Wednesday, April 8, 2015

ATLS Primary and Secondary Surveys (In Brief!)

By virtue of doing medical school in Victoria, one thing I never gained much exposure to was trauma. Edmonton is a whole new ball game. A stabbing that would make the front page in Victoria doesn't even make the news in Edmonton. On my past month of general surgery, not a call shift went by without the trauma team being called down to Emergency to assess a stabbing, gunshot, or motor vehicle collision victim.

Because I'd seen next to no trauma and given my specialty hadn't been required to take an ATLS course, when I realized that general surgery residents had to respond to trauma team calls, the first thing I did was look up the ATLS primary and secondary surveys (just one of many things I'd semi-forgotten since third-year med school).

The resident's role on the trauma team is to conduct and document the primary and secondary surveys; the Emergency nurses also document this information, on a nifty 8-page trauma record, which is actually a pretty clear guide for a med student or resident to follow. I swiped one* and scanned it to share on here.
(*Obligate disclaimer: This trauma record is not my property. It was authored by Alberta Health Services and I am sharing it purely for educational purposes!)

After getting the trauma team call everyone stands around for five minutes or so in the trauma bay, waiting for the patient to arrive. I use this time to grab a consult sheet and set it up like this:
1° Survey:
A - 
B - 
C - 
D - 
E - 

2° Survey:

H&N - 
Resp - 
CV - 
Abdo - 
MSK - 
CNS - 


A - 
M - 
P - 
L - 
E - 

Much later (after the primary and secondary surveys have been completed and investigation results are coming back) I add:
CXR - 
AXR - 
CT head - 
CT c/a/p - 
BW - 
ABG - 

Finally, I list the patient's issues (diagnoses) at the bottom of my consult and draw a dash next to them with a brief plan
(e.g. left distal femur fracture -- splinted; on call for ortho OR).

When the patient arrives in the trauma bay, as its name suggests the first thing to do (while monitors, oxygen, vitals, and i.v.s are being attached) is the primary survey -- here are the things you should document (notice that the A, B, C, and D are here; E is "exposure" (cutting off clothing -- and then making sure to keep the patient warm)).
In performing the primary survey you will notice (or you'll be told) what EMS has already done:
Next comes the secondary survey, a head-to-toe evaluation. This is when the patient is log rolled to examine their back and perform a DRE; the spine board is removed before rolling them back.
The secondary survey requires you to note the patient's GCS, i.e.:
As part of the secondary survey it may be helpful to note the locations of the patient's injuries on a quick diagram (I've never done this, but I've noticed that some of the other residents do). Of course, it's easier when the diagrams are pre-drawn for you!:
Somewhere in the chaos the history unfolds via EMS, police, family, or the patient; I document this information using the mnemonic "AMPLE" (Allergies, Medications, PMHx, Last PO intake, Events surrounding the incident). Here are some things to consider when describing the Event:
Generally while you are performing the secondary survey other team members are getting investigations underway. Blood is drawn, a FAST ultrasound is performed, and portable x-rays are done. Shortly thereafter the patient (if stable) usually goes for CT scans. Document the results of these tests as they become available (ignore "time" here):
Here are some procedures that may be performed; I generally note this sort of thing (e.g. chest tube inserted) within the "plan" part of my consult note.

And that's it (in brief)! There's a lot of information here, but the two most important charts on this page are the primary and secondary surveys -- it'd be a good idea to memorize what's on them.

For completeness, here is the 8-page Alberta Health Services trauma nursing record in its entirety (from which the above images have been borrowed):
I'm sure some of you know significantly more about ATLS than I do, so please feel free to make any suggestions in the comments!

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