intro to atls dr jorge concepcion

INITIAL ASSESSMENT & ABCs in TRAUMA

Jorge M. Concepcion, MD,FPCS

General Surgery & Trauma

ObjectivesAt the end of this session, the participant is

expected to be able to:

• Discuss the social impact of trauma and the importance of trauma prevention.

• Provide the correct sequence of priorities in assessing multiply injured patient.

• Provide guidelines and techniques in the initial management of multiply injured patient.

INJURY (WHO definition)

-a bodily lesion resulting from exposure to energy Mechanical

Thermal

Electrical

Chemical

interacting with the body in the amounts thatexceed the limits of physiologic tolerance.

Radiation

INJURIES

“NOT ACCIDENTS”

PREDICTABLE

PREVENTABLE

Not random events but occur in predictable patterns

VEHICULAR ACCIDENT“VEHICULAR CRASH”

TRIMODAL PATTERN OF DEATH IN INJURY

FIRST PHASE 50 % PREVENTION

SECOND PHASE TRAUMA SYSTEM

THIRD PHASECRITICAL CARE &REHABILITATION

30 %

20 %

YEAR MORTALITY MORBIDITYRANK RANK

1980

1985

1990

1995

1998

7th

7th

9th

6th

5th

7th

6th

5th

5th

5th

UNDERREPORTED???2002 3rd 4th

Epidemiology

TRAUMA IS A DISEASE!!!

Trauma Concepts

1. Treat the greatest threat to life.

2. Lack of definitive diagnosis should not impede the application of an indicated treatment.

3. Detailed history is not essential to begin the evaluation of an acutely injured patient.

1. PRIMARY SURVEY

2. RESUSCITATION

3. SECONDARY SURVEY

4. DEFINITIVE MANAGEMENT

REASSESSMENT

5. TERTIARY SURVEY

Approach To Severely Injured Patient

A - AIRWAY & C-SPINE CONTROL

B - BREATHING

C - CIRCULATION – HEMORRHAGE CONTROL

D - DISABILITY (NEURO EXAM)

E - EXPOSURE / ENVIRONMENT

Primary Survey

AIRWAY

Assessment of Airway Patency

• Look

• Listen

• Feel

PCS Committee on Trauma

Look

• Apprehension • Agitation/restlessness• Unresponsiveness• Sweating and pallor• Cyanosis• Dyspnea/tachypnea• Rib retraction on

inspiration

• Retracting cervical soft tissues

• Use of accessory muscles of respiration

• Alar flaring• Neck hematoma• Profuse bleeding • Gastric contents in

oropharynx


Listen

• Cough• Hoarseness• Stridor• Decreased or absent

breath sounds• Gurgling

• “I can’t breathe!”• Snoring• No air entry• Wheezing


Feel

• Subcutaneous emphysema

• Tracheal deviation

• Chest wall deformity/crepitus

• No air flow on exhalation

• Diaphoretic skin


Factors Affecting Airway Patency

• Maxillofacial trauma– Direct trauma– Hemorrhage– Aspiration of broken

teeth, blood, dentures– Collapse of bony

support– Soft tissue edema– Altered sensorium 2°

to brain injury



• Impaired sensorium– Due to associated brain injury or alcohol/drug

intoxication– Absent gag/cough reflex– Aspiration of blood/gastric contents– Inadequate ventilatory drive/apnea



• Cervical trauma– Hematoma/swelling compressing airway– Direct airway injury

• Laryngeal fracture (e.g., direct blow, strangulation, clothesline injury)

• Vocal cord paralysis

– Cervical spine precautions mandatory


Factors Requiring Airway Control

• Resuscitation of trauma patients in impending arrest due to shock / hypoxia

• Impaired ventilatory mechanics– Flail chest– Pneumo/hemothorax– Diaphragmatic breathing

• Transport/sedation requirements


Factors Requiring Airway Control

• Continuing threats to airway patency– Soft tissue edema (eg, thermal inhalational

injury, massive fluid resuscitation, local trauma)

