ATLS Student Course Manual

ATLS ® Advanced Trauma Life Support® Student Course Manual BRIEF CONTENTS Foreword v Preface vii Acknowledgments xv Course Overview xxix CHAPTER 1 Initial Assessment and Management 2 CHAPTER 2 Airway and Ventilatory Management 22 CHAPTER 3 Shock 42 CHAPTER 4 Thoracic T...

ATLS ® Advanced Trauma Life Support® Student Course Manual BRIEF CONTENTS Foreword v Preface vii Acknowledgments xv Course Overview xxix CHAPTER 1 Initial Assessment and Management 2 CHAPTER 2 Airway and Ventilatory Management 22 CHAPTER 3 Shock 42 CHAPTER 4 Thoracic Trauma 62 CHAPTER 5 Abdominal and Pelvic Trauma 82 CHAPTER 6 Head Trauma 102 CHAPTER 7 Spine and Spinal Cord Trauma 128 CHAPTER 8 Musculoskeletal Trauma 148 CHAPTER 9 Thermal Injuries 168 CHAPTER 10 Pediatric Trauma 186 CHAPTER 11 Geriatric Trauma 214 CHAPTER 12 Trauma in Pregnancy and Intimate Partner Violence 226 CHAPTER 13 Transfer to Definitive Care 240 APPENDICES 255 APPENDIX A: Ocular Trauma 257 APPENDIX B: Hypothermia and Heat Injuries 265 APPENDIX C: Trauma Care during Mass-Casualty, Austere, and Operational Environments 275 APPENDIX D: Disaster Preparedness and Response 289 APPENDIX E: ATLS and Trauma Team Resource Management 303 APPENDIX F: Triage Scenarios 317 APPENDIX G: Skills 335 INDEX 376 xlv DETAILED CONTENTS Foreword v Preface vii Acknowledgments Course Overview CHAPTER 1 INITIAL ASSESSMENT AND MANAGEMENT xv xxix 2 CHAPTER 2 AIRWAY AND VENTILATORY MANAGEMENT 22 Objectives 23 Introduction 24 Airway 24 Ventilation 26 Airway Management 27 Management of Oxygenation 36 Management of Ventilation 38 Teamwork 38 Chapter Summary 39 Bibliography 39 Objectives 3 Introduction 4 Preparation 4 Triage 6 Primary Survey with Simultaneous Resuscitation 7 Adjuncts to the Primary Survey with Resuscitation 10 Consider Need for Patient Transfer 12 Objectives 43 Special Populations 13 Introduction 44 Secondary Survey 13 Shock Pathophysiology 44 Adjuncts to the Secondary Survey 18 Initial Patient Assessment 45 Reevaluation 19 Hemorrhagic Shock 48 Definitive Care 19 Records and Legal Considerations 19 Initial Management of Hemorrhagic Shock Teamwork 19 Chapter Summary 20 Bibliography 21 CHAPTER 3 SHOCK 42 51 Blood Replacement 54 Special Considerations 56 Reassessing Patient Response and Avoiding Complications 58 xlvii ­xlviii DETAILED CONTENTS Teamwork 58 Anatomy Review 104 Chapter Summary 58 Physiology Review 107 Additional Resources 59 Classifications of Head Injuries 109 Bibliography 59 Evidence-Based Treatment Guidelines 111 CHAPTER 4 THORACIC TRAUMA 62 Primary Survey and Resuscitation 117 Secondary Survey 120 Diagnostic Procedures 120 Objectives 63 Introduction 64 Primary Survey: Life-Threatening Injuries 64 Surgical Management 122 Secondary Survey 72 Prognosis 124 Teamwork 78 Brain Death 124 Chapter Summary 78 Teamwork 124 Bibliography 79 Chapter Summary 124 Bibliography 125 CHAPTER 5 ABDOMINAL AND PELVIC TRAUMA 82 Medical Therapies for Brain Injury 120 CHAPTER 7 SPINE AND SPINAL CORD TRAUMA 128 Objectives 83 Introduction 84 Objectives 129 Anatomy of the Abdomen 84 Introduction 130 Mechanism of Injury 85 Anatomy and Physiology 130 Assessment and Management 86 Teamwork 98 Documentation of Spinal Cord Injuries 135 Chapter Summary 98 Specific Types of Spinal Injuries 136 Bibliography 99 Radiographic Evaluation 139 General Management 141 Teamwork 144 102 Chapter Summary 144 Objectives 103 Bibliography 145 Introduction 104 CHAPTER 6 HEAD TRAUMA ­xlix DETAILED CONTENTS CHAPTER 8 MUSCULOSKELETAL TRAUMA 148 Objectives 149 Introduction 150 Primary Survey and Resuscitation of Patients with Potentially LifeThreatening Extremity Injuries 150 Adjuncts to the Primary Survey 152 Secondary Survey 153 Limb-Threatening Injuries 156 Other Extremity Injuries 161 Principles of Immobilization Cold Injury: Systemic Hypothermia 183 Teamwork 183 Chapter Summary 183 Bibliography 184 CHAPTER 10 PEDIATRIC TRAUMA 186 Objectives 187 Introduction 188 Types and Patterns of Injury 188 163 Unique Characteristics of Pediatric Patients 188 Pain Control 163 Airway 190 Associated Injuries 164 Breathing 195 Occult Skeletal Injuries 165 Circulation and Shock 195 Teamwork 165 Cardiopulmonary Resuscitation 199 Chapter Summary 165 Chest Trauma 199 Bibliography 166 Abdominal Trauma 200 Head Trauma 202 CHAPTER 9 THERMAL INJURIES 168 Spinal Cord Injury 205 Objectives 169 Musculoskeletal Trauma 206 Introduction 170 Child Maltreatment 207 Prevention 208 Teamwork 208 Chapter Summary 209 Bibliography 209 CHAPTER 11 GERIATRIC TRAUMA 214 Primary Survey and Resuscitation of Patients with Burns 170 Patient Assessment 174 Secondary Survey and Related Adjuncts 176 Unique Burn Injuries 178 Patient Transfer 180 Cold Injury: Local Tissue Effects 181 Objectives 215 ­l DETAILED CONTENTS Introduction 216 Effects of Aging and Impact of Preexisting Conditions 216 Objectives 241 Mechanism of Injury 217 Introduction 242 Determining the Need for Patient Transfer 242 Treatment before Transfer 245 Transfer Responsibilities 246 Modes of Transportation 248 Transfer Protocols 249 Primary Survey with Resuscitation 217 Specific Injuries 220 Special Circumstances 222 Teamwork 223 Chapter Summary 223 Bibliography 223 CHAPTER 12 TRAUMA IN PREGNANCY AND INTIMATE PARTNER VIOLENCE 226 CHAPTER 13 TRANSFER TO DEFINITIVE CARE 240 Transfer Data 251 Teamwork 251 Chapter Summary 251 Bibliography 251 Objectives 227 Introduction 228 Anatomical and Physiological Alterations of Pregnancy 228 APPENDIX A: Ocular Trauma 257 Mechanisms of Injury 231 Severity of Injury 232 APPENDIX B: Hypothermia and Heat Injuries 265 Assessment and Treatment 233 Perimortem Cesarean Section 235 APPENDIX C: Trauma Care in Mass-Casualty, Austere, and Operational Environments (Optional Lecture) 275 Intimate Partner Violence 235 Teamwork 237 Chapter Summary 238 Additional Resources Concerning Intimate Partner Violence 238 Bibliography 238 APPENDICES 255 APPENDIX D: Disaster Preparedness and Response (Optional Lecture) 289 APPENDIX E: ATLS and Trauma Team Resource Management 303 APPENDIX F: Triage Scenarios 317 APPENDIX G: Skills 335 INDEX 377 1 INITIAL ASSESSMENT AND MANAGEMENT Repeat the primary survey frequently to identify any deterioration in the patient’s status that indicates the need for additional intervention.Objectives CHAPTER 1 Outline Objectives Introduction Preparation • Prehospital Phase • Hospital Phase Triage • Multiple Casualties • Mass Casualties Primary Survey with Simultaneous Resuscitation • Airway Maintenance with Restriction of Cervical Spine Motion • Breathing and Ventilation • Circulation with Hemorrhage Control • Disability (Neurologic Evaluation) • Exposure and Environmental Control Adjuncts to the Primary Survey with Resuscitation • Electrocardiographic Monitoring • Pulse Oximetry • Ventilatory Rate, Capnography, and Arterial Blood Gases • Urinary and Gastric Catheters • X-ray Examinations and Diagnostic Studies Consider Need for Patient Transfer Special Populations Reevaluation Definitive Care Records and Legal Considerations • Records • Consent for Treatment • Forensic Evidence Teamwork Chapter Summary Bibliography Secondary Survey • History • Physical Examination Adjuncts to the Secondary Survey OBJECTIVES After reading this chapter and comprehending the knowledge components of the ATLS provider course, you will be able to: 1. Explain the importance of prehospital and hospital preparation to facilitate rapid resuscitation of trauma patients. 