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Advanced trauma life support
- 2. ATLS Dr. James Styner(1976), Aircraft crash in rural Nebraska
- 4. 4 1. Preparation 2. Triage 3.Primary Survey (ABCDEs) 4. Resuscitation 5. Adjuncts to primary survey & resuscitation 6. Secondary Survey (head to toe evaluation & history) 7. Adjuncts to secondary survey 8. Continued post-resuscitation monitoring & re- evaluation 9. Definite care.
- 5. 5 1. PREPARATION A. Pre-hospitalphase Receiving hospital is notified first. Send to the closest, appropriate facility. B. In Hospital Phase Advanced planning for the trauma pt arrival. Method to summon extra medical assistance Transfer agreement with verified trauma center established. Protect from communicable disease.
- 6. 6 2. TRIAGE A MultipleCasualties no of pt & severity DO NOT EXCEED the ability of the facility. B Mass Casualties no of pt & severity EXCEED the capability of the facility & staff.
- 7. TRIAGE ā¢ Priority 1-Immediate ā¢ Priority 2-Urgent ā¢ Priority 3- Delayed ā¢ Priority 4- Dead
- 8. 8 3. PRIMARY SURVEY A: Airway with cervical spine protect. B : Breathing C : Circulation --control external bleeding. D : Disability or neurological status E : Exposure (undress) & Environment (temp control)
- 9. 9 PRIMARY SURVEY Priorities forthe care of Adult , Pediatrics & Pregnancy women are all the same. During the primary survey life threatening conditions are identified and management is instituted SIMULTANEOUSLY.
- 10. 10 A. Airway Maintenancewith Cervical Spine Protection. * GCS score of 8 or less require the placement of definite airway. *Protection of the spine & spinal cord is the important management principle. *Neurological exam alone does not exclude a cervical spine injury. *Always assume a cervical spine injury in any pt with multi-system trauma, especially with an altered level of consciousness or blunt injury above the clavicle.
- 11. 11 B. Breathing &Ventilation * Airway patency does not assure adequate ventilation. C. Circulation with Hemorrhage Control. 1. Blood Volume & Cardiac Output a. level of consciousness. b. skin color c. Pulse. d. blood pressure. 2. Bleeding *external bleeding is identified & controlled in the primary survey. *Tourniquets should not be used.
- 12. 12 D. Disability (Neurological Evaluation) Simple Mnemonic to describe level of consciousness A : Alert V : Responds to Vocal stimuli P : Responds to Painful stimuli U : Unresponsive to all stimuli Not forget to use also Glascow Coma Scale.
- 13. 13 E. Exposure /Environmental Control *It is the ptās body temp that is most important, not he comfort of the health care provider. *Intravenous fluid should be warm. *Warm environment (room temp) should be maintained. *early control of hemorrhage.
- 14. 14 Primary Survey Potential problems 1.patientson beta blocker may not get tachycardia as a response to bleeding or anemia 2.Elderly patients have less reserve and may deompensate quickly 3.Children have less reserve and will not show signs of shock until severely volume depleted 4.Multiple occult sources for blood loss may exist in one patient
- 15. 15 4. RESUSCITATION A. Airway *definiteairway if there is any doubt about the ptās ability to maintain airway integrity. B. Breathing /Ventilation/Oxygenation *every injured pt should receive supplement oxygen C. Circulation *control bleeding by direct pressure or operative intervention * minimum of two large caliber IV should be established *pregnancy test for all female of child bearing age. * Lactated Ringer is preferred & better if warm.
- 16. 16 5. ADJUNCT TOPRIMARY SURVEY & RESUSCITATION A. Electro-cardiographic Monitoring B. Urinary & Gastric Catheter 1. Urinary catheter. Urethral injury should be suspected if *Blood at the penile meatus *Perineal ecchymosis *Blood in the scrotum *High riding or nonpalpable prostate *Pelvic fracture
- 17. 17 C. Monitoring 1. Ventilatoryrate & ABG 2. Pulse oximetry does not measure ventilation or partial O2 pressure 3. Blood pressure poor measure of actual tissue perfusion. D. X-Ray & Diagnostic Studies C-spine, CXR, Pelvic film, FAST. Essential x-ray should not be avoided in pregnant pt. *** Consider the need for patient transfer.
