preparação, triagem, atendimento 1º e 2º, e PHTLS

Prévia do material em texto

ATLS
Initial assessment:
• 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
Preparation: 
• for trauma patients.
• occurs in two different clinical settings: in the field/prehospital (first, events are coordinated with the clinicians at the receiving hospital) and in the 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 (agilizar) treatment in the field. 
• The prehospital system ideally is set up to notify the receiving hospital before personnel transport the patient from the scene (mobilization of the hospital’s trauma team members so that all necessary personnel and resources are present in the emergency department).
•During this 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 effort to minimize scene time.
• obtaining and reporting information needed for triage at the hospital, including time of injury, events related to the injury, and patient history is important.
• The mechanisms of injury can suggest the degree of injury as well as specific injuries the patient needs evaluated and treated. 
 
Hospital phase:
• Advance planning for the arrival of trauma patients is essential. 
• Critical aspects of hospital preparation include the following: a resuscitation area is available for trauma patients; properly functioning airway equipment (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. 
• recommend the use of standard precautions (face mask, eye protection, water-impervious gown, and gloves) when coming into contact with body fluids. 
Triage:
•involves the sorting (ordenagem) of patients based on the resources required for treatment and the resources that are actually available. 
• 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 triage and treatment priority 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. 
• Triage situations are categorized as multiple casualties (number of patients and the severity of their injuries do not exceed the capability of the facility to render care. Patients with life-threatening problems and those sustaining multiple-system injuries are treated first) or mass casualties (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 personnel are treated first).
Primary survey with simultaneous resuscitation
• Patients are assessed (avaliados), 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. 
• The primary survey encompasses the ABCDEs of trauma care and identifies life-threatening conditions by adhering to this sequence: 1) airway maintenance with restriction of cervical spine motion; 2) breathing and ventilation; 3) circulation with hemorrhage control; 4) disability (assessment of neurologic status); 5) 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 (ability to speak clearly), breathing is not severely compromised (ability to generate air movement to permit speech), and the level of consciousness is not markedly decreased (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 (sucção), administering oxygen, and opening and securing (protegendo) the airway. 
• Because the prioritized sequence is based on the degree of life threat, the abnormality posing the greatest threat to life is addressed first. 
Airway maintenance with restriction of cervical spine motion 
• Upon initial evaluation of a trauma patient, first assess the airway to ascertain patency (patência/desobstruído). 
• 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 (perigo); 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 (cuffed, secured tube in the trachea). 
• Initially, the jaw-thrust (impulso da mandíbula) or chin-lift maneuver (manobra de elevação do queixo) often suffices (basta) as an initial intervention. 
• If the patient is unconscious and has no gag reflex (reflexo de vômito), 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. 
• While assessing and managing a patient’s airway care to prevent excessive movement of the cervical spine. 
• Based on the mechanism of trauma, assume that a spinal injury exists. The cervicalspine is protected 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. 
• 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 (excursão), 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 (prejudicar) ventilation in the short term include tension (hipertensivo) pneumothorax, massive (maciço) hemothorax, open pneumothorax, and tracheal or 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 (agudamennte), 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. 
Circulation with hemorrhage control
• Circulatory compromise in trauma patients can result from a variety of injuries. Blood volume, cardiac output (débito cardíaco), and bleeding are major circulatory issues to consider.
• Blood Volume and Cardiac Output:
- Hemorrhage is the predominant cause of preventable deaths after injury.
- Identifying, quickly controlling hemorrhage, and initiating resuscitation 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 (when circulating blood volume is reduced, cerebral perfusion may be critically impaired altered level of consciousness), skin perfusion (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), and pulse (a rapid, thread/delgado pulse is typically a sign of hypovolemia. Assess a central pulse (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 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 (fixação cega) can result in damage to nerves and veins. 
- major areas of internal hemorrhage chest, abdomen, retroperitoneum, pelvis, and long bones. The source of bleeding is usually identified by physical examination and imaging. Immediate management may include chest decompression, and application of a pelvic stabilizing device and/or extremity splints (tala). 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 (lactato) level are obtained. When peripheral sites cannot be accessed, intraosseous infusion, central venous access, or venous cutdown (corte venoso) may be used depending on the patient’s injuries. 
