Acute Trauma Life Support in Surgery ATLS 1.pptx

Acute Trauma Life Support

1. ATLS 9/8/2024 2

2. ATLS This was developed in the late 1970s by American collage of Surgeons ATLS provides a structured approach to the trauma patient with standard algorithms of care ; It emphasizes the “golden hour” concept that timely, prioritized interventions are necessary to prevent death and disability . The initial management of seriously injured patients consists of phases that include the Primary survey/concurrent resuscitation, Secondary survey/diagnostic evaluation Definitive care, and the tertiary survey. 9/8/2024 3

3. Working Dfns Primary survey: identify and treat life-threatening injuries Secondary survey: head to toe examination, brief focused history, exclusion of major injuries Tertiary survey: a patient evaluation that identifies and catalogues all injuries after the initial resuscitation and operative intervention (Grossman et al, 2000) 9/8/2024 4

4. PRIMARY SURVEY ( cABCDE) c – Control of massive external haemorrhage A – Airway with cervical spine protection B – Breathing and ventilation C – Circulation and haemorrhage control D – Disability (neurological status) E – Exposure (assess for other injuries) If unable to resolve a problem don’t not leave issue until resolved. At any point if there is deterioration start at airway again. 9/8/2024 5

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6. Airway C heck while leaving the C-spine immobilized G enerally assume: anyone with blunt injury above the clavicle is probably a C-spine fracture Talk to the patient to rapidly assess airway patency This is the point where you should look for facial fractures, foreign bodies, vomit and facial burns When their ability to maintain an airway is at all in doubt , intubate the patient Posterior dislocation of the clavicular head can cause an obstruction of the trachea. 9/8/2024 7

7. Breathing Expose the chest Watch chest excursion : symmetrical? Auscultate: equal air entry? Palpate the midline-ness of the trachea and the rest of the chest, looking for surgical emphysema Percuss the chest looking for hyper-resonance of tension pneumothorax, or dullness of haemothorax . Tension pneumothorax, open pneumothorax, massive haemothorax , flail chest - these should be identified during the primary survey High O2 should be administered . One should look for paradoxical respiration pattern due to flail chest, or diaphragmatic breathing due to high spinal cord injury. 9/8/2024 8

8. Circulation Circulatory assessment may be clinical at this stage, or a blood pressure may be available. Features of hypovolemia ( eg . cool peripheries, pallor) should be sought. Blood should be sampled for crossmatch , and uncrossmatched blood should be transfused if the patient is demonstrating features of anaemia . Wide-bore access is established; bloods should be sent: FBC, EUC, CMP, LFT, coags and crossmatch . Blood products should be preferentially used for resuscitation , with a 1:1:1 ratio of PRBCs, FFP and platelets. The MAP target for fluid resuscitation should be a MAP >50mmHg. Cardiac tamponade may become obvious at this stage; its most striking features at this stage would be a raised JVP and dis tended neck veins in general. FBC=Full blood cells, EUC=Electrolytes uremia-Creatinine, CMP= Comprehensive metabolic pane, LFT=liver function tests, PRBC= packed red blood cell, FFF= 9/8/2024 9

9. Disability GCS level of consciousness Lateralising signs (if the patient is obeying commands) Pupil diameter, reactivity and equality 9/8/2024 10

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11. The Glasgow Coma Scale (GCS) score should be determined for all injured patients (Table 7-3). It is calculated by adding the scores of the best motor response, best verbal response, and the best eye response. Scores range from 3 (the lowest) to 15 (normal). Scores of 13 to 15 indicate mild head injury, 9 to 12 moderate injury, and ≤8 severe injury. The GCS is a quantifiable determination of neurologic function that is useful for triage, treatment, and prognosis. 9/8/2024 12

12. Exposure Expose all of the patient At this point, a log roll should happen to examine the back After that, warm blanket and warm fluids to restore temperature and to avoid hypothermia. 9/8/2024 13

