art of life support
DESCRIPTION
Trauma is the 3rd leading cause of death in people aged 1-44 years, and a leading cause of disability. WHO data suggest that 1 in 10 deaths worldwide is a result of trauma. Serious multi-system injuries occur in 10-15% of PTP.TRANSCRIPT
ART OF LIFE ART OF LIFE SUPPORTSUPPORT
BY
Hosam Mohamad Hamza, MscASSISTANT LECTURER OF GI SURGERY
& ENDOSCOPYMinia School Of Medicine
Minia –Egypt
Trauma is the 3rd leading cause of death in people aged 1-44 years, and a leading
cause of disability .
WHO data suggest that 1 in 10 deaths worldwide is a result of trauma .
Serious multi-system injuries occur in
10-15% of PTP.
Trauma related mortality may be:
Immediate death
Early DeathLate Death
%50%30%20%
Time after injury
soon or within min.
1st few hrs (golden hrs)
days or weeks
Causes-major brain injury.
-high cord injury.
-major airway disruption.
-Airway obst.
-disruption of Breathing mech.
-Circulation failure .
-Sepsis.
-M.O.F.
PreventionCommunity education about
trauma- preventing
programs (seat belts, head
protection,…etc)
Training about ABC
resuscitation programs.
Proper patient
follow-up.
Immediate50%
Early30%
Late20%
TRAUMA CARE
Organized trauma teamOrganized trauma system
I. Trauma Team Patients with major trauma are best
treated by a well-organized trauma team.
Each team member should be assigned a specific task or tasks so each of these can be performed simultaneously.
II. Trauma System Recently, many protocols were
introduced for management of multi injured patients including :
ATLS → Advanced Trauma Life Support.
followed by:ATNC → Advanced Trauma Nursing
Course.and more recently:
PHTLS → Pre-Hospital Trauma Life Support.
LIFE SUPPORT Definition:
Several techniques used to maintain life when essential body systems are not sufficiently functioning to sustain life
unaided .
Basic Life Support (B.L.S.)
A specific level of prehospital medical care provided by trained responders, including emergency medical technicians, in the
absence of advanced medical care.
Advanced Trauma Life Support (A.T.L.S.)
In 1970s, an air crash lead to the death of the wife and serious injuries of the three children of James Styner; an American orthopedic surgeon. An event that had forced him to introduce a structured trauma management program which was soon adopted by The American Collage of Surgeons and developed the Advanced Trauma Life Support (ATLS) protocol or EMST (Early Management of Severe Trauma) as known in the UK.
Philosophy of ATLS: “ Treat the lethal injuries first, then
reassess and treat again”
Components of ATLS:
1-Primary Survey
identify what is fatal and treat it.
2-Secondary Survey
proceed to discover all other injuries.
3-Definitive Care
develop a definitive management plan.
TriageTriage SIEVE
Triage SORT
Primary survey and Resuscitation
identify and treat any life threatening condition .
- starts at the scene of accident by trained ambulance personnel.
- must be repeated any time a patient's status changes.
- Steps : (stepwise approach) history : (AMPLE )
Airway, no procedures are initiated until the airway is secured
Breathing Circulation
Disability (N. Dysfunction) Exposure / Environment
Fracture
1 -AIRWAY & SPINE CONTROL (1ry survey)Lack of an airway is one of the few situations in medicine in which
seconds count.
* assess: - esp. in : disturbed conscious level ?? ±
vomition. maxillo-facial trauma.
neck trauma . nasal or oral bleeding.
* maintain: * protect (clear):
* provide: @ endotracheal @ surgical
AIRWAY & SPINE CONTROL (continued)
AIRWAY & SPINE CONTROLAIRWAY & SPINE CONTROL (continued)(continued)
•AIRWAY & SPINE CONTROL (continued)
indications of ETE in trauma:1.Apnea (as part of CPR).
2.Respiratory insufficiency.3.Risk of aspiration (dcl w vomition)
4.Impending upper airway compromise (inhalation, maxillo- facial injuries.)
5.Closed head injuries. (hyperventilation).
Tracheostomy (tracheotomy)
Cricothyroidotomy(cricothyrotomy, mini-
tracheostomy, laryngostomy)
Types :
- needle cricothyrotomy
- surgical cricothyrotomy
? -cricothyroidotomy is more simple
and faster and nowadays is gaining popularity over tracheostomy.
- needle cricothyroidotomy is a temporary method not suitable for proper ventilation.
- surgical cricothyroidotomy can be used for ventilation for only 30-45 minutes.
- cricothyroidotomy (esp. surgical) is not suitable for children < 10 years.
? - cervical spine should be considered
unstable until provedotherwise by radiology (at least 3 views). - esp. in :*Altered level of consciousness
*Blunt injury above the clavicle. *Cervical bony abnormalities or
tenderness. *Maxillofacial trauma.- Immobilization : Backboard and rigid neck collar, sand
bags and fore head tape. If a collar is not available, manual in
line immobilization is necessary.
2 -BREATHING (1ry survey)
% Having a patent airway is not necessarily associated with normal respiration.
