.��This is followed by complete head to toe & systems test.�� All clinical, laboratory & radiological information is assimilated and a management program is formulated for the patient.

During this time there is a process of continued post-resuscitation monitoring & re-evaluation.��Whatever sudden deterioration in the patient should immediately prompt the doctor to return to the primary survey for a re-assesment of the ABCDE's.

AMPLE History :-

���A��-��Allergies
���M��-��Medicines
���P��-��By Medical History��/��Pregnancy
���Fifty��-��Terminal Meal
���E��-��Events��/��Environment leading to the current trauma

7.��Transfer to Definitive Care & Handover

This is governed by the same principles every bit were mentioned above in the emergency transfer of patients.��The level of care should not deteriorate.

MIST Handover

• Mechanism (& time) of injury
• Injuries constitute & suspected
• Symptoms & Signs
• Treatment initiated

---

The Primary Survey & Resuscitation.

(This is the main part which is tested in the applied moulages, so this the part volition be covered in the greatest detail)

NOTE FIRST�:-

ix Immediately Life Threatening Injuries or Weather condition which should be picked up in ABCDE and treated immediately :-

one.����	Inadequate Airway Protection
2.	Airway Obstruction
3.	Tension Pneumothorax
4.	Open up pneumothorax
5.	Flail Chest with Hypoxia
half dozen.	Massive Haemothorax
7.	Cardiac Tamponade
eight.	Severe Hypothermia
nine.	Severe Daze from Haemorrhage Unresponsive to Fluid Resuscitation.

NOTE ALSO�:-

13 Potentially Life Threatening "Non-Obvious" Injuries which should be considered in the traumatised patient, but whose management tin can oftentimes look until later on ABCDE until the time of definitive care :-

1.����	Elementary Pneumothorax
2.	Haemothorax
3.	Pulmonary Contusion
4.	Tracheo-Bronchial Injury
5.	Blunt Cardiac Injury
6.	Traumatic Aortic Disruption
seven.	Diaphragmatic Rupture
8.	Mediastinal Traversing Wounds
9.	Blunt Oesophageal Trauma
10.	Sternal / Scapular / Rib Fractures
11.	Ruptured Liver or Spleen
12.	Rupture of an abdominal or pelvic viscus
13.	Any other chest / abdominal / or pelvic injuries which take resulted in organ damage only not in firsthand stupor

---

How to approach the Primary Survey and what to exercise :-

This next section assumes you are in a moulage scenario and goes through your possible deportment and reactions in response to what yous discover with your patient.

