ADVANCE TRAUMA LIFE ADVANCE TRAUMA LIFE SUPPORTSUPPORT

Jorge M. Concepcion, MD, FPCSJorge M. Concepcion, MD, FPCSTraining Officer Training Officer

Department of SurgeryDepartment of SurgeryThe Medical CityThe Medical City

ACCIDENTS ?

INJURIES?

OBJECTIVESOBJECTIVES To discuss the concepts in ATLS.To discuss the concepts in ATLS. To provide the correct sequence of To provide the correct sequence of

priorities in assessing multiply priorities in assessing multiply injured patient. injured patient.

To introduce the principles in To introduce the principles in definitive trauma care definitive trauma care

INJURY (WHO definition)

-a bodily lesion resulting from exposure to energy Mechanical

Thermal

Electrical Chemical

interacting with the body in the amounts thatexceed the limits of physiologic tolerance.

Radiation

INJURIES

“NOT ACCIDENTS”

PREDICTABLE

PREVENTABLE

Not random events but occur in predictable patterns

PREVENTIONPREVENTION

TRADITIONAL:TRADITIONAL:

HISTORY OF ILLNESSHISTORY OF ILLNESSCOMPLETE P.E.COMPLETE P.E.INITIAL IMPRESSIONINITIAL IMPRESSIONDIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISDIAGNOSTIC TESTDIAGNOSTIC TESTFINAL DIAGNOSISFINAL DIAGNOSISTREATMENTTREATMENT

TRAUMA MANAGEMENTTRAUMA MANAGEMENT

RECOGNITION OF INJURY (P.E.)RECOGNITION OF INJURY (P.E.)TREATMENTTREATMENT

TRAUMA CONCEPTS:TRAUMA CONCEPTS:1. TREAT THE GREATEST THREAT 1. TREAT THE GREATEST THREAT

TO LIFE.TO LIFE.2. LACK OF DEFINITIVE DIAGNOSIS

SHOULD NOT IMPEDE THE APPLICATION OF AN INDICATED TREATMENT.

3. DETAILED HISTORY IS NOT ESSENTIAL TO BEGIN THE EVALUATION OF AN ACUTELY INJURED PATIENT.

APPROACH TO SEVERELY INJURED PATIENT

1. PRIMARY SURVEY

2. RESUSCITATION

3. SECONDARY SURVEY

4. DEFINITIVE MANAGEMENT

REASSESSMENT

5. TERTIARY SURVEY

A - AIRWAY & C-SPINE CONTROL

B - BREATHING

C - CIRCULATION – HEMORRHAGE CONTROL

D - DISABILITY (NEURO EXAM)

E - EXPOSURE / ENVIRONMENT

PRIMARY SURVEY

AIRWAY

CLINICAL

GUARANTEE PATENCY

“WHAT IS YOUR NAME?”

GCS 8 OR LESSOBSTRUCTED AIRWAYHEMORRHAGIC SHOCKCOMBATIVE PATIENT

INTUBATE

AIRWAY RISK FACTORSAIRWAY RISK FACTORS I I nstability (hemodynamic)nstability (hemodynamic) N N eck hematoma/traumaeck hematoma/trauma T T rauma to the face (maxillofacial)rauma to the face (maxillofacial) U U nresponsive (GCS < 8)nresponsive (GCS < 8) B B leeding from oropharynxleeding from oropharynx A A pneapnea T T hermal inhalational injuryhermal inhalational injury E E mesis/epistaxis/hemoptysis mesis/epistaxis/hemoptysis

AIRWAY MAINTENANCE AIRWAY MAINTENANCE MEASURESMEASURES

Finger sweepFinger sweep Chin liftChin lift Jaw thrustJaw thrust Oro/nasopharyngeal airwayOro/nasopharyngeal airway Laryngeal mask airwayLaryngeal mask airway Needle cricothyroidotomyNeedle cricothyroidotomy

DEFINITIVE AIRWAY DEFINITIVE AIRWAY CONTROLCONTROL

IntubationIntubation– OrotrachealOrotracheal– Nasotracheal Nasotracheal

Surgical airwaySurgical airway– CricothyroidotomyCricothyroidotomy– Tracheostomy Tracheostomy

THINGS TO CONSIDERTHINGS TO CONSIDER TTIMING – don’t delayIMING – don’t delay EEQUIPMENT – scope, suction, QUIPMENT – scope, suction,

supppliessuppplies AANESTHEZISENESTHEZISE MMONITORONITOR WWEAR PROTECTIONEAR PROTECTION OOXYGENATEXYGENATE RREINFORCEMENT – ask for helpEINFORCEMENT – ask for help KKEEP NECK PROTECTEDEEP NECK PROTECTED