- Shock associated with injury is most often hypovolemic in origin. In such cases, initiate IV fluid therapy with crystalloids. 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 (criteriosamente), 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 (taxas).
- Some severely injured patients arrive with coagulopathy already established, which has led some jurisdictions to administer tranexamic acid preemptively (ácido tranexâmico preventivamente) in severely injured patients. 
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 (Escala de Coma de Glasgow) is a quick, simple, and objective method of determining the level of consciousness. The motor score of the GCS correlates with outcome (resultado). 
• 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. 
• 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 perfusionare 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. 
Exposure and environmental control
• During the primary survey, completely undress the patient (by cutting off) to facilitate a thorough examination and assessment. 
• After completing the assessment, cover the patient with warm blankets or an external warming device to prevent hypothermia.
• 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. 
• heat crystalloid fluids to 39°C is recommended.
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, 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 
• Dysrhythmias—including unexplained tachycardia, atrial fibrillation, premature ventricular contractions, and ST segment changes—can 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
• 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. 
• 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
• Used to monitor the adequacy of the patient’s respirations.
• Ventilation can be monitored using end tidal (expirado) carbon dioxide levels 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.
• 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, arterial blood gases values provide acid base information. In the trauma setting, low pH and base excess levels indicate shock; therefore, trending these values can reflect improvements with resuscitation.
Urinary catheters 
• Urinary output (débito urinário) is a sensitive indicator of the patient’s volume status and reflects renal perfusion monitoring insertion of an indwelling bladder catheter (cateter vesical de demora). 
• A urine specimen should be submitted for routine laboratory analysis. 
• Transurethral bladder catheterization is contraindicated for patients who may have urethral injury presence of either blood at the urethral meatus or perineal ecchymosis (meato uretral ou equimose perineal). When urethral injury is suspected, confirm urethral integrity by performing a retrograde urethrogram (uretrograma retrógrado) before the catheter is inserted. 
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. Blood in the gastric aspirate may indicate oropharyngeal 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 (via oral) is recommended. 
X-Ray examinations and diagnostic studies
• Anteroposterior (AP) chest and AP pelvic films provide information to guide resuscitation efforts of patients with blunt trauma (trauma contuso – S/ perfurações na pele). 
• 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. 
• The finding of intraabdominal blood indicates the need for surgical intervention in hemodynamically abnormal patients. 
Special populations
• Children, pregnant women, older adults, obese patients, and athletes priorities for their care 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. 
• 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, as well as early fetal assessment, are important for maternal and fetal survival. 
• 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.
• Obese patients pose a particular challenge in the trauma setting, as their anatomy can make procedures such as intubation difficult and hazardous (perigosa). Diagnostictests such as FAST, DPL, and CT are also more difficult. 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 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. 
History
• Every complete medical assessment includes a history of the mechanism of injury prehospital personnel and family must furnish this information. 
• The AMPLE history (história AMPLA) is a useful mnemonic for this purpose: allergies, medications currently used, past illnesses/pregnancy, last meal, events/Environment related to the 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 direction and amount of energy associated with the mechanism of injury.
• Injury patterns are also influenced by age groups and activities. 
• Injuries are divided into two broad categories: blunt and penetrating trauma. Other types of injuries for which historical information is important include thermal injuries and those caused by hazardous environments.
• 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
- 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. 
- In gunshot victims, the velocity, caliber, presumed path of the bullet, and distance from the weapon to the wound can provide important clues regarding the extent 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 (aguda) or chronic hypothermia without adequate protection against heat loss produces either local or generalized cold injuries. Significant heat loss can occur at moderate temperatures 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 obtained from prehospital personnel. 
• Hazardous environment
- A history of exposure to chemicals, toxins, and radiation is important to obtain 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. 
Physical examination
• Head
- Try to identify all related neurologic injuries and any other significant injuries. The entire scalp (couro cabeludo) and head should be examined for lacerations, contusions, and evidence of fractures.
