Challenges and Considerations in Trauma Assessment Protocols

Contributor: Meghan Hurley MD

Educational Pearls:

What is ATLS?

• Advanced Trauma Life Support (ATLS) is a systematic and comprehensive approach to the evaluation and management of trauma patients

• It was developed by the American College of Surgeons (ACS)

• The key components include the Primary Survey ("ABCDE"), the Secondary Survey, Definitive Care, and Special Considerations

What are the issues with ATLS?

• ATLS relies on many algorithms and rules-of-thumb, which might be helpful for individuals with basic skills and training but might actually present obstacles for those with higher levels of training. Dr. Hurley cites several examples.

Example 1: ABC approach to trauma patients

• ABC stands for Airway, Breathing, and Circulation but focusing on the airway first is not always the best decision.

• Immediate attention may need to be applied to massive hemorrhage.

• Intubating a patient that is hemodynamically unstable may cause cardiac arrest.

• A more helpful phrase might be "Resuscitate before you intubate."

Example 2: C-spine precautions

• Cervical collars may impede the likelihood of first-pass success when intubating. The risk of complications from a failed airway may often outweigh the risk of causing a spinal cord injury.

Example 3:Cutting clothes off.

• The E of ABCDE stands for exposure which means fully undressing the patient to look for missing injuries. This often involves cutting their clothes off.

• This practice might be too broadly applied and leave low-risk trauma patients without any clothes to wear when discharged home.

Example 4: Digital rectal exam

• A rectal exam can be a useful tool in the evaluation of patients with abdominal or pelvic injuries. It can help screen for rectal bleeding, pelvic fractures, and neurological function

• However, the rectal exam is not a sensitive test. A retrospective study from the Indian Journal of Surgery found that a rectal exam missed 100% of urethra injuries, 92% of spinal cord injuries, 93% of small bowel injuries, 100% of colon injuries, and 67% of rectal injuries in trauma patients.

Example 6: Pushing on pelvis for pelvic injuries

• Pushing on the pelvis to check for instability can cause further damage to an unstable pelvis. Imaging the pelvis is far more important than pressing on it if a pelvic fracture is suspected.

Example 7: FAST exam

• A FAST exam, which stands for "Focused Assessment with Sonography for Trauma," is a rapid ultrasound examination used to assess trauma patients for signs of internal bleeding or organ damage in the abdomen and chest.

• These can be very useful as an initial test to tell a trauma surgeon where to start looking for internal bleeding in an unstable blunt traumatic injury

• If a patient is stable and likely going to get a CT scan whether the FAST is positive or negative then the test is unnecessary

References

1. ATLS Subcommittee; American College of Surgeons' Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013 May;74(5):1363-6. doi: 10.1097/TA.0b013e31828b82f5. PMID: 23609291.

2. Bloom BA, Gibbons RC. Focused Assessment With Sonography for Trauma. 2023 Jul 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261902.

3. Brown R. Oxygenate and Resuscitate Before You Intubate. Common pitfalls to avoid when managing the crashing airway. EMS World. 2016 Jan;45(1):48-50, 52, 54-5. PMID: 26852546.

4. Chrimes N, Marshall SD. Attempt XYZ: airway management at the opposite end of the alphabet. Anaesthesia. 2018 Dec;73(12):1464-1468. doi: 10.1111/anae.14361. Epub 2018 Jul 11. PMID: 29998563.

5. Docimo S Jr, Diggs L, Crankshaw L, Lee Y, Vinces F. No Evidence Supporting the Routine Use of Digital Rectal Examinations in Trauma Patients. Indian J Surg. 2015 Aug;77(4):265-9. doi: 10.1007/s12262-015-1283-y. Epub 2015 May 19. PMID: 26702232; PMCID: PMC4688269.

6. Groeneveld A, McKenzie ML, Williams D. Logrolling: establishing consistent practice. Orthop Nurs. 2001 Mar-Apr;20(2):45-9. doi: 10.1097/00006416-200103000-00011. PMID: 12024634.

7. Morgenstern, J. The FAST exam: overused and overrated?, First10EM, August 30, 2021.

8. Rodrigues IFDC. To log-roll or not to log-roll - That is the question! A review of the use of the log-roll for patients with pelvic fractures. Int J Orthop Trauma Nurs. 2017 Nov;27:36-40. doi: 10.1016/j.ijotn.2017.05.001. Epub 2017 May 10. PMID: 28797555.

9. Sapsford W. Should the 'C' in 'ABCDE' be altered to reflect the trend towards hypotensive resuscitation? Scand J Surg. 2008;97(1):4-11; discussion 12-3. doi: 10.1177/145749690809700102. PMID: 18450202.

10. Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma. 2014 Mar 15;31(6):531-40. doi: 10.1089/neu.2013.3094. Epub 2013 Nov 6. PMID: 23962031; PMCID: PMC3949434.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII