AMPLE- acronym

If a patient arrives by ambulance and might be hemodynamically unstable, history is still important. But keep it short and simple with the AMPLE- acronym.

• Allergies - To avoid medication that might provoke an adverse event.
• Medication - To prevent any drug interactions and to know if your patient uses anticoagulants.
• Medical history - To understand the patient’s general condition and any previous surgeries and treatments to take into account for the treatment plan.
• Last meal - Anesthesiologists need this to take preventive measures while giving anesthesia for possible surgical treatment.
• Events related to the injury - To understand the trauma mechanism, object used (such as the type of knife or gun), and whether the patient was wearing any protective gear.

Treatment

• Fluid access
  Place two large-bore IV cannulas.
• Lab investigations
  Send blood for type and crossmatch and a full blood count.
• Mass transfusion protocol
  Whole blood-platelet concentrate-FFP, at a ratio of, 1-1-1.
• Stop the bleeding
  Use a tourniquet, bandage or direct pressure as needed

Assessment

• Agitation – Hypoxic patients are often agitated.
• Cyanosis – Blue or purplish skin can indicate hypoxia.
• The use of accessory muscles – Indicates increased work of breathing.
• Abnormal breathing sounds – May suggest an obstruction.

Treatment

• Chin-lift maneuver
  Lifts the chin to open the airway by moving the tongue away from the posterior pharynx.
• Jaw-thrust maneuver
  Moves the mandible anteriorly to create a air passage. Used when cervical injury is suspected.
• Oropharyngeal airway
  Maintains an open airway by preventing the tongue from obstructing the pharynx. Remove if gagging occurs.
• Naso-pharyngeal airway
  Creates an air passage from the nose to the base of the tongue. Size can be estimated using the nose-to-ear distance. Lubricate before insertion. Contraindicated in facial or skull fractures.
• Endotracheal Intubation
  Placement of a tube in the trachea with an inflatable cuff to secure a definitive airway.
• Surgical airway
  An emergency airway created through the neck. Indicated in situations where you cannot intubate and cannot oxygenate the patient.

Considerations

• Spinal injury risk - Airway maneuvers in patients at risk for cervical spine injury should be performed with restricted spinal motion.
• Altered mental status - Not responding to speech does not necessarily indicate airway obstruction; it may be due to an altered level of consciousness. However, patients with a head injury and a reduced level of consciousness, particularly with a Glasgow Coma Scale score of 8 or less, usually require a definitive airway.
• Burn wounds - Burns to the face or neck may rapidly lead to airway edema and obstruction.
• Maxillofacial trauma – Fractures may lead to blood, teeth, or debris obstructing the airway.
• Capnography - Use when available to confirm and monitor endotracheal tube placement.

Assessment

• Breathing frequency – Determine whether the patient is tachypneic.
• Thorax inspection- Look for wounds, tracheal deviation, symmetrical chest movement, flail chest, or bruising.
• Palpation of the thorax – Assess for tenderness, instability, or crepitus.
• Lungs auscultation – Determine whether breath sounds are present bilaterally.
• Saturation - Use a pulse oximeter to asses adequate levels of hemoglobin oxygen saturation.

Treatment

• Provide patient with oxygen
  Use a mask-reservoir device.
• (Tension) pneumothorax
  Urgent chest decompression is indicated. Decompress rapidly by either needle catheter or finger thoracostomy in the fifth intercostal space between the mid and anterior axillary lines.
• Open pneumothorax
  Create a chestseal by covering the wound with a plastic taped on 3 sides only (leaving an opening at the bottom to prevent air trapping and drain fluid).

Considerations

• Low oxygen saturation may indicate impaired gas exchange. Evaluate possible causes in the lungs, chest wall, or diaphragm.
• Tracheal deviation - Tracheal deviation is a sign of a tension pneumothorax; there is no need for a chest X-ray. Treat accordingly.
• Chest X-ray - May be considered when thoracic injury is suspected. Most often only done when primary survey is finished

Assessment

• Pulse - Rate, rhythm and quality for a quick indication of circulatory status.
• Blood pressure - Hypotension is a late sign of shock
• External bleeding - Look for ongoing hemorrhage that has not yet been controlled.
• Signs of perfusion - Skin color, temperature, and capillary refill.
• Potential internal bleeding sites - Consider the major areas where blood loss can occur. (Blood on the floor and 4 more)

Treatment

• Fluid resuscitation
  Ensure IV access, or if not possible, intraosseous access.
• Fracture bleeding
  If a long bone or pelvic fracture is suspected, apply traction or a pelvic binder
• Response to fluid
  Observe the patient’s response to initial fluid resuscitation, but keep in mind that improvement of blood pressure and vital signs does not indicate the amount of tissue oxygenation.

Considerations

• Hypotension is a late sign of shock. Compensatory mechanisms prevent a fall in blood pressure up until 30% of the patients blood volume is lost.
• In hemorrhagic shock, priority is to stop the bleeding. Volume resuscitation alone will not resolve shock until hemorrhage is controlled.
• In trauma consider hemorrhagic shock, until proven otherwise.
• Tachycardia is considered different for every age category – elderly people might not show tachycardia due to the use of medication.
• ECG monitoring, FAST ultrasound, and chest and pelvic X-rays to identify sources of bleeding.

Assessment

• Level of consciousness - By using the Glasgow Coma Scale (GCS).
• Pupil size and reaction – Check for symmetry and response to light.
• Lateralization - Check for unequal neurological findings between the left and right side of the body, (e.g. differences in pupil size or limb movement).
• Spinal cord injury - Assess signs of spinal cord injury (e.g. movement, sensation, priapism).

Treatment

Closely monitor mental status and reassess regularly. In case of a GCS of 8 or lower consider intubation as described above.

Considerations

• Altered mental status may be caused by factors other than brain injury, such as hypoxia, intoxication, hypoglycemia, or medication effects.
• Never forget to measure a trauma patient’s glucose.
• Prevent secondary brain injury by ensuring adequate oxygenation and perfusion.

Assessment

• Full body assessment – Completely uncover a patient and check all extremities for wounds or other injuries.
• Log roll - Perform a log roll together with the team to assess the spine.
• Hypothermia – Worsens shock and coagulopathy.

Treatment

• Stabilization
  Keep the patient on a spinal board, if necessary. Until correct treatment or stabilization is otherwise possible.
• Temperature
  Remain normotemperature by (warm) blankets, resuscitation with warmed fluids or blood transfusions.

Considerations

• After the primary survey and initial resuscitation, CT imaging may be performed, provided the patient is hemodynamically stable.
• Remember to supply ample analgesics, IV fluids, and tetanus vaccinations if necessary.