Advanced Trauma Life Support Reviewer

Quality Development Department

Trauma

� Leading cause of death ages 1- 44 years

� 60 million injuries a year

� $ 400 Billion annually

� 2.7 million admissions / year

� 100,000 deaths per year

� 50 % die prior to receiving any medical care

ATLS

� ATLS formed in 1978 to standardize trauma care

� American College of Surgeons

� Adopted in over 40 countries

� Goal is to teach a simplified and standardized approach to the care of trauma patients

� “Golden Hour”

Types of Trauma

� Blunt Trauma

� Penetrating Trauma

� Burns / Cold

� Environmental Exposure

� Hemorrhage is the # 2 cause of death in trauma

ATLS

� ABCDE

� A = Airway

� B = Breathing / Bleeding

� C = Circulation

� D = Disability

� E = Exposure / Environment

Vital Signs

� Physiological status

– Clinical Clues

� Body temperature

� Heart rate

� Blood pressure

� Respiratory rate

� O2 saturation

� Pulse Pressure

Pulse Pressure

� Pulse pressure is the difference between systolic and diastolic blood pressure

� The change in blood pressure seen during a contraction of the heart

� Normal Range: 30 - 40 mmHg

� Systolic pressure - Diastolic pressure

Low / Narrow Pulse Pressure < 25 mmHg

� Significant blood loss

� Low stroke volume

� Tachycardia

� Severe Aortic Stenosis

� Constrictive Pericarditis

� Pericardial Effusion

� Ascites

� Congestive Heart Failure

� Shock

High Pulse Pressure > 40 mmHg– Stiffness of the major arteries

– Aortic regurgitation

– AV malformation

– Atherosclerosis

– Thyrotoxicosis

– Fever

– Pregnancy

– Heart block

– Aortic dissection

– Endocarditis

– Raised intracranial pressure

Phases of ATLS

� Triage – Rapid initial assessment

and management of the injured patient

� Prehospital Phase

� Hospital

� Posthospital Phase

Triage

Multiple Casualties

� Severity of injuries does not exceed the ability of the facility

Mass Casualties

� Injuries Exceed the capabilities of the facility and staff

Prehospital Phase

� Airway maintenance

� Control external frank bleeding and shock

� Immobilization

� Minimize scene time

� Trauma alert criteria

� Transport to the nearest APPRORIATE facility

� DO NO HARM !

Primary Survey

� ABCDE

� Life threatening conditions are identified and managed simultaneously

Airway and C-Spine

� Airway patency

– Jaw thrust or chin lift

� Immobilize C- Spine

� Head and neck not be moved

� Assume a cervical spine injury in any multisystem trauma

– Especially in patients with AMS

� GCS < 8 or airway compromise - ET / KT intubate

Breathing

� Ventilation involves function of the lungs, chest wall and diaphragm

� Expose patients chest and look

– Flail chest

– Tracheal deviation

– Puncture sites

� Percussion, Inspection & Palpation

– Pneumothorax

– Hemothorax

Bleeding

� External hemorrhage must be identified and controlled in the primary survey

� Hemorrhage is the predominant cause of preventable post injury deaths

Tourniquets

� Used in traumatic amputation

� Use in PRE shock conditions

� Beneficial if saving Life vs. Limb

Circulation

� Hypotension is considered hypovolemia until proven otherwise

� Signs and effects of Severe Hypovolemia:

– 1. LOC

– 2. Skin color

– 3. Pulse quality

Circulation

� Control bleeding by direct pressure or operative interventions

� Minimum 2 large caliber IV’s

� Warmed LR, 2 – 3 L bolus

� Blood Type Specific or O neg.