C-SPINE CONTROLC-SPINE CONTROL ALL PATIENTS WITH BLUNT TRAUMA – ALL PATIENTS WITH BLUNT TRAUMA –

PRESUME TO HAVE C-SPINE INSTABILITYPRESUME TO HAVE C-SPINE INSTABILITY

IMMOBILIZATION OF C-SPINE IS A IMMOBILIZATION OF C-SPINE IS A PRIORITYPRIORITY

C-SPINE CLEARANCE IS NOT A PRIORITYC-SPINE CLEARANCE IS NOT A PRIORITY

C-SPINE CONTROL

IN-LINE STABILIZATION

CERVICAL COLLAR

C-COLLAR SHOULD NOT INTERFERE C-COLLAR SHOULD NOT INTERFERE WITH CLINICAL EXAM OF THE NECKWITH CLINICAL EXAM OF THE NECK

INTUBATION – REMOVE THE COLLAR INTUBATION – REMOVE THE COLLAR AND DO IN-LINE STABILIZATIONAND DO IN-LINE STABILIZATION

WHAT’S WRONG?

BREATHINGGUARANTEE ADEQUATE OXYGENATION AND

VENTILATION

VENTILATION (LUNGS, CHEST WALL & DIAPHGRAM)

ASSESS RESPIRATORY EFFORT, BREATH SOUNDS &OXYGEN DELIVERY

GIVE SUPPLEMENTAL OXYGEN

Objective SignsObjective Signs

InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation

OXYGENATIONOXYGENATIONOxygen delivery L/min. Approx. FiO2

Nasal cannula   Face mask  Face mask w/ reservoir

1246

5-66-77-868

10

0.240.280.350.420.400.500.600.600.801.00

MANAGEMENTMANAGEMENT

VentilationVentilation– Mouth to pocket face Mouth to pocket face

maskmask– Bag-valve-mask ( 2 Bag-valve-mask ( 2

person technique)person technique)

Pleural Pleural DecompressionDecompression– Needle thoracentesisNeedle thoracentesis– Closed-tube Closed-tube

thoracostomythoracostomy– Three-sided dressingThree-sided dressing

CIRCULATION

ASSURE ADEQUATE OXYGEN DELIVERY AND CONTROL BLEEDING

ASSESS VITAL SIGNSCONTROL BLEEDING

DIRECT PRESSUREREDUCTION OF FRACTURES IN LONG BONES

AND PELVIS

RECOGNITION OF SHOCKRECOGNITION OF SHOCK TachycardiaTachycardia Cutaneous vasoconstrictionCutaneous vasoconstriction HypotensionHypotension Narrowed pulse pressureNarrowed pulse pressure

ETIOLOGY OF SHOCKETIOLOGY OF SHOCK HemorrhagicHemorrhagic NonhemorrhagicNonhemorrhagic

– Cardiac compressiveCardiac compressive tension pneumothoraxtension pneumothorax cardiac tamponadecardiac tamponade

– Cardiogenic Cardiogenic – NeurogenicNeurogenic– SepticSeptic

CLASSES OF HEMORRHAGECLASSES OF HEMORRHAGEClass IClass I Class IIClass II Class IIIClass III Class IVClass IV

Blood Loss (ml)Blood Loss (ml) Up to 750Up to 750 750-1500750-1500 1500-1500-20002000

>2000>2000

Blood Loss (% Blood Loss (% blood volume)blood volume)

Up to 15%Up to 15% 15-30%15-30% 30-40%30-40% >40%>40%

Pulse RatePulse Rate <100<100 >100>100 >120>120 >140>140Blood PressureBlood Pressure normalnormal normalnormal decreaseddecreased decreaseddecreasedPulse PressurePulse Pressure normal or normal or

decreaseddecreaseddecreaseddecreased decreaseddecreased decreaseddecreased

Respiratory RateRespiratory Rate 14-2014-20 20-3020-30 30-4030-40 >35>35Urine Output Urine Output (mL/hr)(mL/hr)

>30>30 20-3020-30 5-155-15 negligiblenegligible

CNS/mental CNS/mental statusstatus

Slightly Slightly anxiousanxious

Mildly Mildly anxiousanxious

Anxious, Anxious, confusedconfused

Confused, Confused, lethargiclethargic

CLASSES OF HEMORRHAGECLASSES OF HEMORRHAGE 70 kg male with gunshot wound in 70 kg male with gunshot wound in

the RUQthe RUQ Vital signs:Vital signs:

