Advanced Trauma and Life Support - ATLS.pptx

This is a presentation on the basics of the ATLS protocols

1. ADVANCED TRAUMA LIFE SUPPORT- ATLS AZKA SIBGHAT ROLL NO: 02

2. CASE PRESENTATION The patient Amir Waseem, age 20yrs, resident of Faisalabad, mill worker by profession, presented in surgical emergency on 13 May with complaint of severe pain in back due to fall of a sack of thread rolls on the back of his chest 2 hours ago Patient was brought to emergency by his co-workers

3. Primary survey: ( ABCDE or cABCDE ) 1. Airway and cervical spine control :  In this patient, the Airway was intact as he could speak coherently and was responsive and there was no obstruction in the mouth.  The cervical spine was immobilised with a cervical collar, as we assume cervical spine injury in blunt trauma patients until proven otherwise.

4. 2. Breathing and ventilation:  There were no signs of respiratory distress (use of accessory muscles, in-drawing, cyanosis, tachypnea)  Breathing was normal with normal vesicular breathing sounds and no added sounds on auscultation in all lung fields on the front of chest.  The respiratory rate was 18 per minute  oxygen saturation on pulse oximeter was 98%.  there was no visible chest injury or deformity.

5. 3. Circulation and control of hemorrhage:  circulation was intact with no external bleeding.  the blood pressure was 110/90  the pulse rate was 86 per minute

6. 4. Disability and neurological assessment:  The GCS was 15/15 and patient was concious.  No weakness in limbs and no sensory loss was reported by the patient, power in all 4 limbs was also normal when tested objectively by asking the patient to raise the limbs against gravity and against resistance.  There was no complaint of loss of conciousness, vomiting, seizures or any discharge from nose or ear following trauma.

7. 5. Exposure and environment control:  Maximum possible exposure was obtained and the patient was examined from the front. No bruise or swelling was visible.  The back was examined by “log roll” technique, there was bruise and spine tenderness was positive in thoracic and lumbar regions, so the patient was placed on a spine board.

8. Secondary survey:  There was no history of allergy, medication, past illness and exposure to similar events . Last meal was a few hours ago. ( AMPLE )  Vitals were: BP 118/80, pulse 88per minute, respiratory rate 18per minute, O 2 saturation 98% , temp 98F.  On head and face examination , there were no bruises or swelling, no scalp laceration, pupils normal and reactive, no signs of anemia or jaundice in the eyes, no deformity of nose and pinna, no discharge from nose or ear.  On inspection of oral cavity there was no bleeding, tongue laceration or dental malocclusion, no cyanosis on the tip of tongue.  In neck, there was no venous distension, laryngeal deformity or hematoma.

9. On examination of front of chest , there was no rib, sternal or clavicular fracture, shape of chest was normal and moving symmetrically with respiration, vesicular breathing was present on auscultation. On auscultation of precordium , the heart sounds were normal and there were no added sounds. The abdomen was normal in shape and moving symmetrically with respiration, umbilicus normal in position and inverted, no bruises around umbilicus and on the flanks. On palpation it was soft, non-tender, no mass on deep palpation and bowel sounds were present on auscultation. There was no bone tenderness on palpation of pelvis to indicate a pelvic fracture.

10. On examination of limbs , there was no hematoma. The tone and power was normal in all muscle groups and there was no sensory abnormality. Planters were down going . No cyanosis on tips of digits. Exam of perineum / genitalia was not performed on this patient, it should be done for following findings: Perineum/genitalia: stigmata of urethral injury and pelvic fracture Hematoma/bruising Blood at urethral meatus Vaginal lacerations Scrotal hematoma Anorectum Anal tone, voluntary contraction (sacral sparing with cord injury) Rectum: high-riding prostate, lacerations

11. Investigations :  X-ray cervical and thoracolumbar spine, AP and lateral views Other investigations that could be ordered in this case include: FAST (focussed assessment sonogram for trauma), CT cervical and thoracolumbar spine

12. Management: Patient was managed conservatively and was given IV fluid 1 litre and an IV injection of toradol(ketorolac). He was observed for half hour then sent home with following prescription: capsule osimep 40mg (omeprazole), tab mutex(piroxicam)20mg, twice daily for 8 days tab emosis( multivitamin), tab can-D(vit d and ca) once daily for 8 days Patient was advised to keep wearing a cervical collar and take bed rest for 2 days.

13. Advanced Trauma Life Support

14. Introduction Advanced trauma life support  ( ATLS ) is a training program for the management of acute  trauma  cases, developed by the American College of Surgeons. Originally designed for emergency situations where only one doctor and one nurse are present, ATLS is now widely accepted as the standard of care for initial assessment and treatment in trauma centres.

15. Principles Treat the greatest threat to life first. Definitive diagnosis is not immediately important. Time matters (“golden hour” emphasizes urgency). Do no further harm. Assess, intervene, reassess The golden hour refers to a time period lasting for one hour following traumatic injury during which there is the highest possibility that adequate treatment will prevent death.