� Hypovolemic Shock should NOT be treated with pressors, steroids or HCO3

Disability

� Rapid neurologic evaluation is done at the end of the primary survey

� LOC = AVPU

� A = ALERT

� V = responds to VOCAL stimuli

� P = responds to ONLY PIANFUL stimuli

� U = UNRESPONSIVE to ALL stimuli

Exposure / Environmental Control

� The patient should be completely undressed

� Cover the patient with warm blankets to prevent hypothermia

� Intravenous fluids should be warmed and a warm

environment maintained

Adjuncts to Primary Survey and Resuscitation

� ECG

� NG / OG

� Foley is Contraindicated if– Blood at the meatus

– Perineal ecchymosis

– Blood in the scrotum

– High riding or nonpalpable prostate

– Pelvic fracture

� Monitor

� Labs, UA, X-rays, CT, MRI

Secondary Survey

Secondary Survey

� Head to toe evaluation

� After primary survey is completed

� Resuscitate efforts are established

� Patient has normalization of vital signs

� GCS score and complete neuro exam

� X-rays and special procedures

� “Tubes in every orifice”

Secondary Survey History

� A = Allergies

� M= Medications

� P= Past Illness / Pregnancy

� L = Last meal

� E = Events / Environment leading to injury

Interventional Therapeutics

� IVF– NS / LR / Hespan /

Blood Products

� Needle decompression

� Cricothyroidectomy

� Chest Tubes

� Preicardiocentesis

� Permissive Hypotension

� DPL

� Intubation

IV Fluids

IVF Resuscitation

� Fastest way to deliver, and distribute fluids

Side Effects

� Lowers Hemoglobin

� Deactivates Clotting factors

� Decreases Coagulopathy

� Decreased clotting factors

� Impaired clotting factor function

� Increased bleeding time

Colloids vs. Crystalloids

� Colloids contain larger insoluble molecules – blood

� The most common crystalloid fluid is NS– Sodium chloride at 0.9% concentration – Close to the concentration in the blood – isotonic

� Ringer's lactate is a isotonic solution – For large volume fluid replacement

� A solution of 5% dextrose in water, D5W, is used if there is at risk of low blood sugar or high sodium– D5W is especially used in mixing and infusing medications

due to its hypotonic properties

Intravenous therapy

NS

� Na = 154 and Cl = 154

LR

� Na = 130

� Cl = 109

� Lactate = 28 mmol / L

� K+ = 4 mmol / L

� Ca2+ = 1.5 mmol / L

D5W

� Glucose = 278 mmol / L

Permissive Hypotension

� Hypotension protective

� BP decrease allows clots to stabilize

� Hypotension “good” in other conditions

– Aortic dissection

– Uncontrolled GI bleed

– Extremity bleeding

Permissive Hypotension

� Minimal IVF before hemorrhage control

– Don’t pop the clot!

� Hemodilution by IVF

– Decreases oxygen carrying capacity

– Decreases clotting factor function

� IV fluids activate inflammatory mediators

� Secondary organ damage

Hemorrhagic Shock

� Sudden and rapid loss of significant amounts of blood

� Hypovolemic shock resulting from acute hemorrhage – Hypotension

– Tachycardia

– Oliguria

– Pale, cold, and clammy skin

Battlefield Medicine -Tourniquets

� Improves Long term Survival

� Apply pre shock

� 90 % mortality if placed after shock symptoms

� 10 % mortality pre shock

� Improvised tourniquets should not be used

Hemorrhagic Shock Classifications

Pre Hospital Recommendations

� No fluids if normotensive

� If hypotensive, controlled IVF until goal:

– Radial pulse SBP = 80

– Mentation (non-head injured patient)

– MAP 40–60 mmHg

� Controlled fluid administration

� Small boluses 25 – 500 ml

� Minimum MAP > 60mmHg to maintain CPP

General Trauma Overview

Head Trauma

Physical Examination Head Injury

� # 1 cause of traumatic death

� Visual acuity

� Ear Trauma

– Halo test

� Raccoons Eyes

� Pupillary size

� Ocular damage

– Remove contact lenses

– Lens dislocation

� Penetrating Injury

Head Exam Coup Contra Coup Brain Injury

� A specific area of brain injury located directly opposite to the site of impact to the head that results from linear violent collisions of the brain with the skull.