– BP 80/40BP 80/40– HR 116/minHR 116/min– RR 22/minRR 22/min

Class III hemorrhageClass III hemorrhage EBL= 1470 mLEBL= 1470 mL

– 70 kg x 7% x 30%70 kg x 7% x 30%

INITIAL MANAGEMENTINITIAL MANAGEMENT Recognize shockRecognize shock Stop the bleeding!Stop the bleeding! Replace effective circulating volumeReplace effective circulating volume Restore tissue perfusionRestore tissue perfusion

FLUID THERAPYFLUID THERAPY Warmed crystalloid solutionWarmed crystalloid solution Rapid fluid bolusRapid fluid bolus

– AdultAdult 2 liters2 liters– ChildChild 20 mL/kg20 mL/kg

““3 for 1 rule”3 for 1 rule” Monitor response to therapyMonitor response to therapy

ELECTROLYTES 140 109 4 21

Size (gauge) Time18

16

14

12 min.

9 min.

7 min.

Size of needle in relation to a flow of 1 liter IVF

RESPONSE TO FLUID RESPONSE TO FLUID RESUSCITATIONRESUSCITATION

Rapid responseRapid response Transient responseTransient response Minimal or no responseMinimal or no response

RESPONSE TO FLUID RESPONSE TO FLUID RESUSCITATIONRESUSCITATION

Rapid ResponseRapid Response Transient Transient ResponseResponse

No responseNo response

Vital SignsVital Signs Return to normalReturn to normal Transient Transient improvementimprovement

Remain Remain abnormalabnormal

Estimated blood Estimated blood lossloss

Minimal (10-Minimal (10-20%)20%)

Moderate and Moderate and ongoing (20-ongoing (20-

40%)40%)

Severe (>40%)Severe (>40%)

Need for more Need for more fluidsfluids

LowLow HighHigh HighHigh

Need for bloodNeed for blood LowLow Moderate to highModerate to high ImmediateImmediateBlood Blood preparationpreparation

Type and Type and crossmatchcrossmatch

Type specificType specific Emergency Emergency blood releaseblood release

Need for surgeryNeed for surgery PossiblyPossibly LikelyLikely Highly likelyHighly likelyEarly presence Early presence of surgeonof surgeon

YesYes YesYes YesYes

CIRCULATIONCIRCULATION Hypovolemia most common cause of Hypovolemia most common cause of

shockshock Recognition of its presence 1Recognition of its presence 1stst step step Control of bleedingControl of bleeding Restoration of intravascular volumeRestoration of intravascular volume Monitor patient’s responseMonitor patient’s response

DISABILITYASSESS GCS, PULSES, SENSORY AND

MOTOR FUNCTIONSGCS

BEST MOTOR RESPONSE – 6BEST VERBAL RESPONSE – 5 EYE OPENING – 4

3 - 15

V = ? M = 4 E = 3 GCS = 7V = M(0.5) + E(0.4) V = 4 (0.5) = 2 + 3 (0.4) = 1.2V = 2 + 1.2 = 3.2

V = 3 M = 4 E = 3 GCS = 10

?

EXPOSURE AND ENVIRONMENTAL CONTROL

LOGROLL

KEEP PATIENT WARM

UNDRESS ( CUT CLOTHING )

OFTEN MISSED INJURIESAXILLAPERINEUMBACK

SECONDARY SURVEY

HISTORY

A - ALLERGIES

M - MEDICATIONS

P – PAST ILLNESSES

L – LAST MEAL

E – EVENTS PRECEEDING THE INCIDENT

PHYSICAL EXAMINATION

DETAILED, METICULOUS HEAD TO TOE EXAM

FINGER AND TUBES IN ALL ORIFICES

LOOK, LISTEN, FEEL EVERYWHERE

DEFINITIVE MANAGEMENTDEFINITIVE MANAGEMENT

TERTIARY SURVEYTERTIARY SURVEY

DEFINITIVE MANAGEMENTDEFINITIVE MANAGEMENT PENETRATING NECKPENETRATING NECK PENETRATING CHESTPENETRATING CHEST BLUNT CHESTBLUNT CHEST PENETRATING ABDOMENPENETRATING ABDOMEN BLUNT ABDOMENBLUNT ABDOMEN EXTREMITIESEXTREMITIES

DO’s

SPLINT PATIENTS WHERE THEY LIE

COMFORT THE PATIENT

ALLEVIATE PAIN

HONE YOUR SKILLS

ASK FOR HELP

PRIMUM NON NOCERE

DON’TS

PANIC

INSERT NGT IN PATIENT WITH SUSPECTED FACIAL FRACTURE

FORGET TO WARM THE PATIENT (ESP. CHILDREN)

OVERLOOK THE PERINEUM, BACK AND AXILLA

REMOVE IMPALED OBJECTS

INSERT A FOLEY CATHETER IN PATIENTSSUSPECTED OF URETHRAL INJURY

Thank youThank you