Introduction to Advanced Trauma Life Support ATLS
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1 Introduction to Advanced Trauma Life Support ATLS
2 Objectives Concepts of primary & secondary survey Priorities & Life threatening conditions Clinical & Surgical skills
3 Basic knowledge Rapid assessment Resuscitate & Stabilize (Prioritize) Patient's needs & facility's capabilities Appropriate transfer Optimum care
4 Initial Assessment & Management Preparation (Prehospital - Hospital) Triage Primary survey (ABCDE) Resuscitation Adjuncts to primary survey & resuscitation ->
5 Initial Assessment & Management Secondary survey Adjuncts to the secondary survey Postresuscitation monitoring Definitive care
6 Primary Survey Treatment priorities A: Airway maintenance + C-spine protection B: Breathing & Ventilation C: Circulation & Hemorrhage control D: Disability Neuro E: Exposure / Environment control
7 A Airway Patency / Obstruction Severe head injury -> Definitive airway
8 Airway: Patency Maxillofacial trauma Neck trauma Laryngeal trauma (Hoarseness, Subcutaneous emphysema, Palpable fracture)
9 A C-spine protection Multiple system trauma Altered level of consciousness Blunt injury above clavicle Manual in-line stabilization
10 A: Nexus Midline cervical tenderness Altered level of consciousness Evidence of intoxication Neurologic abnormality Presence of painful distracting injury
11 A Trauma patient is dynamic Repeated assessment
12 A: Resuscitation Jaw thust / Chin lift / Head tilt Naso / Oropharyngeal airway Combitube, LMA Definitive airway (Cuff in trachea) Oro / Naso tracheal intubation Surgical cricothyroidotomy
13 Endotracheal intubation Indication Provide patent airway Deliver supplemental oxygen Support ventilation Prevent aspiration
14 Endotracheal intubation Decision Apnea (orotracheal) Cannot maintain patent airway Protect aspiration / vomitus Impending compromise airway Closed head injury required assisted ventilation Inadequate oxygenation
15 Surgical Airway Cricothyroidotomy / Tracheostomy Indication Unable to intubate (severe maxillofacial injury, failed intubation) Contraindication Airway transection
16 B: Breathing
17 B: Life Threatening Conditions Tension pneumothorax Flail chest with pulmonary contusion Massive Hemothorax Open pneumothorax Cardiac tamponade
18 Thoracic Trauma: Primary survey Looking, Palpation, Percussion, Listening Tension pneumothorax Open pneumothorax (sucking chest wound) Flail chest Massive hemothorax Cardiac tamponade
19 Thoracic Trauma: Primary survey Tension pneumothorax Chest pain, Respiratory distress, Tachycardia, Hypotension, Tracheal deviation, Absent breath sound, Neck vein distension Immediate decompression Needle thoracostomy Intercostal drainage
20 Thoracic Trauma: Primary survey Open pneumothorax (sucking chest wound) > 2/3 of tracheal diameter 3 sided dressing Chest tube insertion
21 Open Chest Wound: 3-Sided Dressing
22 Thoracic Trauma: Primary survey Flail chest >2 ribs fractures in 2 or more places Paradoxical chest wall movement Adequate ventilation Reexpand lungs: Intubation
23 Thoracic Trauma: Primary survey Massive hemothorax >1500 cc of blood (1/3 of blood volume) in chest cavity IV resuscitation Chest tube Thoracotomy >1500 cc immediately 200 cc/h for 2-4 h
24 Thoracic Trauma: Primary survey Cardiac tamponade Penetrating injury Beck's triad DDx from Tension pneumothorax FAST / Echo Pericardiocentesis
25 B: Resuscitation Supplemental oxygen Tension pneumothorax decompression
26 C: Circulation & Hemorrhage control Circulation Blood volume & Cardiac output Level of consciousness Skin color Pulse
27 C Hemorrhage control - External hemorrhage Manual pressure Splinting Tourniquet Hemostats
