Atls; Advanced Trauma Life Support

Atls; Advanced Trauma Life Support Tenth Edition
Updates
Guidelines 2021

1. ATLS Advanced Trauma Life Support Supervised by: Prof. Mahmoud Abu- Ebeeleh Done by: Dr. Faisal Rawagah

2. History Dr James Styner , An orthopedic surgeon crashed his plane in February 1976 “When I can Provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed” -Advanced Trauma Life Support Student Course Manual 10 th edition -Journal of Trauma Nursing April/June 2006, Volume :13 Number 2 , page 41 - 44

3. Do we Need ATLS? ATLS Methods is accepted as a standard for the “ first hour ” of trauma care by many who provide care for the injured. 5.8 million people die every year from unintentional injuries and violence. Motor vehicle crashes alone case: 1.3 million deaths annually. 20 million to 50 million significant injuries. T rauma the leading cause of death in persons 1 through 44 years of age in most developed countries. -Advanced Trauma Life Support Student Course Manual 10 th edition -https :// www.who.int/news-room/fact-sheets/detail/road-traffic-injuries

4. The trimodal distribution of deaths Classically: Immediate (seconds to minutes) S evere brain or high spinal cord injury Rupture of the heart, aorta, or other large blood vessels Early (minutes to several hours) Subdural and epidural hematomas, Hemopneumothorax R uptured spleen, lacerations of the liver, pelvic fractures. Late (Several days to weeks) sepsis and multiple organ system dysfunctions. -Advanced Trauma Life Support Student Course Manual 10 th edition - Gunst M, Ghaemmaghami V, Gruszecki A, Urban J, Frankel H, Shafi S. Changing epidemiology of trauma deaths leads to a bimodal distribution. Proc ( Bayl Univ Med Cent). 2010 Oct;23(4):349-54. doi : 10.1080/08998280.2010.11928649. PMID: 20944754; PMCID: PMC2943446 .

5. T he “ initial assessment” T iming is crucial, systematic approach that can be rapidly and accurately applied is essential •• Preparation •• Triage •• Primary survey (ABCDEs) with immediate resuscitation of patients with life-threatening injuries •• Adjuncts to the primary survey and resuscitation •• Consideration of the need for patient transfer •• Secondary survey (head-to-toe evaluation and patient history) •• Adjuncts to the secondary survey •• Continued postresuscitation monitoring and reevaluation •• Definitive care

6. Preparation Prehospital Phase Airway maintenance, Control of external bleeding and shock. I mmobilization of the patient, and immediate transport to the closest appropriate facility. O btaining and reporting information needed for triage at the hospital. T ime of injury events related to the injury, and patient history . Hospital Phase R esuscitation area . Properly functioning airway equipment. Warmed intravenous crystalloid solutions (37c-40c) + appropriate monitoring devices. P rotocol to summon additional medical assistance + laboratory and radiology personnel. Transfer agreements with verified trauma centers. PPE - standard precautions ( face mask, eye protection, water-impervious gown,and gloves)

7. Triage based on the ABC T he severity of injury. Ability to survive. Available resources. Multiple-casualty event M ass-casualty event -Advanced Trauma Life Support Student Course Manual 10 th edition -CDC , MMWR, Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage, 2011

8. Primary Survey with Simultaneous Resuscitation During the primary survey, life-threatening conditions are identified and treated in a prioritized sequence based on the effects of injuries on the patient’s physiology , because at first it may not be possible to identify specific anatomic injuries . • A irway maintenance with restriction of cervical spine motion. • B reathing and ventilation. • C irculation with hemorrhage control. • D isability(assessment of neurologic status ). • E xposure/Environmental control.

9. A irway maintenance with restriction of cervical spine motion. A sking the patient for his or her name, and asking what happened. Inspecting for foreign bodies. I dentifying facial, mandibular, and/or tracheal/laryngeal fractures and other injuries that can result in airway obstruction. Suctioning to clear accumulated blood or secretions. J aw-thrust or chin-lift. O ropharyngeal airway. Establish a definitive airway. Cervical In-line stabilization. C ervical collar. -Advanced Trauma Life Support Student Course Manual 10 th edition -Austin N, Krishnamoorthy V, Dagal A. Airway management in cervical spine injury. Int J Crit Illn Inj Sci. 2014 Jan;4(1):50-6. doi : 10.4103/2229-5151.128013. PMID: 24741498; PMCID: PMC3982371 .

10. B reathing and ventilation Expose the patient’s neck and chest Assess jugular venous distention. P osition of the trachea C hest wall excursion T ension pneumothorax, Massive hemothorax , Open pneumothorax, and tracheal or bronchial injuries . O2 mask-reservoir device. P ulse oximeter to monitor. Ask but do not stop at; Portable CXR. NOT in Primary Survey: Simple pneumothorax , simple hemothorax , fractured ribs, flail chest, and pulmonary contusion.

