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…