28 C: Resuscitation 2 large-caliber IV catheter warm NSS, RLS Blood Control bleeding Direct pressure Operative control Vasopressors
29 Shock Inadequate tissue perfusion / oxygenation Hemorrhagic / Non-hemorrhagic
30 Hemorrhagic shock Most common cause of shock in trauma External vs Internal hemorrhage Blood volume = 7% of BW Rx: Volume replacement Shock Classification
31 Hemorrhagic shock classification Class I 15% blood loss P < 100 BP normal PP normal RR Urine output >30 cc/h Mental status: Slightly anxious
32 Hemorrhagic shock classification Class II 15-30% blood loss P > 100 BP Normal PP decreased RR Urine output cc/h Mental status: mildly anxious
33 Hemorrhagic shock classification Class III 30-40% blood loss P >120 BP decreased PP decreased RR Urine output 5-15 cc/h Mental status: confused
34 Hemorrhagic shock classification Class IV >40% blood loss P >140 BP decreased PP decreased RR > 35 Urine output --- Mental status: confused / lethargic
35 Fluid replacement Class I, II: Crystalloid Class III, IV: Crystalloid, Blood Initial fluid therapy 1-2 L for adult 20 cc/kg for children 3-for-1 rule 1 cc blood loss = 3 cc crystalloid replacement
36 Response to fluid resuscitation Rapid response <20% blood loss Cross-match, Surgical consultation Transient response 20-40% blood loss On going blood loss Blood transfusion, Surgical intervention
37 Response to fluid resuscitation No response Immediate operative intervention
38 Non-hemorrhagic shock Cardiogenic shock Tension pneumothorax Neurogenic shock Septic shock
39 Cardiogenic shock Cardiac contusion Cardiac tamponade: Beck's triad Tachycardia Muffled heart sound Distended neck vein Echo / FAST
40 Cardiac Tamponade Penetrating injury Beck's triad DDx from Tension pneumothorax FAST / Echo Rx: Pericardiocentesis
41 Tension pneumothorax One-way valve Respiratory distress Subcutaneous emphysema Absent breath sound Hyperresonance on percussion Tracheal shift Distended neck vein Rx: Needle / Tube thoracostomy
42 Neurogenic shock Isolated intracranial injuries do not cause shock Loss of sympathetic tone: Spinal cord injury Hypotension without tachycardia Initially treated as Hypovolemia DDx of non-responder
43 D Neurological status Level of consciousness (AVPU / GCS) Pupil size & Light reaction Lateralizing sign Spinal cord injury level
44 D A: Alert V: Verbal command P: Painful stimuli U: Unresponsive
45 D Factors affect level of consciousness Oxygenation ( ABC ) Ventilation ( ABC ) Perfusion ( ABC ) Hypoglycemia Drugs / Alcohol
46 D Reevaluation
47 E Uncloth patient Logroll patient Prevent hypothermia Warm blanket Warm IV fluid
48 E Rectal examination Sphinctor tone Position of prostate (high-riding?) = urethral injury Gross blood (penetrating abdominal injury) Pelvic fractures
49 Primary survey: Adjuncts Monitor Diagnosis
50 Primary survey: Adjuncts: Monitor EKG monitor Foley's catheter Gastric catheter Respiratory rate ABG Pulse oximetry
51 Primary survey: Adjuncts: Diagnosis CXR, Pelvis AP, Lateral C-spine DPL, FAST Should not interrupt resuscitation process
52 Foley's catheter Contraindicated in Urethral injury Suspected urethral injury Inability to void Unstable pelvic fracture Blood at meatus Scrotal hematoma Perineal ecchymoses High-riding prostate
53 Gastric tube Relieve gastric dilatation Decompress stomach before DPL Reduce risk of aspiration NG tube: contraindicated in basilar skull fracture
54 Secondary Survey Not begin until primary survey is completed History (AMPLE) Head-to-toe evaluation GCS X-rays
55 Secondary Survey: Adjuncts Specialized diagnostic tests (CT, US, scope) Should not be performed until hemodynamic stabilization
56 Secondary Survey History: AMPLE A: Allergies M: Medications P: Past illnesses / Pregnancy L: Last meal E: Events