- Because edema around the eyes can later preclude (impeder) an in-depth examination, the eyes should be reevaluated for: visual acuity (acuidade), pupillary size, hemorrhage of the conjunctiva and/or fundi, penetrating injury, contact lenses (remove before edema occurs), dislocation of the lens, ocular entrapment (compressão ocular).
Clinicians can perform a quick visual acuity examination of both eyes by asking the patient to read printed material. Ocular mobility should be evaluated to exclude entrapment (compressão) of extraocular muscles due to orbital fractures. These procedures frequently identify ocular injuries that are not otherwise apparent. 
• 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. 
- 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.
• Cervical spine and neck 
- Patients with maxillofacial or head trauma should be presumed to have a cervical spine injury, and cervical spine motion must be restricted. 
- The absence of neurologic deficit does not exclude injury to the cervical spine, and such injury should be presumed until evaluation of the cervical spine is completed. 
- Evaluation may include radiographic series and/or computed tomography. 
- Examination of the neck includes inspection, palpation, and auscultation. Cervical spine tenderness (ternura), subcutaneous emphysema, tracheal deviation, and laryngeal fracture can be discovered on a detailed examination. The carotid arteries should be palpated and auscultated for bruits (sopros). A common sign of potential injury is a seatbelt mark. Most major cervical vascular injuries are the result of penetrating injury; however, blunt force (força brusca) to the neck or traction injury (lesão por tração) from a shoulder harness restraint (restrição do cinto) can result in intimal disruption (ruptura da íntima), dissection, and thrombosis. Blunt carotid injury (lesão carotídea contusa) 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. 
- Penetrating injuries to the neck can potentially injure several organ systems. 
- Wounds that extend through the platysma should not be explored manually.
- 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 (raiz) injury and should beaccurately documented.
• Chest
- Visual evaluation of the chest, both anterior and posterior, can identify conditions such as open pneumothorax and large flail segments.
- Complete evaluation of the chest wall palpation of the entire chest cage (including clavicles, ribs, and sternum).
- Sternal pressure can be painful if the sternum is fractured or costochondral separations 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 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. 
- Distant heart sounds and decreased pulse pressure can indicate cardiac tamponade (tamponamento cardíaco).
- 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 (alargado) mediastinum and other radiographic signs can suggest an aortic rupture.
• 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 injury. 
- Close observation and frequent reevaluation of the abdomen, preferably by the same observer, are important in managing blunt abdominal trauma (trauma abdominal contuso), because over time, the patient’s abdominal findings can change. Early involvement of a surgeon is essential. 
- Pelvic fractures can be suspected by the identification of ecchymosis (equimose - extravasamento de sangue dos vasos sanguíneos da pele que se rompem formando uma área de cor roxa) over the iliac wings, pubis, labia, or scrotum. 
- Pain on palpation of the pelvic ring is an important finding in alert patients.
- Assessment of peripheral pulses can identify vascular injuries. Patients with a history of unexplained hypotension, neurologic injury, impaired sensorium secondary to alcohol and/or other drugs, and equivocal abdominal findings should be considered candidates for DPL (diagnostic peritoneal lavage), abdominal ultrasonography, or, if hemodynamic findings are normal, CT of the abdomen. 
- Fractures of the pelvis or lower rib cage (caixa torácica inferior) also can hinder accurate (atrapalhar preciso) diagnostic examination of the abdomen, because palpating the abdomen can elicit pain from these areas.
• Perineum, rectum and vagina
-The perineum should be examined for contusions, hematomas, lacerations, and urethral bleeding. A rectal examination may be performed to assess for the presence of blood within the bowel lumen (lumen intestinal), integrity of the rectal wall, and quality of sphincter tone. 
- Vaginal examination should be performed in patients who are at risk of vaginal injury. The clinician should assess for the presence of blood in the vaginal vault and vaginal lacerations. In addition, pregnancy tests should be performed on all females of childbearing age.
• Musculoskeletal system
- The extremities should be inspected for contusions and deformities. 
- Palpation of the bones and examination for tenderness and abnormal movement aids in the identification of occult fractures.
