Initial assesment atls
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The document outlines the steps of the Advanced Trauma Life Support protocol. It includes: 1) preparing equipment and summoning a trauma team, 2) performing triage on multiple casualties, 3) conducting a primary survey to address life threats like airway, breathing, circulation, disability and exposure, 4) providing resuscitation as needed, 5) using adjuncts like monitoring, IVs and diagnostics, 6) performing a full secondary survey and history, 7) using additional adjuncts, 8) continued re-evaluation of the patient, and 9) arranging for their definite care. The protocol aims to quickly identify and treat life threats in a trauma patient.
Initial assesment atls
- 1. Advanced Trauma Life Support® Dr/ Saleem AL Adhroai
- 2. 1. Preparation 2. Triage 3. Primary Survey (ABCDEs) 4. Resuscitation 5. Adjuncts to primary survey & resuscitation 6. Secondary Survey (head to toe evaluation & history) 7. Adjuncts to secondary survey 8. Continued post-resuscitation monitoring & re- evaluation 9. Definite care.
- 4. Scene size –up :-- 1. Body substance isolation (BSI) review 2. Scene safety (you-patient) 3. Initial triage (total N of patients) 4. Essential equipment / additional resources needed on scene( units- extraction eq.- MCI protocols) 5. Mechanism of injury A Pre-hospital phase
- 5. Scene size –up Body substance isolation (BSI) CapCap GownGown GlovesGloves MaskMask Shoe coversShoe covers Goggles / face shieldGoggles / face shield
- 6. Scene size up Scene safety RescuerRescuer SceneScene PersonalPersonal
- 7. Scene size up Essential equipment 1.1. Personal protectionPersonal protection equipmentsequipments 2.2. Long backboard +headLong backboard +head restriction devicerestriction device 3.3. Rigid cervical extractionRigid cervical extraction collarcollar 4.4. Oxygen and airway eq.Oxygen and airway eq. 5.5. Trauma box (bandage- bpTrauma box (bandage- bp cuff-stethoscope )cuff-stethoscope )
- 8. Scene size up Mechanism of injury 1.1. BluntBlunt 1.1. Rapid forwardRapid forward (collision)(collision) 2.2. Rapid vertical (falls)Rapid vertical (falls) 3.3. Energy transfer fromEnergy transfer from blunt instrumentsblunt instruments 2.2. Penetrating injuriesPenetrating injuries 1.1. ProjectilesProjectiles 2.2. KnivesKnives 3.3. Fall on fixed objectsFall on fixed objects
- 9. General impressionGeneral impression A B C D E PRIORITYA B C D E PRIORITY AGEAGE SEXSEX POSITIONPOSITION ACTIVETYACTIVETY MAJOR TRAUMAMAJOR TRAUMA L O CL O C A B C D E PRIORITYA B C D E PRIORITY
- 10. 2. TRIAGE2. TRIAGE AA Multiple CasualtiesMultiple Casualties No of severity & pt do not exceed the ability of the facility. B Mass Casualties DISATER No & severity of pt EXCEED the capability of the facility & staff.
- 11. Color Codes Triage TagColor Codes Triage Tag RED : Most critical injury YELLOW : Less critical injured GREEN : No life or limb threatened injury BLACK : Death or obviously fatal injury
- 12. Good trauma teamGood trauma team Quiet – leader speaks, others answer report,Quiet – leader speaks, others answer report, not everyone trying to scream over eachnot everyone trying to scream over each otherother Organized – pre-assigned roles andOrganized – pre-assigned roles and responsibilities of team membersresponsibilities of team members
- 13. Preparation for TraumaPreparation for Trauma Gather your Troops: Nurses, Medics,Gather your Troops: Nurses, Medics, Physicians, RadiologyPhysicians, Radiology Divide each to bedsDivide each to beds Gather SuppliesGather Supplies Airway suppliesAirway supplies IV lines, tubing, warm IVF bags, Pressure bagsIV lines, tubing, warm IVF bags, Pressure bags BlanketsBlankets MedicationsMedications Ensure ALL electrical sources are workingEnsure ALL electrical sources are working Active Management as you surveyActive Management as you survey
- 14. B In Hospital Phase Advanced planning for the trauma pt arrival. Method to summon extra medical assistance Transfer agreement with verified trauma center established. Protect from communicable disease.
- 16. Color Codes Triage TagColor Codes Triage Tag RED : Most critical injury YELLOW : Less critical injured GREEN : No life or limb threatened injury BLACK : Death or obviously fatal injury
- 17. CAN PATIENT WALK? NO YES DELAYEDIs PATIENT BREATHING? YES NO Open AirwayCHECK BREATHING < 30 > 30 IMMEDIATECHECK CIRCULATION PR < 12O CRT < 2 sec PR > 120 CRT > 2 sec CHECK LEVEL OF CONSCIOUSNESS IMMEDIATE GOOD DIMINISHED URGENT IMMEDIATE Not Breathing Dead
- 18. RAZ Treatment Area Triage Area Urgent Treatment Area obs Reserved Staff Media Center OR Mortuary
- 19. 3. PRIMARY SURVEY3. PRIMARY SURVEY A :A : Airway with cervical spine protect. B :B : Breathing C :C : Circulation --control external bleeding. D :D : Disability or neurological status E :E : Exposure (undress) & EEnvironment (temp control)
- 20. PRIMARY SURVEY Priorities for the care of Adult , Pediatrics & Pregnancy women are all the same. During the primary survey life threatening conditions are identified and management is instituted SIMULTANEOUSLY.
- 21. A. Airway Maintenance withA. Airway Maintenance with Cervical Spine ProtectionCervical Spine Protection Protection of the spine & spinal cord is the important management principle. Neurological exam alone does not exclude a cervical spine injury. Always assume a cervical spine injury in any pt with multi-system trauma, especially with an altered level of consciousness or blunt injury above the clavicle.
