Advanced trauma life support (atls)

ATLS

1. Dr.Adeel Riaz PGR General Surgery CPTH. Lahore. Advanced Trauma Life Support (ATLS)

2. Advanced Trauma Life Support (ATLS) Most widely recognised and practiced protocol for the management of a trauma patient worldwide. ATLS PROTOCOL OBJECTIVES: A standardized approach to all traumatic patients. A comprehensive assessment and management of patients in emergency situation. Best utilization of golden hour which lies between life and death after a traumatic event.

3. ATLS PROTOCOL PRIMARY SURVEY RESUSCITATION SECONDARY SURVEY TERTIARY SURVEY

4. PRIMARY SURVEY A : AIRWAY & CERVICAL SPINE IMMOBILIZATION B : BREATHING / VENTILATION C : CIRCULATION & HEMORRHAGE CONTROL D : DISABILITY ( NEUROLOGICAL EVALUATION) E : EXPOSURE + ENVIRONMENTAL CONTROL

5. AIRWAY MANAGEMENT & C. SPINE SUCTIONING OF NASOPHARYNGEAL AIRWAY CHIN LIFT JAW THRUST ADVANCED METHODS: ENDOTRACHEAL INTUBATION CRICOTHYROIDOTOMY TRACHEOSTOMY PREVENTION OF CERVICAL SPINE INJURY: IMMOBILIZE THE PATIENT AVOID HYPEREXTENSION OF NECK APPLY CERVICAL COLLAR

6. BREATHING / VENTILATION EXPOSE THE CHEST & ACCESS RR & RESP. TYPE. GIVE O2 INHALLATION CHECK CHEST WALL, LUNGS & DIAPHRAGM BY INSPECTION, PALPATION, PERCUSSION & AUSCULTATION. PULSE OXIMETER LOOK FOR CONDITIONS THAT IMPAIR VENTILATION Tension pneumothorax Massive hemothorax Flail chest Rib fractures Open pneumothorax Pulmonary contusion NEEDS FOR ASSISTED VENTILATION

7. CIRCULATION IMPAIRMENT IN CIRCULATION CAN LEAD TO SHOCK SO LOOK FOR SIGNS OF SHOCK i.e. SKIN COLOUR (PALLOR) NARROW PULSE PRESSURE HYPOTENSION TACHYCARDIA LEVEL OF CONSCIOUSNESS DIMINISHED URINE OUTPUT CONTROL OF HEMORRHAGE : APPLY DIRECT PRESSURE PNEUMATIC SPLINTING DEVICES ACCESS THE NEED FOR SURGICAL INTERVENTION

8. CLINICAL CLASSIFICATION OF SHOCK CLASS I CLASS II CLASS III CLASS IV BLOOD LOSS UPTO 750ml 750-1500ml 1500-2000ml >2000ml % BLOOD VOLUME UPTO 15% 15-30% 30-40% >40% PULSE RATE ( bpm ) <100 100-120 120-140 >140 SYSTOLIC B.P. NORMAL NORMAL DECREASED DECREASED PULSE PRESSURE NORMAL OR INCREASED DECREASED DECREASED DECREASED RESPIRATORY RATE 14-20 20-30 30-40 >35 URINE OUTPUT (ml/ hr ) >30 20-30 5-15 NEGLIGIBLE CNS/MENTAL STATUS SLIGHTLY ANXIOUS MILDLY ANXIOUS ANXIOUS, CONFUSED CONFUSED, LETHARGIC FLUID REPLACEMENT CRYSTALLOIDS CRYSTALLOIDS CRYSTALLOIDS & BLOOD CRYSTALLOIDS & BLOOD

9. FLUID REPLACEMENT THERAPY DOUBLE I/V LINES SHOULD BE MAINTAINED FOR FLUID REPLACEMENT ADULTS SHOULD BE GIVEN 2 L BOLUS FLUID (PREFFERED FLUID IS RINGER LACTATE BETTER IF WARM) CHILDREN SHOULD BE GIVEN @ 20ml/Kg BOLUS FLUID 3 FOR 1 RULE : A rough guideline for the total amount of crystalloid volume acutely 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.

10. DISABILITY ( NEUROLOGICAL EXAMINATION) CHECK THE LEVEL OF CONSCIOUSNESS ( AVPU/GCS ) A: ALERT V : RESPONDS TO VOCAL STIMULI P : RESPONDS TO PAINFUL STIMULI U: UNRESPONSIVE TO ALL STIMULI CHECK PUPIL SIZE & LIGHT REACTION CHECK THE LEVEL OF SPINAL CORD INJURY LEVEL

11. EXPOSURE +ENVIRONMENTAL CONTROL UNDRESS COMPLETELY (USE TRAUMA SCISSORS) PREVENT HYPOTHERMIA ( WARM BLANKETS & WARM FLUIDS) EARLY HEMORRHAGE CONTROL WARM ROOM TEMPERATURE SHOULD BE MAINTAINED

12. SECONDARY SURVEY DOESNOT BEGIN UNTIL THE PRIMARY SURVEY (ABCDEs) IS COMPLETED, RESUSCITATION EFFORTS ARE WELL ESTABLISHED & THE PATIENT IS HAVING NORMALIZATION OF VITAL SIGNS.IT INCLUDES: COMPLETE HISTORY COMPLETE HEAD TO TOE EXAMINATION REASSESSMENT OF VITAL SIGNS COMPLETE NEUROLOGICAL EXAMINATION (GCS) SPECIFIC PROCEDURES, SPECIFIC LAB. INVESTIGATIONS .