- Significant extremity injuries can exist without fractures being evident on examination or x-rays. 
- Ligament ruptures produce joint (articular) instability. 
- Muscle-tendon (tendão muscular) unit injuries interfere with active motion of the affected structures. 
- Impaired (prejudicada) sensation and/or loss of voluntary muscle contraction strength (força) can be caused by nerve injury or ischemia, including that due to compartment syndrome (síndrome compartimental). 
- The musculoskeletal examination is not complete without an examination of the patient’s back. Unless the patient’s back is examined, significant injuries can be missed.
• Neurological system
- A comprehensive neurologic examination includes motor and sensory evaluation of the extremities, as well as reevaluation of the patient’s level of consciousness and pupillary size and response. 
- The GCS score facilitates detection of early changes and trends in the patient’s neurological status. 
- Early consultation with a neurosurgeon is required for patients with head injury.
- Monitor patients frequently for deterioration in level of consciousness and changes in the neurologic examination, as these findings can reflect worsening of an intracranial injury. 
- If a patient with a head injury (traumatismo cranioencefálico) deteriorates neurologically, reassess (reavalie) oxygenation, the adequacy of ventilation and perfusion of the brain (the ABCDEs).
- Intracranial surgical intervention or measures for reducing intracranial pressure may be necessary.
- Thoracic and lumbar spine fractures and/or neurologic injuries must be considered based on physical findings and mechanism of injury. Other injuries can mask the physical findings of spinal injuries, and they can remain undetected unless the clinician obtains the appropriate x-rays.
- Any evidence of loss of sensation, paralysis, or weakness suggests major injury to the spinal column or peripheral nervous system. 
- Protection of the spinal cord is required at all times until a spine injury is excluded. Early consultation with a neurosurgeon or orthopedic surgeon is necessary if a spinal injury is detected.
Reevaluation 
• Trauma patients must be reevaluated constantly to ensure that new findings are not overlooked and to discover any deterioration in previously noted findings.
• As initial life-threatening injuries are managed, other equally life-threatening problems and less severe injuries may become apparent, which can significantly affect the ultimate prognosis of the patient.
 • Continuous monitoring of vital signs, oxygen saturation, and urinary output is essential. For adult patients, maintenance of urinary output at 0.5 mL/kg/h is desirable. In pediatric patients who are older than 1 year, an output of 1 mL/kg/h is typically adequate. Periodic ABG (arterial blood gases) analyses and end-tidal CO2 monitoring are useful in some patients. The relief of severe pain is an important part of treatment for trauma patients. Many injuries, especially musculoskeletal injuries, produce pain and anxiety in conscious patients. Effective analgesia usually requires the administration of opiates or anxiolytics intravenously (intramuscular injections are to be avoided). These agents are used judiciously and in small doses to achieve the desired level of patient comfort and relief of anxiety while avoiding respiratory status or mental depression, and hemodynamic changes.
Definitive care
• Whenever the patient’s treatment needs exceed the capability of the receiving institution, transfer is considered. This decision requires a detailed assessment of the patient’s injuries and knowledge of the capabilities of the institution, including equipment, resources, and personnel. 
• Interhospital transfer guidelines will help determine which patients require the highest level of trauma care. 
Teamwork
• If criminal activity is suspected in conjunction with a patient’s injury, the personnel caring for the patient must preserve the evidence. All items, such as clothing and bullets, are saved for law enforcement personnel. Laboratory determinations of blood alcohol concentrations and other drugs may be pertinent and have substantial legal implications. 
• Trauma team team leader, airway manager, trauma nurse, and trauma technician, as well as various residents and medical students. 
• The teamleader supervises, checks, and directs the assessment; ideally he or she is not directly involved in the assessment itself. The team leader is not necessarily the most senior person present, although he or she should be trained in ATLS and the basics of medical team management. The team leader supervises the preparation for the arrival of the patient to ensure a smooth transition from the prehospital to hospital environment. He or she assigns roles and tasks to the team members, ensuring that each participant has the necessary training to function in the assigned role. 
