approach to trauma- atls update by dr.damodhar.m.v
TRANSCRIPT
Approach to Trauma- ATLS Update
Dr. Damodhar. M.VResident Surgeon,Security Forces Hospital Dammam
*World Health Organization-Global status report on road safety 2013.www.who.int/violence_injury_prevention/road_safety_status/
*World Health Organization-Global status report on road safety2013.www.who.int/violence_injury_prevention/road_safety_status/
*World Health Organization-Global status report on road safety 2013.www.who.int/violence_injury_prevention/road_safety_status/
Approach to Trauma- ATLS Update
Approach to Trauma- ATLS Update
• History of ATLS has its origins in the United States in 1976, when James K. Styner an orthopedic surgeon met with air accident while piloting his flight.
Approach to Trauma- ATLS Update
• Trimodal distribution of trauma deaths.
• The first peak of deaths occurs within few seconds to minutes after injury (50% OF ALL DEATHS). Virtually inevitable & very little can be done.
• The second peak occurs between few minutes and an hour. Can be reduced by prompt initial care in the pre-hospital phase, by early hospital resuscitation and by prompt and competent definitive care. This period has been labeled as “THE GOLDEN HOUR”.
• The third peak is between several days and weeks after initial injury
• The second and third peaks should be regarded as potentially preventable.
Concepts of ATLS
Treat the greatest threat to life first
The lack of a definitive diagnosis should never impede the application of an indicated treatment
A detailed history is not essential to begin the evaluation
“ABCDE” approach
Basics of Trauma Assessment
Preparation– Team Assembly– Equipment Check
Triage– Sort patients by level of acuity (SATS)
Primary Survey– Designed to identify injuries that are immediately life threatening and to treat them as they are identified
Resuscitation– Rapid procedures and treatment to treat injuries found in primary survey before completing the secondary
survey
Secondary Survey– Full History and Physical Exam to evaluate for other traumatic injuries
Monitoring and Evaluation, Secondary adjuncts
Transfer to Definitive Care– ICU, Ward, Operating Theatre, Another facility
Preparation for Patient Arrival
Surgeon
Airway Doctor
Radiographer
IV Access and Medications
Circulation Nurse
Orthopedician
Scribe Nurse
Team Leader
Primary Survey
Airway and Protection of Spinal Cord
Breathing and Ventilation
Circulation
Disability
Exposure and Control of the Environment
A- Airway
Why first in the algorithm?– Loss of airway can result in death in < 3 minutes– Prolonged hypoxia = Inadequate perfusion, End-organ
damage
Airway Assessment– Vital Signs = RR, O2 sat– Mental Status = Agitation, Somnolent, Coma– Airway Patency = Secretions, Stridor, Obstruction– Traumatic Injury above the clavicles– Ventilation Status = Accessory muscle use, Retractions,
Wheezing
C-spine Immobilization
Return head to neutral position Maintain in-line stabilization Correct size collar application Blocks/tape Sandbags
B- Breathing and Ventilation
General Principle: Adequate gas exchange is required to maximize patient oxygenation and carbon dioxide elimination
Breathing/Ventilation Assessment:
– Exposure of chest– General Inspection
Tracheal Deviation Accessory Muscle Use Retractions Absence of spontaneous breathing Paradoxical chest wall movement
– Auscultation to assess for gas exchange Equal Bilaterally Diminished or Absent breath sounds
– Palpation Deviated Trachea Broken ribs Injuries to chest wall
B- Breathing and Ventilation
Identify Life Threatening Injuries– Tension Pneumothorax
Air trapping in the pleural space between the lung and chest wall Sufficient pressure builds up and pressure to compress the lungs and shift the
mediastinum Physical exam
– Absent breath sounds– Air hunger– Distended neck veins– Tracheal shift
Treatment– Needle Decompression
2nd Intercostal space, Midclavicular line– Tube Thoracostomy
5th Intercostal space, Anterior axillary line
Thoracic Trauma
• 8 lethal Injury1. 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.