A��-��AIRWAY & CERVICAL SPINE CONTROL

• Say you are wearing universal precautions.
• Approach patient from caput side and stabilise cervical spine using in-line immobilisation.��Try to avoid placing your easily over the patient's ears.
• Introduce yourself and reassure patient.
• Assess preliminary ABC from patients response to this.
• IF THE AIRWAY IS NOT AT Least PARTIALLY SECURE, then definitive cervical spine control will have to wait.��Ask the nurse to take over the role of in-line immobilisation of the cervical spine, and Move ONTO AIRWAY Direction. ��Don't forget to come back to cervical spine management later.
• CERVICAL SPINE Management :-
• Ask for a hard neck collar.��Measure out the size of collar by measuring from the angle of mandible to the top of shoulder / trapezius.� The collar should be the same size from the blackness marker peg to the base of the hard part of the collar.
• Apply Neck Blocks and Record.
• AIRWAY Direction :-
• In the trauma patient, if the patient is likely to need intubation eventually, then early intubation is preferred, and so as to prevent the patient from tiring and condign acidotic.
• Suction out the airway or remove foreign bodies if necessary.
• IF��-��BREATHING IS SPONTANEOUS AND THE PATIENT IS Conscious, BUT AIRWAY IS COMPROMISED BY POOR PHARYNGEAL TONE��/��REDUCED LEVEL OF CONSCIOUSNESS�� (GCS 9-xiii) :-
  • Endeavor jaw thrust / chin elevator and enquire for response.
  • If the response is good, insert an oropharyngeal (Guedel) or nasopharyngeal airway.
  • Notes :-
    • The oropharyngeal airway is measured from the 'midline of the mouth to the angle of the mandible'. (Also measured equally 'edge of mouth to the tragus of ear').
    • The nasopharyngeal airway is measured from the 'tip of the nose to the earlobe'. Its diameter is besides conveniently estimated by looking at the patient's little finger.
    • Don't attempt to insert a nasopharyngeal airway if the patient has a head injury with the possibility of a basal skull fracture.
  • Assuming the patient responds to this, utilize oxygen using a confront mask with fastened reservoir purse.
  • If you haven't already done so, most patients should now take their neck immobilised with a hard cervix collar, blocks and tape.
• IF��-��THE SUPPORTIVE MEASURES ABOVE Have FAILED, OR IF PATIENT IS UNCONSCIOUS WITH A GCS OF eight OR LESS, OR IF THE PATIENT IS APNOEIC :-
  • The patient needs a definitive airway.
  • Call for an anaesthetist.
  • If the patient is COMPLETELY UNRESPONSIVE, information technology is necessary to proceed straight to endotracheal intubation.
  • Method of ENDOTRACHEAL INTUBATION.
    • Pre-oxygenate with bag and mask.
    • The cervix neckband volition need to be removed during intubation and during this fourth dimension your assistant must provide in-line immobilisation of the neck.
    • Standing above the head of the patient, insert a laryngoscope into the oropharynx, pushing the tongue to the left.��Pull the scope upwards and away from yourself until the vocal chords become visible.
    • Slip the endotracheal tube through the vocal chords, if necessary using a gum rubberband bougie.��Inflate the tube's balloon seal and connect the tube to a reservoired 'bag & mask' or ventilator.��Some patients may exist suffiently stable with the ET tube in situ to exhale spontaneously without the need for bag & mask or ventilator.
    • Ensure positioning of tube in trachea past listening to the breast (listen to the lung apices, bases and over the tummy).��Concluding confirmation tin be fabricated by connecting the tube to a capnograph.
    • Secure the tube using a commercially bachelor ET tube securing device.
    • Once finished, re-establish cervical spine control using the difficult neck neckband, blocks and tape.
    • See LEMON notes at end for 'Difficult Intubation'. See 'DOPE' notes for Failed Intubation.
  • If the patient is Withal PARTIALLY Conscious AND RESPONSIVE, then intubation will need to exist carried out by 'RAPID SEQUENCE Consecration', using anaesthetic drugs.  The procedure should only be carried out by practitioners who are quite familiar with its 'ins and outs' (which usually excludes everyone except experienced anaesthetists).��If you aren't experienced enough to perform RSI, and then 'bag & mask' until the anaesthetist arrives.
• IF��-��THE ACTIVE MEASURES Higher up Have FAILED, OR THERE IS Partial UPPER AIRWAY Obstruction WITH STRIDOR, OR THE PATIENT IS APNOEIC FROM Consummate AIRWAY Obstacle :-
  • Perform NEEDLE CRICOTHYROIDOTOMY and draw this method.
  • A large bore cannula is inserted through the crico-thyroid membrane and is so connected to high flow oxygen at 15 litres / infinitesimal.�� Inspiration / Expiration is accomplished by intermittently holding ones thumb over the side of an open Y-connector attached to the cannula - ane 2d inspiration, 4 seconds expiration.��The patient tin can just exist fairly oxygenated using this method for�about thirty - 45 minutes.�
  • Call for an anaesthetist.
  • Finally establish definitive airway by formal cricothyroidotomy and draw this method.
• OTHER INDICATIONS FOR A DEFINITIVE AIRWAY INCLUDE :-
  • Astringent maxillofacial / laryngeal / cervix injuries with impending obstacle.��The patient will about certainly require a surgical airway.
  • Severe Closed Head Injuries with a reduced level of consciousness, a risk of aspiration, and the need for hyperventilation.
• If y'all haven't already done so, utilise 100% oxygen.
• Enquire nurse to apply Pulse Oximeter, Blood Pressure level Monitor and Cardiac Monitor.��Ask her to take readings from all these monitors.