2. Identify the correct sequence of priorities for the assessment of injured patients. 3. Explain the principles of the primary survey, as they apply to the assessment of an injured patient. 4. Explain how a patient’s medical history and the mechanism of injury contribute to the identification of injuries. 8. Explain the management techniques employed during the primary assessment and stabilization of a multiply injured patient. 9. Identify the adjuncts to the assessment and management of injured patients as part of the primary survey, and recognize the contraindications to their use. 10. Recognize patients who require transfer to another facility for definitive management. 11. Identify the components of a secondary survey, including adjuncts that may be appropriate during its performance. 5. Explain the need for immediate resuscitation during the primary survey. 12. Discuss the importance of reevaluating a patient who is not responding appropriately to resuscitation and management. 6. Describe the initial assessment of a multiply injured patient, using the correct sequence of priorities. 13. Explain the importance of teamwork in the initial assessment of trauma patients. 7. Identify the pitfalls associated with the initial assessment and management of injured patients and describe ways to avoid them. n BACK TO TABLE OF CONTENTS 3 ­4 CHAPTER 1 n Initial Assessment and Management W hen treating injured patients, clinicians rapidly assess injuries and institute lifepreserving therapy. Because timing is crucial, a systematic approach that can be rapidly and accurately applied is essential. This approach, termed the “initial assessment,” includes the following elements: •• Preparation •• Triage •• Primary survey (ABCDEs) with immediate resuscitation of patients with life-threatening injuries •• Adjuncts to the primary survey and resuscitation •• Consideration of the need for patient transfer •• Secondary survey (head-to-toe evaluation and patient history) •• Adjuncts to the secondary survey •• Continued postresuscitation monitoring and reevaluation •• Definitive care The primary and secondary surveys are repeated frequently to identify any change in the patient’s status that indicates the need for additional intervention. The assessment sequence presented in this chapter reflects a linear, or longitudinal, progression of events. In an actual clinical situation, however, many of these activities occur simultaneously. The longitudinal progression of the assessment process allows clinicians an opportunity to mentally review the progress of actual trauma resuscitation. ATLS® principles guide the assessment and resuscitation of injured patients. Judgment is required to determine which procedures are necessary for individual patients, as they may not require all of them. pr eparation Preparation for trauma patients occurs in two different clinical settings: in the field and in the hospital. First, during the prehospital phase, events are coordinated with the clinicians at the receiving hospital. Second, during the hospital phase, preparations are made to facilitate rapid trauma patient resuscitation. Prehospital Phase Coordination with prehospital agencies and personnel can greatly expedite treatment in the field (n FIGURE n BACK TO TABLE OF CONTENTS n FIGURE 1-1 Prehospital Phase. During the prehospital phase, personnel emphasize airway maintenance, control of external bleeding and shock, immobilization of the patient, and immediate transport to the closest appropriate facility, preferably a verified trauma center. 1-1). The prehospital system ideally is set up to notify the receiving hospital before personnel transport the patient from the scene. This allows for mobilization of the hospital’s trauma team members so that all necessary personnel and resources are present in the emergency department (ED) at the time of the patient’s arrival. During the prehospital phase, providers emphasize airway maintenance, control of external bleeding and shock, immobilization of the patient, and immediate transport to the closest appropriate facility, preferably a verified trauma center. Prehospital providers must make every effort to minimize scene time, a concept that is supported by the Field Triage Decision Scheme, shown in (n FIGURE 1-2) and MyATLS mobile app. Emphasis also is placed on obtaining and reporting information needed for triage at the hospital, including time of injury, events related to the injury, and patient history. The mechanisms of injury can suggest the degree of injury as well as specific injuries the patient needs evaluated and treated. The National Association of Emergency Medical Technicians’ Prehospital Trauma Life Support Committee, in cooperation with the Committee on Trauma (COT) of the American College of Surgeons (ACS), has developed the Prehospital Trauma Life Support (PHTLS) course. PHTLS is similar to the ATLS Course in format, although it addresses the prehospital care of injured patients. The use of prehospital care protocols and the ability to access online medical direction (i.e., direct medical control) can facilitate and improve care initiated in the field. Periodic multidisciplinary review of patient care through a quality improvement process is an essential component of each hospital’s trauma program. PREPARATION n FIGURE 1-2 Field Triage Decision Scheme n BACK TO TABLE OF CONTENTS 5 ­6 CHAPTER 1 n Initial Assessment and Management Hospital Phase Advance planning for the arrival of trauma patients is essential (see Pre-alert checklist on the MyATLS mobile app.) The hand-over between prehospital providers and those at the receiving hospital should be a smooth process, directed by the trauma team leader, ensuring that all important information is available to the entire team. Critical aspects of hospital preparation include the following: •• A resuscitation area is available for trauma patients. •• Properly functioning airway equipment (e.g., laryngoscopes and endotracheal tubes) is organized, tested, and strategically placed to be easily accessible. •• Warmed intravenous crystalloid solutions are immediately available for infusion, as are appropriate monitoring devices. •• A protocol to summon additional medical assistance is in place, as well as a means to ensure prompt responses by laboratory and radiology personnel. •• Transfer agreements with verified trauma centers are established and operational. (See ACS COT’s Resources for Optimal Care of the Injured Patient, 2014). Due to concerns about communicable diseases, particularly hepatitis and acquired immunodeficiency syndrome (AIDS), the Centers for Disease Control and Prevention (CDC) and other health agencies strongly recommend the use of standard precautions (e.g., face mask, eye protection, water-impervious gown, and gloves) when coming into contact with body fluids (n FIGURE 1-3). The ACS COT considers these to be minimum precautions and protection for all healthcare providers. Standard precautions are also an Occupational Safety and Health Administration (OSHA) requirement in the United States. Tr i ag e Triage involves the sorting of patients based on the resources required for treatment and the resources that are actually available. The order of treatment is based on the ABC priorities (airway with cervical