ATLS.pptx

ATLS

1. ATLS, Management of Trauma patient at ER Presented by: Dr. Meron Zewde (Intern) Moderator: Dr. Misale (General Surgeon) 07/09/2022 1

2. Outline Definition Epidemiology Primary survey Secondary survey Tertiary survey 07/09/2022 2

3. Introduction Trauma, or injury, is defined as cellular disruption caused by environmental energy that is beyond the body’s resilience, which is compounded by cell death due to ischemia/reperfusion. Trauma is the most common cause of death for all individuals between the ages of 1 and 44 years, and is the third most common cause of death regardless of age. It is also the leading cause of years of productive life lost. 07/09/2022 3

4. Epidemiology 07/09/2022 4

5. Emergency Approach to Trauma Trimodal distribution of trauma deaths: Immediate deaths (on scene): Hemorrhage due to great vessel injury, severe TBI, High spinal cord injury etc. Early deaths (1st 1-4 hours): chest trauma, abdomino thoracic injuries, pelvic injuries most common Gives rise to the concept of the “golden hour” Late deaths (hours-days-weeks): from secondary insult –pneumonia, PE, sepsis, coagulopathy 07/09/2022 5

6. Trauma Death by Time of Injury 07/09/2022 6

7. Primary Survey Encompasses the ABCDEs of trauma care and identifies life-threatening conditions by adhering to this sequence. Airway maintenance with restriction of cervical spine motion Breathing and ventilation Circulation with hemorrhage control Disability(assessment of neurologic status) Exposure/Environmental control 07/09/2022 7

8. Airway Maintenance with restriction of cervical spine motion This rapid assessment for signs of airway obstruction includes inspecting for Foreign bodies; Identifying facial, mandibular, and/or tracheal/laryngeal fractures; Suctioning to clear accumulated blood or secretions In patients with severe head injuries with GCS score of 8 or lower the tongue may fall backward and obstruct the hypopharynx; this can be relieved by either a chin lift , jaw thrust or by inserting a nasopharyngeal or oropharyngeal airway but endotracheal intubation might be needed at last. 07/09/2022 8

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10. Inserting Oral Airway. A. In this technique, the oral airway is inserted upside down until the soft palate is encountered. B. The device is then rotated 180 degrees and slipped into place over the tongue. 07/09/2022 10

11. Contd. Establishing a definitive airway (i.e., endotracheal intubation) is indicated in patients with: - Apnea; Inability to protect the airway due to altered mental status; Impending airway compromise due to inhalation injury, hematoma, facial bleeding, soft tissue swelling, or aspiration; Inability to maintain oxygenation. 07/09/2022 11

12. Contd. Patients in whom attempts at intubation have failed or who are precluded from intubation due to extensive facial injuries require operative establishment of an airway like: - Cricothyroidotomy or Emergent tracheostomy 07/09/2022 12

13. Contd. While assessing and managing a patient’s airway, take great care to prevent excessive movement of the cervical spine. This can be achieved manually (as in the picture) or by using cervical collar 07/09/2022 13

14. Breathing and ventilation The following conditions constitute an immediate threat to life due to inadequate ventilation and should be checked: Tension pneumothorax Open pneumothorax, Flail chest with underlying pulmonary contusion, Massive hemothorax, and Major air leak due to a tracheobronchial injury. 07/09/2022 14

15. Contd. Give supplemental oxygen to every injured patient. If the patient is not intubated, oxygen should be delivered by a mask-reservoir device to achieve optimal oxygenation. Use a pulse oximeter to monitor adequacy of hemoglobin oxygen saturation. 07/09/2022 15

16. Tension Pneumothorax Develops when a “one-way valve” air leak occurs from the lung or through the chest wall. Air is forced into the pleural space with no means of escape, eventually collapsing the affected lung. The mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lung causing hypotension 07/09/2022 16

17. Contd. is characterized by some or all of the following signs and symptoms: Chest pain, Respiratory distress Tachycardia and Hypotension Tracheal deviation away from the side of the injury Unilateral absence of breath sounds Neck vein distention Cyanosis 07/09/2022 17

18. Contd. Treatment is Immediate decompression either by Large-bore needle insertion into the 2nd ICS in the MCL of the affected hemithorax or A chest tube through the 5th ICS in the anterior axillary line. 07/09/2022 18

19. Open Pneumothorax Large injuries to the chest wall that remain open can result in a sucking chest wound causing a disequilibrium in airway pressure Air passes preferentially through the chest wall defect with each inspiration. Effective ventilation is thereby impaired, leading to hypoxia and hypercarbia. Treatment is by 3-sided cover over defect Chest tube insertion Definitive operation 07/09/2022 19

20. Flail Chest Three or more contiguous ribs are fractured in at least two locations Treatment Mechanical ventilation until fibrous union of broken ribs occur Oxygen administration Adequate analgesia & physiotherapy 07/09/2022 20

21. Circulation with hemorrhage control Blood pressure and pulse should be measured at least every 5 minutes in patients with significant blood loss until normal vital sign values are restored. Look for external bleeding, extremity hematoma, abdominal or pelvic bruises or lacerations. 07/09/2022 21

22. Contd. Signs of inadequate circulation: Skin Perfusion - skin is cool, clammy, pale Pulse - tachycardia, feeble pulse Altered Mental Status Tachypnea Hypotension Decreased urine output 07/09/2022 22

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24. Contd. External control of any visible hemorrhage should be achieved promptly while circulating volume is restored. For open wounds with ongoing bleeding, manual compression should be done with a single 4 × 4 gauze and a gloved hand. 07/09/2022 24