B��-��BREATHING & OXYGENATION

• If patient suddenly deteriorates at whatsoever point, move back and check airway again.
• Move down neck.
• Assess Carotid pulse for Rate, Grapheme & Volume.
• Bank check Neck veins for distension.
• Check for Wounds, Laryngeal crepitus & Subcutaneous emphysema.
• Check if Trachea is fundamental.
• Then motion onto breast.
• Inspect for Bruising / Asymmetry of expansion.
• Palpate any areas of interest.
• Check for Subcutaneous emphysema and Flail chest.
• Percuss and Auscultate both anterior and lateral chest and enquire for results.
• Most people listen to the heart hither (even though it is officially 'C' - Apportionment).
• IF��-��PATIENT HAS A SIMPLE PHEUMOTHORAX :-
  • Hyper-resonant chest, reduced / absent breath sounds, only cervix veins down and trachea fundamental.
  • Inquire the nurse to set upward formal Chest Drain set.
  • Don't insert the chest drain even so, just land that yous intend to insert it afterwards.
  • Chest Drain INSERTION :-
    • Drape & surgically prepare the chest.
    • If there is time, requite an injection of lignocaine local anaesthetic.
    • Make an incision in the 5th intercostal space just inductive to the mid-axillary line, and simply above the upper edge of the 6th rib.
    • Edgeless dissect down through the intercostal muscles, until the pleura is punctured.��Clear abroad adhesions, clots or strange bodies using a finger sweep.
    • Clamp the proximal end of the chest bleed and then advance information technology into the breast to the desired length.
    • Connect the chest bleed to an underwater-seal apparatus and so unclamp information technology.
    • Check the bleed is operation correctly - the water column at the underwater-seal appliance should motion up on inspiration and bubble during expiration.
    • Suture the tube in place using a purse-string suture and so apply an adhesive non-gas-permeable dressing to the site.   Apply the dressing to iii out of iv sides of the drain tube.
    • Finally re-examine the breast and obtain an early on chest ten-ray.
• IF��-��Neck VEINS DILATED, TRACHEA DEVIATED, ABSENT OR REDUCED Jiff SOUNDS AND CHEST HYPER-RESONANT, THEN THINK 'TENSION�PNEUMOTHORAX' :-�
  • Ask nurse to prepare formal Chest Drain set.
  • In the meantime, perform Needle Thoracostomy (Thoracentesis) and check for hissing sound.��Leave the needle thoracostomy open up.
  • Re-examine chest and enquire for response.
  • If patient stabilises, so go out formal chest drain until afterwards.
  • If they don't stabilise, perform some other Needle Thoracostomy and proceed straight to formal Chest Bleed insertion.
  • Describe this method.
• IF��-��PATIENT HAS Testify OF CHEST TRAUMA, DILATED Neck VEINS, MUFFLED Middle SOUNDS, AND DECREASED ARTERIAL BLOOD PRESSURE��(Maybe Fifty-fifty PULSELESS Electrical ACTIVITY) (BECK's TRIAD), And so Call up 'PERICARDIAL�TAMPONADE' :-
  • Proceed directly to Needle Pericardiocentesis.
  • Depict this method and check for response.
  • NEEDLE PERICARDIOCENTESIS :-
    • Monitor the patient'due south vital signs and ECG before, during & afterwards the procedure.
    • Drapery & surgically prepare the xiphoid area.
    • Employ a #16 approximate 15cm needle, 3 mode tap, and a 20cm syringe.
    • Puncture the skin 1 - 2cm below and lateral to the left xiphi-chondral junction, pointing the needle at an bending 45� to the peel and aiming for the tip of the left scapula.
    • Advance the needle until there is a flush-back of blood, and at this point withdraw as much claret every bit possible.
    • If the needle is avant-garde so that it penetrates the myocardium, the ECG design will modify, producing wild ST-T segment variation and widened / enlarged QRS complexes.��If this occurs, the needle should exist withdrawn slightly until the ECG pattern returns to normal.
    • It is sometimes necessary to leave a cannula in situ for repeat aspirations, and and so here the needle may be changed to a plastic cannula using the Seldinger technique.
• IF��-��PATIENT IS HYPOXIC, SHOCKED, HAS A STONY Wearisome CHEST, ABSENT BREATH SOUNDS AND A TRACHEA DEVIATED AWAY FROM THIS SIDE, And then Retrieve 'MASSIVE�HAEMOTHORAX' :-
  • Plant intravenous admission using two big bore cannulas.
  • Urgently call Cardiothoracic Surgeons, and in the meantime proceed to chest bleed insertion.
• IF��-��PATIENT HAS A FLAIL CHEST AND IS HYPOXIC :-
  • Early intubation is essential.
  • Perform Orotracheal intubation yourself preferably by 'Rapid Sequence Induction' or call for an anaesthetist to do it.
• IF��-��PATIENT HAS AN OPEN PNEUMOTHORAX :-
  • Cover this opening with an occlusive dressing with ane-way valve (to allow approachable air leak).
  • Secure the dressing well and so equally to prevent air-leaks through the adhesive.
  • Proceed straight to Chest Drain, placing the drain well away from the wound of the original open pneumothorax.