spine protection, breathing, and circulation with hemorrhage control). Other factors that can affect n BACK TO TABLE OF CONTENTS n FIGURE 1-3 Trauma team members are trained to use standard precautions, including face mask, eye protection, water-impervious gown, and gloves, when coming into contact with body fluids. triage and treatment priority include the severity of injury, ability to survive, and available resources. Triage also includes the sorting of patients in the field to help determine the appropriate receiving medical facility. Trauma team activation may be considered for severely injured patients. Prehospital personnel and their medical directors are responsible for ensuring that appropriate patients arrive at appropriate hospitals. For example, delivering a patient who has sustained severe trauma to a hospital other than a trauma center is inappropriate when such a center is available (see n FIGURE 1-2). Prehospital trauma scoring is often helpful in identifying severely injured patients who warrant transport to a trauma center. (See Trauma Scores: Revised and Pediatric.) Triage situations are categorized as multiple casualties or mass casualties. Multiple Casualties Multiple-casualty incidents are those in which the number of patients and the severity of their injuries do not exceed the capability of the facility to render care. In such cases, patients with life-threatening problems and those sustaining multiple-system injuries are treated first. Mass Casualties In mass-casualty events, the number of patients and the severity of their injuries does exceed the capability of the facility and staff. In such cases, patients having the greatest chance of survival and requiring the least expenditure of time, equipment, supplies, and PRIMARY SURVEY WITH SIMULTANEOUS RESUSCITATION personnel are treated first. (See Appendix D: Disaster Management and Emergency Preparedness.) Primary Survey with Simultaneous Resuscitation Patients are assessed, and their treatment priorities are established, based on their injuries, vital signs, and the injury mechanisms. Logical and sequential treatment priorities are established based on the overall assessment of the patient. The patient’s vital functions must be assessed quickly and efficiently. Management consists of a rapid primary survey with simultaneous resuscitation of vital functions, a more detailed secondary survey, and the initiation of definitive care (see Initial Assessment video on MyATLS mobile app). The primary survey encompasses the ABCDEs of trauma care and identifies life-threatening conditions by adhering to this sequence: •• Airway maintenance with restriction of cervical spine motion •• Breathing and ventilation •• Circulation with hemorrhage control •• Disability(assessment of neurologic status) •• Exposure/Environmental control Clinicians can quickly assess A, B, C, and D in a trauma patient (10-second assessment) by identifying themselves, asking the patient for his or her name, and asking what happened. An appropriate response suggests that there is no major airway compromise (i.e., ability to speak clearly), breathing is not severely compromised (i.e., ability to generate air movement to permit speech), and the level of consciousness is not markedly decreased (i.e., alert enough to describe what happened). Failure to respond to these questions suggests abnormalities in A, B, C, or D that warrant urgent assessment and management. During the primary survey, life-threatening conditions are identified and treated in a prioritized sequence based on the effects of injuries on the patient’s physiology, because at first it may not be possible to identify specific anatomic injuries. For example, airway compromise can occur secondary to head trauma, injuries causing shock, or direct physical trauma to the airway. Regardless of the injury causing airway compromise, the first priority is airway management: clearing the airway, suctioning, administering oxygen, and opening and securing the airway. Because the prioritized sequence is based on the degree of life n BACK TO TABLE OF CONTENTS 7 threat, the abnormality posing the greatest threat to life is addressed first. Recall that the prioritized assessment and management procedures described in this chapter are presented as sequential steps in order of importance and to ensure clarity; in practice, these steps are frequently accomplished simultaneously by a team of healthcare professionals (see Teamwork, on page 19 and Appendix E). Airway Maintenance with RESTRICTION OF CERVICAL SPINE MOTION Upon initial evaluation of a trauma patient, first assess the airway to ascertain patency. This rapid assessment for signs of airway obstruction includes inspecting for foreign bodies; identifying facial, mandibular, and/or tracheal/laryngeal fractures and other injuries that can result in airway obstruction; and suctioning to clear accumulated blood or secretions that may lead to or be causing airway obstruction. Begin measures to establish a patent airway while restricting cervical spine motion. If the patient is able to communicate verbally, the airway is not likely to be in immediate jeopardy; however, repeated assessment of airway patency is prudent. In addition, patients with severe head injuries who have an altered level of consciousness or a Glasgow Coma Scale (GCS) score of 8 or lower usually require the placement of a definitive airway (i.e., cuffed, secured tube in the trachea). (The GCS is further explained and demonstrated in Chapter 6: Head Trauma and the MyATLS app.) Initially, the jaw-thrust or chin-lift maneuver often suffices as an initial intervention. If the patient is unconscious and has no gag reflex, the placement of an oropharyngeal airway can be helpful temporarily. Establish a definitive airway if there is any doubt about the patient’s ability to maintain airway integrity. The finding of nonpurposeful motor responses strongly suggests the need for definitive airway management. Management of the airway in pediatric patients requires knowledge of the unique anatomic features of the position and size of the larynx in children, as well as special equipment (see Chapter 10: Pediatric Trauma). While assessing and managing a patient’s airway, take great care to prevent excessive movement of the cervical spine. Based on the mechanism of trauma, assume that a spinal injury exists. Neurologic examination alone does not exclude a diagnosis of cervical spine injury. The spine must be protected from excessive mobility to prevent development of or progression of a deficit. The cervical spine is protected ­8 CHAPTER 1 n Initial Assessment and Management Pitfall prevention Equipment failure • Test equipment regularly. • Ensure spare equipment and batteries are readily available. Unsuccessful intubation • Identify patients with difficult airway anatomy. • Identify the most experienced/ skilled airway manager on your team. • Ensure appropriate equipment is available to rescue the failed airway attempt. • Be prepared to perform a surgical airway. Progressive airway loss • Recognize the dynamic status of the airway. • Recognize the injuries that can result in progressive airway loss. • Frequently reassess the patient for signs of deterioration of the airway. n FIGURE 1-4 Cervical spine motion restriction technique. When the cervical collar is removed, a member