– Deteriorating sensorium– Aspiration risk:

• Full stomach/abdominal distention• Continued bleeding/hemoptysis


Airway Risk Factors

I nstability, hemodynamicN eck hematoma/traumaT rauma to the face (maxillofacial)U nresponsive (GCS < 8)B leeding from oropharynxA pneaT hermal inhalational injuryE mesis/epistaxis/hemoptysis/


Airway Algorithm

Trauma patient withairway risk factors

Oxygenate

Airway compromise No airway compromise

Ventilate/Intubate with cervical in-line stabilization

Unable to intubate

Cricothyroidotomy

Observe/reassess

Airway compromise?

Continue monitoring patient’s progress

Reassess adequacy of ventilation

YES

NO

Airway Maintenance Measures

• Finger sweep

• Chin lift

• Jaw thrust

• Oropharyngeal/nasopharyngeal airway

• Laryngeal mask airway

• Needle cricothyroidotomy


Oropharyngeal Airway

Laryngeal Mask Airway

Definitive Airway Methods

• Intubation– Orotracheal– Nasotracheal

• Surgical Airway– Cricothyroidotomy– Tracheostomy


Orotracheal Intubation


Cricothyroidotomy


Associated Skills

• Assisted/bag-mask ventilation

• Esophageal compression

• Checking tube placement

• Anchoring


BREATHING

• Guarantee adequate oxygenation and ventilation• Give supplemental oxygen• Ventilation (lungs, chest wall & diaphragm)• Assess respiratory effort, breath sounds &

oxygen delivery• Use of pulse oximetry

BREATHING: Problem Recognition

• Objective Signs:• Inspection• Palpation• Percussion• Auscultation

Oxygenation

Oxygen delivery

L/min. Approx. FiO2

Nasal cannula Face mask Face mask w/ reservoir

1246

5-66-77-868

10

0.240.280.350.420.400.500.600.600.801.00

Management

• Ventilation

– Mouth to pocket face mask

– Bag-valve-mask – ( 2 person

technique)

• Pleural Decompression– Needle thoracentesis

– Closed-tube thoracostomy

– Three-sided dressing

BREATHING

Bag Mask Ventilation


Needle Thoracentesis

• IndicationTension Pneumothorax

Complications: Local hematoma Pneumothorax Lung laceration

Closed Tube Thoracostomy

• Indications– Simple Pneumothorax

– Massive Hemothorax

– Tension Pneumothorax

– Open Pneumothorax

Closed Tube Thoracostomy

Complications:Laceration or puncture of

thoracic & abdominal organs

Pleural infectionDamage to intercostals

nerves, artery or veinIncorrect tube positionChest tube kinking, clogging

or dislodging

Three-sided Dressing

• Indications– Open pneumothorax

Pulse Oximetry

• The pulse oximeter is designed to measure oxygen saturation and pulse rate in peripheral circulation.

CIRCULATION

CIRCULATION

• Assure adequate oxygen delivery and control bleeding

• Assess vital signs • Control bleeding by

direct pressure• Reduction of fractures

in long bones and pelvis

Recognition of Shock

• Tachycardia

• Cutaneous vasoconstriction

• Narrowed pulse pressure

• Hypotension

Pitfalls of Shock Recognition

• Extremes of age

• Athletes

• Pregnancy

• Medications– beta blockers– pacemakers

• Hypothermia

Classes of HemorrhageClass I Class II Class III Class IV

Blood Loss (ml) Up to 750 750-1500 1500-2000 >2000

Blood Loss (% blood volume)

Up to 15% 15-30% 30-40% >40%

Pulse Rate <100 >100 >120 >140

Blood Pressure normal normal decreased decreased

Pulse Pressure normal or decreased

decreased decreased decreased

Respiratory Rate 14-20 20-30 30-40 >35

Urine Output (mL/hr) >30 20-30 5-15 negligible

CNS/mental status Slightly anxious

Mildly anxious

Anxious, confused

Confused, lethargic

Initial Management

• Recognize shock

• Stop the bleeding!