C��-��CIRCULATION & Haemorrhage Command

• Ask nurse to echo measurements of Oxygen Saturation, Claret Pressure & Pulse.
• Palpate the patients head and hands looking for signs of 'shock'.��This is defined equally insufficient organ perfusion and oxygenation.��It is suspected in a patient with cold, damp, pale, peripherally shut down extremities.
• Movement onto Abdomen & Pelvis.
• Abdomen :-
  • Inspect abdomen for injuries or distension.
  • Palpate belly for any masses or signs of peritonism.
  • Consider intestinal percussion & auscultation.
  • If in that location are signs of abdominal bleeding, enquire the nurse to fast bleep the on-phone call surgeon and ask them to come to casualty.
  • Ask the nurse to state that y'all have a clinically shocked patient in casualty who yous suspect has abdominal bleeding, who you lot are in the process of resuscitating, only who may urgently need to exist taken to theatre for laparotomy.
• PELVIS :-
  • Palpate the Pelvis.
  • Use both lateral and antero-posterior springing forces onto the anterior superior iliac spines and feel for aberrant mobility or crepitus.��This examination should be performed once past an experienced practitioner.
  • Ask examiner whether the pelvis is stable or unstable.
  • If there are signs of a fractured pelvis, apply a 'Pelvic Binder' to temporarily stabilise the pelvis (close an open-volume pelvic fracture) and reduce bleeding.
  • Ask the nurse to fast bleep the orthopaedic surgeon on call and tell them that you have a clinically shocked patient in prey who y'all suspect has an unstable fracture of the pelvis, who you are in the process of resuscitating, who requires urgent stabilisation with a pelvic external fixator.
  • Try to get a pelvis x-ray before the orthopaedic surgeon arrives, provided this doesn't interfere with the rest of your resuscitation.
• LIMBS :-
  • Speedily move onto the limbs, cutting off clothes as necessary, and examining for the presence of obvious deformity or soft tissue haematoma.
  • Any sources of external haemorrhage should immediately be stemmed by applying direct pressure and wrapping in a cast.
  • If at that place are Open (Chemical compound) Fractures, then these should be photographed, and then immediately packed with a Betadine soaked cast and straight pressure applied. Long bone fractures should be stabilised in Traction Splints.
  • Ask the nurse to stand past with intravenous morphine, a tetanus injection and intravenous antibiotics (normally cefuroxime & metronidazole).��The orthopaedic team should be informed and asked to attend the A&East department.
• FLUID RESUSCITATION :-
  • Having examined the body for potential sources of haemorrhage as well as stemming whatsoever areas of overt haemorrhage, fluid resuscitation should begin in earnest.
  • You demand to place 2 large diameter (#fourteen guess) intravenous cannulas, one in each cubital fossa.
  • Blood should be aspirated into a syringe for FBC, U&E, and Cantankerous-Lucifer.��Ask the nurse to ensure that the sample is rushed to the lab.��Ask for 2 - iv units of O Negative Blood, 2 - 4 units of Blazon Specific Blood, and 2 - 4 units of Crossmatched Blood, depending on the private circumstances.
  • If cannulation is unsuccessful, and then alternatives include the other cubital fossa, the femoral vein, the subclavian vein, the external jugular vein, the internal jugular vein, or a venous cut-down for the great saphenous vein. Intraosseous Infusion is increasingly beingness used in both children & adults.
  • Immediately prepare 1 litre of warmed Hartmanns or Ringer'southward Lactate for each of the ii cannulas and run equally a bolus through using a fast infuser.��This can have i - 2 minutes to run in.
  • In children under 6 years, intra-osseous infusion is the preferred method of admission after two unsuccessful attempts at cannulation.��In infants, scalp veins may be tried, and in neonates the umbilical vein oft provides excellent access.��The volume of the infusion bolus in children is 20mls / kg and this can exist repeated 2 or 3 times depending on response.
  • Ask the nurse to repeat Oxygen Saturation, Blood Pressure, Pulse & Respiratory Rate.��Cheque also the Temperature.
  • According to response, 2 units of O Negative blood (which accept just arrived from the lab) should be given using the fast infuser.��If the patient tin wait 10 minutes for type specific blood, then this is preferable. Colloids are no longer used as standard.
  • The aim is 'counterbalanced fluid resuscitation', possibly with balmy permissible hypotension.   Avert ambitious over-zealous fluid infusions, which tin re-precipitate haemorrhage which had previously stopped.
  • Burns accept fluid resuscitation according to the Modified Parkland Formula.
• Check for Clinical Response.