of the trauma team manually stabilizes the patient’s head and neck. with a cervical collar. When airway management is necessary, the cervical collar is opened, and a team member manually restricts motion of the cervical spine (n FIGURE 1-4). While every effort should be made to recognize airway compromise promptly and secure a definitive airway, it is equally important to recognize the potential for progressive airway loss. Frequent reevaluation of airway patency is essential to identify and treat patients who are losing the ability to maintain an adequate airway. Establish an airway surgically if intubation is contraindicated or cannot be accomplished. Breathing and Ventilation Airway patency alone does not ensure adequate ventilation. Adequate gas exchange is required to maximize oxygenation and carbon dioxide elimination. Ventilation requires adequate function of the lungs, chest wall, and diaphragm; therefore, clinicians must rapidly examine and evaluate each component. To adequately assess jugular venous distention, position of the trachea, and chest wall excursion, expose the patient’s neck and chest. Perform auscultation to ensure gas flow in the lungs. Visual inspection and palpation can detect injuries to the chest wall that may be compromising ventilation. Percussion of the thorax can also identify abnormalities, but during a noisy resuscitation this evaluation may be inaccurate. Injuries that significantly impair ventilation in the short term include tension pneumothorax, massive hemothorax, open pneumothorax, and tracheal or n BACK TO TABLE OF CONTENTS bronchial injuries. These injuries should be identified during the primary survey and often require immediate attention to ensure effective ventilation. Because a tension pneumothorax compromises ventilation and circulation dramatically and acutely, chest decompression should follow immediately when suspected by clinical evaluation. Every injured patient should receive supplemental oxygen. If the patient is not intubated, oxygen should be delivered by a mask-reservoir device to achieve optimal oxygenation. Use a pulse oximeter to monitor adequacy of hemoglobin oxygen saturation. Simple pneumothorax, simple hemothorax, fractured ribs, flail chest, and pulmonary contusion can compromise ventilation to a lesser degree and are usually identified during the secondary survey. A simple pneumothorax can be converted to a tension pneumothorax when a patient is intubated and positive pressure ventilation is provided before decompressing the pneumothorax with a chest tube. Airway and ventilatory management are described in further detail in Chapter 2. Circulation with Hemorrhage Control Circulatory compromise in trauma patients can result from a variety of injuries. Blood volume, cardiac output, and bleeding are major circulatory issues to consider. PRIMARY SURVEY WITH SIMULTANEOUS RESUSCITATION Blood Volume and Cardiac Output Hemorrhage is the predominant cause of preventable deaths after injury. Identifying, quickly controlling hemorrhage, and initiating resuscitation are therefore crucial steps in assessing and managing such patients. Once tension pneumothorax has been excluded as a cause of shock, consider that hypotension following injury is due to blood loss until proven otherwise. Rapid and accurate assessment of an injured patient’s hemodynamic status is essential. The elements of clinical observation that yield important information within seconds are level of consciousness, skin perfusion, and pulse. •• Level of Consciousness—When circulating blood volume is reduced, cerebral perfusion may be critically impaired, resulting in an altered level of consciousness. •• Skin Perfusion—This sign can be helpful in evaluating injured hypovolemic patients. A patient with pink skin, especially in the face and extremities, rarely has critical hypovolemia after injury. Conversely, a patient with hypovolemia may have ashen, gray facial skin and pale extremities. •• Pulse—A rapid, thready pulse is typically a sign of hypovolemia. Assess a central pulse (e.g., femoral or carotid artery) bilaterally for quality, rate, and regularity. Absent central pulses that cannot be attributed to local factors signify the need for immediate resuscitative action. Bleeding Identify the source of bleeding as external or internal. External hemorrhage is identified and controlled during the primary survey. Rapid, external blood loss is managed by direct manual pressure on the wound. Tourniquets are effective in massive exsanguination from an extremity but carry a risk of ischemic injury to that extremity. Use a tourniquet only when direct pressure is not effective and the patient’s life is threatened. Blind clamping can result in damage to nerves and veins. The major areas of internal hemorrhage are the chest, abdomen, retroperitoneum, pelvis, and long bones. The source of bleeding is usually identified by physical examination and imaging (e.g., chest x-ray, pelvic x-ray, focused assessment with sonography for trauma [FAST], or diagnostic peritoneal lavage [DPL]). Immediate n BACK TO TABLE OF CONTENTS 9 management may include chest decompression, and application of a pelvic stabilizing device and/ or extremity splints. Definitive management may require surgical or interventional radiologic treatment and pelvic and long-bone stabilization. Initiate surgical consultation or transfer procedures early in these patients. Definitive bleeding control is essential, along with appropriate replacement of intravascular volume. Vascular access must be established; typically two large-bore peripheral venous catheters are placed to administer fluid, blood, and plasma. Blood samples for baseline hematologic studies are obtained, including a pregnancy test for all females of childbearing age and blood type and cross matching. To assess the presence and degree of shock, blood gases and/or lactate level are obtained. When peripheral sites cannot be accessed, intraosseous infusion, central venous access, or venous cutdown may be used depending on the patient’s injuries and the clinician’s skill level. Aggressive and continued volume resuscitation is not a substitute for definitive control of hemorrhage. Shock associated with injury is most often hypovolemic in origin. In such cases, initiate IV fluid therapy with crystalloids. All IV solutions should be warmed either by storage in a warm environment (i.e., 37°C to 40°C, or 98.6°F to 104°F) or administered through fluidwarming devices. A bolus of 1 L of an isotonic solution may be required to achieve an appropriate response in an adult patient. If a patient is unresponsive to initial crystalloid therapy, he or she should receive a blood transfusion. Fluids are administered judiciously, as aggressive resuscitation before control of bleeding has been demonstrated to increase mortality and morbidity. Severely injured trauma patients are at risk for coagulopathy, which can be further fueled by resuscitative measures. This condition potentially establishes a cycle of ongoing bleeding and further resuscitation, which can be mitigated by use of massive transfusion protocols with blood components administered at predefined low ratios (see Chapter 3: Shock). One study that evaluated trauma patients receiving fluid in the ED found that crystalloid resuscitation of more than 1.5 L independently increased the