ADVANCED TRAUMA LIFE SUPPORT.pdf

A presentation that will help clinicians attain the basic diagnostic skills required to effectively manage patients.

1. SURGERY

ADVANCED TRAUMA LIFE SUPPORT

DR. CHONGO SHAPI (BSc. HB, MBChB)

2. ADVANCED TRAUMA LIFE SUPPORT (ATLS)
1. Primary survey and Resuscitation
• A = Airway and cervical spine
• B = Breathing
• C = Circulation and haemorrhage control
• D = Dysfunction of the central nervous system
• E = Exposure
2. Secondary Survey - Head to Toe Examination
• History
• Head. Face. Eyes Ears. Nose. Neck
• Chest, Abdomen & Pelvis
• Musculoskeletal
3. Definitive Treatment

1. Primary Survey and Resuscitation
A. Airway and Cervical Spine
• Secure the airway as the initial action in trauma resuscitation
• A cervical spine injury should be assumed until proven otherwise
• Place a collar until cervical spine has been confirmed to be intact
• If patient can talk then he is able to maintain own airway
• If airway compromised attempt a chin lift and clear airway of foreign bodies
• If gag reflex present insert nasopharyngeal airway
• If no gag reflex put in an endotracheal tube
• If unable to intubate do a cricothyroidotomy

3. • Give 100% oxygen through a mask
Airway assessment
• The patient should be asked a simple question
• If he responds appropriately
o The airway is patent
o Ventilation is intact
o The brain is being adequately perfused
• Confusion and agitation is usually a sign of hypoxia

Airway management
• These can be achieved with
• (a) Basic, (b) advanced and (c) surgical techniques
(a) Basic life support
• Foreign bodies should be removed from the mouth and throat
• Secretions and blood should be removed with suction
• Airway can usually be secured with a chin lift or jaw thrust
• An oropharyngeal airway may be required
• Oxygen should be given at a rate of 10-12 l/min
• Use a tight fitting mask
(b) Advanced measures
• If absent gag reflex, endotracheal intubation is required
• If no cervical spine fracture orotracheal intubation is preferred
• If cervical spine injury can not be excluded consider nasotracheal intubation
• The position of the tube should be checked
• Complications include:
o Oesophageal intubation
o Intubation of right main bronchus
o Failure of intubation
o Aspiration
(c) Surgical airways
• If unable to intubate the trachea a surgical airway is required
• There are few indications for an emergency tracheostomy
• Surgical airway can be achieved with a needle or surgical cricothyroidotomy

4. Needle cricothyroidotomy
• Cricothyroid membrane is punctured with a 12 or 14 Fr cannula
• Connected to oxygen supply via a Y connector
• Oxygen supplied at a rate of 15 l/min
• Jet insufflation achieved by occlusion of Y connection
• Insufflation provided one second on and four seconds off
• Jet insufflation can result in significant hypercarbia
• Should only be used for 30 - 40 minutes
Surgical cricothyroidotomy
• A small incision is made over cricothyroid membrane
• 5 mm incision made in membrane
• Small tracheostomy tube inserted
• Complications of surgical airways include:
o Aspiration
o Haemorrhage / haematoma
o Cellulitis
o False passage
o Subglottic stenosis
o Mediastinal emphysema
B. Breathing
o Check position of trachea, respiratory rate and air entry
o If clinical evidence of tension pneumothorax will need immediate
relief
o Place venous cannula through second intercostal space in the mid-
clavicular line
o If open chest wound seal with occlusive dressing
Ventilation
• In the non-intubated patient ventilation can be achieved with either
o Mouth to face-mask
o Bag-valve-face-mask
• The later is more efficient if performed with a two person technique
• One maintains face seal - other ventilates patient
• If endotracheal intubation required should be performed with cricoid pressure
• If rib fractures present need to insert chest drain on side of injury to prevent
pneumothorax

5. C. Circulation
o Assess pulse, capillary return and state of neck veins
o Identify exsanguinating haemorrhage and apply direct pressure
o Place two large calibre intravenous cannulas
o Take venous blood for FBC, U+E, and Cross match
o Take sample for arterial blood gasses
o Give intravenous fluids
o Crystalloid or colloid in adequate volume
o Attach patient to ECG monitor
o Insert urinary catheter

