Atls 5th Sem
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Transcript of Atls 5th Sem
ATLS(Advance Trauma Life Support)
Dr. Tanuj Paul Bhatia
History
• Introduced by Dr. James Styner, an orthopedic surgeon in 1970s.
• Now considered the ‘Gold standard’ in initial management and resuscitation of trauma cases.
Importance of ATLS‘The Golden Hour’
ATLS components
1. Primary survey2. Resuscitation 3. Secondary survey4. Definitive care
Aims of ATLS
1. Primary survey – To identify what is KILLING the patient.
2. Resuscitation – To treat what is killing the patient.
3. Secondary survey – To identify all other injuries.
4. Definitive care – Develop a definitive management plan.
Pre hospital care
• Objectives – (1) assessment of the injury scene; (2) stabilization and monitoring of the injured patient;
and (3) safe and rapid transportation of critically ill patients
to the appropriate trauma center.
• MVIT - Mechanism, Vital signs, Injury inventory, Treatment
Primary survey
• A – Airway with cervical spine control• B – Breathing• C – Circulation• D – Disability• E - Exposure
Airway
• Establishing a patent airway is highest priority.• To prevent irreversible brain damage .• A patient who is able to respond verbally has a
patent airway.• For every patient - Oxygen administered (via
nasal cannula or bag valve facemask) and an oxygen saturation monitor (i.e., pulse oximeter) placed.
Stabilizing cervical spine
O2
C-spine
PulseOxi.
Airway (contd.)
• Basic maneuvers – Simple suctioning.– Jaw-thrust maneuver.– Oropharyngeal airway.
• Tracheal intubation– indicated in any patient in whom concern for
airway integrity exist.– Adequacy of ventilation should be verified .
Airway (contd.)
• Direct cricoid membrane airways.– Cricothyrotomy is the method of choice .– Percutaneous transtracheal ventilation.
Breathing
• Once an airway is established, attention is directed at assessing the patient's breathing .
• The chest wall motion is observed and axillae are auscultated to check delivery to the peripheral lung.
• Life threats– Tension pneumothorax– Pneumothorax/hemothorax– Flail chest– Open pneumothorax
Pneumothorax
Treatment
• Tube thoracostomy.• Mechanical ventilation.
Circulation
• To identify and treat the presence of shock in the patient.
• Initially, all active external hemorrhage is controlled with direct pressure.
• The pulse is characterized, and a blood pressure (BP) is obtained.
• Shock is defined as the inadequate delivery of oxygen and nutrients to tissue.
Etiologies of shock
1.Hypovolemic 2.Cardiogenic3.Distributive
Hypovolemic shock
• Most common in trauma(Haemmorhagic shock).
• Decreased intravascular volume secondary to blood loss .
• S/S - rapid pulse, decreased pulse pressure, diminished capillary refill, and cool, clammy skin.
Management
• two large-bore intravenous lines placed (14- or 16-gauge).
• The antecubital veins are the preferred sites.• A blood specimen should be simultaneously
obtained for cross-matching.• Resuscitation should consist of an initial bolus
of 2 L of a balanced salt solution, typically Ringer's solution.
Classification of hypovolemic Shock
Class EBL Treatment
I <15% (<750ml) Fluids
II 15-30% (750-1.5L) Fluids
III 30-40% (1.5L-2.0L) Fluids + Blood
IV >40% (>2.0L) Fluids + Blood
Cardiogenic shock
• heart is unable to provide adequate cardiac output.
• In the trauma setting, such shock can occur in one of two ways:
(1) extrinsic compression of the heart or (2) myocardial injury causing inadequate
myocardial contraction and decreased cardiac output.
Management
• I.V. fluids• E.C.G.• Chest x ray• Tube thoracostomy if tension pneumothorax is
the cause.
Distributive shock
• as a result of an increase in venous capacitance leading to decreased venous return.
• Loss of peripheral sympathetic tone is responsible.
• often respond to an initial fluid bolus but will eventually require pharmacologic support.
• Phenylephrine is the drug of choice.
Disability
• Assessment of the neurologic status.• to identify and treat life-threatening
neurologic injuries.• Intracranial injuries(Mannitol, 0.25–1.00 g/kg)• Spinal cord injuries(methylprednisolone)• Neurosurgical consultation.
Exposure
• Last step• Exposure with environmental control.• Remove clothes and look for other dangerous
injuries.
Completion of primary survey
• Monitoring.• Laboratory values.• Adequacy of resuscitation.• Radiographic investigations.• FAST(focussed abdominal sonography for
trauma)• CT SCAN.
FAST
Secondary surveyKEY COMPONENTS
• History• Complete head-to-toe examination• “Tubes and Fingers in every orifice”• Complete Neuro exam• Special diagnostic tests• Reevaluation
HISTORY
• A Allergies• M Medications• P Past Medical/Surgical
History/Pregnancy• L Last meal• E Events/Environment related to injury
HEAD
• Complete Neuro exam• GCS Score• Comprehensive eye/ear exams MAXILLOFACIAL• Bony crepitus/stability• Palpable deformity
Cervical Spine
• Palpate for tenderness/stepoffs/crepitus• Complete motor/sensory exams• Reflexes• C-spine imaging
Neck (soft tissues)
• Mechanism: blunt vs penetrating• Symptoms: airway obstruction,
hoarseness• Findings: crepitus, hematoma, stridor,
bruit
Chest
• Inspect• Palpate• Percuss• Auscultate• X-rays
Abdomen
• Inspect, auscultate, palpate, percuss
• Reevaluate frequently• Special studies
Musculoskeletal:Extremities
• contusion, deformity• pain• perfusion• peripheral NV status• X-rays as indicated
Neurologic
• Spine/Cord:– complete motor and sensory exams– reflexes– imaging as indicated
• CNS:– frequent reevaluation– prevent secondary brain injury
• Early neurosurgical consultation
Definitive care
• Definitive hospital care is undertaken .• Ranging from emergent celiotomy to
admission and further assessment.• Diagnostic evaluations are completed and
therapeutic interventions performed.
Roles of the Trauma Team
Airway
Nurse
Boss
Attending
Team Member
Team Member
Nurse
Roles of the Trauma Team
• Boss– Directs the team, communicates decisions– Free to roam– Attending speaks through Boss (or teaches
directly)
Roles of the Trauma Team
• Airway– A & B of primary survey– Intubation (if needed)– Head / Neck in secondary survey
• Nurses– Attach monitors, give blood / fluids / meds– Recording nurse records at foot of bed
Roles of the Trauma Team
• Team Members– Expose, examine (secondary survey)– Procedures as directed (by boss)
• Chest Tubes• Lac repairs
– Rectals, foleys routinely assigned to team member.
Overview of ATLS
D e fin it ive C a re
D a ta / In fo rm a tio n /R e spo n se to T h era py
S e co nd a ry S u rvey
R e su sc ita tion
P rim a ry S u rvey(A B C D E 's )
HANK YOU