16. STEPS Preparation Triage Primary survey (ABCDEs) with immediate resuscitation of patients with life-threatening injuries Secondary survey (head-to-toe evaluation and patient history) Definitive care

17. Preparation Training as a team Equipment maintained and ready for rapid use Appropriate supplies available Referral resources and transfer policies clearly defined

18. Triage T he assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties .

19. Primary Survey First and key part of the assessment of patients presenting with trauma is called the primary survey. During this time, life-threatening injuries are identified and simultaneously resuscitation is begun Follow algorithm ABCDE

20. A: Airway maintenance and cervical spine protection This assessment is of the patency of the patient’s airway. It is assessed by asking a question . If the patient can speak coherently, the patient is responsive, and the airway is open . Observe patient for signs of respiratory distress (use of accessory muscles, in-drawing , cyanosis, tachypnea) Inspect the mouth for obstruction (e.g.. due to blood or vomitus) Perform either a chin lift or jaw thrust if upper airway obstruction is identified; although, jaw thrust is preferred if cervical spine injury is suspected.

21. Chin lift  by placing the thumb underneath the chin and lifting forward. Jaw thrust  by placing the long fingers behind the angle of the mandible and pushing anteriorly and superiorly. Clear the oropharynx of blood, mucus and foreign bodies with help of rigid sucker . Falling back of tongue is prevented in unconscious (most common cause of airway obstruction in unconscious) patient by maintaining oropharyngeal airway .

22. Lower airway definitely managed by intubation. If GCS score =<8, endotracheal intubation is next step as patient is unconscious and unable to protect his airways. Severe maxillofacial fractures, laryngeal or tracheal injury, evolving airway loss due neck hematoma – intubate If patient is in apnea or in respiratory distress -tachypnea >30, hypoxia/hypercarbia- intubate as a conduit for ventilation. If patient has burn injuries with evidence of respiratory involvement patient is intubated out of precaution. If it’s not possible , cricothyroidotomy is performed .

23. Use hard collars to immobilize the neck to prevent spinal injury. Use long spinal board to immobilize the whole body. Log roll technique can be used to shift the patient . Assume cervical spine injury in blunt trauma patients until proven otherwise. Spine precautions should only be discontinued when patients gain back consciousness and are alert to communicate sufficiently on spinal discomfort or neurologic sensations before the spine is cleared. Log roll important to assess the dorsum of the cervical to the sacral spine and to look out for any signs of bruising, open wounds, tender points and to palpate the paravertebral tissue and posterior processes.

24. B : BREATHING AND VENTILATION Attach pulse oximeter to all trauma patients to monitor oxygen saturation and provide them with 100% oxygen . Inspect chest wall- look for symmetry/asymmetry of movements, paradoxical movements, rate and pattern of respiration, signs of respiratory distress Inspect neck veins for jugular venous distension. Palpate the trachea and chest wall - look for tenderness, crepitus, emphysema, fractures. Percuss the chest wall- look for resonance or dullness. Auscultate the chest wall – look for decreased/absent breath sounds. 

25. Aim is to identify and treat six life-threatening conditions: Airway obstruction, Tension pneumothorax, Massive hemothorax, Open pneumothorax, Flail chest and Cardiac tamponade.

26. Tension pneumothorax (Severe respiratory distress, deviated trachea, absent breath sounds, resonant percussion note + hemodynamic instability, hypotension) - needle decompression (second intercostal space, mid-clavicular line), followed by chest tube placement . Simple pneumothorax - anterior chest tube Open pneumothorax with 3 way occlusive chest wall dressing and followed by anterior chest tube ( Open chest wounds should be covered immediately with a bandage taped on three sides to prevent the entry of atmospheric air into the chest. If the bandage is taped on all four sides it may create a tension pneumothorax ) Massive hemothorax with posterior chest tubes en route to operating room.

27. Flail chest /severe pulmonary contusion with intubation and oxygenation/mechanical ventilation + analgesia. Cardiac tamponade- perform needle pericardiocentesis until definitive management which is thoracotomy and repair of lesion.

28. C: Circulation and Haemorrhage control Hemorrhagic shock is the most common form of shock in trauma. It develops when there is loss of 1.5L of blood. Blood can be lost externally or it can go into thorax, abdomen, pelvis, long bones (multiple fractures).

