Orthopedic Teaching Cases 2023, Jan, 20 | 12:00 am

Principles of ATLS

You are the sole provider in a small rural hospital when a 56-year-old female is brought in after a MVC rollover. The patient is brought on a backboard in a cervical collar by EMS who reports a prolonged extrication. She has an obviously deformed left thigh and is bleeding from a scalp wound.

What is the first step in assessing the patient upon arrival?

  1. Put direct pressure on the scalp wound.

  2. Have someone apply direct in-line traction to the left lower extremity to stabilize the fracture.

  3. Call the closest trauma center to prepare for transport of the patient.

  4. Ask the patient to state her name.

 

Discussion

The correct answer is (D). ATLS principles should be followed in surgical management such as this. Although all of the answers are actions that are likely to be taken, the first priority is to assess the patient’s airway. This can quickly be done by asking her to state her name. As she answers, you know that her airway is patent, and she is alert enough to follow directions.

On the same patient, you get a set of vitals which shows her blood pressure at 90/40, heart rate 120, and pulse-ox of 99%. She has a GCS of 14, and you note that she appears drowsy and confused, leading you to be concerned for hemorrhagic shock.

What amount of blood loss has she most likely sustained?

  1. 10%

  2. 25%

  3. 40%

  4. 55%

 

Discussion

The correct answer is (C). Class I hemorrhage is when there is a loss of <15% blood volume. This is equivalent to donating a unit of blood and usually shows no systemic cardiovascular changes. Class II hemorrhage is a loss of between 15% and 30% blood volume. At that point, tachycardia is seen, but most people are able to sustain a normal blood pressure. Class III hemorrhage, 30% to 40%, is when systolic blood pressure drops, which is where our patient is in this example. More blood loss than this is Class IV hemorrhage, and the patient is considered on the verge of dying unless drastic measures are taken immediately.

What is the most appropriate fluid resuscitation to initiate at this time?

  1. Give 1 L of crystalloid at 200 cc/hr.

  2. Administer 2 L of crystalloid as a fluid bolus. Alert the blood bank for possible transfusion needs.

  3. Give 1 unit PRBCs now, alert the blood bank to start bringing platelets and plasma.

  4. Monitor her urine output and administer fluid to keep UOP at 1 to 2 cc/kg/hr.

 

Discussion

The correct answer is (B). The standard ATLS protocol includes giving 2 L of warmed crystalloid fluid prior to initiating blood transfusions. However, when transfusions are expected, the blood bank should be alerted soon in the process with an initiation of a massive transfusion protocol as allowed by your facility. Using urine output is appropriate for maintaining fluids but not during an initial trauma resuscitation.

 

Objectives: Did you learn...?

 

Principles of ATLS?

 

Classes of hemorrhagic shock?