13. The value of the digital rectal exam One looks for:  Sphincter tone (cord injury) Gross blood (GI tract injury) Swelling (pelvic haematoma ) "High riding" prostate - urethral injury Mobile coccyx- sacral or coccygeal fracture Obvious external anal damage Disrupted rectal wall integrity According to a recent review, the PR changed management in 1.2% of observed cases. 9/8/2024 14

14. Adjuncts to the primary survey: After the completion of the primary survey, the following investigations must urgently take place  Bloods:  FBC EUC LFT Coags Crossmatch 9/8/2024 15

15. Cont Imaging  Chest X-ray FAST including pericardium Pelvic X-ray Long bone X-rays CT trauma series including aortogram Monitoring ECG Urine output Arterial invasive blood pressure ICP monitoring may be indicated if the intracranial pressure cannot be monitored clinically 9/8/2024 16

16. Secondary survey This is a head-to-toe examination, including an AMPLE history: Allergies Medications Past history Last meal Events and environment of the injury 9/8/2024 17

17. Key features It is more important to identify a problem (e.g. significant abdominal pain) than the exact diagnosis (spleen laceration) A checklist should be used to prevent missed injuries A standardised sequence of examination should be followed , so that the examination can be reproduced if needed 9/8/2024 18

18. Tertiary survey This is a post-operative repeat of the primary and secondary survey, usually performed in the ICU after all the dust has settled. During this review, a catalogue of remaining injuries and problems is made. Frequently missed injuries are uncovered during this survey (Biffl et al, 2003) - after the implementation of this practice the rate of missed injuries decreased from 5.7% to 3.4% at a busy Rhode Island trauma ICU. 9/8/2024 19

19. Key features A standardised sequence of examination should be followed, so that the examination from the secondary survey can be reproduced and referred to. The patients in whom this is of greatest importance are patients with a decreased level of consciousness Ideally, a person who is not familiar with the patient should be involved 9/8/2024 20

20. THE MANAGEMENT OF TRAUMA From the moment that injury is sustained, every aspect of decision making and management is essential in terms of the survival of the victim. A better understanding of the physiological processes underpinning the host responses to an acute threat to our homeostatic mechanisms, together with protocols formulated to allow clinicians to use standardised measures and to speak a common language, have revolutionised the way we manage patients. 9/8/2024 21

21. Cont. All of the above help to reduce delays, particularly when under pressure to make a decision. In trauma, as in other acute conditions, the patient is particularly reliant upon the clinician. 9/8/2024 22

22. The significance of time in the outcome All subsequent events, including the acute physiological response to injury, the body’s internal mechanisms to maintain homeostasis, the healing processes and the actions instigated by health professionals, are associated with a ‘timeline’. Being familiar with the ‘ timeline principle’, one should be aware that there is a critical time window in which we can intervene for a positive treatment outcome , before the loss of compensatory mechanisms. 9/8/2024 23

23. Cont. Overall, interventions can be distinguished as Emergency (life saving), Acute (restoring haemodynamic stability) and Delayed or semielective, focusing on the treatment of complications Thus, the seriousness and the immediate impact of a specific clinical condition should be prioritised and treated in a systematic approach. 9/8/2024 24

24. Cont. The ATLS (Advanced Trauma Life Support) system delineates an order of priorities set by ABCD This hierarchy of priorities is instituted upon the ‘time dependence’ principle. The clinician should bear in mind that a successful management plan is dependent on, first, the time needed to evaluate and diagnose the nature of the problem and, second, the time taken to respond effectively to the condition discovered 9/8/2024 25

25. Cont. Evaluating and diagnosing a condition can be challenging, as the initial clinical signs may be non-specific. The clinical condition will continue to evolve as the time progresses, that by the time the diagnosis has been made it may be too late to prevent mortality. Taking into consideration the mechanism of the accident and promptly requesting special investigations, for example computed tomography (CT), the underlying diagnosis can be made punctually, thus allowing intervention in a timely fashion 9/8/2024 26

