Advanced Trauma Life Support

Sushil Paudel , MD

Consultant Orthopedics

Polytrauma

Prime most on national agenda world over

Involves diverse specialists and procedures

Polytrauma

Management starts ROADSIDE

Emphasis on QUICK DIAGNOSIS AND RAPID INTERVENTION

Management at site of accident :

Access trapped & buried Do not Pull or TwistPriority Freeing head, neck &

trunk by clearing depress

Gently move out patient

Transport Severely injured Move patient on stretcher Three people ideally

required Transfer like one piece of

log

Emergency Room management :

TAILORED RAPID ACTIVE URGENT METHODICAL AUTHORITATIVE

Death from trauma : trimodol

distribution

The first peak of death- sec-

min Cause: Aortic Rupture

The second peak of death –

min-hr This is the Golden

hour on which ATLS focuses

The third peak of death –

days-wks Causes: Sepsis, SIRS

Establishing assessment and management

Vital functions

Rapid primary evolution

Resuscitation

Secondary assessment

Definitive care

Primary Survey

A- airway

B- breathing

C- circulation

D-Disability

E- exposure

Resuscitation phase

Shock management,

patient oxygenation and

hemorrhage control

Replacement of fluid

Urinary and nasogastric

catheter inserted

Secondary survey

Head-to-toe evaluation

Look, listen and feel

Examine each region

Neurological examination

X-ray of chest and cervical

spine

Tubes and fingers in every

orifice

Definitive care phase

All injuries managed

Comprehensive

management, fracture

stabilization operative

intervention and

transfer

Triage Sorting of patients based on need for treatment

Two type No. of patients and severity of their injuries do not exceed

ability of the facility. Here patient with life threatening problems and there sustaining multiple system are treated first

No. of patients and severity of their injuries exceed capability of the facility and staff. Here patients with the greatest chance of survival with the least expenditure of time, equipment supplies and personnel are managed first

Priority plan- treatment and management

A.Primary surveyAirway and cervical spine

Assessment Management- patent

airway Chin lift or jaw thrust Clear foreign bodies Oropharyngeal airway Orotracheal/ nasotracheal

intubation Cricothyroidotomy

Cervical spine in a neutral position

Airway management

Airway obstruction “Look”

Agitation.Poor air movementRib retractionForeign material

“Listen”

Speech Hoarseness. Noisy breathing Stridor

“Feel” Airway structure in neck Tracheal deviation Hemorrhage

Abnormal Breathing

• “ Look”

Cyanosis Mental StateChest asymmetryTachyponeaParalysis

• “Listen” Can’t breath Stridor, wheezing Breath sound

• “Feel” Surgical emphysema Chest tenderness

Treatment Clear secretion, Debris Pull jaw foreword Oral airway Nasopharangeal airway Endotracheal airway Procedure

Definitive airway “Cuffed tube in the trachea.

IndicationsA- Airway- obstructed gag reflex.B- Breathing- O2 Saturation < 90%.C- Circulation systolic BP <75mm.D- Disability

Glasgow coma scale score < 8E- Environment

hypothermia (core temp <330C)

When to ventilate.

Apnoea Hypoventilation Flail chest Spiral cord injury Glasgow come score < 9

Surgical airway Inability to intubate Neck injury Maxilo facial injury

Needle cricothyroiodectomy

Tracheostomy.

Assume a cervical spine injury in any patient with Polytrauma who has

- Altered level of consciousness.- Blunt or penetrating injury above the level of clavicles.

Protecting the cervical spine

Aim to prevent damage or transection of the spinal cord in case patient has a fracture or unstable dislocation of cervical spine

One member of team holds head in the line of the body

Another member applies a well-fitting hard collar and immobilises the head by placing sandbags on either side of the head

Sticky-tape is passed from one side of the bed across the forehead to the opposite side of bed to further reduce movement of the head and neck

Protecting the cervical spine

Protecting the cervical spine

Breathing control life-threatening chest injuries,

and treatment should be expedited immediately: sucking chest wound tension

pneumothorax/Hemothorax large flail segment cardiac tamponade

Management High conc. of oxygen Alleviate tension pneumothorax Seal open pneumothorax

Management of a Tension Pneumothorax

Insert a large-bore intravenous cannula into second intercostal space in midclavicular line on affected side

If there is a sudden release of air, the diagnosis is confirmed and should be followed immediately by an intercostal chest drain in the fifth intercostal space in the midaxillary line

If the diagnosis is in doubt, order a chest x-ray and proceed with the chest drain if confirmatory

Circulation and Hemorrhage control

Assessment

State of consciousness

Pulse

Color of skin

Capillary blanch test

Identity exsanguinating

hemorrhage

SHOCK

“Principle problem is poor oxygen delivery.”

