PRINCIPLES OF ADVANCED TRAUMA LIFE SUPPORT.pptx

Basic principles of ATLS

1. PRINCIPLES OF ADVANCED TRAUMA LIFE SUPPORT BY DR MS AMINU 1

2. History ATLS has its origins in the US in 1976, when James K Styner, an Orthopedic surgeon piloting a light aircraft, crashed into a field in Nebraska. His wife, Charlene was instantly killed while 3 of his four children, Richard, randy and Kim sustained critical injuries. 2

3. History 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 ro transport him to the nearest hospital, upon arrival, he found it closed. Even when the hospital was opened, the emergency care was inadequate and inappropriate. 3

4. History The initial ATLS course 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. 4

5. ATLS Represents an organized approach for evaluation and management of trauma patients. Has 2 phase Pre-hospital phase Hospital phase 5

6. PREHOSPITAL PHASE This covers the initial phase pf trauma management Covered normally by first responders in the field at the site of the trauma prior to transfer to a hospital Triage is carried out and patient are sorted out according to urgency prior to transport to the health care facility. 6

7. OBJECTIVES By the end of this session, we will be able to Review core principle and ABCDE approach Discuss rapid primary/ secondary survey technique Master critical interventions (hemorrhage control, airway management) 7

8. WHY ATLS Trauma kills >5 million/year globally. In the US, it’s the #1 cause of death for ages 1-44. But here’s the key:  systematic care reduces mortality by 30% . ATLS isn’t optional – it’s how we buy time in the Golden Hour. 8

9. CORE ATLS PHILOSOPHY Key principles: Treat greatest threat to life first. Never delay resuscitation for diagnostics ABCDE: Sequential & concurrent priorities 9

10. INITIAL ASSESSMENT AND MANGEMENT Preparation (Prehospital – Hospital) Triage Primary survey (ABCDE) Resuscitation Adjuncts to primary survey 10

11. INITIAL ASSESSMENT AND MANGEMENT Secondary survey Adjuncts to secondary survey Post-resuscitation monitoring Definitive care 11

12. PRIMARY SURVEY Treatment priorities A: Airway maintenance + C-spine protection B: Breathing and ventilation C : Circulation ad hemorrhage control D: Disability – Neuro E: Exposure/ Environment control 12

13. A - Airway Airway Patency/ obstruction Severe head injury -> Definite airway 13

14. Airway: Patency Maxillofacial trauma Neck trauma Laryngeal trauma (Hoarseness, Subcutanenous emphysema, Palpable fracture) 14

15. A/C-Spine Protection C-spine protection Multiple system trauma Altered level of consciousness Blunt injury above the clavicle Manual in-line stabilization Immobilization with blocks/collar 15

16. A/C-Spine Protection: NEXUS Midline cervical tenderness Altered level of conscienceness Evidence of intoxication Neurological abnormality Presence of painful distracting injury 16

17. A/C-Spine Trauma patient is dynamic Repeated assessment 17

18. A: Resuscitation Jaw thrust/ Chin lift Naso/ oropharyngeal airway Combitube , LMA Definitive airway (cuff in the trachea) Oro/ Naso tracheal intubation Surgical cricothyroidotomy 18

19. Endotracheal intubation Indication Provide patent airway Deliver supplemental oxygen Support ventilation Prevent aspiration 19

20. Endotracheal intubation Decision Apnea (orotracheal) Cannot maintain patent airway Protect aspiration/vomitus Impending compromise airway Closed head injury required assisted ventilation Inadequate oxygenation 20

21. Surgical Airway Cricothyroidotomy/ Tracheostomy Indication Unabale to intubate (Severe maxillofacial injury, failed intubation) Contraindication Airway transection 21

22. B: Breathing 22

23. B: Breathing Life threatening conditions Tension pneumothorax Flail chest Massive haemothorax Open pneumothorax Cardiac tamponade 23

24. Tension Pnemothorax Chest pain, respiratory distress, tachycardia, hypotension, tracheal deviation, absent breath sound, neck vein distension Rx: Immediate decompression Needle thoracotomy Intercostal drainage 24

25. Open Pnemothorax > 2/3 of tracheal diameter Rx: 3 sided dressing Chest tube insertion 25

26. Open Pnemothorax 26

27. Open Pnemothorax 27

28. Flail Chest > 2 ribs fractured in 2 or more places Paradoxial chest wall movement Rx: 28

29. Massive Haemothorax > 1500ml of blood (1/3 of blood volume) in the chest cavity Rx IV resuscitation Chest tube Thoracotomy >1500ml immediately 200ml/ hr for 2 – 4 hours 29