% Abnormal resp. after trauma may be:
§ Central (severe head trauma, RC depression)
§ Peripheral ( Suction pneumothorax, Tension
pneumothorax, Tension hameothorax, flail chest)
2 -BREATHING (1ry survey)
*assess: Inspection :- chest wall bulge or retraction.
chest expansion. wounds. respiratory rate .
tracheal shift. use of accessory muscles of
respiration. Palpation :- surgical emphysema. Tenderness.
fracture click. flail segments. Auscultation :-
air entry at different lung fields on both sides.Percussion :- (less commonly used ) for hyperresonance or dullness over different lung fields on
both sides.
*test :
1 -Pulse oximetry? (unreliable)
2-ABG sampling 3 -Diagnostic Thoracocentesis
(Diagnostic Aspiration = in respiratory distress)
-site : -result :
4-Imaging
Flail chest
Hypoxia
1- Rib fracture pain may cause the patient to hold the chest still.
2- Pulmonary contusion (if present) causes extravasation of fluid and blood into the alveoli.
3- Paradoxical respiration .
Tension pneumothorax is a clinical diagnosis.
do not wait for radiographs if suspecting Classic signs :
- respiratory distress .- cyanosis .- chest pain .
- refractory shock. - decreased breath sounds .
- tympany of the affected lung .- jugular venous distension .
- tracheal deviation to the opposite side
Tension (Massive) hemothorax is defined as 1500 mL of blood in the chest cavity.
Patient who continues to bleed (a flow of 200 mL / h for 2-4 hours) may require thoracotomy to control bleeding.
3 -CIRCULATION (1ry survey)
Failure of peripheral circulation is known as SHOCK.
causes of SHOCK with trauma: 1 - hypovolaemic (hgic) :
commonest. 2 -neurogenic : severe pain.
3 -cardiogenic : haemopericarcardium or
cardiac trauma. 4 -septic : late and rare.
*assess: -fatigue . - altered mentality . - cold pale
clammy skin with slow capillary
refill and collapsed veins.
- vital signs :
weak rapid pulse. hypotension. hypothermia.
hunger to air (tachypnea).
-oliguria: ↓ urine output < 0.5 ml/kg/hour in adults.
* estimate : (amount of blood loss) -clinically:
- external blood loss : (WTa –WTb x 1.5 -2)
- internal blood loss:
¤type of injury: hematoma in closed fracture tibia → 500 –
1500 ml.
hematoma in closed fracture femur →500 –2000 ml.hematoma in closed fracture pelvis →2000 –3000 ml.
¤abdominal US or CT scan.
Class IClass IIClass IIIClass IV
Blood lossUp to 15%15 – 30%30 – 40%> 40%
Mental stateNormal to Anxious
Anx. to Restless
Aggressive or Drowsy
Drowsy to
unconscious
Pulse / min< 100100 - 120100 – 140 140
Systolic BPNormalNormal )supine(
↓↓
Diastolic BPNormal↑↓↓
Pulse P.Normal↓↓↓
Cap. refillNormal> 2 sec> 2 sec> 2 sec
R.R.14 - 2020 - 3030 - 35>35
SkinNormalPale & coldPale &colder
P &very cold
Urine )ml/h(0 - 1010 - 2020 - 30> 30
* treat:
-define & treat the cause.
- 4 tubes:
*Resuscitate with:
two large-bore (14- to 16-gauge) I.V. catheters
warmed fluids.
packed RBCs if necessary.
*Control hemorrhage .
*Use the left lateral position for all pregnant patients at more than 20 weeks of gestation .
4 -DISABLITY (1ry survey) *causes :
head injury, shock , hypoxia and intoxication.
*assess:
AVPU method Alert and responsive .
Vocal stimulus elicits response.
Painful stimulus is needed to elicit a response.
Unresponsive.
Response SCORE
Eye opening response
Spontaneous4
To voice3
To pain2
None1
Best verbal response
Oriented5
Confused 4
Inappropriate speech3
Incomprehensible speech2
None1
Best motor response
Obeys commands6
Localizes pain5
Withdraws to pain4
Flexes to pain3
Extends to pain2
None1
TOTAL3 - 15
5 -EXPOSURE / ENVIRONMENT (1ry
survey)
All clothes are removed using large sharp scissors.
Keep the emergency room
warm and use blankets to prevent hypothermia.
Some cases may require transfer to another hospital with higher facilities or to another department in the same hospital. The level of care MUST not be allowed to DROP during the transfer .
Summary of the primary survey
Airway - Airway opened, airway obstruction treated, possible definitive airway placed
Breathing - Breathing assessed, treat threats . Circulation - Blood circulation and tissue
perfusion assessed, intravascular volume loss replaced with fluids and blood, external hemorrhage controlled .
Disability - Neurologic status assessed Exposure/environment - Patient fully
undressed and environment controlled to protect from hypo or hyperthermia
Consider transfer - For higher level of care if necessary.Adjuncts - Trauma radiographs, laboratory studies, urinary or gastric catheters, temperature monitoring, consider blood transfusion
Secondary Survey -starts once resuscitation efforts are
underwent and preliminary X rays have been evaluated.
-steps : * examine the patient from head to
toe and from front to back. * complete and integrate all data
(clinical, laboratory and radiological) .
* Formulate a management plan .
Definitive Care * after identification of the cause &
region of injury . * Patients with multiple injuries require
the attention of a number of specialists. * The most appropriate person to take
the primary responsibility in such cases is usually the general surgeon.
* Patients require repeated evaluation as some injuries may present late e.g. delayed splenic injuries, retroperitoneal duodenal injuries and subdural hematomas.