Introduction to Advanced Trauma Life Support ATLS

Objectives

Concepts of primary & secondary survey Priorities & Life threatening conditions Clinical & Surgical skills

Basic knowledge

Rapid assessment Resuscitate & Stabilize (Prioritize) Patient's needs & facility's capabilities Appropriate transfer Optimum care

Initial Assessment & Management

Preparation (Prehospital - Hospital) Triage Primary survey (ABCDE) Resuscitation Adjuncts to primary survey & resuscitation ->

Initial Assessment & Management

Secondary survey Adjuncts to the secondary survey Postresuscitation monitoring Definitive care

Primary Survey

Treatment priorities A: Airway maintenance + C-spine protection B: Breathing & Ventilation C: Circulation & Hemorrhage control D: Disability Neuro E: Exposure / Environment control

Airway

Patency / Obstruction Severe head injury -> Definitive airway

Airway: Patency

Maxillofacial trauma Neck trauma Laryngeal trauma (Hoarseness, Subcutaneous emphysema, Palpable fracture)

C-spine protection

Multiple system trauma Altered level of consciousness Blunt injury above clavicle Manual in-line stabilization

A: Nexus

Midline cervical tenderness Altered level of consciousness Evidence of intoxication Neurologic abnormality Presence of painful distracting injury

Trauma patient is dynamic Repeated assessment

A: Resuscitation

Jaw thust / Chin lift / Head tilt Naso / Oropharyngeal airway Combitube, LMA Definitive airway (Cuff in trachea)

Oro / Naso tracheal intubation Surgical cricothyroidotomy

Endotracheal intubation

Indication

Provide patent airway Deliver supplemental oxygen Support ventilation Prevent aspiration

Endotracheal intubation

Decision

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

Surgical Airway

Cricothyroidotomy / Tracheostomy
Indication Unable to intubate (severe maxillofacial injury, failed intubation) Contraindication Airway transection

B: Breathing

B: Life Threatening Conditions

Tension pneumothorax Flail chest with pulmonary contusion Massive Hemothorax Open pneumothorax Cardiac tamponade

Thoracic Trauma: Primary survey

Looking, Palpation, Percussion, Listening

Tension pneumothorax Open pneumothorax (sucking chest wound) Flail chest Massive hemothorax Cardiac tamponade

Thoracic Trauma: Primary survey

Tension pneumothorax

Chest pain, Respiratory distress, Tachycardia, Hypotension, Tracheal deviation, Absent breath sound, Neck vein distension Immediate decompression

Needle thoracostomy Intercostal drainage

Thoracic Trauma: Primary survey

Open pneumothorax (sucking chest wound)

> 2/3 of tracheal diameter 3 sided dressing Chest tube insertion

Open Chest Wound: 3-Sided Dressing

Thoracic Trauma: Primary survey

Flail chest

>2 ribs fractures in 2 or more places Paradoxical chest wall movement Adequate ventilation Reexpand lungs: Intubation

Thoracic Trauma: Primary survey

Massive hemothorax

>1500 cc of blood (1/3 of blood volume) in chest cavity IV resuscitation Chest tube Thoracotomy

>1500 cc immediately 200 cc/h for 2-4 h

Thoracic Trauma: Primary survey

Cardiac tamponade

Penetrating injury Beck's triad DDx from Tension pneumothorax FAST / Echo Pericardiocentesis

B: Resuscitation

Supplemental oxygen Tension pneumothorax decompression

C: Circulation & Hemorrhage control

Circulation Blood volume & Cardiac output Level of consciousness Skin color Pulse

Hemorrhage control - External hemorrhage

Manual pressure Splinting Tourniquet Hemostats

C: Resuscitation

2 large-caliber IV catheter warm NSS, RLS Blood Control bleeding

Direct pressure Operative control

Vasopressors

Shock

Inadequate tissue perfusion / oxygenation Hemorrhagic / Non-hemorrhagic

Hemorrhagic shock

Most common cause of shock in trauma External vs Internal hemorrhage Blood volume = 7% of BW Rx: Volume replacement Shock Classification

