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ADVANCE TRAUMA LIFE SUPPORT Jorge M. Concepcion, MD, FPCS Training Officer Department of Surgery The Medical City ACCIDENTS ? INJURIES? OBJECTIVES To discuss the concepts in ATLS. To provide the correct sequence of priorities in assessing multiply injured patient. To introduce the principles in definitive trauma care INJURY (WHO definition) -a bodily lesion resulting from exposure to energy Mechanical Thermal Radiation Electrical Chemical interacting with the body in the amounts that exceed the limits of physiologic tolerance. INJURIES “NOT ACCIDENTS” PREDICTABLE PREVENTABLE Not random events but occur in predictable patterns PREVENTION TRADITIONAL: HISTORY OF ILLNESS COMPLETE P.E. INITIAL IMPRESSION DIFFERENTIAL DIAGNOSIS DIAGNOSTIC TEST FINAL DIAGNOSIS TREATMENT TRAUMA MANAGEMENT RECOGNITION OF INJURY (P.E.) TREATMENT TRAUMA CONCEPTS: 1. TREAT THE GREATEST THREAT TO LIFE. 2. LACK OF DEFINITIVE DIAGNOSIS SHOULD NOT IMPEDE THE APPLICATION OF AN INDICATED TREATMENT. 3. DETAILED HISTORY IS NOT ESSENTIAL TO BEGIN THE EVALUATION OF AN ACUTELY INJURED PATIENT. APPROACH TO SEVERELY INJURED PATIENT 1. PRIMARY SURVEY 2. RESUSCITATION 3. SECONDARY SURVEY 4. DEFINITIVE MANAGEMENT 5. TERTIARY SURVEY REASSESSMENT PRIMARY SURVEY A - AIRWAY & C-SPINE CONTROL B - BREATHING C - CIRCULATION – HEMORRHAGE CONTROL D - DISABILITY (NEURO EXAM) E - EXPOSURE / ENVIRONMENT AIRWAY GUARANTEE PATENCY CLINICAL “WHAT IS YOUR NAME?” INTUBATE GCS 8 OR LESS OBSTRUCTED AIRWAY HEMORRHAGIC SHOCK COMBATIVE PATIENT AIRWAY RISK FACTORS I nstability (hemodynamic) N eck hematoma/trauma T rauma to the face (maxillofacial) U nresponsive (GCS < 8) B leeding from oropharynx A pnea T hermal inhalational injury E mesis/epistaxis/hemoptysis AIRWAY MAINTENANCE MEASURES Finger sweep Chin lift Jaw thrust Oro/nasopharyngeal airway Laryngeal mask airway Needle cricothyroidotomy DEFINITIVE AIRWAY CONTROL Intubation – Orotracheal – Nasotracheal Surgical airway – Cricothyroidotomy – Tracheostomy THINGS TO CONSIDER TIMING – don’t delay EQUIPMENT – scope, suction, suppplies ANESTHEZISE MONITOR WEAR PROTECTION OXYGENATE REINFORCEMENT – ask for help KEEP NECK PROTECTED C-SPINE CONTROL ALL PATIENTS WITH BLUNT TRAUMA – PRESUME TO HAVE C-SPINE INSTABILITY IMMOBILIZATION OF C-SPINE IS A PRIORITY C-SPINE CLEARANCE IS NOT A PRIORITY C-SPINE CONTROL IN-LINE STABILIZATION CERVICAL COLLAR C-COLLAR SHOULD NOT INTERFERE WITH CLINICAL EXAM OF THE NECK INTUBATION – REMOVE THE COLLAR AND DO IN-LINE STABILIZATION WHAT’S WRONG? BREATHING GUARANTEE ADEQUATE OXYGENATION AND VENTILATION GIVE SUPPLEMENTAL OXYGEN VENTILATION (LUNGS, CHEST WALL & DIAPHGRAM) ASSESS RESPIRATORY EFFORT, BREATH SOUNDS & OXYGEN DELIVERY Inspection Palpation Percussion Auscultation Objective Signs OXYGENATION Oxygen delivery Nasal cannula Face mask Face mask w/ reservoir L/min. 1 2 4 6 5-6 6-7 7-8 6 8 10 Approx. FiO2 0.24 0.28 0.35 0.42 0.40 0.50 0.60 0.60 0.80 1.00 MANAGEMENT Ventilation – Mouth to pocket face mask – Bag-valve-mask ( 2 person technique) Pleural Decompression – Needle thoracentesis – Closed-tube thoracostomy – Three-sided dressing CIRCULATION ASSURE ADEQUATE OXYGEN DELIVERY AND CONTROL BLEEDING ASSESS