odds ratio of death. Some severely injured patients arrive with coagulopathy already established, which has led some jurisdictions to administer tranexamic acid preemptively in severely injured patients. European and American military studies demonstrate improved survival when tranexamic acid is administered within 3 hours of injury. When bolused in the field follow up infusion is given over 8 hours in the hospital (see Guidance Document for the Prehospital Use of Tranexamic Acid in Injured Patients). ­10 CHAPTER 1 n Initial Assessment and Management Disability (Neurologic Evaluation) A rapid neurologic evaluation establishes the patient’s level of consciousness and pupillary size and reaction; identifies the presence of lateralizing signs; and determines spinal cord injury level, if present. The GCS is a quick, simple, and objective method of determining the level of consciousness. The motor score of the GCS correlates with outcome. A decrease in a patient’s level of consciousness may indicate decreased cerebral oxygenation and/or perfusion, or it may be caused by direct cerebral injury. An altered level of consciousness indicates the need to immediately reevaluate the patient’s oxygenation, ventilation, and perfusion status. Hypoglycemia, alcohol, narcotics, and other drugs can also alter a patient’s level of consciousness. Until proven otherwise, always presume that changes in level of consciousness are a result of central nervous system injury. Remember that drug or alcohol intoxication can accompany traumatic brain injury. Primary brain injury results from the structural effect of the injury to the brain. Prevention of secondary brain injury by maintaining adequate oxygenation and perfusion are the main goals of initial management. Because evidence of brain injury can be absent or minimal at the time of initial evaluation, it is crucial to repeat the examination. Patients with evidence of brain injury should be treated at a facility that has the personnel and resources to anticipate and manage the needs of these patients. When resources to care for these patients are not available arrangements for transfer should begin as soon as this condition is recognized. Similarly, consult a neurosurgeon once a brain injury is recognized. Exposure and Environmental Control During the primary survey, completely undress the patient, usually by cutting off his or her garments to facilitate a thorough examination and assessment. After completing the assessment, cover the patient with warm blankets or an external warming device to prevent him or her from developing hypothermia in the trauma receiving area. Warm intravenous fluids before infusing them, and maintain a warm environment. Hypothermia can be present when the patient arrives, or it may develop quickly in the ED if the patient is uncovered and undergoes rapid administration of room-temperature fluids or refrigerated blood. Because hypothermia is a potentially lethal complication in injured patients, take aggressive measures to prevent the loss of body heat and restore body temperature n BACK TO TABLE OF CONTENTS to normal. The patient’s body temperature is a higher priority than the comfort of the healthcare providers, and the temperature of the resuscitation area should be increased to minimize the loss of body heat. The use of a high-flow fluid warmer to heat crystalloid fluids to 39°C (102.2°F) is recommended. When fluid warmers are not available, a microwave can be used to warm crystalloid fluids, but it should never be used to warm blood products. Pitfall prevention Hypothermia can be present on admission. • Ensure a warm environment. • Use warm blankets. • Warm fluids before administering. Hypothermia may develop after admission. • Control hemorrhage rapidly. • Warm fluids before administering. • Ensure a warm environment. • Use warm blankets. Adjuncts to the Primary Survey with Resuscitation Adjuncts used during the primary survey include continuous electrocardiography, pulse oximetry, carbon dioxide (CO2) monitoring, and assessment of ventilatory rate, and arterial blood gas (ABG) measurement. In addition, urinary catheters can be placed to monitor urine output and assess for hematuria. Gastric catheters decompress distention and assess for evidence of blood. Other helpful tests include blood lactate, x-ray examinations (e.g., chest and pelvis), FAST, extended focused assessment with sonography for trauma (eFAST), and DPL. Physiologic parameters such as pulse rate, blood pressure, pulse pressure, ventilatory rate, ABG levels, body temperature, and urinary output are assessable measures that reflect the adequacy of resuscitation. Values for these parameters should be obtained as soon as is practical during or after completing the primary survey, and reevaluated periodically. Electrocardiographic Monitoring Electrocardiographic (ECG) monitoring of all trauma patients is important. Dysrhythmias—including unexplained tachycardia, atrial fibrillation, premature ventricular contractions, and ST segment changes—can ADJUNCTS TO THE PRIMARY SURVEY WITH RESUSCITATION indicate blunt cardiac injury. Pulseless electrical activity (PEA) can indicate cardiac tamponade, tension pneumothorax, and/or profound hypovolemia. When bradycardia, aberrant conduction, and premature beats are present, hypoxia and hypoperfusion should be suspected immediately. Extreme hypothermia also produces dysrhythmias. Pulse Oximetry Pulse oximetry is a valuable adjunct for monitoring oxygenation in injured patients. A small sensor is placed on the finger, toe, earlobe, or another convenient place. Most devices display pulse rate and oxygen saturation continuously. The relative absorption of light by oxyhemoglobin (HbO) and deoxyhemoglobin is assessed by measuring the amount of red and infrared light emerging from tissues traversed by light rays and processed by the device, producing an oxygen saturation level. Pulse oximetry does not measure the partial pressure of oxygen or carbon dioxide. Quantitative measurement of these parameters occurs as soon as is practical and is repeated periodically to establish trends. In addition, hemoglobin saturation from the pulse oximeter should be compared with the value obtained from the ABG analysis. Inconsistency indicates that one of the two determinations is in error. Ventilatory Rate, Capnography, and Arterial Blood Gases Ventilatory rate, capnography, and ABG measurements are used to monitor the adequacy of the patient’s respirations. Ventilation can be monitored using end tidal carbon dioxide levels. End tidal CO2 can be detected using colorimetry, capnometry, or capnography—a noninvasive monitoring technique that provides insight into the patient’s ventilation, circulation, and metabolism. Because endotracheal tubes can be dislodged whenever a patient is moved, capnography can be used to confirm intubation of the airway (vs the esophagus). However, capnography does not confirm proper position of the tube within the trachea (see Chapter 2: Airway and Ventilatory Management). End tidal CO2 can also be used for tight control of ventilation to avoid hypoventilation and hyperventilation. It reflects cardiac output and is used to predict return of spontaneous circulation(ROSC) during CPR. In addition to providing information concerning the adequacy of oxygenation and ventilation, ABG values provide