11. C irculation with hemorrhage control . c ABCDE ; Catastrophic Haemorrhage Control . Blood Volume and Cardiac Output If there is no tension pneumothorax then consider that hypotension following injury is due to blood loss until proven otherwise . Evaluation: Level of Consciousness Skin Perfusion Pulse BP Bleeding Blood on the floor and four more

12. External hemorrhage is identified and controlled during the primary survey. D irect manual pressure Tourniquet: carry a risk of ischemic injury Do NOT do Blind clamping. I nternal hemorrhage; Four More Physical examination and imaging; C hest x-ray, Pelvic x-ray, focused assessment with sonography for trauma [FAST ], or diagnostic peritoneal lavage [DPL ]. C hest decompression, and application of a pelvic stabilizing device and/ or extremity splints . Definitive management may require surgical or interventional radiologic treatment and pelvic and long-bone stabilization . Definitive bleeding control is essential, along with appropriate replacement of intravascular volume.

13. Vascular access Two large-bore peripheral venous catheters (g16 cannula) Send 5 Blood samples CBC Blood gases and/or lactate level Blood Group/ Xmach Pt Ptt INR Toxicology +/- pregnancy test P eripheral sites cannot be accessed I ntraosseous infusion, central venous access ( Cordis catheter ), or venous cutdown . - Advanced Trauma Life Support Student Course Manual 10 th edition -Schwartz’s Principles of Surgery Eleventh Edition: chapter 7, page 183- 249

14. Aggressive and continued volume resuscitation is NOT a substitute for definitive control of hemorrhage. B olus of 1 L warm (37°C to 40°C ) normal saline IV Unresponsive ; activate massive blood transfusion protocol (1:1:1) Your target is permissive hypotension T ranexamic acid; best within 1 h of trauma, up to 3 h, followed by 2 nd dose infusion over 8 hours in the hospital.

15. D isability(assessment of neurologic status ). P atient’s level of consciousness and pupillary size and reaction. I dentifies the presence of lateralizing signs. D etermines spinal cord injury level, if present . GCS Decrease in a patient’s level of consciousness may indicate: D ecreased cerebral oxygenation and/or perfusion, D irect cerebral injury Hypoglycemia, alcohol , narcotics, and other drugs Call neurosurgeon once a brain injury is recognized Your main goal to Prevent secondary brain injury by maintaining adequate oxygenation and perfusion.

16. E xposure/Environmental control C utting off his or her garments Examine the anterior surface Examine areas that not easy to access ; axilla, perineum Log rolling maneuver; Examine the back, PR. C over the patient with warm blankets or an external warming device. Use only warm IV fluids. Hypothermia one of the trauma’s lethal triad.

17. Adjuncts to the Primary Survey with Resuscitation Physiologic parameters such as pulse rate, blood pressure , pulse pressure, ventilatory rate, ABG levels, body temperature, and urinary output are assessable measures that reflect the adequacy of resuscitation. Values for these parameters should be obtained as soon as is practical during or after completing the primary survey, and reevaluated periodically . It is important not to delay transfer to perform an indepth diagnostic evaluation.

18. Special Populations Pediatric patients Pregnant women Older adults Obese patients Athletes

19. Secondary Survey The secondary survey does not begin until the primary survey (ABCDE) is completed, resuscitative efforts are under way, and improvement of the patient’s vital functions has been demonstrated . History ( A llergies, M edications, P ast illnesses/ P regnancy, L ast meal, E vents/ E nvironment) Blunt Trauma Penetrating Trauma Thermal Injury Hazardous Environment

20. Physical Examination Head Maxillofacial Structures Cervical Spine and Neck Chest Abdomen and Pelvis Perineum, Rectum, and Vagina Musculoskeletal System Neurological System

21. Blunt Trauma

22. Penetrating and Thermal Trauma

23. HEAD TRAUMA Classification of head injuries Severity of Injury Mild Brain Injury (GCS Score 13–15 ) Moderate Brain Injury (GCS Score 9–12 ) Severe Brain Injury (GCS Score 3–8 ) Morphology Skull Fractures Intracranial Lesions Diffuse Brain Injuries Focal Brain Injuries Epidural Hematomas Subdural Hematomas Contusions and Intracerebral Hematomas