13. COMPLETE HISTORY A: ALLERGIES M: MEDICATIONS P: PAST ILLNESS/ PREGNANCY L: LAST MEAL E: EVENTS/ ENVIRONMENT/MECHANISM OF INJURY: BLUNT TRAUMA : AUTOMOBILE COLLISIONS PENETRATING TRAUMA : FIREARMS/STABBING THERMAL INJURIES : BURNS/EXPLOSIONS HAZARDOUS INJURIES : CHEMICALS/TOXINS/ RADIATIONS

14. PHYSICAL EXAMINATION HEAD MAXILLOFACIAL STRUCTURES CERVICAL SPINE & NECK CHEST ABDOMEN PERINEUM,RECTUM & VAGINA MUSCULOSKELETAL SYSTEM NEUROLOGICAL SYSTEM

15. HEAD VISUAL ACUITY PUPPILARY SIZE CONJUNCTIVAL HEMORRHAGE PENETRATING INJURY CONTACT LENSES (REMOVE BEFORE EDEMA DEVELOPS) DISLOCATION OF THE LENS OCULAR ENTRAPMENT MAXILLOFACIAL STRUCTURES PALPATE ALL BONY STRUCTURES INTRAORAL EXAMINATION ASSESSMENT OF SOFT TISSUES TRAUMA NOT RELATED TO AIRWAY OR BLEDDING CAN BE DELAYED

16. CERVICAL SPINE AND NECK PATIENTS WITH HEAD TRAUMA OR MAXILLOFACIAL TRAUMA SHOULDE BE PRESUMED TO HAVE UNSTABLE CERVICAL INJURY (FRACTURE/LIGAMENT INJURY), NECK SHOULD BE IMMOBILIZED IMMEDIATELY, UNTIL INVESTIGATED. CERVICAL SPINE TENDERNESS, SUBCUTANEOUS EMPHYSEMA, TRACHEAL DEVITATION & LARYNGEAL FRACTURES OR PENETRATING INJURIES SHOULD BE SEEN DURING EXAMINATION OF NECK. CHEST A THOROUGH EXAMINATION OF CHEST WALL SHOULD BE DONE TO RULE OUT OPEN OT TENSION PNEUMOTHORAX, HEMOTHORAX, FLIAL CHEST OR CONTUSIONS.

17. ABDOMEN AFTER INITIAL EXAMINATION, CLOSE OBSERVATION AND FREQUENT RE-EVALUATION OF THE ABDOMEN SHOULD BE DONE BY THE SAME OBSERVER TO NOTE ANY INTRAABDOMINAL INJURY AND IT SHOULD BE DEALT AGGRESSIVELY. PERINEUM, RECTUM & VAGINA PERINEUM SHOULD BE EXAMINED FOR CONTUSIONS,LACERATIONS,HEMATOMA & URETHRAL BLEEDING RECTUM MUST BE EXAMINED FOR BLOOD IN BOWEL LUMEN, PELVIC FRACTURES OR HIGH RIDING PROSTATE. VAGINAL EXAMINATION SHOULD BE DONE IN WOMEN WITH PELVIC FRACTURES FOR PRESENCE OF BLOOD.

18. MUSCULOSKELETAL SYSTEM THE EXTREMITIES MUST BE INSPECTED FOR CONTUSIONS & DEFORMITIES. BONES SHOULD BE PALPATED & MOVEMENTS AT THE JOINTS SHOULD BE CHECKED. ASSESSMENT OF PERIPHERAL PULSES SHOULD BE DONE FOR VASCULAR INJURIES.

19. REASSESSMENT OF VITAL SIGNS DONE BY: CLINICAL REASSESSMENT MONITORING OF LOC, PR, BP MONITORING, ABGs & UOP REVIEW OF DIAGNOSTIC RESULTS USE OF ANALGESIA COMPLETE NEUROLOGICAL EXAMINATION LOC/GCS CNs EXAMINATION DETERIORATION/IMPROVEMENT IN LOC/GCS

20. SPECIFIC PROCEDURES, SPECIFIC LAB. INVESTIGATIONS AFTER HISTORY & EXAMINATION, RELEVANT INVESTIGATIONS SHOULD BE ADVISED e.g. FOR SUSPECTED CERVICAL SPINE INJURY X-RAYS SHOULD BE DONE AS: LATERAL VIEW: OCCIPUT TO TOP OF T1 ANTERO-POSTERIOR VIEW: SPINOUS PROCESSES C2-C7 Additional X-rays Extremities, Spine CT-SCAN Contrast X-rays, Urography, Angiography Endoscopy ARE ADVISED ACCORDINGLY…

21. DEFINATIVE CARE & TRANSFER ACCORING TO CLINICAL AND OTHER DATA PATIENT IS SHIFTED TO ICU , OT OR OTHERS RESPECTIVELY. OR TRANSFRRED TO OTHER FACILITY ACCORDING TO PATIENT’S NEED OR INSTITUTION’S CAPABILITY. TERTIARY SURVEY DEFINED AS PATIENT’S EVALUATION THAT IDENTIFIES AND CATALOGUES ALL INJURIES AFTR INITIAL RESUSSITATION AND OPERATIVE INTERVENTIONS PATIENT IS MORE AWAKE MORE INFORMATION ABOUT MODE OF INJURY BY PATIENT IS GATHERED

22. ATLS OUTLINE PRIMARY SURVEY (ABCDE) SECONDARY SURVEY 1. HISTORY 2. PHYSICAL EXAMINATION 3. RELEVANT INVESTIGATIONS RE-EVALUATION DEFINATIVE CARE TRANSFER