• Replace effective circulating volume

• Restore tissue perfusion

Initial Management

• Physical examination– ABCDEs– gastric and bladder decompression

• Vascular access– basic principles– initial blood tests

• Fluid therapy– isotonic fluid

Hemorrhage Control Techniques

• Direct pressure

• Inflow occlusion

• Tourniquets

• Reduction of pelvic volume maneuvers

• Application of folded sheets

• PASG

Severe Pelvic Fractures

C-CLAMP

Vascular Access

• 2 large bore peripheral IV lines

• Venous cutdown– saphenous vein

• Central access– femoral– jugular– subclavian

• Intraosseous• Obtain blood for type

and cross matching

Fluid Therapy

• Warmed crystalloid solution

• Rapid fluid bolus– Adult 2 liters– Child 20 mL/kg

• “3 for 1 rule”

• Monitor response to therapy

Size (gauge) Time

18

16

14

9 min.

12 min.

7 min.

Fluid Therapy

Response to Fluid Resuscitation

• Rapid response

• Transient response

• Minimal or no response

Response to Fluid Resuscitation

Rapid Response Transient Response

No response

Vital Signs Return to normal Transient improvement

Remain abnormal

Estimated blood loss

Minimal (10-20%) Moderate and ongoing (20-40%)

Severe (>40%)

Need for more fluids

Low High High

Need for blood Low Moderate to high Immediate

Blood preparation Type and crossmatch

Type specific Emergency blood release

Need for surgery Possibly Likely Highly likely

Early presence of surgeon

Yes Yes Yes

Assess GCS, pulses, sensory and motor functions

GCS BEST MOTOR RESPONSE – 6BEST VERBAL RESPONSE – 5 EYE OPENING – 4

3 - 15

V = ? M = 4 E = 3 GCS = 7

V = M(0.5) + E(0.4)

V = 4 (0.5) = 2 + 3 (0.4) = 1.2

V = 2 + 1.2 = 3.2

V = 3 M = 4 E = 3 GCS = 10

?

Disability

Exposure and Environmental Control

• Undress (cut clothing!)

• Keep patient warm

• Logroll

• Often missed injuries

Axilla

Perineum

Back

ED THORACOTOMYEXPLORATORY LAPAROTOMY

X-FIX

PERICARDIOCENTESIS

CHEST TUBEINSERTION IV ACCESS

Resuscitation

- ALLERGIES

- MEDICATIONS

- PAST ILLNESSES

- LAST MEAL

- EVENTS PRECEEDING THE INCIDENT

A

M

P

L

E

Secondary Survey

• History

Secondary Survey

• Physical Examination

Detailed, meticulous head-to-toe exam

Finger and tubes in all orifices

Look, listen, feel everywhere

DEFINITIVE MANAGEMENT

TERTIARY SURVEY

PANIC

INSERT NGT IN PATIENT WITH SUSPECTED FACIAL FRACTURE

FORGET TO WARM THE PATIENT (ESP. CHILDREN)

OVERLOOK THE PERINEUM, BACK AND AXILLA

REMOVE IMPALED OBJECTS

INSERT A FOLEY CATHETER IN PATIENTSSUSPECTED OF URETHRAL INJURY

DON’T

SPLINT PATIENTS WHERE THEY LIE

COMFORT THE PATIENT

ALLEVIATE PAIN

HONE YOUR SKILLS

ASK FOR HELP

PRIMUM NON NOCERE

DO

Summary

1. Rapid but thorough assessment.

2. Treat the greatest threat to life: a. Control airway

b. Provide oxygen and adequate ventilation

c. Control bleeding and restore blood volume

3. Continuously monitor patient’s condition: treat continuing threats to life and limb

4. Prompt definitive treatment

intro to atls dr jorge concepcion

Documents