- 18. 18 6 SECONDARY SURVEY Doesnot begin until the primary survey (ABCDEs) is completed, resuscitative effort are well established & the pt is demonstrating normalization of vital sign. * Head to Toe evaluation & reassessment of all vital signs. * A complete neurological exam is performed including a GCS score and examination of pupil * Special procedure is ordered if needed.
- 19. 19 History A : Allergies. M: Medication currently used. P : Past illness/ Pregnancy. L : Last Meal E : Events/Environment related to the injury. *blunt trauma/penetrating trauma/injuries due to cold & burn/hazardous environment?
- 20. 20 Secondary survey ā¢ āTotal patient evaluation ā¢ ā¢ history : AMPLE physical examination ā¢ ā Complete neurologic examination ā¢ ā Head and skull ā¢ ā Maxillofacial ā¢ ā Neck ā¢ ā Chest ā¢ ā Abdomen ā¢ ā Perineum/rectum/vagina ā¢ ā Musculoskeletal ā¢ ā Tubes and fingers in every orifice!
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- 22. 22 PHYSICAL EXAMINATION 1. Head Visualacuity Pupillary size Hemorrhage of conjunctiva and fundi Penetrating injury Contact lenses(remove before edema occurs) Dislocation of lens Ocular movement
- 23. 23 2. Maxillofacial Injury noNG tube, definite airway? 3. Cervical Spine & Neck *Pt with maxillofacial or head trauma should be presumed to have and unstable cervical spine. 4. Chest *elderly pt are not tolerant of even relatively minor chest injury. *Children often sustain significant injury to the intrathoracic structure without evidence of thoracic skeletal trauma.
- 24. 24 ā¢ ā¢ Physicalexamination ā Chest ā¢ ā¢ Visual evaluation of anterior and posterior chest ā¢ ā open pneumothorax ā¢ ā flail chest ā¢ ā¢ Pain , dyspnea , signs of hypoxia, distended neck veins, distant heart sound ā¢ - Cardiac tamponade , ā¢ -tension pneumothorax
- 25. 25 5. Abdomen *excessive manipulationof the pelvic should be avoided. 6. Perineum/rectum/vagina ā¢ contusion , hematoma , laceration , urethral bleeding ā¢ rectal examination : blood , high-riding prostate , integrity of rectal wall , sphincter tone ā¢ female : ā Vg exam.: blood , Vg laceration. ā pregnancy test
- 26. 26 7. Physical examinationāMusculoskeletal ā¢ ā¢ Inspection : contusion , deformity, external wound ā¢ ā¢ palpation : tenderness , abnormal movement ā¢ ā¢ pelvic #: ecchymosis on iliac wings , pubis , labia ,scrotum , pain on palpation of pelvic ring , Pelvic CompressionTest ā¢ ā¢ Assessment of peripheral pulses and distal neurological deficit ā¢ Beware of compartment syndrome of extremity ā¢ ā¢ patientās back examination-logroll
- 27. 27 8. Neurologic * Protectionof spinal cord is required at all times until a spine injury excluded, especially when the pt is to be transfered.