- 22. Indication For Definite Airway 1. * Unconscious 2. * Severe maxillo-facial fracture 3. * Risk for aspiration : Bleeding/ vomiting 4. * Risk for obstruction : neck hematoma/laryngeal,tracheal injury/ stridor 5. * Apnea : Neuromuscular paralysis/unconscious 6. * Inadequate respiratory effort: tachypnea/hypoxia/hypercapnia/cyanosis 7. * Severe closed head injury need for hyperventilation
- 23. AirwayAirway SNORINGSNORING GURGLIGGURGLIG STRIDORSTRIDOR SILENCESILENCE
- 24. B. Breathing & VentilationB. Breathing & Ventilation Airway patency does not assure adequate ventilation. lock – lesson – feel Idication treatment imediatelyIdication treatment imediately TentionpnumothoraxTentionpnumothorax Open pnumothoraxOpen pnumothorax Flaial chestFlaial chest HaemothoraxHaemothorax
- 25. C. Circulation with HemorrhageC. Circulation with Hemorrhage ControlControl.. 1. Blood Volume & Cardiac Output a. level of consciousness. b. skin color c. Pulse. 2. Bleeding *external bleeding is identified & controlled in the Tourniquets should not be use. Control obvious externalControl obvious external hemorrhagehemorrhage clamp vesselsclamp vessels Direct pressure is still effectiveDirect pressure is still effective Identify and Treat ShockIdentify and Treat Shock 2 Large bore IV’s or central2 Large bore IV’s or central venous accessvenous access Warm IVFWarm IVF Normal Saline vs.Normal Saline vs. Ringers LactateRingers Lactate Emergency release bloodEmergency release blood
- 26. D. Disability ( Neurological Evaluation)D. Disability ( Neurological Evaluation) Simple Mnemonic to describe level of consciousness A : Alert V : Responds to Vocal stimuli P : Responds to Painful stimuli U : Unresponsive to all stimuli Not forget to use also Glascow Coma Scale.
- 27. E. Exposure / EnvironmentalE. Exposure / Environmental ControlControl Completely UndressCompletely Undress Must occur when patient hitsMust occur when patient hits the doorthe door Don’t miss injuriesDon’t miss injuries Roll the patientRoll the patient Look in creases/ back ofLook in creases/ back of head/neckhead/neck Keep WarmKeep Warm Hypothermia leads toHypothermia leads to coagulopathy and increasedcoagulopathy and increased blood lossblood loss
- 28. 55. ADJUNCT TO PRIMARY SURVEY &. ADJUNCT TO PRIMARY SURVEY & RESUSCITATIONRESUSCITATION A. Electro-cardiographic Monitoring B. Urinary & Gastric Catheter 1. Urinary catheter. Urethral injury should be suspected if 1. Blood at the penile meatus 2. Perineal ecchymosis 3. Blood in the scrotum 4. High riding or nonpalpable prostate 5. Pelvic fracture
- 29. C. Monitoring 1. Ventilatory rate & ABG 2. Pulse oximetry does not measure ventilation or partial O2 pressure 3. Blood pressure poor measure of actual tissue perfusion. D. X-Ray & Diagnostic Studies 1. C-spine, 2. CXR, 3. Pelvic film Essential x-ray should not be avoid in pregnant pt. C1 C2 C3 C5 C6 C7 C4
- 30. Secondary SurveySecondary Survey HistoryHistory A AllergiesA Allergies M MedicationsM Medications P PMHP PMH L Last MealL Last Meal E Events relatingE Events relating to injuryto injury Physical ExamPhysical Exam Head and NeckHead and Neck ChestChest AbdomenAbdomen PelvisPelvis Genital/RectalGenital/Rectal ExtremitiesExtremities BackBack
- 31. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION 1. Head • Visual acuity • Pupillary size • Hemorrhage of conjunctiva and fundi • Penetrating injury • Contact lenses(remove before edema occurs) • Dislocation of lens • Ocular movement
- 32. 2. Maxillofacial Injury no NG tube, definite airway? 3. Cervical Spine & Neck *Pt with maxillofacial or head trauma should be presumed to have and unstable cervical spine. 4. Chest *elderly pt are not tolerant of even relatively minor chest injury. *Children often sustain significant injury to the intrathoracic structure without evidence of thoracic skeletal trauma.
- 33. 5. Abdomen *excessive manipulation of the pelvic should be avoided. 6. Perineum/rectum/vagina 7. Musculoskeletal 8. Neurologic * Protection of spinal cord is required at all times until a spine injury excluded, especially when the pt is transfer.
- 34. 7. ADJUNCT TO THE SECONDARY SURVEY7. ADJUNCT TO THE SECONDARY SURVEY include additional x-ray and all other special procedure. 8. RE-EVALUATION8. RE-EVALUATION Adult urine output 0.5ml/kg/hr Pediatric urine output 1mg/kg/hr *Pain relief -- IM should be avoid. 9. DEFINITE CARE9. DEFINITE CARE
Editor's Notes
- #14: Preparation spares panic.
- #16: Our interpreter, most whom were docs were great at getting the secondary survey hx while your team was accomplishing the primary survey.
- #31: C- Spine AP/lateral AP CXR AP Abdomen AP Pelvis Extremity evaluations CT Pulse Oximeter Cardiac Monitor LABS: cbc, chem7, lft’s, Amylase, UA, Coags,T&S/T&C, HCG, ABG, EtOH, UDS Gastric Tube, oral Foley Catheter NOT w/ blood at meatus, scrotal or perineal hematoma, high riding prostate, +/- pelvic fx