BASIC ATLS principle, management and therapy.pptx

this slide about principle, management

1. ATLS

2. ATLS has its origins in the United States in 1976, when James K Styner , an Orthopedic surgeon piloting a light aircraft, crashed his plane into a field in Nebraska. His wife Charlene was killed instantly and three of his four children, Richard, Randy, and Kim sustained critical injuries.

3. His son Chris suffered a broken arm. He carried out the initial Triage of his children at the crash site. Dr. Styner had to flag down a car to transport him to the nearest hospital; upon arrival, he found it closed. Even once the hospital was opened and a doctor called in, he found that the emergency care provided at the small regional hospital where they were treated was inadequate and inappropriate.

4. the initial ATLS course which was held in 1978. In 1980, the American College of Surgeons Committee on Trauma adopted ATLS and began US and international dissemination of the course. Styner himself recently recertified as an ATLS instructor, teaching his Instructor Candidate course in Nottingham in the UK, July 2007

5. The A dvanced T rauma L ife S upport ( ATLS ) system was therefore created initially in the USA and rapidly taken up globally. At present, over 50 countries worldwide are actively providing the ATLS course to their physicians

6. Triage Triage is an important concept in modern health-care systems, and three essential phases have developed: pre-hospital triage – in order to dispatch ambulance and pre hospital care resources; at the scene of trauma ; on arrival at the receiving hospital

7. 2 types of triage Multiple casualties : Here, the number and severity of injuries do not exceed the ability of the facility to render care. Priority is given to the life-threatening injuries Mass casualties: The number and severity of the injuries exceed the capability and facilities available to the staff. In this situation, those with the greatest chance of survival and the least expenditure of time, equipment and supplies are prioritized

8. Multiple causalities

9. Massive causalities

10. The steps in the ATLS philosophy Primary survey with simultaneous resuscitation – identify And treat what is killing the patient Secondary survey – proceed to identify all other injuries Definitive care – develop a definitive management plan

11. PRIMARY SURVEY AND RESUSCITATION A – A irway maintenance and cervical spine protection B – B reathing and ventilation C – C irculation with haemorrhage control D – D isability: neurological status E – E xposure: completely undress the patient and assess for other injuries

12. 1. Airway The airway must be evaluated first. If there is vocal response from the patient, then the patient’s airway is not immediately at risk, but repeated assessment is prudent. If there is no or limited response, then a rapid investigation and assessment for signs of airway obstruction should be undertaken. This includes inspection for foreign bodies, maxillofacial or mandibular fractures, tracheal or laryngeal injury or oedema

13. 1. Airway

14. National Emergency X-radiography utilization Study (NEXUS) Criteria

15. 2. Breathing Oxygen must be administered to all trauma patients, usually at high flow and via a reservoir mask. Ventilation requires an adequately functioning chest wall, lungs and diaphragm, and each must be systematically evaluated. Signs of surgical emphysema, dilatation of the neck veins, symmetry of the chest wall, respiratory effort and rate should be evaluated and recorded. Percussion and auscultation should be performed both front and back after log rolling

16. Flail Chest

17. This young man fell off his bike and landed on his left side. His CXR shows a large left pneumothorax (pleural line indicated by white arrows) with shift of the trachea and mediastinum to the right side

18. 2. Breathing

19. Class % Blood Loss HR BP Urine pH MS Treatment I < 15% (<750ml) normal normal > 30 mL/hr normal anxious Fluid II 15% to 30% (750-1500ml)   > 100 bpm normal 20-30 mL/hr normal confused irritable combative Fluid III 30% to 40% (1500-2000ml)   > 120 bpm decreased 5-15 mL/hr decreased lethargic irritable Fluid & Blood IV > 40% (life threatening) (>2000ml) > 140 bpm decreased negligible decreased lethargic coma Fluid & Blood Hemorrhagic Shock Classification

20. Fluid Resuscitation Introduction average adult (70 kg male) has an estimated 4.7 - 5 L of circulating blood average child (2-10 years old) has an estimated 75 - 80 ml/kg of circulating blood Methods of Resuscitation fluids crystalloid isotonic solution blood options O negative blood (universal donor) Type specific blood Cross-matched blood transfuse in 1:1:1 ratio (red blood cells: platelets: plasma)

21. Responder

22. Updated ATLS for Sho c k Class of haemorrhage table amended: Base excess Early use of blood and blood products Management of coagulopathy Tranexamic acid Trauma team

23. ATLS classification of hypovolemic shock *

24. Early use of blood and blood products Early resuscitation with blood and blood products must be considered in patients with evidence of class III and IV hemorrhage. Early administration of blood products at a low ratio of packed red blood cells to plasma and platelets can prevent the development of coagulopathy and thrombocytopenia.