acid base information. In the trauma n BACK TO TABLE OF CONTENTS 11 setting, low pH and base excess levels indicate shock; therefore, trending these values can reflect improvements with resuscitation. Urinary and Gastric Catheters The placement of urinary and gastric catheters occurs during or following the primary survey. Urinary Catheters Urinary output is a sensitive indicator of the patient’s volume status and reflects renal perfusion. Monitoring of urinary output is best accomplished by insertion of an indwelling bladder catheter. In addition, a urine specimen should be submitted for routine laboratory analysis. Transurethral bladder catheterization is contraindicated for patients who may have urethral injury. Suspect a urethral injury in the presence of either blood at the urethral meatus or perineal ecchymosis. Accordingly, do not insert a urinary catheter before examining the perineum and genitalia. When urethral injury is suspected, confirm urethral integrity by performing a retrograde urethrogram before the catheter is inserted. At times anatomic abnormalities (e.g., urethral stricture or prostatic hypertrophy) preclude placement of indwelling bladder catheters, despite appropriate technique. Nonspecialists should avoid excessive manipulation of the urethra and the use of specialized instrumentation. Consult a urologist early. Gastric Catheters A gastric tube is indicated to decompress stomach distention, decrease the risk of aspiration, and check for upper gastrointestinal hemorrhage from trauma. Decompression of the stomach reduces the risk of aspiration, but does not prevent it entirely. Thick and semisolid gastric contents will not return through the tube, and placing the tube can induce vomiting. The tube is effective only if it is properly positioned and attached to appropriate suction. Blood in the gastric aspirate may indicate oropharyngeal (i.e., swallowed) blood, traumatic insertion, or actual injury to the upper digestive tract. If a fracture of the cribriform plate is known or suspected, insert the gastric tube orally to prevent intracranial passage. In this situation, any nasopharyngeal instrumentation is potentially dangerous, and an oral route is recommended. ­12 CHAPTER 1 n Initial Assessment and Management Pitfall prevention Gastric catheter • Be prepared to logroll the patient. • Ensure suction is immediately available. placement can induce vomiting. Pulse oximeter findings can be inaccurate. • Ensure placement of the pulse oximeter is above the BP cuff. • Confirm findings with ABG values. X-ray Examinations and Diagnostic Studies Use x-ray examination judiciously, and do not delay patient resuscitation or transfer to definitive care in patients who require a higher level of care. Anteroposterior (AP) chest and AP pelvic films often provide information to guide resuscitation efforts of patients with blunt trauma. Chest x-rays can show potentially life-threatening injuries that require treatment or further investigation, and pelvic films can show fractures of the pelvis that may indicate the need for early blood transfusion. These films can be taken in the resuscitation area with a portable x-ray unit, but not when they will interrupt the resuscitation process (n FIGURE 1-5). Do obtain essential diagnostic x-rays, even in pregnant patients. FAST, eFAST, and DPL are useful tools for quick detection of intraabdominal blood, pneumothorax, and hemothorax. Their use depends on the clinician’s skill and experience. DPL can be challenging to perform in patients who are pregnant, have had prior laparoto- n FIGURE 1-5 Radiographic studies are important adjuncts to the primary survey. n BACK TO TABLE OF CONTENTS mies, or are obese. Surgical consultation should be obtained before performing this procedure in most circumstances. Furthermore, obesity and intraluminal bowel gas can compromise the images obtained by FAST. The finding of intraabdominal blood indicates the need for surgical intervention in hemodynamically abnormal patients. The presence of blood on FAST or DPL in the hemodynamically stable patient requires the involvement of a surgeon as a change in patient stability may indicate the need for intervention. Consider Need for Patient Transfer During the primary survey with resuscitation, the evaluating doctor frequently obtains sufficient information to determine the need to transfer the patient to another facility for definitive care. This transfer process may be initiated immediately by administrative personnel at the direction of the trauma team leader while additional evaluation and resuscitative measures are being performed. It is important not to delay transfer to perform an indepth diagnostic evaluation. Only undertake testing that enhances the ability to resuscitate, stabilize, and ensure the patient’s safe transfer. Once the decision to transfer a patient has been made, communication between the referring and receiving doctors is essential. n FIGURE 1-6 shows a patient monitored during critical care transport. n FIGURE 1-6 Vigilant care is also required when transfer takes place within an institution. SECONDARY SURVEY Spec i a l P opul ations Patient populations that warrant special consideration during initial assessment are children, pregnant women, older adults, obese patients, and athletes. Priorities for the care of these patients are the same as for all trauma patients, but these individuals may have physiologic responses that do not follow expected patterns and anatomic differences that require special equipment or consideration. Pediatric patients have unique physiology and anatomy. The quantities of blood, fluids, and medications vary with the size of the child. In addition, the injury patterns and degree and rapidity of heat loss differ. Children typically have abundant physiologic reserve and often have few signs of hypovolemia, even after severe volume depletion. When deterioration does occur, it is precipitous and catastrophic. Specific issues related to pediatric trauma patients are addressed in Chapter 10: Pediatric Trauma. The anatomic and physiologic changes of pregnancy can modify the patient’s response to injury. Early recognition of pregnancy by palpation of the abdomen for a gravid uterus and laboratory testing (e.g., human chorionic gonadotropin [hCG]), as well as early fetal assessment, are important for maternal and fetal survival. Specific issues related to pregnant patients are addressed in Chapter 12: Trauma in Pregnancy and Intimate Partner Violence. Although cardiovascular disease and cancer are the leading causes of death in older adults, trauma is also an increasing cause of death in this population. Resuscitation of older adults warrants special attention. The aging process diminishes the physiologic reserve of these patients, and chronic cardiac, respiratory, and metabolic diseases can impair their ability to respond to injury in the same manner as younger patients. Comorbidities such as diabetes, congestive heart failure, coronary artery disease, restrictive and obstructive pulmonary disease, coagulopathy, liver disease, and peripheral vascular disease are more common in older patients and may adversely affect outcomes following injury. In addition, the long-term use of medications can alter the usual physiologic response to injury and frequently leads to over-resuscitation or