B- Breathing and Ventilation
Ventilate with 100% oxygen
Needle decompression if tension pneumothorax suspected
Chest tubes for pneumothorax / hemothorax
Occlusive dressing to sucking chest wound
If intubated, evaluate ETT position
Chest Tube Insertion
C- Circulation
Hemorrhagic shock should be assumed in any hypotensive trauma patient
Rapid assessment of hemodynamic status– Level of consciousness– Skin color– Pulses in four extremities– Blood pressure and pulse pressure
C- Circulation
• 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
3 for 1 Rule
• A rough guideline for the total amount of crystalloid volume 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
Initial Fluid Therapy
Lactated Ringer is preferred
• For adult 1-2 liters bolus
• For child 20ml/kg bolus
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
D- Disability
Abbreviated neurological exam – Level of consciousness– Pupil size and reactivity– Motor function– GCS • Utilized to determine severity of injury• Guide for urgency of head CT and ICP monitoring
GCS
• Mild : GCS 14-15
• Moderate : GCS 9-13
• Severe : GCS 3-8
• Coma = GCS score of 8 or less
Disability Interventions
Spinal cord injury– High dose steroids if within 8 hours
ICP monitor- Neurosurgical consultation Elevated ICP– Head of bed elevated– Mannitol– Hyperventilation– Emergent decompression
E- Exposure
Complete disrobing of patient
Logroll to inspect back
Rectal temperature
Warm blankets/external warming device to prevent hypothermia
Always Inspect the Back
ADJUNCT TO PRIMARY SURVEY & RESUSCITATION
• A. Electro-cardiographic Monitoring
• B. Urinary & Gastric Catheter
– 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
Secondary Survey
Physical exam from head to toe, including rectal exam
Frequent reassessment of vitals
Secondary Survey
AMPLE History– Allergies– Medications– Past Medical History, Pregnancy– Last Meal– Events surrounding injury, Environment
History may need to be gathered from family members or ambulance service
Adjuncts to Secondary Survey
Radiology– Standard emergent films
C-spine, CXR, Pelvis
– Focused Abdominal Sonography in Trauma (FAST)
– Additional filmsCat scan imagingAngiography
Pain Control Tetanus Status Antibiotics for open fractures
Diagnostic Aids
Standard trauma labs– CBC, K, Cr, PTT, ABG
Standard trauma radiographs– CXR, pelvis, lateral C-spine
CT/FAST scans
FAST Exam
• Focused Abdominal Sonography in Trauma
• 4 views of the abdomen to look for fluid.– RUQ/Morrison’s pouch– Sub-xiphoid – view of heart– LUQ – view of spleno-renal junction– Bladder – view of pelvis
FAST Exam
• Sensitivity of 94.6%
• Specificity of 95.1%
• Overall accuracy of 94.9% in identifying the presence of intra-abdominal injuries*
*Yoshil: J Trauma 1998; 45
FAST-Right Upper Quadrant - Morrison’s
• Between the liver and kidney in RUQ.
• First place that fluid collects in supine patient
University of Louisville ED, www.louisville.edu/medschool/emergmed/ultrasoundfast.htm
FAST – Sub-xiphoid
• Evaluate for pericardial fluid• View through liver – Transhepatic or
Parasternal• Searches for fluid between
heart and pericardium
University of Louisville ED.www.louisville.edu/medschool/emergmed/ultrasoundfast.htm
FAST – Left Upper Quadrant
• View between the spleen and kidney
• Another dependent place that fluid collects
• Also see diaphragm in this view
University of Louisville ED,www.louisville.edu/medschool/emergmed/ultrasoundfast.htm
FAST- Bladder view
Simple Pneumothorax
Tension Pneumothorax
Hemothorax
Widened Mediastinum
www.trauma.org/index.php/main/image/45/prin
Bilateral Pubic Ramus Fractures and Sacroiliac Joint Disruption
Author unknown, http://www.itim.nsw.gov.au/images/Open_book_pelvic_fracture_xray.jpg
http://rad.usuhs.mil/medpix/tachy_pics/thumb/synpic4098.jpg
Abdominal contents up in the chest
http://commons.wikimedia.org/wiki/File:Diaphragmatic_rupture_spleen_herniation.jpg
Trauma in Special Populations
Pregnancy
– Supine Hypotensive SyndromeAfter 20 weeks, enlarged uterus with fetus and amniotic
fluid compresses inferior vena cavaDecreases venous return and decrease cardiac outputKeep pregnant patients in left lateral decubitus position
to avoid excessive hypotension– Optimal maternal and fetal outcome is determined by
adequate resuscitation of mother– Fetal Monitoring
Priorities with multiple injuries1. Thoracic trauma or tamponade
2. Abdominal hemorrhage
3. Pelvic Hemorrhage
4. Extremity Hemorrhage
5. Intra-cranial Injury
6. Acute Spinal Cord Injury
Definitive Care
Secondary Survey followed by radiographic evaluationConsultation:• Neurosurgery• Orthopedic Surgery• Vascular Surgery
Transfer to Definitive Care:• Operating Room• ICU• Higher level facility
ATLS 9th Edition Compendium of changes
ATLS 9th Edition Compendium of changes
ATLS 9th Edition Compendium of changes
Source
American College of Surgeons. Advanced Trauma Life Support. 9th. 2012
Hockberger, Robert et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 6th Edition. Mosby. 2006.
Tintinalli et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 6th Edition. McGraw Hill. 2003.
Thank you,
Have a nice day…