Hypovolaemic shock
Grades of hypovolaemic shock
• Grade 1
o 15% blood volume (~750 ml)
o Mild resting tachycardia
• Grade 2
o 15 - 30% blood volume (750 - 1500 ml)
o Moderate tachycardia, fall in pulse pressure, delayed capillary return
• Grade 3
o 30 - 40% blood volume (1500 - 2000 ml)
o Hypotension, tachycardia, low urine output
• Grade 4
o 40-50% blood volume (2000 -2500 ml)
o As above but with profound hypotension
Fluid resuscitation and blood transfusion
• Early volume intravascular volume replacement in trauma patients is essential
• The ideal resuscitation fluid is uncertain
• Timing and end-points of resuscitation unclear
A. STABLE PATIENT
1. 3L of crystalloid (Ringer Lactate or Normal Saline) / 24 hrs.

2. Transfuse if Hb < 8 gm / dl; use clinical judgement
- 1 unit over 4 hrs for each gram below 8 gm / dl

B. UNSTABLE PATIENT

6. - (Blood group & X match 4 units. Active bleeding: 6-8 units.)

1. 2L of crystalloid (Ringer Lactate or Normal Saline- Rapidly)

2. Assess clinical response:

• Rapid response : Reduce rate

• Transient response: Continue fluids. Initiate B/T.

• Minimal or no response: Rapid Blood Transfusion.

- Consider O –ve blood in urgent situation

- Transfuse 1 unit of blood over each 15 min.

- Increase rate if BP fails to rise or falls.

- Stop blood if patient stable and maintain IV fluids.
(Massive transfusion – citrate toxicity/ K+ toxicity / coagulation disorders)

• Aim - Maintain vital signs : P, BP, CVP
- Maintain urinary catheter output > 30 ml/hr
- Maintain Hct at over 30%

3. If CVP is measured
• Infuse until CVP > 5 cm water

• If CVP > 12 cm & BP > 100 mm Hg – Stop infusion/ Frusemide

• If CVP > 12 cm & BP < 100 mm Hg - Transfer to ICU
- Dopamine 5mcg/kg/min or
- Dobutamine 2.5-5 mcg/kg/min
- Involve physician
Crystalloid versus Colloid
• None of the trials of crystalloid vs. colloid resuscitation has shown either type
of fluid to be associated with a reduction in mortality
• No single type of colloid has been shown to be superior
• Albumin solution may be associated with slight increase in mortality
• Colloids can more rapidly correct hypovolaemia
• Also maintain intravascular oncotic pressure
• Crystalloids require large volume but are equally effective
• Cheaper and have fewer adverse side effects

7. Hypertonic solutions
• Subjected to recent intensive investigation
• Can resuscitate patient rapidly with a reduced volume of fluid
• May reduce cerebral oedema in patients with severe head injuries
Oxygen therapeutic agents
• Currently being extensively investigated in clinical trials
• Not widely used at present outside of clinical trials
• Potential advantages over blood include:
o Free potential viral contamination
o Longer shelf life
o Universal ABO compatibility
o Similar oxygen carrying capacity to blood
• Agents being studied include:
o Perflurocarbons
o Human haemoglobin solutions
o Polymerised bovine haemoglobin
IV. Dysfunction
o Assess level of consciousness using AVPU method
(A = alert, V = responding to voice, P = responding to pain, U= unresponsive)
o Or use the GCS
o Assess pupil size, equality and responsiveness
V. Exposure
o Fully undress the patient for a complete- head to toe examination
o Avoid hypothermia

8. Secondary Survey & Definitive Management
History
AMPLE
• Allergies
• Medications
• Past illnesses
• Last meal
• Events/environment related to injury
1. Blunt trauma - Direction and speed of impact
2. Pentrating trauma
3. Thermal injury
4. Exposure to chemicals/radiation and toxins

Examination
• Shock
Shock is a state characterized by inadequate tissue and organ perfusion
1. Haemorrhagic shock
2. Cardiogenic shock
3. Tension pneumothorax
4. Neurogenic shock
5. Septic shock

• Head and Neck
• Chest
• Abdomen
• Musculoskeletal System
• Neurological

For patients in shock and those planned for surgery:

9. • Ensure adequate perfusion
• Catheterize provided there is no blood at meatus or in scrotum, and prostate is
palpable
• Nasogastric tube
• Preoperative prophylactic antibiotic cover