Post on 09-Apr-2018
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Principles of
Resuscitation in TraumaDr Simon Albert
Clinical FellowEmergency Medicine
St Thomas Hospital
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Contents
Advanced Trauma Life Support
Tension Pneumothorax
Head Injuries & Glasgow Coma Score
Burns
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Advanced Trauma Life
Support Standardised framework for the
management of trauma
Treat the greatest threat first
Injury kills in a predictable timeframe
ABCDE
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Primary Survey
AAirway + C-spine control
BBreathing + oxygen
CCirculation + haemorrhage and iv access
DDisability
EExposure without hypothermia
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Airway & C-spine control Look & Listen for signs of obstruction
Beware of facial fractures, foreignbodies, GCS
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Airways and Ventillation
Oxygen mask
Manoevres
Oropharyngeal airway Nasopharyngeal airway
Bag-valve-mask
Endotracheal tube Cricothyroidotomy
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Breathingand VentilationAssessment of ventilation
Chest wall excursion/inspection/palpation
Percussion
Auscultation
End tidal CO2
ABG
Level of consciousness
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Life threatening ConditionsLife threatening Conditions
Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest Cardiac tamponade
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Circulation with external
haemorrhage control Control external bleeding with direct
pressure
IV access 2 x 16G minimum + bloods
Flow is proportional radius 4
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SHOCKCLASS I II III IV
Blood loss ml 2000
% 40%
Pulse 100 >120 >140
BP normal normal low Low
Pulse pressure Normal/incr decrease decrease Decrease
RR 14-20 20-30 30-40 >35
Urine O/P >30 20-30 5-15 NegligibleCNS Slight anxious Mildly anxiousconfused Confused
lethargic
Fluid Hartmans Hartmans Hartmans + blood Hartmans + blood
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Disability - neurological
AVPU or GCS
AVPU
Alert
Verbal
Pain
Unresponsive
GCS
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Exposure & Environmental
Control Patient should be exposed fully
Dignity Maintained
Kept warm
Log roll
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Why we Logroll
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Adjuncts to the Primary Survey
Monitoring ECG, SpO2, P/BP, ABG
NGT/OGT, Urinary catheter
Imaging
C-spine, chest and pelvis x-rays
FAST scan
CT
DPL
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Secondary survey
Ample history
Top to toe physical examination
Head and faceNeck
Chest
Abdomen & Perineum
Musculoskeletal & log roll
Neurological
tubes and fingers in every orifice
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ATLS Summary
ABCDE
Primary survey must be repeated often and
with any change in the patients condition Secondary survey may not be completed in
the Emergency department
A normal C-spine XR does not exclude afracture
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Tension Pneumothorax
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Tension Pneumothorax
Life threatening emergency
Air progressively enters the pleuralspace but is unable to leave
Separation of the pleura and collapseof the affected lung leading tomediastinal shift to the opposite side
Kinking of SVC/IVC giving decreasevenous return and cardiac outputleading to circulatory collapse
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Diagnosis
Symptoms
History, dyspnoea, tachypnoea, distress
Signs
External examination, tracheal deviation,breath sounds, resonance, tachycardia,
hypotension, distended neck veins,unconscious, high ventilator pressures.
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Head Injuries and GCS
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Head Injuries AMPLE history
Time of injury & Mechanism
Loss of consciousness
Amnesia anterograde/retrograde Headache
Diplopia
Nausea or vomiting Anti-coagulants
Alcohol consumption
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Examination
AVPU / Glasgow Coma Score
Vital signs + BSL
Area of impacthaematoma/laceration/bony tenderness or step
CNS exam with Pupil size and reactivity
Nose - rhinorrhea / rhinorrhagia
Ears - otorrhea / otorragia
Signs of base of skull fracture
PNS
C-Spine
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Basal Skull Fractures
Indicated by CSF / ecchymosis / anosmia / ear ornasal csf / blood
Periorbital ecchymosis Raccoon eyes
Retroauricular ecchymosis Battle sign Haemotympanum
Subconjuntival haemorrage (no posterior margin)
No antibiotics
Meningitis & head injury advice CT
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GCS
Best Eyes Response4 Eyes open spontaneously
3 Eyes open to speech
2 Eyes open to pain
1 Eyes dont open
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GCS
Best Verbal Response5 Normal speech
4 Confused
3 Words
2 Sounds
1 None
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GCS
Best Motor Response6 Obeys commands
5 Localises to pain
4 Normal flexion/withdraw
3 Abnormal flexion (decorticate)
2 Extension (decerebrate)
1 No movement
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GCS
Best eyes response 4
Best verbal response 5
Best motor response 6
3-15 / 153-15 / 15
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Burns
Thermal
ChemicalRadiation
Electrical
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Burns Management
ABCDE + Analgesia
Airway hoarseness, stridor, facialburn, singed nasal hair, soot in nose ormouth. Early intubation
Smoke inhalation
Measurement of surface area
Assessment of burn thickness
Escharotomy chest/limbs
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Measurement of Body Surface
Area
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Superficial Erythema
Pain
Absence of blisters
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Partial thickness
Red or mottled
Blistered, broken
epidermis, swelling Weeping, wet
surfaces
Painful
Sensitive to air
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Full thickness
Pale, white, charredleatheryappearance.
Damage to all skinlayers, nerveendings, and evensubcutaneoustissues.
Dry surface,Painless, insensate
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Burns: iv fluid calculation
ParklandParkland formula (Hartmans)
4 x weight x % burn = 24hr fluids
Half given in first 8 hrs.
Timed from burn not arrival
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Criteria for transfer
Partial thickness >10%
Full thickness
Face, hands, feet, genitalia, perineumor major joints
Paediatric
Inhalation injury
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Summary
ATLS framework ABCDE
Diagnosis and management of Tension
Pneumothorax Assessment and classification of head
injuries, GCS, AVPU
Burns measurement, management andreferral
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Any Questions?