• The following are some of the possible roles, depending on the size and composition of the team: assessing the patient, including airway assessment and management; undressing and exposing the patient; applying monitoring equipment; obtaining intravenous access and drawing blood; serving as scribe or recorder of resuscitation activity.
• On arrival of the patient, the team leader supervises the hand-over by emergency medical services personnel, ensuring that no team member begins working on the patient unless immediate life-threatening conditions are obvious. A useful acronym to manage this step is MIST: Mechanism (and time) of injury + Injuries found and suspected + Symptoms and Signs + Treatment initiated.
• As the ABC assessment proceeds, it is vital that each member knows what the other members have found and/or are doing. 
• The team leader checks the progress of the assessment, periodically summarizes the findings and the patient’s condition, and calls for consultants as required. He or she also orders additional examinations and, when appropriate, suggests/directs transfer of the patient. 
• Throughout the process, all team members are expected to make remarks, ask questions, and offer suggestions, when appropriate. In that case, all other team members should pay attention and then follow the team leader’s directions. 
• When the patient has left the ED, the team leader conducts an “After Action” session. In this session, the team addresses technical and emotional aspects of the resuscitation and identifies opportunities for improvement of team performance. 
Summary
1. The correct sequence of priorities for assessment of a multiply injured patient is preparation; triage; primary survey with resuscitation; adjuncts to the primary survey and resuscitation; consider need for patient transfer; secondary survey, adjuncts to secondary survey; reevaluation; and definitive care again considering the need for transfer.
2. Principles of the primary and secondary surveys and the guidelines and techniques in the initial resuscitative and definitive care phases of treatment apply to all multiply injured patients.
3. A patient’s medical history and the mechanism of injury are critical to identifying injuries.
4. Pitfalls associated with the initial assessment and management of injured patients need to be anticipated and managed to minimize their impact. 
5. The primary survey should be repeated frequently, and any abnormalities will prompt a thorough reassessment. 
6. Early identification of patients requiring transfer to a higher level of care improves outcomes.
PHTLS
The phases of trauma care
• Traumatic incidents fall into two categories: intentional and unintentional. 
• Trauma care is divided into three phases: pre-event, event, and post event. The prehospital care provider has responsibilities in each phase.
Pre-event phase
• Involves the circumstances leading up to an injury. 
• Efforts in this phase are primarily focused on injury prevention educate the public to increase the use of vehicle occupant restraint systems, promote methods to reduce the use of weapons in criminal activities, and promote nonviolent conflict resolution.
• In addition to caring for the trauma patient, all members of the health care delivery team have a responsibility to reduce the number of trauma victims. 
• The other component of the pre-event phase is preparation by prehospital care providers for the events that are not prevented by prevention efforts (cinto, cadeirinha de criança, capacete nas motos). Preparation includes proper and complete education with updated information to provide the most current medical care. 
• In addition, you must review the equipment on the response unit at the beginning of every shift and review with your partner the individual responsibilities and expectations of who will carry out what duties. It is just as important to review the conduct of the care when you arrive on the scene as it is to decide who will drive and who will be in the back with the patient.
Event phase
• Is the moment of the actual trauma. 
• Steps performed in the pre-event phase can influence the outcome of the event phase. This applies not only to our patients but also to ourselves. "Do no further harm" (não cause mais danos) is the admonition (advertência) for good patient care. Whether driving a personal vehicle or an emergency vehicle, prehospital care providers need to protect themselves and teach by example. You are responsible for yourself, your partner, and the patients under your care while in your ambulance vehicle; therefore prevent injury by safe and attentive driving. The same level of attention you give to your patient care must be given to your driving. Always drive safely, follow traffic laws, refrain from distracting activities and use the personal protective devices available, such as vehicle restraints.
Postevent phase
• Deals with the outcome of the traumatic event.
• Trimodal distribution of trauma deaths first phase of deaths occurs within the first few minutes and up to an hour after an incident. These deaths would likely occur even with prompt medical attention. The best way to combat them is through injury prevention and safety strategies. The second phase occurs within the first few hours of an incident. They can be prevented by good prehospital care and hospital care. The third phase occurs several days to several weeks after the incident. Are generally caused by multiple organ failure. Much more needs to be learned about managing and preventing multiple organ failure; however, early and aggressive management of shock in the prehospital setting can prevent some of these deaths. 
