Advanced trauma life support

ATLS

1. A Presentation on Advanced Trauma Life Support (ATLS ) Delivered by Dr Ahmed Daniel (Registrar) Department of Orthopedics & Traumatology University of Uyo Teaching Hospital.

2. OUTLINE - Introduction - Definition - ATLS Approach - Preparation - Triaging - Primary Survery - Secondary Survey - Disaster Preparedness - Conclusion - Bibliography

3. INTRODUCTION Emergency of trauma management by Dr. James K. Styne. ATLS course which held in 1978. International disemmination of the ATLS course began about 2 years thereafter. ATLS is a course that enables health personnels apply organized, safe and reliable techniques for the immediate treatment of injured persons via team approach in a simultanous fashion.

4. INTRDUCTION CONTINUES ATLS in Nigerian medical practice - 2009 D. Nnamdi Nwauwa as the course chairman and Dr. Bob Yellowe as the course director.

5. CAUSES OF DEATH GLOBALLY Excerpted from WHO files

6. INTRODUCTION CONTNUES Trimodal Death Distribution: THE FIRST PEAK occurs within seconds to minutes of injury. THE SECOND PEAK occurs within minutes to several hours following injury. THE THIRD PEAK occurs several days to weeks after the initial injury .

7. ATLS may be defined as A protocol that constitutes a set of diagnostic and therapeutic interventions intended to identify and treat acute life threathening injuries, beginining with the most immediate through collaborative and simultaneous team effort that is hedged on world best practices.

8. ATLS APPROACH - Preparation - Triage - Primary survey: Airway & C-spine managment Breathing and ventilation managment Circulatory optimization Disability assessment Exposure - Adjuncts of primary survey - Secondary survey

9. PREPARATION - Prehosipital phase, MUST BE TIMELY - Hospital Phase, MUST BE READY

10. TRIAGING (AND REFERRAL SYSTEM) Simply the sorting of patients. Aim: Prevent avoidable deaths Prevent further deterioration of injured patient Ensure efficient utilization of resources

11. TRIAGING CONTINUES Some triaging systems commonly employed are: - START Triaging System - JumpSTART Triaging system - SALT Triaging System

12. PRIMARY SURVEY “ ABCDEs” - A process that involves a SIMULTANEOUS team effort geared towards saving the life of the patient using the ABCDE ATLS guidelines. - The team approach allows for timely assessment and establishment of treatment priorities. Speaking to the patient , this serves as a quick assesstment of the degree of cardiorespiratory and neurological compromise/injury. A communicating patient may translate to: - Prevailing airway p atency - Breathing isn’t severely compromised - Appreciable cerebral function, invariably reflecting - Current/transciently normotensive state

13. PRIMARY SURVEY A simultaneous approach (not in sequence) - Airway maintenance and spinal protection - Breathing and ventilation - Circulation with bleeding control - Disability (AVPU/GCS) - Exposures

14. Primary Survey - Team Set Up

15. AIRWAY MAINTENANCE AND SPINAL PROTECTION CONTINUES - All traumatized patients must be assumed to have sustained a spinal injury until proven otherwise. - Patient must be nursed on a hard spinal boardwith strappings - Log-rolling maneuver. - Do not apply traction until spinal injuries have been excluded - C-spinal protection using an appropriately sized rigid cervical collar and immobilizaton - Chin lift/Jaw thrust - Airway clearance and maintenance with minimal cervical motion.

16. Log Rolling Maneuver

17. Log Rolling Maneuver Continues

18. Log Rolling Maneuver Continues

19. Airway Maneuvers

20. Rigid Adjustable Cervical Collar

21. AIRWAY MANAGEMENT - Intubation Indications: - Inability to maintain airway patency - Inability to protect the airway against aspiration - failure to ventilate - failure to oxygenate - Anticipation of a deteriorating course that may eventually lead to respiratory failure Drug Assisted Intubation: Pre-LOAD + Anesthetic agent + Neuromuscular blocker

22. Intubation Continues - Pre -oxygenation using a 100% oxygen at 10 - 15L/min via a non re-breathable mask for 3minutes OR via BVM in patients poorly ventilating or not ventilating. - L idocaine intraveous dosing - O poid anagelsic - A tropine - D e-fasiculating agent - Anesthetic agent - Neuromuscular blocker Then intubate, confirm position, ventilate and review response Other airway management options : Cricothyroidotomy Tracheostomy

23. Airway Management Device - Laryngoscopes

24. Airway Management Devices - ETT & Buogie

25. Airway Management Device - CO2 Detector

26. Airway Management - Alternatives

27. BREATHING AND VENTILATION Assessment: - Inspection (SpO2) - Palpation - Percussion - Auscultation Life threathening injuries: - Massive hemothorax - Tension pneumothorax - Hemopneumothorax - Flail chests - Cardiac tamponade - Tracheo-bronchial injuries

28. Breathing & Ventilation Management Cont’ Life Saving Interventions: - High flow 100% oxygen via a NRM 10 -15L/min with/without airway devices - Needle decompression * Chest tube thoracostomy & Endotracheal intubation

29. Breathing & Ventilation Management Cont’ - Triangle of Safety

30. REMEMBER! ATLS management IS NOT a sequential but rather a simultaneous TEAM effort towards saving the life of the patient.