What is a TBI?

� Sudden damage to the brain by an external force

2 Types� Closed Head Injury

– Head forcefully collides with another object

� No skull injury

� Open Head Injury– Object fractures the skull and

debris enters the brain � Brain tissue damage

TBI Severity Levels

� Mild

– Change in the mental status at the time of the injury

– Concussion.

� Moderate

– Loss of consciousness last for minutes to hours

– confused for days or weeks

� Impairments can be temporary or permanent.

� Severe

– Unconscious state for days, weeks, or months

� Impairments are permanent.

Concussion Grades

� Grade 0 results when the head is struck or moved rapidly– Post injury headache and difficulty with concentration

� Grade 1 concussions the patient may appear stunned or dazed– No LOC, and sensory difficulties clear < 1 minute

� “I got my bell rung” description from the athlete

� Grade 2 Headache, cloudy senses > 1 minute, and no LOC – Tinnitus, amnesia, irritability, confusion, or dizziness

� Grade 3 concussions experience a LOC < 1 minute– Not comatose, with the same symptoms as a grade 2 concussion

� Grade 4 concussions experience a LOC > 1 minute– Exhibits the symptoms of the grade 2 and 3 concussions

Post-Concussion Syndrome

� Decreased Processing Speed

� Short Term Memory Impairment

� Concentration/Attention Deficit

� Irritability/Anxiety/Depression

� Fatigue/Sleep Disturbance

� General Feeling of “Fogginess”

� Academic Difficulties

� Persistent headache

� Intolerance of Lights and Noise

Concussion Treatment

� Transport ALL concussions

� Head CT Scan required

� Grades 2 – 4

– Most serious

� Needs neurologic specialists

Differential diagnosis

� Subdural hematoma

� Epidural hematoma

Subdural and Epidural Hematomas

Subdural Hematomas

� Due to the shearing forces of acceleration

� The blood vessels on the surface of the brain are torn and begin to bleed

� No LOC

� Slow developing injury

� Treatment < 4 hours lowers mortality

Epidural hematomas

� Faster progressing injury– LOC

– Then a lucid moment

– Rapid decline in mental function

� Most are associated with a skull fracture

� Surgical intervention is a must to prevent death

Signs of Increased ICP

� Visual difficulties

� Vomiting

� Dyspnea

� Decreased pulse

CPP = MAP - ICP

CPP: Cerebral Perfusion PressureMAP: Mean Arterial PressureICP: Intracranial Pressure

Maxillofacial

� Cribriform fractures

� OG Tube ONLY

� Le Fort fracture– 3 types

� Bilateral horizontal fracture of the maxilla

Maxillofacial Le Fort fractureLe Fort I fracture� Horizontal segmented fracture of the alveolar process of the

maxilla, the teeth are contained in the detached portion

Le Fort II fracture� Fracture of the maxilla, in which the body of the maxilla is

separated from the facial skeleton and the separated portion is pyramidal in shape; the fracture may extend through the body of the maxilla down the midline of the hard palate, through the floor of the orbit, and into the nasal cavity

Le Fort III fracture� Entire maxilla and one or more facial bones are completely

separated from the craniofacial skeleton; such fractures are almost always accompanied by multiple fractures of the facial bones

Cervical Injuries

Cervical Spine and Neck

� Head and spinal cord injury # 1 cause of traumatic death

� Head and Maxillofacial trauma are presumed to have an unstable C-spine

� C-spine immobilization

� Absence of neurologic deficit does not exclude injury

� DO NOT EXPLORE Zone 1 Penetrating injuries– The Platysma

Spinal Cord Injury Definitions

Spinal Shock

� Flaccidity and loss of reflexes after spinal cord injury, variable duration

Neurogenic Shock

� Impairment of the descending sympathetic pathways in the spinal cord

� Loss of sympathetic innervation to the heart and vascular system - vasomotor tone