• Golden Hour patients who received definitive care soon after an injury had a much higher survival rate than those whose care was delayed. One reason for this improvement in survival is prompt treatment of hemorrhage and preservation of the body's ability to produce energy to maintain organ function. For the prehospital care provider, this translates into maintaining oxygenation and perfusion and providing rapid transport to a facility that is prepared to continue the process of resuscitation using blood and plasma (damage control resuscitation) and to not elevate the blood pressure (over 90 mm Hg) by using large volumes of crystalloid. 
• Prehospital care providers spend too much time on the scene many times, which is bad for the golden hour. 
• There are questions that all prehospital care providers need to ask when caring for a trauma victim: "Is what I am doing going to benefit the patient? Does that benefit outweigh (supera) the risk of delaying (atrasar) transport?" One of the most important responsibilities of a prehospital care provider is to spend as little time on the scene as possible. 
• A second responsibility is transporting the patient to an appropriate facility. The factor that is most critical to any patient's survival is the length of time that elapses between the incident and the provision of definitive care. For a cardiac arrest patient, definitive care is the restoration of a normal heart rhythm and adequate perfusion. Cardiopulmonary resuscitation (CPR) is merely a holding pattern. For a patient whose airway is compromised, definitive care is the management of the airway and restoration of adequate ventilation. The re-establishment of either ventilation or normal cardiac rhythm by defibrillation is usually easily achievedin the field. 
• Definitive care for the trauma patient usually involves control of hemorrhage and restoration of adequate perfusion by replacement of fluids as near to whole blood as possible. 
• Administration of reconstituted whole blood (packed red blood cells and plasma, in a ratio of 1:1) replace the lost oxygen-carrying capacity, the clotting (coagulação) components, and the oncotic pressure to prevent fluid loss from the vascular system. They are not currently available for use in the field and are an important reason for rapid transport to the hospital. 
• Enroute (a caminho) to the hospital, balanced resuscitation has proven to be important. 
• Hemostasis (hemorrhage control) cannot always be achieved in the field or in the emergency department (ED); it must often be achieved in the operating room (OR). 
• When determining an appropriate facility to which a patient should be transported, it is important that the prehospital care provider utilize the critical thinking process and consider the transport time to a given facility and the capabilities of that facility.
• A hospital without such in-house surgical capabilities must await the arrival of the surgeon and the surgical team before transporting the patient from the ED to the OR. 
Scene assessment
• There are a number of concerns that the prehospital care provider must consider when responding to and arriving at a scene: 1. Immediately upon being assigned to a call and receiving dispatch information, the potential issues and hazards associated with that type of call should be anticipated. Preliminary assessment of scene safety issues and the situation is initiated while en route to the scene based on information from the dispatcher. This assessment takes into consideration also the need for other public safety emergency responders (police and fire), and preparations for patient-specific concerns. 2. The first priority for everyone arriving at a trauma incident is overall assessment of the scene. Scene assessment involves establishing that the scene is safe enough for emergency medical services (EMS) to enter and carefully considering the exact nature of the situation to ensure provider and patient safety and to determine what alterations in patient care are indicated by the current conditions. Scene safety considerations continue even after that initial scene survey and as the prehospital care providers approach the patient. Any issues identified in this evaluation must be addressed before beginning the assessment of individual patients. In some situations, such as combat or tactical situations or hazardous materials incidents, this evaluation process becomes even more critical and can alter the methods of providing patient care. Scene assessment is not a one-time event. Continuous attention must be paid to what is going on around the emergency responders. Scenes initially deemed (considerada) safe for entry can change rapidly, and all emergency responders must be prepared to take appropriate steps to ensure their continued safety should the conditions on scene change. 3. After performing the scene assessment, the next priority is evaluating individual patients. The overall scene assessment will indicate whether the incident involves only a single patient or multiple patients. If the scene involves more than one patient, the situation is classified as either a multiple-patient incident/masscasualty incident (MCI) in which the number of patients exceeds available resources. The priority shifts from focusing all resources on the most injured patient to saving the maximum number of patients - that is, providing the greatest good to the greatest number of people. An initial abbreviated form of triage identifies the most severely injured patients to be treated first when there are multiple victims. The prioritization of patient management is (a) conditions that may result in the loss of life, (b) conditions that may result in the loss of limb (membros), and (c) all other conditions that do not threaten life or limb.