---

If the patient fails to reply, or initially responds but subsequently deteriorates, you should reverberate on the various possible causes of this state of affairs :-

1.����	Go dorsum and check Airway & Breathing.
2.	The patient could be Haemorrhage faster than y'all are replacing blood.��These patients demand to be taken to theatre immediately for surgical repair of the injured organ or vessel. Patients with severe blood loss & daze may be considered suitable for early administration of Tranexamic Acid. Consider activating the 'Massive Transfusion Protocol'.
iii.	The patient could be HYPOTHERMIC and therefore may be responding more slowly than a normothermic patient.
iv.	The patient could be in CARDIOGENIC SHOCK: Here the heart pump is declining due to blunt trauma, or sometimes due to penetrating trauma.��Consider again pericardial tamponade and act appropriately if required.��Consider early CVP monitoring.
5.	The patient may be Significant.��If moderately or heavily significant women are treated in the supine position, the bulky uterus may impede the menstruum of blood in the Inferior Vena Cava.��Such patients should exist bolstered and then that they are lying slightly on their left side by placing sand-bags or pillows under the right side of the pelvis and chest.��This manoeuvre should exist carried out earlier rather than later in the resuscitation.
6.	The patient may be in NEUROGENIC SHOCK: This occurs with spinal cord injuries in which the sympathetic outflow is damaged.��This denervation of the center and blood vessels results in a clinical moving-picture show of hypotension without tachycardia or peripheral vasoconstriction.��Volume resuscitation is notwithstanding the primary treatment, but consideration should be given to the judicious use of vasopressors.��Early on CVP monitoring & Swan-Ganz pulmonary avenue catheterisation may also be useful.
7.	SEPTIC Stupor: This is uncommon in the early flow following trauma just may occur in penetrating abdominal injuries with a perforated viscus or in other penetrating injuries where the wound has been contaminated with muddy exogenous droppings, especially if arrival in A&E has been delayed for hours or days.��It is identified by the presence of hypotension, tachycardia, pyrexia and cutaneous vasodilation.

All the above are treated by generous volume replacement along with definitive treatment of the cause of the shock.

Other Considerations in the Diagnosis & Treatment of Shock.

