Advanced Trauma Life Support Sushil Paudel , MD Consultant Orthopedics
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