25. Management of coagulopathy Uncontrolled blood loss can occur in patients taking antiplatelet or anticoagulant medications. Prevention Obtain medication list as soon as possible. Administer reversal agents as soon as possible. Where available, monitor coagulation with thromboelastography (TEG) or rotational thromboelastometry (ROTEM). Consider administering platelet transfusion, even with normal platelet count.

26. Tranexamic acid (TXA) European and American military studies demonstrate improved survival when TXA is administered over 10 minutes within 3 hours of injury . When bolused in the field, follow up infusion TAX 1 gram over 8 hours in the hospital.

27. Indicators of adequate resuscitation urine output 0.5-1.0 ml/kg/hr (30 cc/hr) serum lactate levels (normal < 2.5 mmol/L) gastric mucosal pH (>7.3) base deficit normal -2 to +2

28. DCO

29. Early Total Care vs Damage Control Orthopaedic Early Total Care (ETC): a concept implying the primary definitive management of all major injuries within 24 hours after the trauma Damage Control Ortopaedics (DCO): minimally invasive surgical techniques are used for the primary stabilization of all major fractures. Based upon the patient’s physiological status, temporary stabilization with external fixation for certain fracture is used.

30. Damage Control Orthopaedic Design to avoid worsening patient’s condition due to “second hit” phenomenon Delay definitive surgery until patient’s condition is optimized Focuses in hemorrhagic control, management of soft tissue injury and provisional fracture stability Consist 4 phase Acute phase, life saving procedure Control of hemorrhage , temporary stabilization of major skeletal fractures and management soft tissue injuries Monitoring period in ICU Definitive fracture fixation

31. First hit and second hit phenomena

32. Timing for Definitive Surgery

33. Parameters that help decide who should be treated with DCO ISS >40 (without thoracic trauma) ISS >20 with thoracic trauma GCS of 8 or below multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock bilateral femoral fractures pulmonary contusion noted on radiographs hypothermia <35 degrees C head injury with AIS of 3 or greater IL-6 values above 500pg/dL

34. Injury Severity Scale (ISS) First scoring system to be based on anatomic criteria ISS = sum of squares for the highest AIS grades in the three most severely injured body regions ISS = A 2 +B 2 +C 2 Score ranged from 1-75 ISS >15 associated with mortality of 10% (severe trauma patient)

35. Abbreviated Injury Scale (AIS) Value Injury Description No injury 1 Minor 2 Moderate 3 Severe ( Not-life threatening) 4 Severe (life threatening, survival probable) 5 Severe (Critical, survival uncertain) 6 Maximal, possibly fatal Single score of 6 on any AIS region results in automatic score of 75

36. ISS Calculation Region Injury Description AIS Grades Top 3 squared AIS Grade Head Face Neck Thorax Abdominal and Pelvic Content Spine Upper Exteremity Lower Extermity External ISS SCORE

37. DCO therefore only potentially life-threatening injuries should be treated in DCO including unstable pelvic fracture compartment syndrome fractures with vascular injuries unreduced dislocations traumatic amputations unstable spine fractures cauda equina syndrome open fractures

38. Stabilization and Definitive treatment To minimize trauma, initial stabilization should be performed  Definitive treatment delayed for 7-10 days

39. MESS

40. Mangled Extremity Severity Score (MESS) Used to predict necessity of amputation after lower extremity trauma Variables skeletal and soft tissue injury limb ischemia shock age Calculation score determined by adding scores of components in four categories Interpretation score of >7 is predictive of amputation

41. MESS SCORE

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