Download ATLS - Trauma Overview

TRAUMA OVERVIEW
Mark E. Armstrong, M.D.
Overview
1. Preparation
2. Triage
3. Primary Survey
4. Resuscitation
5. Secondary Survey
6. Continued postresuscitation monitoring
and re-evaluation
7. Definitive care
Preparation
Prehospital
 Notify receiving hospital


Closest appropriate facility
Report pertinent information
Inhospital



Warmed IV solutions
Ancillary departments notified
Equipment made readily available

Hospital personnel protection
Primary Survey
Airway
Breathing
Circulation
Disability: Neurologic Evaluation
Exposure/Environmental Control
Primary Survey
Airway
Patency
Foreign bodies
Facial Fractures
Protect C-spine
Primary Survey
Breathing
 Patency does not equal adequate ventilation
 Expose chest
 Auscultate
 Conditions that may acutely impair ventilation
Tension pneumothorax
 Massive hemothorax
 Flail chest
 Rib fractures
 Open pneumo
 Pulmonary contusion
Primary Survey
Circulation
Hemorrhage control
Two Key Elements
1. Level of Consciousness
-AVPU
-Glasgow Coma Score
2. Pulse
Bleeding
Control
No hemostats
Consider occult sources
Primary Survey
Disability
AVPU
Glasgow Coma
Verbal Response
Oriented
Confused
Inappropriate words
Incomprehensible sounds
None
Eye Opening
Spontaneous
To speech
To pain
None
4
3
2
1
Motor response
5
4
3
2
1
Obeys
Localizes
Withdraws
Decortication
Decerebration
None
6
5
4
3
2
1
Primary Survey
Exposure
Remove all clothes
Cover to prevent hypothermia
Resuscitation
Airway
 Oral
 Nasal- do not put in someone with facial
trauma
 Endotracheal
 Surgical
Breathing
 Supply O2
 Ventilate alveoli
Resuscitation
Circulation







Establish 2 large bore IVs
Draw blood
Vigorous IV therapy
ECG monitoring
Avoid hypothermia
Evaluate PEA
Other dysrhythmias
Hemorrhage classification
Class
% blood
loss
10 – 19
(750 cc)
Heart rate
Blood
pressure
II
20 – 29
(1250)
>100
Slightly
III
30 – 39
(2000)
>120
IV
>40
>140
I
Pulse
pressure
Resp rate
Capillary
refill
Normal
Urine
output
Other
Mortality
Oliguria
Acidosis
25%
Delayed
(>30)
Very
Delayed
Anuria
60%
Resuscitation
Catheters
 Urinary
 Rectal first
 Check for other signs of urethral injury
 Gastric
 Oral v.s. nasal placement
NGT Intracranial
Resuscitation
Monitoring




ABG’s
Pulse oximetery
Blood pressure
ECG
Roentgenograms
Should not delay resuscitation
AP pelvis
AP chest
Lateral C-spine
Odontoid, AP C-spine
Other Imaging
FAST scan
Focused Assessment Sonography in Trauma
Ultrasound
1.
2.
3.
4.
Pericardial sac (epigastric area)
Hepatorenal fossa
Splenorenal fossa
Pelvis or Pouch of Douglas (bladder)
Secondary Survey
Head-to toe evaluation
 Vital sign evaluation
 Detailed neuro exam if not done in primary
survey
 Special procedures
“Tubes and fingers in every orifice”
Secondary Survey
History
A
M
P
L
E
Allergies
Medications
Past illnesses
Last meal
Events related to injury
1.Blunt
2.Penetrating
3.Burns
4.Hazardous Environment
Secondary Survey
History
A
M
P
L
E
Allergies
Medications
Past illnesses
Last meal
Events related to injury
1.Blunt
2.Penetrating
3.Burns
4.Hazardous Environment
Secondary Survey (PE)
Head
Scalp
Eyes
Nose
Mouth
Bite occlusion
Secondary Survey (PE)
Head
PITFALLS
Hyphema
Optic nerve injury
Lens dislocation
Head injury
Posterior scalp laceration
Secondary Survey (PE)
Maxillofacial
Midline facial fractures
Bite occlusion
Bleeding
Fracture repair can wait
Midface Fractures
LaFort
I: Maxilla only transversely above the
alveolar ridge
Most common isolated
II (pyramidal): Through nasal bone or
nasal bone disarticulation with frontal
bone
Most common when associated with other fractures
III (dislocated face): Through nasal bone,
across floor of orbit, through lateral wall
of orbit, zygomatic arch Rare
Secondary Survey (PE)
Maxillofacial
PITFALLS
Pending airway obstruction
Changes in airway status
Cervical spine injury
Exsanguinating midface fracture
Lacrimal duct lacerations
Facial nerve injuries
Secondary Survey (PE)
C-spine and neck
Must be immobilized
Inspection
Palpation
Auscultation (carotids)
Secondary Survey (PE)
C-spine and neck
PITFALLS
C-spine injury
Esophageal injury
Tracheal or laryngeal injury
Carotid injury (blunt or penetrating)
Secondary Survey (PE)
Chest
Visual evaluation (ant & post)
Palpate rib cage
Sternal pressure
Auscultation (heart & lungs)
Chest xray
Secondary Survey (PE)
Chest
PITFALLS
Tension pneumothorax
Open chest wound
Flail chest
Cardiac tamponade
Aortic rupture (widened mediastinum)
Pneumothorax
Tension Pneumothorax
Secondary Survey (PE)
Abdomen
Frequently repeated exams
Inspection
Palpation
Normal initial exam does not rule out
injury
Peritoneal lavage v.s. CT scan v.s. U/S
(FAST)
Secondary Survey (PE)
Abdomen
PITFALLS
Liver or splenic flexure
Deceleration injuries
Hollow viscus, Lumbar spine
Pancreatic injury
Major intraabdominal vascular injury
Renal injury
Pelvic fractures
Secondary Survey (PE)
Perineum/Rectum/Vagina
Contusions,Hematomas, Lacerations
Urethral bleeding
Rectal blood
High riding prostate
Sphincter tone
Vaginal vault injuries (pelvic fractures)
Secondary Survey (PE)
Perineum/Rectum/Vagina
PITFALLS
Urethral injury
Rectal injury
Bladder injury
Vaginal injury
Retrograde urethrogram
Secondary Survey (PE)
Musculoskeletal
Contusion
Deformity
Palpation
Pelvic pressure and compression
Vascular exam
Neurologic exam
Secondary Survey (PE)
Musculoskeletal
PITFALLS
SPINE FRACTURES
Fractures with vascular compromise
Pelvic fractures
Digital fractures
Secondary Survey (PE)
Neurologic
Immobilization of entire patient
Reevaluate GCS
Cranial nerve exam
Motor exam
Sensory exam
Monitor frequently for changes in neuro
status
Assess O2 delivery if changes noted
Early neurosurgical consultation
Secondary Survey (PE)
Neurologic
PITFALLS
Increased intracranial pressure
Subdural hematoma
Epidural hematoma
Depressed skull fracture
Spine injury
Beware of unconscious patient
Subdural Hematoma
Epidural Hematoma
Aftercare
Continuous reevaluation
Definitive care