Approach to trauma- ATLS update by Dr.Damodhar.M.V
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This document provides an overview of the Approach to Trauma- Advanced Trauma Life Support (ATLS) program. It discusses the history and concepts of ATLS, which was created in 1976 to standardize trauma care. The document outlines the ABCDE approach to the primary and secondary trauma surveys, which are designed to rapidly identify and treat life-threatening injuries. It covers steps for airway management, breathing and ventilation support, circulation stabilization, disability assessment, and full patient exposure and monitoring. Adjunct procedures like IV access, imaging, and fluid resuscitation are also reviewed.
Approach to trauma- ATLS update by Dr.Damodhar.M.V
- 1. Approach to Trauma- ATLS Update Dr. Damodhar. M.V Resident Surgeon, Security Forces Hospital Dammam
- 2. *World Health Organization-Global status report on road safety 2013.www.who.int/violence_injury_prevention/road_safety_status/
- 3. *World Health Organization-Global status report on road safety2013.www.who.int/violence_injury_prevention/road_safety_status/
- 4. *World Health Organization-Global status report on road safety 2013.www.who.int/violence_injury_prevention/road_safety_status/
- 5. Approach to Trauma- ATLS Update
- 6. 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.
- 7. 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.
- 8. 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
- 9. 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
- 10. Preparation for Patient Arrival Surgeon Airway Doctor Radiographer IV Access and Medications Circulation Nurse Orthopedician Scribe Nurse Team Leader
- 11. Primary Survey Airway and Protection of Spinal Cord Breathing and Ventilation Circulation Disability Exposure and Control of the Environment
- 12. 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
- 13. C-spine Immobilization Return head to neutral position Maintain in-line stabilization Correct size collar application Blocks/tape Sandbags
- 14. 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
- 15. 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
- 16. Thoracic Trauma • 8 lethal Injury 1. 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.
- 17. 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
- 19. 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
- 20. 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
- 21. 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
- 22. Initial Fluid Therapy Lactated Ringer is preferred • For adult 1-2 liters bolus • For child 20ml/kg bolus
- 23. 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
- 24. 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
- 25. GCS • Mild : GCS 14-15 • Moderate : GCS 9-13 • Severe : GCS 3-8 • Coma = GCS score of 8 or less
- 26. 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
- 27. E- Exposure Complete disrobing of patient Logroll to inspect back Rectal temperature Warm blankets/external warming device to prevent hypothermia
- 28. Always Inspect the Back
- 29. 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
- 30. Secondary Survey Physical exam from head to toe, including rectal exam Frequent reassessment of vitals
- 31. 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
- 32. Adjuncts to Secondary Survey Radiology – Standard emergent films C-spine, CXR, Pelvis – Focused Abdominal Sonography in Trauma (FAST) – Additional films Cat scan imaging Angiography Pain Control Tetanus Status Antibiotics for open fractures
- 33. Diagnostic Aids Standard trauma labs – CBC, K, Cr, PTT, ABG Standard trauma radiographs – CXR, pelvis, lateral C-spine CT/FAST scans
- 34. 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
- 35. 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
- 36. 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
- 37. 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
- 38. 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
- 42. Hemothorax
- 44. Bilateral Pubic Ramus Fractures and Sacroiliac Joint Disruption Author unknown, http://www.itim.nsw.gov.au/images/Open_book_pelvic_fracture_xray.jpg
- 46. Abdominal contents up in the chest http://commons.wikimedia.org/wiki/File:Diaphragmatic_rupture_spleen_herniation.jpg
- 47. Trauma in Special Populations Pregnancy – Supine Hypotensive Syndrome After 20 weeks, enlarged uterus with fetus and amniotic fluid compresses inferior vena cava Decreases venous return and decrease cardiac output Keep 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
- 48. Priorities with multiple injuries 1. Thoracic trauma or tamponade 2. Abdominal hemorrhage 3. Pelvic Hemorrhage 4. Extremity Hemorrhage 5. Intra-cranial Injury 6. Acute Spinal Cord Injury
- 49. Definitive Care Secondary Survey followed by radiographic evaluation Consultation: • Neurosurgery • Orthopedic Surgery • Vascular Surgery Transfer to Definitive Care: • Operating Room • ICU • Higher level facility
- 50. ATLS 9th Edition Compendium of changes
- 51. ATLS 9th Edition Compendium of changes
- 52. ATLS 9th Edition Compendium of changes
- 53. 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.
- 54. Thank you, Have a nice day…