Introduction To ATLS

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Information about Introduction To ATLS
Health & Medicine

Published on December 28, 2008

Author: narenthorn

Source: slideshare.net

Description

Introduction to ATLS for medical students

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

A ● Airway – Patency / Obstruction – Severe head injury -> Definitive airway

Airway: Patency ● Maxillofacial trauma ● Neck trauma ● Laryngeal trauma (Hoarseness, Subcutaneous emphysema, Palpable fracture)

A ● 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

A ● 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

C ● 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 ● “3-for-1” rule – 1 cc blood loss = 3 cc crystalloid replacement

Response to fluid resuscitation ● Rapid response – <20% blood loss – Cross-match, Surgical consultation ● Transient response – 20-40% blood loss – On going blood loss – Blood transfusion, Surgical intervention

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

D ● Neurological status – Level of consciousness (AVPU / GCS) – Pupil size & Light reaction – Lateralizing sign – Spinal cord injury level

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

D ● Factors affect level of consciousness – Oxygenation ( ABC ) – Ventilation ( ABC ) – Perfusion ( ABC ) – Hypoglycemia – Drugs / Alcohol

D ● Reevaluation

E ● Uncloth patient ● Logroll patient ● Prevent hypothermia – Warm blanket – Warm IV fluid

E ● 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 ● Relative contraindications – Previous abdominal operations – Morbid obesity – Advanced cirrhosis – Coagulopathy

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 ● Normocapnia – Hyperventilation -> CO2 -> Cerebral vasoconstriction -> CPP

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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