25. Contd. Intravenous (IV) access for fluid resuscitation and medication administration is obtained with two peripheral catheters, 16-gauge or larger in adults. For patients in whom IV access is difficult, intraosseous (IO) needles can be placed in the proximal humerus or tibia. Fluid resuscitation begin with a 1 L (adult) or 20 mL/kg (child) IV bolus of isotonic crystalloid, typically RL. If hypotension persists, initiate RBC and FFP also for patients with class III and IV hemorrhage it should be considered earlier on. 07/09/2022 25

26. Contd. This life-threatening injuries must be identified promptly: Massive hemothorax, Cardiac tamponade, Massive hemoperitoneum, Mechanically unstable pelvic fractures with bleeding. Critical tools used to differentiate these in the multisystem trauma patient are the chest and pelvis radiographs, and extended focused abdominal sonography for trauma ( eFAST ) 07/09/2022 26

27. Contd. Management Massive hemothorax – Chest Tube insertion Cardiac tamponade - Pericardiocentesis Massive hemoperitoneum – Exploratory Laparotomy Mechanically unstable pelvic fractures with bleeding – Stabilize the pelvis and definite surgery 07/09/2022 27

28. Disability Determine the patients Glasgow Coma Scale (GCS) The GCS is a quantifiable determination of neurologic function that is useful for triage, treatment, and prognosis. Severity of head Injury 13 to 15 indicate mild head injury, 9 to 12 moderate injury, and ≤8 severe injury 07/09/2022 28

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31. Contd. Look for signs of increased ICP: - Bradycardia Hypertension Progressively deteriorating mental status Irregular respiratory pattern Papilledema in fundoscopy Vomiting, headache 07/09/2022 31

32. Contd. Look for signs of neurogenic shock: - Hypotension with relative bradycardia, Paralysis, Decreased rectal tone, Priapism Patients with high spinal cord disruption are at greatest risk for neurogenic shock due to physiologic disruption of sympathetic fibers; treatment consists of volume loading and a dopamine infusion. 07/09/2022 32

33. Exposure All clothing is removed at this time to allow for an adequate examination, core body temperature measurement, and any required intervention. Prevent hypothermia with blankets, heating elements, elevated room/operating room (OR) temperature, and warmed resuscitative fluids. 07/09/2022 33

34. Adjuncts to the Primary Survey Continuous electrocardiography, pulse oximetry, carbon dioxide (CO2) monitoring, Assessment of ventilatory rate, and arterial blood gas (ABG) measurement. Insertion of urinary catheters to monitor urine output and assess for hematuria. Gastric catheters to decompress distention. Chest and pelvis x-ray FAST 07/09/2022 34

35. Secondary Survey does not begin until the primary survey is completed, resuscitative efforts are under way, and improvement of the patient’s vital functions has been demonstrated. Comprises history and a thorough head-to-toe physical examination. AMPLE history Allergies Medications Past illnesses or Pregnancy Last meal Events related to the injury 07/09/2022 35

36. Contd. Ask about the mechanism of injury (e.g. blunt, penetrating trauma, thermal injury) Physical Examination It should be literally head to toe, with special attention to the patient’s back, axillae, and perineum, because injuries here are easily overlooked 07/09/2022 36

37. Contd. HEENT Inspect the face and scalp. Look for any lacerations or bruising, including mastoid or periorbital bruising. Gently palpate for any depressions or irregularities in the skull. Assess the ears for any signs of cerebrospinal fluid leak, bleeding or blood behind the tympanic membrane. Look in the eyes for any foreign body, subconjunctival hemorrhage. Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness or deformity. 07/09/2022 37

38. Contd. Chest Palpate for rib tenderness and subcutaneous emphysema. Auscultate the lung fields; note any percussion abnormality, lack of breath sounds, wheezing or crepitations. Check the heart sounds: apex beat and presence and quality of heart sounds. 07/09/2022 38

39. Contd. Abdomen and Pelvis Inspect the abdomen. Palpate for areas of tenderness especially over the liver, spleen, kidneys and bladder. Look for any bruising, lacerations or penetrating injuries. Auscultate bowel sounds. Inspect the perineum and external genitalia for bruising or hemorrhage. 07/09/2022 39

40. Contd. Perineum, Rectum, and Vagina The perineum should be examined for contusions, hematomas, lacerations, and urethral bleeding. A rectal examination may be performed to assess for the presence of blood within the bowel lumen, integrity of the rectal wall, and quality of sphincter tone. Vaginal examination to assess for the presence of blood in the vaginal vault and vaginal lacerations. 07/09/2022 40

41. Contd. Musculoskeletal system Inspect all the limbs and joints, palpate for bony and soft-tissue tenderness and check joint movements, stability and muscular power. Log roll the patient. Palpate the spine for any tenderness or steps between the vertebrae. Neurological examination includes motor and sensory evaluation of the extremities, as well as reevaluation of the patient’s level of consciousness and pupillary size and response. 07/09/2022 41

42. Adjuncts to the Secondary Survey Specialized diagnostic tests may be performed to identify specific injuries. X-ray examinations of the spine and extremities; CT scans of the head, chest, abdomen, and spine; Contrast urography and angiography; Transesophageal ultrasound; Bronchoscopy; Esophagoscopy; 07/09/2022 42

43. Tertiary Survey Structured and comprehensive reexamination that takes place within 24 hours of initial assessment. 7-13% of patients have injuries that are missed during the initial evaluation. 07/09/2022 43

44. References Schwartz principles of surgery 11 th edition ATLS 2018 Student Course Manual UpToDate 2022 Nebyou Seyoum , A Azaj , Berhanu Nega , Trauma in Ethiopia Revisited: A systematic Review; East Cent. Afr. J. surg, 2013, Volume 18 (2) 07/09/2022 44