advancedtraumalifesupportatls-180209201352 2.pptx

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1. Advanced Trauma Life Support (ATLS) Presented by : Dr. Aryan kush sharma PG 2 Orthopedics SSIMS Bhilai

2. 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. Advanced Trauma Life Support (ATLS)

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 & A SS ESS 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

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  A SS ESS THE NEED FOR SURGICAL INTERVENTION

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

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

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

12. SECONDARY SURVEY DOES NOT 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/

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  PA LPAT E 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 O R 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 .

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  CN S 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: 1. LATERAL VIEW: OCCIPUT TO TOP OF T1 2. ANTERO-POSTERIOR VIEW: SPINOUS PROCESSES C2-C7 • Additional X-rays Extremities, Spine • CT-SCAN • Contrast X-rays, Urography, Angiography • Endoscopy

21. DEFIN I TIVE CARE & TRANSFER  ACCORING TO CLINICAL AND OTHER D ATA 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 AFT E R 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