– Hypotension and Bradycardia

� Treatment - Vasopressors and Atropine

Spinal Cord Injuries

Brown SéquardSyndrome

� Penetrating trauma

– GSW

� Loss of function on affected side

� Loss of pain and temperature sensation on opposite side

Anterior Cord Syndrome

� Bony fragments or pressure on spinal arteries

� Loss of motor function

� Loss of pain sensation

� Loss of light touch sensation

– Some sparing of light touch, vibration, and proprioreception

Spinal Cord Injuries

Central Cord Syndrome

� Hyperextension of c - spine

� Weakness / parasthesia

– UE > LE

� Preserved function of lower extremities

� Bladder dysfunction

Posterior Cord Syndrome

� Rare

� Hyperextension injury

� Partial loss of proprioreception

� Loss of sensation

– Deep touch

– Vibratory

Chest Trauma

Chest Trauma

� Pain, Dyspnea, or Hypoxia

� 25% of all trauma deaths

� 2/3 of deaths occur after reaching hospital

� 2nd leading cause of death from physical trauma after head and spinal cord injury

Chest Trauma Differential Diagnosis

� Thracheobroncial Injury

� Pneumothorax

� Hemothorax

� Rib / Sternal fractures

� Diaphragm Rupture

� Flail Chest

� Open Chest Wound

� Penetrating Injury

� Pulmonary contusion

Rib Fracture Differential Diagnosis

� 1-3 ribs & Scapula

– High mortality

– Thoracic Injury

� 4-9 ribs

– Intrathoracic injury

� 10 -12 ribs

– Left lower six ribs 20% spleen

– Right lower six ribs 10% liver

– Abdominal Organ Injury

Pneumothorax

� Air in the pleural cavity

� Any injury that disrupts the parietal or visceral pleura

� Unilateral signs:

– ↓movement and breath sounds

– Resonant to percussion

� Confirmed by CXR

Treatment

NRB if < 20 % of chest cavity

Chest Tube if > 20 %

Tension Pneumothorax

� “1 way valve" air leaks into the lung– Air enters is unable to escape the pleural space

� Clinical Diagnosis – Not radiologic– Respiratory distress

– Tachycardia

– Hypotension

– Tracheal deviation to opposite side

– Shift of mediastinum to opposite side

– Decreased LOC

– Neck vein distension - JVD

� Unilateral absence of breath sounds

� Immediate Needle decompression in 2nd space followed by chest tube

Chest Tube Indications

� Pneumothorax– Air in the pleural space

� Pleural effusion– Fluid in the pleural space

� Chylothorax– Lymphatic fluid in the pleural space

� Empyema– Infection of the pleural space

� Hemothorax– Blood in the pleural space

� Hydrothorax– Serous fluid in the pleural space

Massive Hemothorax

� Rapid accumulation of ≥1500 ml blood results in hypoxia

� Shock + absent breath sounds

� Flat or distended neck

Treatment

� Chest decompression # 38 CT

� If 1500 ml evacuated by CT, or > 200 ml/hour continuous loss

� Thoracotomy surgery

Flail Chest

� A segment of chest wall looses continuity with rest of the chest

� Hypoxia from lung injury

Diagnosis

� Asymmetric chest wall movement

� Palpation of crepitus

� Chest X ray

Treatment

� Intubation as indicated

� Analgesia

Cardiac Tamponade

� Pericardium a fixed fibrous structure

– Small amounts of blood can restrict ALL cardiac activity

� Distant heart sounds

� Narrow pulse pressure

Diagnosis

� Pulse Paradoxus

� Beck's Triad

– JVD, Muffled Heart tones, Low BP

� Treatment - Pericardiocentesis

– Requires open pericardotomy

Aortic Rupture

� Blunt trauma involving deceleration forces / injury

� ~90% die within minutes

� Most common site is near the ligamentum arteriosum

Diagnosis:

