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:
ID:
PC:
1° Survey:
A - 
B - 
C - 
D - 
E - 

2° Survey:

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

Hx:

A - 
M - 
P - 
L - 
E - 

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

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).
Issues:
1)
2)
3)
etc....

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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