30. Cardiac Tamponade Penetrating injury Beck’s triad Rx Diagnosis: FAST/Echo pericardiocentesis 30

31. C: Circulation and Hemorrhage control Circulation - Blood volume and cardiac output Level of consciousness Skin colour Pulse 31

32. C: Circulation and Hemorrhage control Hemorrhage control – External hemorrhage Manual pressure Splinting Tourniquet hemostats 32

33. C: Resuscitation 2 Large-caliber IV catheter “Warm” N/S, R/L Blood Control bleeding Direct pressure Operative control Vasopressors 33

34. C: Shock Inadequate tissue perfusion / oxygenation Haemorrhagic / non- haemorrhagic 34

35. Haemorrhagic Shock Most common cause of shock in trauma External vs Internal haemorrhage Rx: volume replacement 35

36. Haemorrhagic Shock Classification Class I 15% blood loss PR < 100bpm BP normal PP normal RR 14 – 20 Urine output > 30 ml/ hr Mental status: Slightly anxious 36

37. Haemorrhagic Shock Classification Class II 15 – 30% blood loss PR > 100bpm BP normal PP decreased RR 20 – 30 Urine output: 20 – 30 ml/ hr Mental status: mildly anxious 37

38. Haemorrhagic Shock Classification Class III 30 – 40% blood loss PR > 120bpm BP decreased PP decreased RR 30 - 40 Urine output: 5 – 15ml/ hr Mental status: confused 38

39. Haemorrhagic Shock Classification Class IV >40% blood loss PR > 140bpm BP decreased PP decreased RR >35 Urine output: ----- Mental status: confused/lethargic 39

40. Fluid Replacement Class I, II: Crystalloid Class III, IV : Crystalloids, blood Initial fluid therapy 1-2 L for adults 20 ml/kg for children 40

41. Response to Fluid Resuscitation Rapid response <20% blood loss Cross-match, Surgical consultation Transient response 20 – 40% blood loss Ongoing blood loss Blood transfusion, surgical intervention 41

42. Response to Fluid Resuscitation No response Immediate operative intervention 42

43. Non-hemorrhagic shock Cardiagenic shock Tension pneumothorax Neurogenic shock Septic shock 43

44. Cardiogenic shock Cardiac contusion Cardiac tamponade: “Beck’s triad” Tachycardia Muffled heart sound Distended neck veins DX: Echo/FAST 44

45. Cardiac Tamponade Penetrating injury Beck’s triad DDX from tension pneumothorax FAST/Echo Rx: Pericardiocentesis 45

46. Neurogenic Shock Isolated intracranial injuries do not cause shock Loss of sympathetic tone: Spinal cord injury Hypotension without tachycardia Initially treated as hypovolemia DDx of non-responder 46

47. D Neurological Status Loss of consciousness (AVPU / GCS) Pupil size and light reaction Lateralizing signs Spinal cord injury level 47

48. D A : Alert V : Verbal command P : Painful stimuli U : Unresponsive 48

49. D Factors that affect level of consciousness Oxygenation Ventilation Perfusion Hypoglycemia Drugs/ Alcohol 49

50. D Reevaluation 50

51. E : Exposure/ Environment Uncloth patient Logroll patient and look for hidden injuries Prevent hypothermia Warm blanket Warm IV fluid 51

52. E : Exposure/ Environment Rectal examination Sphincteric tone Position of the prostate (high-riding) = urethral injury Gross blood (penetrating abdominal injury) Pelvic fractures 52

53. Primary survey: Adjuncts Pulse Oximeter Cardiac Monitoring +/- ECG Foley Catheter NG Tube Chest Xray/Pelvic Xray Blood Glucose 53

54. Secondary survey Not began until primary survey is completed History (AMPLE) Head-to-toe examination GCS Xrays 54

55. Secondary survey History Allergies Medications Past illnesses/pregnancy Last meal Events 55

56. Secondary survey Head-to-toe examination Physical examination Head-to-toe examination All systems 56

57. Secondary survey Investigations Re-evaluation Resuscitation 57

58. Definitive Care 58

59. Conclusion The knowledge of ATLS is an invaluable tool in the arsenal of every orthopaedic surgeon, as such efforts must be made to gain this skill as it could very well be the deciding factor between life and death of a trauma patient 59

60. References Solomon, L., Warwick, D., & Nayagam , S. (Eds.). (2010). Apley's System of Orthopaedics and Fractures (9th ed.). CRC Press.  American College of Surgeons. (2021). Advanced Trauma Life Support (ATLS): Student Course Manual (11th ed.). American College of Surgeons.  60