– Clinical suspicion

– CXR

– Aortography

– Contrast CT or TEE

� Treatment

– Surgical…poor prognosis

Abdomen Trauma

Abdominal Injuries 2 types

Closed

� Bleeding of organs

� Seatbelts can cause internal damage

� Abdomen may become distended w / blood

Open

� Abdominal cavity has been opened

� Very important to watch for infection

� Abdominal organs may protrude out of body

Frequency of Organ Injury

1. Spleen 46%

2. Liver 33%

3. Mesentery 10%

4. Urological 9%

5. Pancreas 9%

6. Small bowel 8%

7. Colon 7%

8. Duodenum 5%

Eviscerated Bowel Treatment

� Position patient on their back – Knees flexed & head & shoulders slightly raised to take the

pressure off the abdomen

� Expose the wound

� DO NOT try to reduce the abdominal organs in the cavity

� Cover the exposed organs with sterile moist gauze

� Cover the gauze with plastic wrap to keep in moisture

� Cover the wrap with abdominal pads to maintain warmth

� Place bulky dressings around protruding organs

� Tape dressings in place

� DO NOT put any pressure on exposed wounds

Diffuse Abdominal Pain Differential Diagnosis

� AAA� Renal artery � Vein thrombosis� Acute appendicitis� Bowel obstruction� Retroperitoneal Bleed� Mesenteric Ischemia � GI tract perforation� Colitis

– Chrons Disease – Ulcerative Colitis

Abdomen Trauma

� A Normal initial exam means nothing

� Unexplained hypotension

– Viscous Injury

– Intra abdominal bleed

� Retroperitoneal Area Injury

– Splenic Bleed

– Renal Laceration

Cullen's Sign

� Superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus

� Ecchymoses in the periumbilical region

� 24 - 48 hours to appear

Abdominal Trauma Signs

Kehr's Sign

� Acute pain in the tip of the shoulder

� Presence of blood or irritants in the peritoneal cavity when a person is lying down and the legs are elevated

� Classical referred pain of a ruptured spleen

Abdominal Trauma Signs

Grey Turner's Sign

– Bruising of the flank, may be indicative of Pancreatic necrosis with retroperitoneal or intra-abdominal bleeding

Cullen's or Turner's sign

– Occurs in approximately 3 % of patients

– Mortality of 37 %

– Retroperitoneal Bleeding

Trauma in Pregnancy

Trauma in Pregnancy

� 34% of traumatic death cases due to MVC

� Amount of blood loss to have clinical signs is greater than nonpregnant

� Pelvic Fracture are highly concern because

� Risk of massive hemorrhage

� Nausea and vomitting

� Supine hypotensive syndrome

� Greater risk of pulmonary edema

� Kleihauer-Betke test

Placental Abruption

� Most likely cause of preterm labor in trauma patients

� Findings

– Contraction

– Fetal tachycardia

– Late deceleration

– Fetal death

Management in Pregnancy� Tachycardia & hypotension are not accurate indicators of shock

� 30% or 2 L blood volume loss - Unstable

� Vasoconstrictive agents

� Use ephedrine & phenylephrine

� Epinephrine & norepinephrine cause

� Uteroplacental vasoconstriction

� Reposition uterus after 20 weeks

Management of Pregnancy

� Non Viable Fetus < 23 wks or < 500 g

� Supportive care

� Close observation

Fetus viable & mother unstable

� Exploratory laparoscopy

� Attempt delivery within 6 minutes after maternal cardiac arrest via C-Section

� CPR continued during and after delivery

Perineum / Rectum

� Examine for Contusions, hematomas, lacerations and urethral bleeding

� High riding prostate

� Blood in bowel lumen

� Vaginal lacerations

Extremity Trauma

Extremity

� Check for Pulses

� Save severed limb and place in plastic bag and place ice in the bag surrounding the limb

� Check capillary refill

� Splint wounds

� Pain Management

Musculoskeletal / Extremity� Bones should be palpated for any deformity

� Examine the patients back !