57 Secondary Survey Physical examination Head-to-toe examination
58 Thoracic Trauma: Secondary Survey Simple pneumothorax Hemothorax Pulmonary contusion Tracheobronchial tree injury Blunt cardiac injury Traumatic aortic disruption Traumatic diaphragmatic injury Mediastinal transvering wound
59 Abdominal Trauma
60 Abdominal Trauma External anatomy Anterion Flank Back
61 Abdominal Trauma Internal anatomy Peritoneal cavity Pelvic cavity Retroperitoneal space
62 Abdominal Trauma Mechanism of injury Blunt Penetrating
63 Abdominal Trauma: Assessment History Physical Exam Inspection, Auscultation, Percussion, Palpation Evaluation of penetrating wound Pelvic stability Penile, Perineal, Rectal exam Vaginal, Gluteal exam
64 Celiotomy: Indications Blunt abdominal trauma with hypotension & evidence of intraperitoneal bleeding Blunt abdominal trauma with positive DPL or FAST Hypotension with penetrating abdominal wound GSW traversing the peritoneal cavity / visceral / vascular retroperitoneum Evisceration
65 Celiotomy: Indications (cont.) Penetrating trauma with Bleeding from stomach, rectum, GU Peritonitis Free air, retroperitoneal air, ruptured hemidiaphragm after blunt trauma Ruptured hollow viscus
66 Diagnostic Studies Diagnostic peritoneal lavage: DPL FAST CT scan Urethrography, Cystography, IVP
67 Diagnostic Peritoneal Lavage:DPL Indications Altered level of conscious / Spinal cord injury Injury to adjacent structures Equivocal physical exam Prolonged loss of contact with patient Lap-belt sign
68 Diagnostic Peritoneal Lavage:DPL Contraindications Existing indication for celiotomy Relative contraindications Previous abdominal operations Morbid obesity Advanced cirrhosis Coagulopathy
69 Diagnostic Peritoneal Lavage:DPL 1 L of LRS Fluid return: >30% of infused volume Positive Interpretation (blunt abdominal injury): Gross blood > 10 cc RBC >100,000 /mm3 WBC > 500 /mm3 Food particles Gram stain +ve
70 Head injury
71 Head Injury Classification Mechanism (Blunt, Penetrating) Severity (mild, moderate, severe) Morphology (Skull fractures, Intracranial)
72 Head Injury: Severity Mild: GCS Moderate: GCS 9-12 Severe: GCS 3-8
73 Head Injury: Morphology Skull fractures Intracranial Epiduralhematoma Subdural hematoma Intracerebral hematoma Diffuse brain injury
74 Skull fractures Cranium Maxillofacial Basilar skull fractures
75 Basilar skull fracture Raccoon's eyes Battle's sign CSF rhinorrhea / otorrhea
76 Epidural Hematoma Arterial origin (middle meningeal a.) CT: lenticular shape
77 Subdural Hematoma Venous origin CT: Crescent shape
78 Intracerebral Hematoma Brain laceration
79 Head Injury: Management Mild HI (GCS 13-15) Observe CT: Lost of conscious > 5 min Amnesia Severe headache Focal neurological deficit
80 Head Injury: Management Moderate HI (GCS 9-12) CT brain Admit observe neurosigns F/U CT brain h
81 Head Injury: Management Severe HI (GCS < 9) Prompt diagnosis & treatment Don't delay patient transfer to obtain CT scan
82 Monro-Kellie Doctrine
83 Brain resuscitation Maintain adequate Cerebral Perfusion Pressure (CPP) Oxygenation Normocapnia
84 Cerebral Perfusion Pressure CPP = MAP ICP MAP = Mean Arterial Pressure ICP = Intracranial Pressure
85 Cerebral Perfusion Pressure CPP = MAP ICP MAP = Mean Arterial Pressure Stabilize Vital signs IV fluids ICP = Intracranial Pressure Hyperventilation (limited usage) Mannitol (1g/kg) Furosemide
86 Brain resuscitation Oxygenation Oxygen supplement Anticonvulsants Normocapnia Hyperventilation -> CO 2 -> Cerebral vasoconstriction -> CPP
87 Conclusions Initial Assessment (Primary survey, Secondary survey) Adjuncts Priority: Life threatening first Knowledge & Skills for specific conditions DOs & DON'Ts
88 Q?
89
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