31. CIRCULATION Assessment: - Feel for cool extremities - Pulse rate: Infants 160bpm, pre-schoolers 140bpm, schoolage & teenagers 120bpm and adults 100bpm. - Pulse pressure - Altered mental status - Pulse volume - Capillary refill - Pallor - Systolic blood pressure (Continous cardiac monitoring) If in shock, assume hemorrhagic shock until proven otherwise

32. CIRCULATION CONTINUES What are the possible sources of concealed hemorrhage? Note, the most effective way of restoring adequate cardiac output, end-organ perfusion and tissue oxygenation is by restoring venous return to normal by locating and stopping source of hemorrhage. Volume replacement will correct shock only after bleeding has been arrested. ARREST BLEEDING, THIS IS THE ULMITATE GOAL. Resuscitative Effort: Secure 2 wide bore cannula in large veins (Blood samples) Alternatives: - Intra-osseous access - Venous cut-down - Central IV access

33. CIRCULATION CONTINUES - Intra-osseous Needles

34. CIRCULATION CONTINUES Sites of Intraosseous Access - Sternum - Humerus - Distal femur - Proximal tibia : 1 cm to 2 cm inferior and medial to the tibial tuberosity in the flat portion of the tibia - Distal tibia : 2 cm proximal to the medial malleolus in the flat portion of the tibia.

35. Venous Cut-down

36. CIRCULATION CONTINUES Resuscitative Effort: - Arrest hemorrhage. - IV crystalloids (Normal salline/lactated ringers) 1L or 20ml/kg in pediatric patients <40kg stat. - Commence blood transfusion immediately if still in shock after 2nd bolus of IV crystalloids resuscitation while actively searching for possible causes of ongoing hemorhage. - Prevent hypothermia. - Monitor efforts.

37. CIRCULATION CONTINUES Resuscitative Efforts Continues - IV Tranexamic acid given within 3hours of trauma over 10minutes, follow up dose 1g is given over 8hours - Use of FFP and platelet concentrate may be employed as necessary particularly in the face of massive blood transfusion. - FAST: Sonographic images are targeted *Morisons pouch, Subxiphoid pericardial view, perisplenic view, suprapubic window (pouch of douglas). - DPL: Diagnosis indicated by *10ml of gross blood on peritneal tap; >500ml/mm3 WBC; 100,000ml/mm3 RBC; Enteric/vegetable matter upon sampling.

38. CIRCULATION CONTINUES - All severely traumatized patient can be safely considered as having a pelvic fracture and managed acutely with a pelvic binder until proven other wise. - Sources of Concealed Massive Hemorrhage: Hemothorax Femoral Fractures Pelvic fractures Intra-abdominal viscus injuries - Brain CT Scan in acute care of trauma patient.

39. CIRCULATION CONTINUES Other Non-hemorhagic Causes of Shock: Cardiogenic shock: Blunt cardiac injury Distributive shock: Spinal cord injury Obstructive shock: Tension pneumothorax; pericardial tamponade.

40. DISABILITY - GCS - AVPU - Pupillary light reflexes

41. EXPOSURE - Remove all clothings carefully and examine from head to toe judicously - Avoid hyporthermia - Log roll the patient to expose the back, then inspect and palpate the spine.

42. Adjuncts of Primary Survey - Trauma x-ray series - Other specialized imaging investigations - Gastric catheters - SpO2 or Capnography - ABG level *Vitals are constantly being monitored throughout primary survey.

43. SECONDARY SURVEY Commenced after patient has been successfully resuscitated and stabilzed in primary survey. AMPLE history - Events leading to/surrounding the injury (complications, care) - Past medical history - Medications - Allergies - Last meal

44. SECONDARY SURVEY CONTINUES Detailed examination: - Head/Neck - ENT - Eye examination - Chest - Abdomen (DRE) - Pelvic - Genitourinary - CNS - MSK DOCUMENTATION!

45. SECONDARY SURVEY CONTINUES Adjuncts of secondary survey: These include specialized interventions employed to determine the extent of injury, to reveal or rule out sinister injuries. - Consultatons/referral - Supportive care - Rehabiliitative care

46. CONCLUSION ATLS is an extensive course that summarily entails immediate assessment, resuscitation and stabilization of an injured person in a timely fashion with eventual definitive therapy. It employs an organized, simultanous team approach via researched methods.

47. BIBLIOGRAPHY - Advance Trauma Life Support 10th Edition - Medscape, ATLS - Trauma in a Flash, Arizona Trauma Association - Ultimate ATLS 10 Prep Course Update 2021, Ultimate ATLS Prep - Evaluation of Trauma PAtients ATLS Protocol - Everything you need to know, Dr Nabil Ebraheim - Trauma (ATLS) Asssessment - Multiple Injury, Oxford Medical Education