� Ligament disruption will cause joint instability

� Pelvic fractures can have ecchymosis over the iliac wings, pubis, labia, or scrotum– Pain to palpation to the pubic ring

– Mobility of the pelvis to gentle anterior to posterior pressure suggests pelvic ring Fracture

– If Unstable consider pelvic binder

Musculoskeletal Compartment Syndrome

� Compression of nerves, vessels and muscle inside a closed space - compartment

� This leads to tissue death from the lack of oxygenation as the blood vessels are compressed by the raised pressure in the compartment – Most commonly in the forearm and lower leg

� Striker with pressures > 30 mmHg

� <30 mmHg difference between intracompartmental pressure and DBP is an indication for fasciotomy

Compartment Syndrome

� There are classically 6 "Ps“ :

– Pain out of proportion

– Pallor

– Paralysis

– Pulselessness

– Poikilothermia - failure to thermoregulate

– Paresthesia

� Paresthesia, is a late symptom

� Only the first two are reliable in the diagnosis

Thermal Injuries

Thermal

� Rule of Nines

– Parkland Formula

– Pain management

� Fluid resuscitation is critical < 24 hours

� Airway protection

� Look for singed nasal or facial hairs

� If Uncertain Intubate

Parkland Formula for Treating Burn Victims

� Fluid resuscitation is determined from the percentage BSA involved

� "Rule of 9's" estimates the % BSA

Fluid Requirements for first 24 hours

� TBSA burned(%) x Wt (kg) x 4mL

� Give 1/2 of total requirements in 1st 8 hours

� Give 2nd half over next 16 hours

Neurologic Trauma

Neurologic

� Motor and Sensory Exam

� Revaluation of LOC / GCS

� Tracheal Intubation increases ICP

� Pupillary size

� Paralysis

� Immobilization of entire patient

� Rigid longboard, semi rigid c-collar

Glasgow Coma Scale

Eye opening (E)� – Spontaneous 4� – To speech 3� – To pain 2� – None 1

Verbal response (V)� – Oriented 5� – Confused conversation 4� – Inappropriate words 3� – Incomprehensible sounds 2� – None 1

Best motor response (M)� – Obeys commands 6� – Localizes pain 5� – Normal flexion (withdrawal) 4� – Abnormal flexion (decorticate) 3� – Extension 2� – None (flaccid) 1

Spinal Cord Injuries

Complete injury

� NO motor or sensory impulses pass below lesion

� 50% of injuries

Incomplete injury

� Some signals pass– May have some motor and sensation below level

� Injury > T1 = Quadriplegia

� Injury < T1 = Paraplegia

Cauda Equina Syndrome

� Cauda equina or "horse-tail“ is the mass of nerves after the conus

� Acute loss of function of the lumbar plexus below the termination of the conus of the spinal cord

� Saddle anesthesia

� Lower extremity parasthesia

� Sciatica

� Regeneration possible

� Treatment is surgical decompression

Secondary Survey Adjuncts

� Constant Revaluation

� CPP > 60 mm / Hg

� Adult UO = 0.5 mL / Kg / hour

� Pediatric UO = 1 mL / Kg / hour

� Transfer to a higher level facility if needed

ATLS Summary

� Bleeding control

� C- Spine control

� Splint

� IVF – NS / LR

� Hespan

� Permissive Hypotension

� Blood products

� Pressers if needed

ATLS Summary

� Standard for trauma care for hospitals and advanced paramedical services

� Treat the greatest threat to life first

� Lack of a definitive diagnosis and a detailed history should not slow the application of indicated treatment for life-threatening injury

� Most time-critical interventions performed early

� ATLS improves patient outcomes

Thanks

Please complete the post test and return to administration via interoffice mail or fax to: 352-735-4475 attention Scott Temple

This program is worth 2 CEUs in the Trauma or Electives categories

Please specify on your post test where you would like the CEUs to be inserted.