29. Assess for and stop external haemorrhage . Direct manual pressure. For traumatic amputation/severe mangled extremity, application of a tourniquet Assess circulatory status, pulse (central: carotids and femoral and peripheral pulses), heart rate, blood pressure (skip to end if it delays rest of primary survery) Gain vascular access. Draw blood for blood typing and cross match

30. Administer initial volume, first 1 L to 2 L isotonic solutions , such as normal saline or lactated Ringer, but it should then be followed by  blood products or plasma expanders. If on-going haemorrhage,   transfuse specific blood type or type O-ve blood . Patients with severe shock resulting from trauma can present with or develop coagulopathy from blood loss, dilution from large volume crystalloid fluid resuscitation, or hypothermia. If significant haemorrhage and persistent hemodynamic instability, transfuse platelets, RBC and plasma in 1:1:1 - the use of 1:1:1 both treats and prevents coagulopathy associated with trauma and massive transfusion of blood

31. Perform FAST especially in haemodynamically unstable patients, may be part of secondary survey if patient haemodynamically stable. Consider and intervene to stop hidden sources of bleeding. Pelvis: pelvic binder Long bone fracture: reduce and splint Laceration: closure Anterior/posterior nasal packing Emergency Thoracotomy Emergency Laparotomy Consider non-hemorrhagic sources of shock Tension pneumothorax Cardiac tamponade Neurogenic shock (relative hypovolemia due to vasodilatation )

32. D : DisabIlity /Neurological status Assess level of consciousness ( Glasgow Coma Scale ), Assess pupils (size, reactivity) Look for lateralizing signs like hemiparesis Raised intracranial pressure should be ruled out and if present, managed immediately . Hypoglycemia  and drugs, including alcohol, are to be excluded. If these are excluded, changes in the level of consciousness should be considered to be due to  traumatic brain injury  until proven otherwise.

33. E: Exposure and environmental control Temperature of ER is maintained before uncovering the patient. Undress the patient completely for thorough examination. Warm blankets are used to cover the patient after examination IV fluids should be warmed Patient privacy should be maintained Log roll important to assess the dorsum of the cervical to the sacral spine and to look out for any signs of bruising, open wounds, tender points and to palpate the paravertebral tissue and posterior processus.

34. ADJUCNTS TO PRIMARY SURVEY Foley placement to monitor urinary output; withhold for evidence of urethral injury (blood at the urethral meatus, perineal hematoma, high-riding prostate) Gastric tube placement to prevent gastric dilatation; no nasal placement in setting of facial fractures ECG for cardiac rhythm Arterial blood gas/pH and lactate monitoring (for shock ) CBC, electrolytes, glucose, creatinine (relevant for contrast administration), INR (relevant to detect antecedent anticoagulation), type and screen vs. crossmatching

35. Assessment for intraperitoneal injury Focused Assessment by Sonography in Trauma (FAST) Looks for fluid in 4 areas (hepatorenal, splenorenal, pelvic, and pericardial spaces) Diagnostic peritoneal lavage (DPL) Radiographs AP chest , to assess for tube and line placements, as well as subclinical hemopneumothoraces. Pelvis, to assess for pelvic fracture as a source of hidden bleeding Cervical spine . As long as the cervical spine is protected with immobilization, this radiologic evaluation can be moved to the secondary survey. CT imaging of the cervical spine has replaced Xray (lateral, AP, and open-mouth odontoid ). Other area as needed based on clinical examination.

36. Secondary Survey Consists of: Detailed history Head to toe physical examination of the patient Reassessment of vital signs Started when: Primary survey is completed Resuscitative efforts are underway Patient’s vital signs are normalizing

37. Secondary Survey History:

38. Secondary Survey Physical examination Neurological Assessment GCS Pupillary size and light reaction Lateralising signs Peripheral nerve injuries Spinal injuries Head: Scalp contusions, lacerations, fractures and crepitus
Ear and Eye injuries

39. Maxillofacial structures Palpation of all bony structures for crepitus Malocclusion Intraoral examination Assessment of soft tissues Cervical spine and neck Cervical spine tenderness
Subcutaneous emphysema
Hoarseness
Carotid bruit

40. Chest: Breath sounds
Hyper-resonance or dullness to percussion
Rib, sternal, and clavicular fractures
Subcutaneous emphysema Abdomen and pelvis Scars and open wounds
Distention
Tenderness
Peritoneal signs Pelvic fractures

41. Perineum, rectum and vagina Perineum : contusions, hematomas, lacerations, and urethral bleeding Rectum: assess for the presence of blood within the bowel lumen, integrity of the rectal wall, and quality of sphincter tone Vagina: lacerations Musculoskeletal examination Visible injuries Abnormal movements

42. Adjuncts to Secondary Survey Include specialized diagnostic tests to identify specific injuries such as: X-ray examinations of the spine and extremities CT scans of the head, chest, abdomen, and spine Contrast urography and angiography Transesophageal ultrasound Bronchoscopy Esophagoscopy Diagnostic laparoscopy and other diagnostic procedures

43. Management Clean and dress all bleeding wounds Oxygenation with continued cervical spine care Pack eviscerated gut with warm, moist packs Laparotomy (blunt or penetrating abdominal trauma, peritonitis, evisceration) Apply pelvic binder if pelvic fracture is suspected Splinting of limb fractures Management of compartment syndrome by fasciotomy

44. Definitive Care (Tertiary survey) Transfer of patient to concerned ward is required when the patient’s treatment needs exceed the capability of the receiving institution Tertiary survey consists of : Evaluating adequacy of resucitation Reviewing all imaging A careful and complete examination to recognize missed injuries and related problems, allowing a definitive care management.

45. Thank you