Primary Assessment in Trauma ( For the Interns)

The protocol for assessment and the management of trauma victims is called ATLS (Advanced Trauma Life Support) The founder of ATLS is Dr James K. Styner .

The Story Behind ATLS !

In 1976, Dr. James K. Styner, met with an accident. His wife was killed instantly and three of his four children sustained critical injuries. The care his children  received from the nearest hospital was totally inadequate due to the lack of proper training of the staff !

Hence he started a training programme to the health care workers in 1976 called ATLS (Advanced Trauma Life Support) and now it is the accepted protocol for trauma management in the world over.

General Principles of ATLS

1. Rapid Evaluation of Patient-Time wasted costs lives!
2. A definitive diagnosis is Not necessary to start Rx.
3. Treatment should be started in the Golden Hour !
4. Fixing up the Priorities!
5. Should be governed by ‘First do no harm’ principle.

Golden Hour

It is the First Hour following the injury and Not after reaching the Hospital! If treatment is started during this period the complication rates are less and the survival rates are more.

Fixing up of Priorities

The things which will kill the patient first are always checked and treated first.  

Things which will kill the patient later are managed later.  

Thus, airway problems are managed first. Secondly treat breathing problems,

Later treat circulatory problems. Finally offer the definitive treatment.

Guidelines of Approach to a Trauma Victim

First Check for Responsiveness …Shake or Tap or Shout, "Are you OK?

If No Response, Look for Respiration and Pulse.

Carefully place the person on his back without twisting the head and neck .

Remove crash helmet with manual in-line stabilization of the cervical spine

Look for chest/abdominal movement . Listen for breath sounds and abnormal noises

Feel at mouth and nose for expired air.

Then feel for the pulse. Radial/Brachial/Carotid-Do not palpate both the carotids simultaneously!

Remember -complete airway obstruction is silent. If the person can utter his name properly, that means his airway is intact.

If there is no respiration/pulse start CPR as follows:-

Clear the airway – Only Jaw Thrust( No head tilt or chin lift )with manual in-line stabilization of the cervical spine. Pull the tongue out so that it stays in the mouth and not obstructing the throat. An ‘Oropharyngeal Airway’ if available can be used to keep the tongue forward.

In Standard CPR, a cycle includes 30 chest compressions followed by two rescue breathing. 5 cycles can be given within 2 minutes. Re assess the patient after every 5 cycles.

Hands-only CPR can be given by those who are reluctant to give mouth-to-mouth breathing. Blood circulation can be restored with chest compress ions.

For rescue breathing, one should use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs).

In a hospital set up one can use a face mask or an Ambu Bag for giving artificial respiration. If a Defibrillator is available, deliver one shock if instructed by the device, then begin CPR.

Remember giving CPR doubles a person's chances of survival. The difference between your doing something and doing nothing could be someone's life!

Never be panic or lose the presence of mind if something goes wrong unexpectedly. Take control of the situation as team leader. Do not hesitate to get help when needed. The most important first aid is ‘Common sense.’ Do not pull out an impacted object like a knife or push the protruded intestines back in to the abdomen ,at the site of event.

 The person who provides the first aid should look after his safety first. Consider all patients as Biohazards and take maximum precautions possible for your safety.

Start an intravenous infusion. Control bleeding if any. Remember 5 Ps to control bleeding-Positioning(a limb above the level of head), Pressure, Packing ,Procedural (wound suturing) and Patience ( the most important!).

Any major trauma victim will be benefited by giving oxygen inhalation. Re assure the victim and give maximum comfort as possible. Remember the famous quote by Hippocrates -Cure sometimes, treat often, comfort always!

Do not forget that a doctor is also a human being. He also makes mistakes. The best way to minimize mistakes is to follow this golden principle ‘Check, Re check and Check again!’

People judge you by your physical appearance, your ability to communicate, your knowledge and skills in the subject and your attitude and behavior towards the patients and the relatives. So keep a watch on these four aspects. (Dress neatly, be polite and empathetic as well as keep updated in your knowledge and skills.)

Empathy means understanding what others are feeling because you have experienced it yourself or can put yourself in their shoes.  

Sympathy means acknowledging another person's emotional hardships and providing comfort and assurance.

Follow the principles of Medical Ethics ( Dharma). If you safeguard ethics (dharma), it will protect you in return. But if you destroy ethics (dharma), it will destroy you.

There is no substitute for experience. Surgical techniques are learned through supervised practice. Learn the art of performing following surgical procedure. Grab the first opportunity. Don’t wait for the next

Practicals:-

         1.      How to establish an intravenous access
2.      How to do endo tracheal intubation
3.      How to insert a inter costal drainage tube
4.      How to give a splint immobilization  for fractures
5.      How to do wound suturing
6.      How to do dressing in various parts of the body
7.      How to do needle pericardio centesis
8.      How to do tracheostomy
9.      How to do needle cricothyroidotomy
10.  How to needle drainage of tension pneumo thorax