Hemorrhagic shock classification

Class I

15% blood loss P < 100 BP normal PP normal RR 14-20 Urine output >30 cc/h Mental status: Slightly anxious

Hemorrhagic shock classification

Class II

15-30% blood loss P > 100 BP Normal PP decreased RR 20-30 Urine output 20-30 cc/h Mental status: mildly anxious

Hemorrhagic shock classification

Class III

30-40% blood loss P >120 BP decreased PP decreased RR 30-40 Urine output 5-15 cc/h Mental status: confused

Hemorrhagic shock classification

Class IV

>40% blood loss P >140 BP decreased PP decreased RR > 35 Urine output --Mental status: confused / lethargic

Fluid replacement

Class I, II: Crystalloid Class III, IV: Crystalloid, Blood Initial fluid therapy

1-2 L for adult 20 cc/kg for children 1 cc blood loss = 3 cc crystalloid replacement

3-for-1 rule

Response to fluid resuscitation

Rapid response

<20% blood loss Cross-match, Surgical consultation 20-40% blood loss On going blood loss Blood transfusion, Surgical intervention

Transient response

Response to fluid resuscitation

No response

Immediate operative intervention

Non-hemorrhagic shock

Cardiogenic shock Tension pneumothorax Neurogenic shock Septic shock

Cardiogenic shock

Cardiac contusion Cardiac tamponade: Beck's triad

Tachycardia Muffled heart sound Distended neck vein

Echo / FAST

Cardiac Tamponade

Penetrating injury Beck's triad DDx from Tension pneumothorax FAST / Echo Rx: Pericardiocentesis

Tension pneumothorax

One-way valve Respiratory distress Subcutaneous emphysema Absent breath sound Hyperresonance on percussion Tracheal shift Distended neck vein Rx: Needle / Tube thoracostomy

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

Neurological status

Level of consciousness (AVPU / GCS) Pupil size & Light reaction Lateralizing sign Spinal cord injury level

A: Alert V: Verbal command P: Painful stimuli U: Unresponsive

Factors affect level of consciousness

Oxygenation ( ABC ) Ventilation ( ABC ) Perfusion ( ABC ) Hypoglycemia Drugs / Alcohol

Reevaluation

Uncloth patient Logroll patient Prevent hypothermia

Warm blanket Warm IV fluid

Rectal examination

Sphinctor tone Position of prostate (high-riding?) = urethral injury Gross blood (penetrating abdominal injury) Pelvic fractures

Primary survey: Adjuncts

Monitor Diagnosis

Primary survey: Adjuncts: Monitor

EKG monitor Foley's catheter Gastric catheter Respiratory rate ABG Pulse oximetry

Primary survey: Adjuncts: Diagnosis

CXR, Pelvis AP, Lateral C-spine DPL, FAST

Should not interrupt resuscitation process

Foley's catheter

Contraindicated in Urethral injury Suspected urethral injury

Inability to void Unstable pelvic fracture Blood at meatus Scrotal hematoma Perineal ecchymoses High-riding prostate

Gastric tube

Relieve gastric dilatation Decompress stomach before DPL Reduce risk of aspiration NG tube: contraindicated in basilar skull fracture

Secondary Survey

Not begin until primary survey is completed History (AMPLE) Head-to-toe evaluation GCS X-rays

Secondary Survey: Adjuncts

Specialized diagnostic tests (CT, US, scope) Should not be performed until hemodynamic stabilization

Secondary Survey

History: AMPLE

A: Allergies M: Medications P: Past illnesses / Pregnancy L: Last meal E: Events

Secondary Survey

Physical examination Head-to-toe examination

Thoracic Trauma: Secondary Survey

Simple pneumothorax Hemothorax Pulmonary contusion Tracheobronchial tree injury Blunt cardiac injury Traumatic aortic disruption Traumatic diaphragmatic injury Mediastinal transvering wound