under-resuscitation in this patient population. Despite these facts, most elderly trauma patients recover when they are appropriately treated. Issues specific to older adults with trauma are described in Chapter 11: Geriatric Trauma. Obese patients pose a particular challenge in the trauma setting, as their anatomy can make procedures such as intubation difficult and hazardous. Diagnostic tests such as FAST, DPL, and CT are also more difficult. n BACK TO TABLE OF CONTENTS 13 In addition, many obese patients have cardiopulmonary disease, which limits their ability to compensate for injury and stress. Rapid fluid resuscitation can exacerbate their underlying comorbidities. Because of their excellent conditioning, athletes may not manifest early signs of shock, such as tachycardia and tachypnea. They may also have normally low systolic and diastolic blood pressure. Secondary Surv e y The secondary survey does not begin until the primary survey (ABCDE) is completed, resuscitative efforts are under way, and improvement of the patient’s vital functions has been demonstrated. When additional personnel are available, part of the secondary survey may be conducted while the other personnel attend to the primary survey. This method must in no way interfere with the performance of the primary survey, which is the highest priority. The secondary survey is a head-to-toe evaluation of the trauma patient—that is, a complete history and physical examination, including reassessment of all vital signs. Each region of the body is completely examined. The potential for missing an injury or failing to appreciate the significance of an injury is great, especially in an unresponsive or unstable patient. (See Secondary Survey video on MyATLS mobile app.) History Every complete medical assessment includes a history of the mechanism of injury. Often, such a history cannot be obtained from a patient who has sustained trauma; therefore, prehospital personnel and family must furnish this information. The AMPLE history is a useful mnemonic for this purpose: •• Allergies •• Medications currently used •• Past illnesses/Pregnancy •• Last meal •• Events/Environment related to the injury The patient’s condition is greatly influenced by the mechanism of injury. Knowledge of the mechanism of injury can enhance understanding of the patient’s physiologic state and provide clues to anticipated injuries. Some injuries can be predicted based on the ­14 CHAPTER 1 n Initial Assessment and Management table 1-1 mechanisms of injury and suspected injury patterns MECHANISM OF INJURY SUSPECTED INJURY PATTERNS MECHANISM OF INJURY SUSPECTED INJURY PATTERNS BLUNT INJURY Frontal impact, automobile collision • Bent steering wheel • Knee imprint, dashboard • Bull’s-eye fracture, windscreen Side impact, automobile collision • • • • • • • Cervical spine fracture Anterior flail chest Myocardial contusion Pneumothorax Traumatic aortic disruption Fractured spleen or liver Posterior fracture/dislocation of hip and/or knee Rear impact, automobile collision Ejection from vehicle • Head injury • Facial fractures • Contralateral neck sprain Head injury Cervical spine fracture Lateral flail chest Pneumothorax Traumatic aortic disruption Diaphragmatic rupture Fractured spleen/liver and/or kidney, depending on side of impact • Fractured pelvis or acetabulum • • • • • • • Motor vehicle impact with pedestrian Fall from height PENETRATING INJURY Stab wounds • Anterior chest • Left thoracoabdominal • Left diaphragm injury/spleen injury/hemopneumothorax • Abdomen • Abdominal visceral injury possible if peritoneal penetration Gunshot wounds (GSW) • Truncal • Extremity n • Cardiac tamponade if within ”box” • Hemothorax • Pneumothorax • Hemopneumothorax • High likelihood of injury • Trajectory from GSW/retained projectiles help predict injury • Neurovascular injury • Fractures • Compartment syndrome BACK TO TABLE OF CONTENTS • Cervical spine injury • Head injury • Soft tissue injury to neck • E  jection from the vehicle precludes meaningful prediction of injury patterns, but places patient at greater risk for virtually all injury mechanisms. • • • • Head injury Traumatic aortic disruption Abdominal visceral injuries Fractured lower extremities/pelvis • Head injury • Axial spine injury • Abdominal visceral injuries • Fractured pelvis or acetabulum • Bilateral lower extremity fractures (including calcaneal fractures) THERMAL INJURY Thermal burns • Circumferential eschar on extremity or chest • Occult trauma (mechanism of burn/means of escape) Electrical burns • Cardiac arrhythmias • Myonecrosis/compartment syndrome Inhalational burns • Carbon monoxide poisoning • Upper airway swelling • Pulmonary edema SECONDARY SURVEY direction and amount of energy associated with the mechanism of injury. (n TABLE 1-1) Injury patterns are also influenced by age groups and activities. Injuries are divided into two broad categories: blunt and penetrating trauma (see Biomechanics of Injury). Other types of injuries for which historical information is important include thermal injuries and those caused by hazardous environments. Blunt Trauma Blunt trauma often results from automobile collisions, falls, and other injuries related to transportation, recreation, and occupations. It can also result from interpersonal violence. Important information to obtain about automobile collisions includes seat-belt use, steering wheel deformation, presence and activation of air-bag devices, direction of impact, damage to the automobile in terms of major deformation or intrusion into the passenger compartment, and patient position in the vehicle. Ejection from the vehicle greatly increases the possibility of major injury. Penetrating Trauma In penetrating trauma, factors that determine the type and extent of injury and subsequent management include the body region that was injured, organs in the path of the penetrating object, and velocity of the missile. Therefore, in gunshot victims, the velocity, caliber, presumed path of the bullet, and distance from the wea-pon to the wound can provide important clues regarding the extent of injury. (See Biomechanics of Injury.) Thermal Injury Burns are a significant type of trauma that can occur alone or in conjunction with blunt and/or penetrating trauma resulting from, for example, a burning automobile, explosion, falling debris, or a patient’s attempt to escape a fire. Inhalation injury and carbon monoxide poisoning often complicate burn injuries. Information regarding the circumstances of the burn injury can increase the index of suspicion for inhalation injury or toxic exposure from combustion of plastics and chemicals. Acute or chronic hypothermia without adequate protection against heat loss produces either local or generalized cold injuries. Significant heat loss can occur at moderate temperatures (15°C to 20°C or 59°F to 68°F) if wet clothes, decreased activity, and/or vasodilation caused by alcohol or drugs compromise the patient’s ability to conserve heat. Such historical information can be n BACK TO TABLE OF CONTENTS 15 obtained from prehospital personnel. Thermal injuries are addressed in more detail in Chapter 9: Thermal Injuries and Appendix B: Hypothermia and Heat Injuries. Hazardous Environment A history of exposure to chemicals, toxins, and radiation is important to obtain for two main reasons: These agents can produce