ATLSDr. James Styner (1976), Aircraft

crash in rural Nebraska

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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.

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1. PREPARATIONA. Pre-hospital phase 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.

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2. TRIAGE

A Multiple Casualties

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.

TRIAGE

• Priority 1- Immediate• Priority 2-Urgent• Priority 3- Delayed• Priority 4- Dead

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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)

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PRIMARY SURVEYPriorities for the care of Adult , Pediatrics & Pregnancy women are all the same.

During the primary survey life threatening conditions are identified and management is instituted SIMULTANEOUSLY.

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A. Airway Maintenance with 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.

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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.

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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.

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E. Exposure / Environmental Control*It is the pt’s 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.

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Primary Survey

Potential problems1.patients on 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

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4. RESUSCITATIONA. Airway

*definite airway if there is any doubt about the pt’s ability to maintain airway integrity.B. Breathing /Ventilation/Oxygenation

*every injured pt should receive supplement oxygenC. 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.

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5. ADJUNCT TO PRIMARY 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

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C. Monitoring

1. Ventilatory rate & 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.

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6 SECONDARY SURVEY Does not 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.

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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?

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Secondary survey

• – Total patient evaluation• • history : AMPLE

physical examination• – Complete neurologic examination• – Head and skull• – Maxillofacial• – Neck• – Chest• – Abdomen• – Perineum/rectum/vagina• – Musculoskeletal• – Tubes and fingers in every orifice!

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GCS

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PHYSICAL EXAMINATION1. Head

Visual acuity

Pupillary size

Hemorrhage of conjunctiva and fundi

Penetrating injury

Contact lenses(remove before edema occurs)

Dislocation of lens

Ocular movement

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2. Maxillofacial Injury

no NG 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.

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• • Physical examination – Chest

• • Visual evaluation of anterior and posterior chest

• – open pneumothorax• – flail chest

• • Pain , dyspnea , signs of hypoxia, distended neck veins, distant heart sound

• - Cardiac tamponade , • -tension pneumothorax

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5. Abdomen

*excessive manipulation of the pelvic should be

avoided.

6. Perineum/rectum/vagina• contusion , hematoma , laceration , urethral bleeding• rectal examination : blood , high-riding prostate , integrity of rectal wall , sphincter tone• female : – Vg exam.: blood , Vg laceration. – pregnancy test

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7. Physical examination– Musculoskeletal

• • Inspection : contusion , deformity, external wound

• • palpation : tenderness , abnormal movement

• • pelvic #: ecchymosis on iliac wings , pubis ,

labia ,scrotum , pain on palpation of pelvic ring , Pelvic CompressionTest

• • Assessment of peripheral pulses and distal neurological deficit

• Beware of compartment syndrome of extremity

• • patient’s back examination-logroll

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8. Neurologic * Protection of spinal cord is

required at all times until a spine injury excluded, especially when the pt is to be transfered.

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ADJUNCT TO THE SECONDARY SURVEY

include additional x-ray and all other special

procedure.

Adjuncts to secondary survey

– hemodynamic status• CT scan• Contrast x-ray studies• Extremitry x-ray• Endoscopy and ultrasonography

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Tertiary Survey

• UNRECOGNISED INJURIES 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

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• 8. RE-EVALUATION• re-evaluation for new findings or

overlooked• continuous monitoring of vital

signs , and urinary output urine output> 0.5ml/kg/hr • ABG , ECG , pulse oximetry• Effective analgesia

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9. DEFINITE CARE

• After identifying the patient’s injuries• Managing life-threatening problems• Obtaining special studies• Transfer if the patient’s injuries exceed the

institution’s treatment capabilities

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Indication For Definite Airway* 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

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Normal Blood Amount:Normal adult 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

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3 for 1 Rule

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

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Initial Fluid Therapy

Lactated Ringer is preferred

* For adult 1-2 liters bolus

* For child 20ml/kg bolus

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Intraosseous Puncture/Infusion

Children less than 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.

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Head Injury Classification:

Mild : GCS 14-15

Moderate : GCS 9-13

Severe : GCS 3-8

Coma = GCS score of 8 or less

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Determining the level of 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

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Thoracic Trauma8 lethal Injury

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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Fluid Therapy in 2nd or 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

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Referral to Burn Center

* 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

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Priorities with multiple injuries

1. Thoracic trauma or tamponade

2. Abdominal hemorrhage

3. Pelvic Hemorrhage

4. Extremity Hemorrhage

5. Intra-cranial Injury

6. Acute Spinal Cord Injury

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TAKE HOME MESAGES1. 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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Thank You