• Scene and patient assessment starts by gathering information through questioning the caller or from information provided by other public safety or prehospital care units already on the scene and by providing that initial information about the incident and the patient to the responding EMS unit. 
• While travelling to the scene, taking the time to prepare mentally for a call and practicing basic communication between partners may be the difference between a well-managed scene and a hostile confrontation (or a physical assault). Good observation, perception, and communication skills are the best tools. 
• Before making contact with the patient, the prehospital care provider should evaluate the scene by: 
1. Obtaining a general impression of the situation for scene safety;
2. Looking at the cause and results of the incident;
3. Observing family members and bystanders.
• A wealth of information is gathered by simply looking, watching, listening, and cataloguing as much information as possible, including the mechanisms of injury, the present situation, and the overall degree of safety.
• Just as the patient's condition can improve or deteriorate, so can the condition of the scene. Evaluating the scene initially then failing to reassess how the scene may change can result in serious consequences to the prehospital care providers and the patient. Awareness of the situation on the scene, not just upon arrival, but as the scene evolves and unfolds over time, is crucial to the safety of all emergency responders present at the incident.
• Scene assessment includes the following two major components: safety and situation.
• Safety
- The primary consideration when approaching any scene is the safety of all emergency responders. 
- When EMS personnel become victims, they can no longer assist other injured people and they add to the number of patients. Patient care may need to wait until the scene is safe enough that EMS can enter without undue risk.
- No scene is ever 100% safe and all emergency responders must maintain continued vigilance and awareness.
- Safety concerns vary from the exposure to body fluids that may occur on every call to rare events such as exposure to a chemical weapon of mass destruction. 
- Scene safety involves both emergency responder safety and patient safety.
- Patients in a hazardous situation should be moved to a safe area before assessment and treatment begin.
- Threatening conditions fire, downed electrical lines, explosives, hazardous materials (including blood or body fluid, traffic, floodwater, and weapons such as guns or knives), and environmental conditions. Also, an assailant may still be on the scene and may intervene to harm the patient, emergency responders, or bystanders. However, in situations involving an active shooter or assailant, having EMS work in a coordinated fashion with law enforcement to enter a scene as soon as possible improves patient survival. 
- The preferences employed for patient care can be drastically altered by the conditions on the scene. 
• Situation
-Assessment of the situation follows the safety assessment. 
- Some of the issues that must be assessed based upon the individual situation include: What really happened at the scene? What were the circumstances that led to the injury? Why was help summoned and who summoned it? What was the mechanism of injury (kinematics), and what forces and energies led to the victims injuries (a majority of patient injuries can be predicted based on evaluating and understanding the kinematics involved in the incident)? How many people are involved, and what are their ages? Are additional EMS units needed for scene management, patient treatment, or victim transport? Is mutual aid (ajuda mútua) needed? Are any other personnel or resources needed (law enforcement, fire department, power company)? Is special extrication or rescue equipment needed? Is helicopter transport necessary? Is a physician needed to assist with triage or on-scene medicalcare issues? Could a medical problem be the instigating factor that led to the trauma (a vehicle crash that resulted from the driver's heart attack)? 
- Issues related to both safety and situation have significant overlap; many safety topics are also specific to certain situations, and certain situations pose serious safety hazards. 
• Vehicle positioning and warning devices
-Vehicle positioning at the scene of an MVC is of the utmost (máxima) importance. 
- The incident commander or the safety officer should ensure that the responding vehicles are placed in the best positions to protect prehospital care providers. It is important for the first-arriving emergency vehicles to "take the lane" of the accident. Although placement of the ambulance behind the scene will not facilitate the loading of the patient, it will protect the prehospital care providers and patient from oncoming traffic.