Abdominal Trauma

Abdominal Trauma

External anatomy

Anterion Flank Back

Abdominal Trauma

Internal anatomy

Peritoneal cavity Pelvic cavity Retroperitoneal space

Abdominal Trauma

Mechanism of injury

Blunt Penetrating

Abdominal Trauma: Assessment

History Physical Exam

Inspection, Auscultation, Percussion, Palpation Evaluation of penetrating wound Pelvic stability Penile, Perineal, Rectal exam Vaginal, Gluteal exam

Celiotomy: Indications

Blunt abdominal trauma with hypotension & evidence of intraperitoneal bleeding Blunt abdominal trauma with positive DPL or FAST Hypotension with penetrating abdominal wound GSW traversing the peritoneal cavity / visceral / vascular retroperitoneum Evisceration

Celiotomy: Indications (cont.)

Penetrating trauma with Bleeding from stomach, rectum, GU Peritonitis Free air, retroperitoneal air, ruptured hemidiaphragm after blunt trauma Ruptured hollow viscus

Diagnostic Studies

Diagnostic peritoneal lavage: DPL FAST CT scan Urethrography, Cystography, IVP

Diagnostic Peritoneal Lavage:DPL

Indications

Altered level of conscious / Spinal cord injury Injury to adjacent structures Equivocal physical exam Prolonged loss of contact with patient Lap-belt sign

Diagnostic Peritoneal Lavage:DPL

Contraindications

Existing indication for celiotomy Previous abdominal operations Morbid obesity Advanced cirrhosis Coagulopathy

Relative contraindications

Diagnostic Peritoneal Lavage:DPL

1 L of LRS Fluid return: >30% of infused volume Positive Interpretation (blunt abdominal injury):

Gross blood > 10 cc RBC >100,000 /mm3 WBC > 500 /mm3 Food particles Gram stain +ve

Head injury

Head Injury

Classification

Mechanism (Blunt, Penetrating) Severity (mild, moderate, severe) Morphology (Skull fractures, Intracranial)

Head Injury: Severity

Mild: GCS 13-15 Moderate: GCS 9-12 Severe: GCS 3-8

Head Injury: Morphology

Skull fractures Intracranial

Epiduralhematoma Subdural hematoma Intracerebral hematoma Diffuse brain injury

Skull fractures

Cranium Maxillofacial Basilar skull fractures

Basilar skull fracture

Raccoon's eyes Battle's sign CSF rhinorrhea / otorrhea

Epidural Hematoma

Arterial origin (middle meningeal a.) CT: lenticular shape

Subdural Hematoma

Venous origin CT: Crescent shape

Intracerebral Hematoma

Brain laceration

Head Injury: Management

Mild HI (GCS 13-15)

Observe CT:

Lost of conscious > 5 min Amnesia Severe headache Focal neurological deficit

Head Injury: Management

Moderate HI (GCS 9-12)

CT brain Admit observe neurosigns F/U CT brain 12-24 h

Head Injury: Management

Severe HI (GCS < 9)

Prompt diagnosis & treatment Don't delay patient transfer to obtain CT scan

Monro-Kellie Doctrine

Brain resuscitation

Maintain adequate

Cerebral Perfusion Pressure (CPP) Oxygenation Normocapnia

Cerebral Perfusion Pressure

CPP = MAP ICP

MAP = Mean Arterial Pressure ICP = Intracranial Pressure

Cerebral Perfusion Pressure

CPP = MAP ICP

MAP = Mean Arterial Pressure

Stabilize Vital signs IV fluids

ICP = Intracranial Pressure

Hyperventilation (limited usage) Mannitol (1g/kg) Furosemide

Brain resuscitation

Oxygenation

Oxygen supplement Anticonvulsants Hyperventilation -> CO2 -> Cerebral vasoconstriction -> CPP

Normocapnia

Conclusions

Initial Assessment (Primary survey, Secondary survey) Adjuncts Priority: Life threatening first Knowledge & Skills for specific conditions DOs & DON'Ts

Q?

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