24. Decompressive Craniectomy Prophylactic Hypothermia ( not Recommended) Hyperosmolar Therapy (Hypertonic , Mannitol ) Cerebrospinal Fluid Drainage (All Severe TBI) Ventilation Therapies ((PaCO2) ≤ 25 mmHg is not recommended) Anesthetics, Analgesics, and Sedatives ( High-dose barbiturate administration is recommended) Steroids ( not recommended) Nutrition ( Feeding on day 5-7) Infection Prophylaxis (Early tracheostomy is recommended) Deep Vein Thrombosis Prophylaxis Seizure Prophylaxis (Phenytoin is recommended) Intracranial Pressure Monitoring ( All Severe TBI) Cerebral Perfusion Pressure Monitoring (All Severe TBI ) Advanced Cerebral Monitoring Jugular bulb monitoring of arteriovenous oxygen content difference (AVDO2) Blood Pressure Thresholds (SBP >100 -110) (50-69 yr ) Intracranial Pressure Thresholds (>22 mmHg) Cerebral Perfusion Pressure Thresholds (60-70 mmHg ) Advanced Cerebral Monitoring Thresholds (SJVO2>50%) -Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi : 10.1227/NEU.0000000000001432. PMID: 27654000 . -Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension N Engl J Med 2016; 375:1119-1130, DOI: 10.1056/NEJMoa1605215

25. THORACIC TRAUMA Primary Survey: Airway Obstruction Tracheobronchial Tree Injury Breathing Tension Pneumothorax Open Pneumothorax Massive Hemothorax Circulation Massive Hemothorax Cardiac Tamponade Traumatic Circulatory Arrest Secondary survey: Potentially Life-Threatening Injuries Simple Pneumothorax Hemothorax Flail Chest and Pulmonary Contusion Blunt Cardiac Injury Traumatic Aortic Disruption Traumatic Diaphragmatic Injury Blunt Esophageal Rupture

26. Traumatic Circulatory Arrest

27. -Resuscitative endovascular balloon occlusion of the aorta: current evidence Open Access Emerg Med.  2019; 11: 29–38. Published online 2019 Jan 14.  doi :  10.2147/OAEM.S166087 -Sridhar , Srikanth MD * ; Gumbert , Sam D. MD * ; Stephens, Christopher MD * ; Moore, Laura J. MD † ; Pivalizza , Evan G. MBChB , FFASA *  Resuscitative Endovascular Balloon Occlusion of the Aorta: Principles, Initial Clinical Experience, and Considerations for the Anesthesiologist, Anesthesia & Analgesia: September 2017 - Volume 125 - Issue 3 - p 884-890 doi : 10.1213/ANE.0000000000002150 Resuscitative endovascular balloon occlusion of the aorta (REBOA)

28. ABDOMINAL AND PELVIC TRAUMA Blunt Spleen (40% to 55 %) L iver (35% to 45 %) S mall bowel (5% to 10 %) Retroperitoneal hematoma Pelvic Fractures Penetrating Stab wounds Liver (40 %), Small bowel (30%), Diaphragm (20 %), colon (15%) High-energy low-energy gunshot wounds small bowel (50%), colon (40 %), liver (30%), and abdominal vascular structures (25%).

29. FAST

30. References Advanced Trauma Life Support Student Course Manual 10 th edition Journal of Trauma Nursing April/June 2006, Volume:13 Number 2 , page 41-44 https:// www.who.int/news-room/fact-sheets/detail/road-traffic-injuries Gunst M, Ghaemmaghami V, Gruszecki A, Urban J, Frankel H, Shafi S. Changing epidemiology of trauma deaths leads to a bimodal distribution. Proc ( Bayl Univ Med Cent). 2010 Oct;23(4):349-54. doi : 10.1080/08998280.2010.11928649. PMID: 20944754; PMCID: PMC2943446 . CDC, MMWR, Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage, 2011 Austin N, Krishnamoorthy V, Dagal A. Airway management in cervical spine injury. Int J Crit Illn Inj Sci. 2014 Jan;4(1):50-6. doi : 10.4103/2229-5151.128013. PMID: 24741498; PMCID: PMC3982371. Schwartz’s Principles of Surgery Eleventh Edition: chapter 7, page 183- 249 Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi : 10.1227/NEU.0000000000001432. PMID: 27654000. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension N Engl J Med 2016; 375:1119-1130, DOI : 10.1056/NEJMoa1605215 https:// www.grepmed.com/images/2422/echocardiogram-tamponade-clinical-cardiac-pocus Resuscitative endovascular balloon occlusion of the aorta: current evidence Open Access Emerg Med.  2019; 11: 29–38. Published online 2019 Jan 14.  doi :  10.2147/OAEM.S166087 Sridhar, Srikanth MD * ; Gumbert , Sam D. MD * ; Stephens, Christopher MD * ; Moore, Laura J. MD † ; Pivalizza , Evan G. MBChB , FFASA *  Resuscitative Endovascular Balloon Occlusion of the Aorta: Principles, Initial Clinical Experience, and Considerations for the Anesthesiologist, Anesthesia & Analgesia: September 2017 - Volume 125 - Issue 3 - p 884-890 doi : 10.1213/ANE.0000000000002150

31. Thank you Supervised by: Prof. Mahmoud Abu- Ebeeleh Cardiothoracic surgery consultant Done by: Dr. Faisal Rawagah Critical Care Fellow Jordan University Hospital 17.03.2022