VITAL SIGNS CONTROL BLEEDING DIRECT PRESSURE REDUCTION OF FRACTURES IN LONG BONES AND PELVIS RECOGNITION OF SHOCK Tachycardia Cutaneous vasoconstriction Hypotension Narrowed pulse pressure ETIOLOGY OF SHOCK Hemorrhagic Nonhemorrhagic – Cardiac compressive tension pneumothorax cardiac tamponade – Cardiogenic – Neurogenic – Septic CLASSES OF HEMORRHAGE Class I Class II Class III Class IV Blood Loss (ml) Up to 750 750-1500 1500-2000 >2000 Blood Loss (% blood volume) Up to 15% 15-30% 30-40% >40% <100 >100 >120 >140 Blood Pressure normal normal decreased decreased Pulse Pressure normal or decreased decreased decreased decreased 14-20 20-30 30-40 >35 >30 20-30 5-15 negligible Slightly anxious Mildly anxious Anxious, confused Confused, lethargic Pulse Rate Respiratory Rate Urine Output (mL/hr) CNS/mental status CLASSES OF HEMORRHAGE 70 kg male with gunshot wound in the RUQ Vital signs: – BP 80/40 – HR 116/min – RR 22/min Class III hemorrhage EBL= 1470 mL – 70 kg x 7% x 30% INITIAL MANAGEMENT Recognize shock Stop the bleeding! Replace effective circulating volume Restore tissue perfusion FLUID THERAPY Warmed crystalloid solution Rapid fluid bolus – Adult – Child 2 liters 20 mL/kg “3 for 1 rule” Monitor response to therapy ELECTROLYTES 140 109 4 21 Size of needle in relation to a flow of 1 liter IVF Size (gauge) Time 18 12 min. 16 9 min. 14 7 min. RESPONSE TO FLUID RESUSCITATION Rapid response Transient response Minimal or no response RESPONSE TO FLUID RESUSCITATION Rapid Response Transient Response No response Vital Signs Return to normal Transient improvement Remain abnormal Estimated blood loss Minimal (10-20%) Moderate and ongoing (20-40%) Severe (>40%) Need for more fluids Low High High Need for blood Low Moderate to high Immediate Blood preparation Type and crossmatch Type specific Emergency blood release Need for surgery Possibly Likely Highly likely Early presence of surgeon Yes Yes Yes CIRCULATION Hypovolemia most common cause of shock Recognition of its presence 1st step Control of bleeding Restoration of intravascular volume Monitor patient’s response DISABILITY ASSESS GCS, PULSES, SENSORY AND MOTOR FUNCTIONS GCS ? BEST MOTOR RESPONSE – 6 BEST VERBAL RESPONSE – 5 EYE OPENING – 4 V=? M=4 E=3 3 - 15 GCS = 7 V = M(0.5) + E(0.4) V = 4 (0.5) = 2 + 3 (0.4) = 1.2 V = 2 + 1.2 = 3.2 V=3 M=4 E=3 GCS = 10 EXPOSURE AND ENVIRONMENTAL CONTROL UNDRESS ( CUT CLOTHING ) KEEP PATIENT WARM LOGROLL OFTEN MISSED INJURIES AXILLA PERINEUM BACK SECONDARY SURVEY HISTORY A - ALLERGIES M - MEDICATIONS P – PAST ILLNESSES L – LAST MEAL E – EVENTS PRECEEDING THE INCIDENT PHYSICAL EXAMINATION DETAILED, METICULOUS HEAD TO TOE EXAM FINGER AND TUBES IN ALL ORIFICES LOOK, LISTEN, FEEL EVERYWHERE DEFINITIVE MANAGEMENT TERTIARY SURVEY DEFINITIVE MANAGEMENT PENETRATING NECK PENETRATING CHEST BLUNT CHEST PENETRATING ABDOMEN BLUNT ABDOMEN EXTREMITIES DO’s PRIMUM NON NOCERE SPLINT PATIENTS WHERE THEY LIE COMFORT THE PATIENT ALLEVIATE PAIN HONE YOUR SKILLS ASK FOR HELP DON’TS PANIC INSERT NGT IN PATIENT WITH SUSPECTED FACIAL FRACTURE REMOVE IMPALED OBJECTS FORGET TO WARM THE PATIENT (ESP. CHILDREN) INSERT A FOLEY CATHETER IN PATIENTS SUSPECTED OF URETHRAL INJURY OVERLOOK THE PERINEUM, BACK AND AXILLA Thank you