- As additional emergency vehicles arrive, they should generally be placed on the same side of the road as the incident. These vehicles should be placed farther from the incident to give increased warning time to oncoming drivers.
- Headlights (faróis), especially high beams (faróis altos), should be turned off to avoid blinding oncoming drivers, unless the beams are needed to illuminate the scene.
- The number of warning lights at the scene should be evaluated; too many lights will only serve to confuse oncoming drivers.
- Many departments use warning signs stating "accident ahead" to give ample warning time for drivers.
- Flares (chamas) may be arranged to warn and direct traffic flow; however, care should be used in dry conditions so as not to start grass fires.
- Reflective cones serve as good devices to direct traffic flow away from the lane taken up by the emergency.
- If traffic needs to be directed, this task should be handled by law enforcement or those with special training in traffic control so EMS can focus on patient management.
- Confusing or contradicting instructions given to drivers create additional safety risks. The best situations are created when traffic is not impeded and normal flow can be maintained around the emergency. 
• Physical barriers gloves; masks and face shields; eye protection; gowns (traje); resuscitation equipment (dispositivos de máscara de bolsa ou bocais) 
• Patient assessment and triage
- Once all the preceding issues have been addressed, the actual process of assessing and treating patients can begin.
- Greatest challenge multiple victims. 
- Triage is a French word meaning "to sort" (ordenar).
- Triage process used to assign priority for treatment and transport.
- In the prehospital environment, triage is used in two different contexts:
 1. Sufficient resources are available to manage all patients. In this triage situation, the most severely injured patients are treated and transported first, and those with lesser injuries are treated and transported later;
 2. The number of patients exceeds the immediate capacity of on-scene resources. Patients are sorted into categories for patient care. Patient care must be rationed. 
- Incidents that involve sufficient emergency responders and medical resources allow for treatment and transport of the most severely injured patients first In a large-scale MCI, limited resources will require that patient treatment and transport be prioritized to salvage the victims with the greatest chance of survival. These victims are prioritized for treatment and transport.
- It is the responsibility of the prehospital care provider to make decisions about who is to be managed first. 
- The decision is always to save the most lives; however, when the available resources are not sufficient for the needs of all the injured patients present, these resources should be used for the patients who have the best chance of surviving.
- In a choice between a patient with a catastrophic injury, such as severe brain trauma, and a patient with acute intra-abdominal hemorrhage, the proper course of action in an MCI is to manage first the salvageable patient -the patient with the abdominal hemorrhage. Treating the patient with severe head trauma first will probably result in the loss of both patients; the head trauma patient may die because he or she may not be salvageable, and the abdominal hemorrhage patient may die because time, equipment, and EMS personnel spent managing the unsalvageable patient kept this salvageable patient from receiving the simple care needed to survive until definitive surgical care was available. 
- In a triage MCI situation, the catastrophically injured patient may need to be considered "lower priority," with treatment delayed until more help and equipment become available. 
- EMS personnel should not make efforts to resuscitate a traumatic cardiac arrest patient with little or no chance of survival while three other patients die because of airway compromise or external hemorrhage.
- The "sorting scheme" most often used divides patients into five categories based on need of care and chance of survival:
 1. Immediate - Patients whose injuries are critical, but who will require only minimal time or equipment to manage and who have a good prognosis for survival. An example is the patient with a compromised airway or massive external hemorrhage.
2. Delayed - Patients whose injuries are debilitating, but who do not require immediate management to salvage life or limb. An example is the patient with a long-bone fracture.
3. Minor-Patients/"walking wounded" - have minor injuries that can wait for treatment or who may even assist in the interim (provisório) by comforting other patients or helping as litter bearers.
4. Expectant - Patients whose injuries are so severe that they have only a minimal chance of survival. An example is the patient with a 90% full-thickness burn and thermal pulmonary injury.
5. Dead - Patients who are unresponsive, pulseless, and breathless. In a disaster, resources rarely allow for attempted resuscitation of cardiac arrest patients (parada cardíaca).