- 28. 28 ADJUNCT TO THESECONDARY SURVEY include additional x-ray and all other special procedure. Adjuncts to secondary survey ā hemodynamic status ā¢ CT scan ā¢ Contrast x-ray studies ā¢ Extremitry x-ray ā¢ Endoscopy and ultrasonography
- 29. 29 Tertiary Survey ā¢ UNRECOGNISEDINJURIES MAY OCCUR IN 65% OF PATIENTS AND ARE SIGNIFICANT IN 15 % OF PATIENTS .THEREFORE, AN ADDITIONAL THOROUGH SURVEY IS DONE TYPICALLY WITHIN 24 HOURS OF ADMISSION
- 30. 30 ā¢ 8. RE-EVALUATION ā¢re-evaluation for new findings or overlooked ā¢ continuous monitoring of vital signs , and urinary output urine output> 0.5ml/kg/hr ā¢ ABG , ECG , pulse oximetry ā¢ Effective analgesia
- 31. 31 9. DEFINITE CARE ā¢After identifying the patientās injuries ā¢ Managing life-threatening problems ā¢ Obtaining special studies ā¢ Transfer if the patientās injuries exceed the institutionās treatment capabilities
- 32. 32 Indication For DefiniteAirway * Unconscious * Severe maxillo-facial fracture * Risk for aspiration : Bleeding/ vomiting * Risk for obstruction : neck hematoma/laryngeal,tracheal injury/ stridor * Apnea : Neuromuscular paralysis/unconscious * Inadequate respiratory effort: tachypnea/hypoxia/hypercapnia/cyanosis * Severe closed head injury need for hyperventilation
- 33. 33 Normal Blood Amount: Normaladult blood volume : 7% of body weight Normal blood volume for child : 8-9% of body weight Hemorrhage Classification : Class I Hemorrhage : up to 15% loss Class II Hemorrhage : 15-30% loss Class III Hemorrhage : 30-40% loss Class IV Hemorrhage : >40% loss
- 34. 34 3 for 1Rule a rough guideline for the total amount of crystalloid volume acutely is to replace each ML of blood loss with 3 ML of crystalloid fluid, thus allowing for restitution of plasma volume lost into the interstitial & intracellular space
- 35. 35 Initial Fluid Therapy LactatedRinger is preferred * For adult 1-2 liters bolus * For child 20ml/kg bolus
- 36. 36 Intraosseous Puncture/Infusion Children lessthan 6 y of age for whom IV access is impossible due to circulatory collapse or for whom percutaneous peripheral venous cannulation had failed on two attempt.
- 37. 37 Head Injury Classification: Mild: GCS 14-15 Moderate : GCS 9-13 Severe : GCS 3-8 Coma = GCS score of 8 or less
- 38. 38 Determining the levelof quadriplegia a. Raise elbow to level of shoulder -- Deltoid C5 b. Flexes the forearm -- Biceps C6 c. Extend the forearm -- Triceps C7 d. Flexes wrist & finger -- C8 e. Spread finger -- T1
- 39. 39 Thoracic Trauma 8 lethalInjury 1. Simple pneumothorax 2. Hemothorax 3. Pulmonary contusion 4. Tracheo-bronchial tree injury 5. Blunt cardiac injury 6. Traumatic aortic disruption 7. Traumatic diaphragmatic injury 8. Mediastinal traversing wounds.
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- 41. 41 Fluid Therapy in 2ndor 3rd Degree Burn Total amount of first 24 hours: 4 ml of Ringer lactate x BW(kg) x BSA * give 1/2 in first 8 hrs * 1/2 in remaining 16 hrs
- 42. 42 Referral to BurnCenter * 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y of age * 2nd or 3rd degree burn > 20% BSA in other age group * 2nd or 3rd degree burn of face/eye/ear/hands/feet/ genitalia/perineum or major joints * 3rd degree burn >5% in any age group * Significant electrical/lightning injury * Significant chemical burn * Inhalation injury
- 43. 43 Priorities with multipleinjuries 1. Thoracic trauma or tamponade 2. Abdominal hemorrhage 3. Pelvic Hemorrhage 4. Extremity Hemorrhage 5. Intra-cranial Injury 6. Acute Spinal Cord Injury
- 44. 44 TAKE HOME MESAGES 1.To improve survival, injury management must be prioritized in the multiply injured patient 2.The order of priority among injuries is related to time and degree of life threat posed by each injury. 3. Immediate priority is given to airway control and to maintenance of ventilation, oxygenation, and perfusion. 4. Cervical spine protection is crucial during airway intubation. 5.A trauma team leader is important to coordinate management in the multiply injured patient.
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