Shock should be recognized before B.P. figure is available. Cool, pale skin, sweating

peripheries (Poor blood flow in skin)

Anxiety, confusion & restlessness (Poor blood flow in brain)

Oliguria after catheterization ( Poor blood flow in kidneys)

After recognition of shock Initiate 2 I/V catheter

Blood for examination

Initiate ringer lactate and blood replacement

Pneumatic antishock garment

E.C.G. monitor

Urinary and nasogastric catheter

Restore oxygen delivery Immediate intervention

Stop external bleeding by local pressure

For extremity bleeding compression bandage

Elevate with traction

Difficult venous access If access cannot be gained within 5

minutes and patient is shocked, then further measures should be taken until access is gained

Sites for cannulation include: Cut-down in the antecubital fossa -

safest, most effective site Cut-down to the long saphenous vein

in the groin, rather than at the ankle, as intense vasospasm may prevent infusion

Percutaneous cannulation of the femoral vein - using the Seldinger technique

Percutaneous cannulation of neck veins using Seldinger technique

Intra-osseous infusion in a severely ill child

Disability- brief neurological

Level of consciousness using AVPU method A-alert V-Responds to vocal

stimuliP-Responds to painful

stimuli U-Unresponsive

The pupils for size, equality and reaction

Glasgow coma scale

GCS

Exposure

Patient should be fully exposed in the ATLS setting.

Clothes should be cut off, if necessary.

Every orifice, i.e. ear, eye, nostril, mouth, etc. should be looked at

All limbs palpated for fractures so that nothing is missed

Also, one should not forget to perform a log roll and look at the back

Secondary Survey

Head and face Assessment

Inspection Re-evaluate pupils Palpation Cranial nerve function

Management Maintain airway Hemorrhage control

Cervical spine/neck

Assessment Inspection Auscultation Palpation Lateral, cross table cervical x-ray

Management Inline immobilization of the cervical

spine

Chest

Assessment Inspection Percussion Auscultation Palpation

Management Pleural decompression ThoracocentesisPericardiocentesisChest X-ray

Abdomen

Assessment Inspection Percussion Auscultation Palpation

Management Peritoneal lavage Pneumatic antishock

garment

Perineal and rectal

Evaluate for

Anal sphincter tone

Rectal blood

Bowel well integrity

Prostate position

Blood on urinary meat us

Scrotol hemotoma

Back

Evaluate for

Bony of deformity

Evidence of

penetrating / blunt

trauma

HePriorities Unstable Stable Highest 1. Dislocations

2. Vascular injuries requiring repair 3. Open fracture

4. Unstable pelvic ring fracture5. Femur fracture 6. Unstable spinal fracture

7. Other wounds . 8. Unstable spinal fractures

Lowest 9. Intraarticular fractures 10. Other long bone injuries11.Deep hand injuries

Musculoskeletal Injury

Extremities

Assessment Inspection-

contusion/deformity Palpation – tenderness/

crepitation

Management Splinting for fractures Pneumatic antishock

garment Relief of pain Tetanus injection

Neurological Evaluation

Assessment

Sensorimotor evaluation

Paralysis

ParesisManagement

Immobilization of entire patient

Definitive care

Inter hospital triage

criteria help determine

the level, pace and

intensity of initial

management

Outline rationale for

patient transfer

Re-evaluate the patient

Re-evaluate

continuously – new

sign/symptoms

Monitor vitals sign and

urinary output

Records and legal consideration

RecordsRecord keeping Reporting

chronologically

Consent for treatment Consent In life-threatening

emergencies- treatment first

Forensic evidence Overcoming poverty is not a task of charity, it is an act of justice

Thank you