26. Cont. Reducing the diagnosis time and response time of our interventions is dependent not only on the clinical staff but also on the availability of resources. All clinical conditions are characterised by a dynamic process. Our observations and analysis of the situation can change rapidly and to an extent that interventions would have to be modified accordingly. 9/8/2024 27

27. Cont. Ongoing evaluation of the patient is therefore essential in order to identify and respond to the changes noted in a timely fashion. The initial primary survey, applied according to the ATLS protocol in trauma patients, should be followed by secondary and tertiary clinical assessment, even after the acute phase of treatment has been completed successfully. Ongoing monitoring of vital organ activity, ordering of the necessary biochemical and radiological investigations and recording of all the findings in a single place can allow easier evaluation 9/8/2024 28

28. Cont. The timeline following an injury is continuous, and th accumulated documentation may become voluminous, complex and confusing. It is helpful periodically to make the effort to stand back and summarize the situation. 9/8/2024 29

29. The assessment of trauma The initial assessment of the trauma patient, besides the clinical examination, should include analysis of the interactions between the patient, the mechanism of injury and the extent of the injury sustained . Being able to synthesise the inter-relationships among these parameters is essential to addressing the pressures of the ‘timeline concept’. 9/8/2024 30

30. Mechanisms Mechanisms may be blunt, penetrating or even of a combined nature Blunt trauma can be categorized as direct or indirect , and continues to be the most common mechanism. In a direct mechanism , the damage is localised to the site of injury. In contrast, in an indirect mechanism the damage occurs at a distant site after transmission of the force 9/8/2024 31

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32. Cont. Penetrating mechanisms can be divided into those caused by sharp objects and those induced by firearms By sharp objects , it is necessary to take into account the length of the sharp object, its surface area and the size of the entry point . Being familiar with the relevant anatomy of the area involved allows assessment of the peripheral nerve function, and tendon and muscle integrity. 9/8/2024 33

33. Cont. Firearms induce penetrating injuries , which are more difficult to comprehend than incisional injuries caused by sharp objects. For instance, a high velocity projectile (bullet) causes extensive damage to the tissues as it travels , inducing lateral acceleration far from the point of impact, and producing either a permanent or a temporary cavity It is important to be aware that this temporary cavity usually extends far from the boundaries of the apparent injury 9/8/2024 34

34. Patient factors All patients possess a unique profile and medical history and so will react and respond differently to a given traumatic incident. Children and adults of different ages will sustain different injuries as a result of the same mechanism. Past medical history, medication and allergy risk will direct affect not only the clinical assessment but also the treatment 9/8/2024 35

35. Obvious injuries Some injuries are very obvious and can be identified before details of the mechanism or patient are known. One can take advantage of this, as the presence of an obvious injury can inform and lead to the identification of another which is less obvious. Bruising to the scrotum of a motorcyclist following a collision with a car suggests a pelvic fracture. Finger-shaped bruises on a child’s arms or thighs suggest NAI. 9/8/2024 36

36. Hidden factors MECHANISMS When analysis of the relationship of the formula ‘mechanism+ patient = injury ’ does not seem to add up, then the hidden information may be contained in the mechanism. Occasionally, it is observed that there has been a deliberate attempt to misinform. While the majority of alert and orientated patients tell the truth , others, in order to protect themselves or others, may fabricate a mechanism. 9/8/2024 37

37. Cont. A hidden mechanism can also arise when the patient is unable to give their history of events, for instance patients who are unconscious. Parameters that should alert the clinician and raise suspicion of NAI include: External signs of injuries not consistent with the mechanism reported long bone fractures in a preambulatory child; inconsistent or changing history; aggressive or unusual behaviour of carers at interview; posterior rib injuries 9/8/2024 38

38. Cont. PATIENTS In circumstances where the injury and mechanism are inconsistent, one should consider the possibility that the patient may have an unknown pre-existing condition. For example osteoporosis. Treatment should not be confined to the local injury, but should extend to appropriate investigation and treatment of the underlying fragility of the skeleton, thus reducing the risk of further fracture. 9/8/2024 39