a variety of pulmonary, cardiac, and internal organ dysfunctions in injured patients, and they can present a hazard to healthcare providers. Frequently, the clinician’s only means of preparation for treating a patient with a history of exposure to a hazardous environment is to understand the general principles of management of such conditions and establish immediate contact with a Regional Poison Control Center. Appendix D: Disaster Management and Emergency Preparedness provides additional information about hazardous environments. Physical Examination During the secondary survey, physical examination follows the sequence of head, maxillofacial structures, cervical spine and neck, chest, abdomen and pelvis, perineum/rectum/vagina, musculoskeletal system, and neurological system. Head The secondary survey begins with evaluating the head to identify all related neurologic injuries and any other significant injuries. The entire scalp and head should be examined for lacerations, contusions, and evidence of fractures. (See Chapter 6: Head Trauma.) Because edema around the eyes can later preclude an in-depth examination, the eyes should be reevaluated for: •• Visual acuity •• Pupillary size •• Hemorrhage of the conjunctiva and/or fundi •• Penetrating injury •• Contact lenses (remove before edema occurs) •• Dislocation of the lens •• Ocular entrapment Clinicians can perform a quick visual acuity examination of both eyes by asking the patient to ­16 CHAPTER 1 n Initial Assessment and Management read printed material, such as a handheld Snellen chart or words on a piece of equipment. Ocular mobility should be evaluated to exclude entrapment of extraocular muscles due to orbital fractures. These procedures frequently identify ocular injuries that are not otherwise apparent. Appendix A: Ocular Trauma provides additional detailed information about ocular injuries. Maxillofacial Structures Examination of the face should include palpation of all bony structures, assessment of occlusion, intraoral examination, and assessment of soft tissues. Maxillofacial trauma that is not associated with airway obstruction or major bleeding should be treated only after the patient is stabilized and life-threatening injuries have been managed. At the discretion of appropriate specialists, definitive management may be safely delayed without compromising care. Patients with fractures of the midface may also have a fracture of the cribriform plate. For these patients, gastric intubation should be performed via the oral route. (See Chapter 6: Head Trauma.) Pitfall prevention Facial edema in patients • Perform ocular examination before edema develops. • Minimize edema development by elevation of the head of bed (reverse Trendelenburg position when spine injuries are suspected). with massive facial injury can preclude a complete eye examination. Some maxillofacial fractures, such as nasal fracture, nondisplaced zygomatic fractures, and orbital rim fractures, can be difficult to identify early in the evaluation process. • Maintain a high index of suspicion and obtain imaging when necessary. • Reevaluate patients frequently. and such injury should be presumed until evaluation of the cervical spine is completed. Evaluation may include radiographic series and/or CT, which should be reviewed by a doctor experienced in detecting cervical spine fractures radiographically. Radiographic evaluation can be avoided in patients who meet The National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) or Canadian C-Spine Rule (CCR). (See Chapter 7: Spine and Spinal Cord Trauma.) Examination of the neck includes inspection, palpation, and auscultation. Cervical spine tenderness, subcutaneous emphysema, tracheal deviation, and laryngeal fracture can be discovered on a detailed examination. The carotid arteries should be palpated and auscultated for bruits. A common sign of potential injury is a seatbelt mark. Most major cervical vascular injuries are the result of penetrating injury; however, blunt force to the neck or traction injury from a shoulderharness restraint can result in intimal disruption, dissection, and thrombosis. Blunt carotid injury can present with coma or without neurologic finding. CT angiography, angiography, or duplex ultrasonography may be required to exclude the possibility of major cervical vascular injury when the mechanism of injury suggests this possibility. Protection of a potentially unstable cervical spine injury is imperative for patients who are wearing any type of protective helmet, and extreme care must be taken when removing the helmet. Helmet removal is described in Chapter 2: Airway and Ventilatory Management. Penetrating injuries to the neck can potentially injure several organ systems. Wounds that extend through the platysma should not be explored manually, probed with instruments, or treated by individuals in the ED who are not trained to manage such injuries. Surgical consultation for their evaluation and management is indicated. The finding of active arterial bleeding, an expanding hematoma, arterial bruit, or airway compromise usually requires operative evaluation. Unexplained or isolated paralysis of an upper extremity should raise the suspicion of a cervical nerve root injury and should be accurately documented. Chest Cervical Spine and Neck Patients with maxillofacial or head trauma should be presumed to have a cervical spine injury (e.g., fracture and/or ligament injury), and cervical spine motion must be restricted. The absence of neurologic deficit does not exclude injury to the cervical spine, n BACK TO TABLE OF CONTENTS Visual evaluation of the chest, both anterior and posterior, can identify conditions such as open pneumothorax and large flail segments. A complete evaluation of the chest wall requires palpation of the entire chest cage, including the clavicles, ribs, and sternum. Sternal pressure can be painful if the sternum is fractured or costochondral separations SECONDARY SURVEY exist. Contusions and hematomas of the chest wall will alert the clinician to the possibility of occult injury. Significant chest injury can manifest with pain, dyspnea, and hypoxia. Evaluation includes inspection, palpation, auscultation and percussion, of the chest and a chest x-ray. Auscultation is conducted high on the anterior chest wall for pneumothorax and at the posterior bases for hemothorax. Although auscultatory findings can be difficult to evaluate in a noisy environment, they can be extremely helpful. Distant heart sounds and decreased pulse pressure can indicate cardiac tamponade. In addition, cardiac tamponade and tension pneumothorax are suggested by the presence of distended neck veins, although associated hypovolemia can minimize or eliminate this finding. Percussion of the chest demonstrates hyperresonace. A chest x-ray or eFAST can confirm the presence of a hemothorax or simple pneumothorax. Rib fractures may be present, but they may not be visible on an x-ray. A widened mediastinum and other radiographic signs can suggest an aortic rupture. (See Chapter 4: Thoracic Trauma.) Abdomen and Pelvis Abdominal injuries must be identified and treated aggressively. Identifying the specific injury is less important than determining whether operative intervention is required. A normal initial examination of the abdomen does not exclude a significant intraabdominal