ane.����	OLD Age - Elderly patients take less 'physiological reserve':��They are less able to increment heart rate and stroke volume in response to daze.��Vital organs are more sensitive to the decreased blood flow and hypoxia associated with shock.��The lungs are less efficient at the gaseous commutation of oxygen.�� The kidney is less able to answer to the volume preserving stimulus of the stress hormones Aldosterone, Anti-Diuretic Hormone & Cortisol.��All these facts contribute to its increased morbidity and mortality.��It is thus even more crucial in the elderly patient to pay meticulous attention to book resuscitation, and the placement of arterial and CVP invasive monitoring devices will greatly assist in its assessment.�� These devices should be placed earlier rather than later.
2.	Immature AGE - Children and babies accept an specially high physiological reserve.��Homeostatic mechanisms maintain blood pressure and cardiac output despite the loss of big percentages of their blood volume.��However when the percentage of blood loss gets to nigh forty% (Class IV bleeding), the blood force per unit area and cardiac output drop precipitously.��The lesson here is that children may still have normal vital observations despite being in a high level of shock.��Ever take communication from a paediatrician early on.
3.	ATHLETES - Althletes may accept an increased blood volume of upwardly to xv - 20%, stroke volume tin can increment by 50%, cardiac output tin increment by 600% and resting pulse is generally lower than unfit individuals.��These facts mean that the usual clinical signs of hypovolaemia may non be manifested in athletes, even though pregnant claret loss may take occurred.
4.	PREGNANCY - Women take a higher plasma volume during pregnancy.��Cardiac output increases by one.0 - ane.v litres / minute, and heart rate increases by 10 - 15 beats / minute.��Minute ventilation increases too (primarily due to an increase in the respiratory tidal volume), and the Renal Glomerular Filtration Rate also increases.��All these things increase the physiological reserve of the mother and hateful that signs of hypovolaemia appear later.��The physiological responses to shock will always favour the female parent, and whereas fifty-fifty in moderate daze, the mother may be quite well, the foetus may actually be in astringent stupor, deprived of the majority of its perfusion.�� Invasive maternal monitoring and foetal cardiotocographic monitoring are often required at an early stage to minimise complications to both mother and foetus.��Always accept advice from an obstetrician early.
five.	DRUGS - Various drugs can affect the torso'south response to stress.��Beta- blockers prevent the tachycardia and increased sympathetic responses to shock and may confuse the clinical picture.��Diuretic use causes a relative hypovolaemia which may impair the body'southward reserve to reply to stress.
vi.	HEAD INJURIES - The brain has a very loftier demand for oxygen and and so secondary encephalon damage volition occur very chop-chop if the brain is deprived of its supply of oxygenated claret.��The Cerebral Perfusion Pressure is equal to the Mean Arterial Blood Force per unit area minus the Intra-Cranial Pressure.��Thus, encephalon perfusion is reduced either by a decrease in blood pressure, or by an increase in intra-cranial pressure.��Caput injuries may increment intra-cranial pressure past the presence of mass-lesions (haematoma) preventing the gratis circulation of cerebro-spinal fluid.��Sub-arachnoid haemorrhage increases intra-cranial force per unit area because the blood in the cerebro-spinal fluid blocks the arachnoid granulations and thereby stops the CSF from beingness reabsorbed back into the venous organization. There are a number of alien processes in the head injured patient that make information technology essential to treat shock and hypovolaemia in a very precise style.�� Over cautious volume resuscitation volition result in hypotension wheras over enthusiastic book resuscitation will issue in volume overload which may exacerbate an already precarious intra-cranial force per unit area.��The key aspects in the optimal management of the head injured patient include : early invasive monitoring to assist in authentic volume resuscitation, early endotracheal intubation to assist with hyperventilation (aim low end of normal pCO2), and early consultation with an experienced neurosurgeon.

D��-��DYSFUNCTION & DISABILITY OF THE CNS

• An AVPU or GCS assessment is carried out.
• The patient's pupils are examined for size, symmetry & reaction to light.
• The consensual pupillary reflex can besides be tested here.

AVPU Assessment :-

�������A��-��Alert
�������V��-��Responding to Voice
�������P��-��Responding to Hurting
�������U��-��Unresponsive

Glasgow Blackout Scale (GCS) :-

• Heart Opening
  ��������4��-��Spontaneous
  ��������3��-��To Speech
  ��������ii��-��To Pain
  ��������i��-��No Middle Opening
• All-time Exact Response
  ��������5��-��Orientated
  ��������4��-��Confused Conversation
  ��������3��-��Inappropriate Words
  ��������2��-��Incomprehensible Sounds
  ��������1��-��No Response
• Best Motor Response
  ��������half-dozen��-��Obeys commands
  ��������five��-��Appropriate localising response to hurting
  ��������4��-��Withdrawal response
  ��������3��-��Abnormal flexion response (Decorticate Rigidity)
  ��������2��-��Extension response (Decerebrate rigidity)
  ��������1��-��No Response
  

E��-��EXPOSURE��&��ENVIRONMENTAL CONTROL

• Here, any clothes which haven't already gone are removed.
• Care is nevertheless taken to protect all areas of the spine from undue movement.
• Log Roll is sometimes done at 'E'.
• Finally, the patient is covered with a blanket or other suitable warm covering to prevent hypothermia.

Here endeth the lesson !!

---

��To contact me : E-mail��

���My Website is at� http://www.jwolfe.clara.net.

����Back to� Height of this folio

---

���Last Modified : twelfth January 2019

---

Source: http://wolfescape.com/WebPages/Atls.htm

Share this post