Introduction To ATLS

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Introduction to ATLS for medical students

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Introduction To ATLS

  1. 1. Introduction to Advanced Trauma Life Support ATLS
  2. 2. Objectives ● Concepts of primary & secondary survey ● Priorities & Life threatening conditions ● Clinical & Surgical skills
  3. 3. Basic knowledge ● Rapid assessment ● Resuscitate & Stabilize (Prioritize) ● Patient's needs & facility's capabilities ● Appropriate transfer ● Optimum care
  4. 4. Initial Assessment & Management ● Preparation (Prehospital - Hospital) ● Triage ● Primary survey (ABCDE) ● Resuscitation ● Adjuncts to primary survey & resuscitation ● ->
  5. 5. Initial Assessment & Management ● Secondary survey ● Adjuncts to the secondary survey ● Postresuscitation monitoring ● Definitive care
  6. 6. Primary Survey ● Treatment priorities ● A: Airway maintenance + C-spine protection ● B: Breathing & Ventilation ● C: Circulation & Hemorrhage control ● D: Disability – Neuro ● E: Exposure / Environment control
  7. 7. A ● Airway – Patency / Obstruction – Severe head injury -> Definitive airway
  8. 8. Airway: Patency ● Maxillofacial trauma ● Neck trauma ● Laryngeal trauma (Hoarseness, Subcutaneous emphysema, Palpable fracture)
  9. 9. A ● C-spine protection – Multiple system trauma – Altered level of consciousness – Blunt injury above clavicle – Manual in-line stabilization
  10. 10. A: Nexus ● Midline cervical tenderness ● Altered level of consciousness ● Evidence of intoxication ● Neurologic abnormality ● Presence of painful distracting injury
  11. 11. A ● Trauma patient is dynamic ● Repeated assessment
  12. 12. A: Resuscitation ● Jaw thust / Chin lift / Head tilt ● Naso / Oropharyngeal airway ● Combitube, LMA ● Definitive airway (Cuff in trachea) – Oro / Naso tracheal intubation – Surgical cricothyroidotomy
  13. 13. Endotracheal intubation ● Indication – Provide patent airway – Deliver supplemental oxygen – Support ventilation – Prevent aspiration
  14. 14. Endotracheal intubation ● Decision – Apnea (orotracheal) – Cannot maintain patent airway – Protect aspiration / vomitus – Impending compromise airway – Closed head injury required assisted ventilation – Inadequate oxygenation
  15. 15. Surgical Airway ● Cricothyroidotomy / Tracheostomy ● Indication – Unable to intubate (severe maxillofacial injury, failed intubation) ● Contraindication – Airway transection
  16. 16. B: Breathing
  17. 17. B: Life Threatening Conditions ● Tension pneumothorax ● Flail chest with pulmonary contusion ● Massive Hemothorax ● Open pneumothorax ● Cardiac tamponade
  18. 18. Thoracic Trauma: Primary survey ● Looking, Palpation, Percussion, Listening – Tension pneumothorax – Open pneumothorax (sucking chest wound) – Flail chest – Massive hemothorax – Cardiac tamponade
  19. 19. 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
  20. 20. Thoracic Trauma: Primary survey ● Open pneumothorax (sucking chest wound) – > 2/3 of tracheal diameter – 3 sided dressing – Chest tube insertion
  21. 21. Open Chest Wound: 3-Sided Dressing
  22. 22. Thoracic Trauma: Primary survey ● Flail chest – >2 ribs fractures in 2 or more places – Paradoxical chest wall movement – Adequate ventilation – Reexpand lungs: Intubation
  23. 23. 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
  24. 24. Thoracic Trauma: Primary survey ● Cardiac tamponade – Penetrating injury – Beck's triad – DDx from Tension pneumothorax – FAST / Echo – Pericardiocentesis
  25. 25. B: Resuscitation ● Supplemental oxygen ● Tension pneumothorax decompression
  26. 26. C: Circulation & Hemorrhage control ● Circulation – Blood volume & Cardiac output ● Level of consciousness ● Skin color ● Pulse
  27. 27. C ● Hemorrhage control - External hemorrhage – Manual pressure – Splinting – Tourniquet – Hemostats
  28. 28. C: Resuscitation ● 2 large-caliber IV catheter ● “warm” NSS, RLS ● Blood ● Control bleeding – Direct pressure – Operative control ● Vasopressors
  29. 29. Shock ● Inadequate tissue perfusion / oxygenation ● Hemorrhagic / Non-hemorrhagic
  30. 30. Hemorrhagic shock ● Most common cause of shock in trauma ● External vs Internal hemorrhage ● Blood volume = 7% of BW ● Rx: Volume replacement ● Shock Classification
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. Hemorrhagic shock classification ● Class IV – >40% blood loss – P >140 – BP decreased – PP decreased – RR > 35 – Urine output --- – Mental status: confused / lethargic
  35. 35. 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
  36. 36. 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
  37. 37. Response to fluid resuscitation ● No response – Immediate operative intervention
  38. 38. Non-hemorrhagic shock ● Cardiogenic shock ● Tension pneumothorax ● Neurogenic shock ● Septic shock
  39. 39. Cardiogenic shock ● Cardiac contusion ● Cardiac tamponade: “Beck's triad” – Tachycardia – Muffled heart sound – Distended neck vein ● Echo / FAST
  40. 40. Cardiac Tamponade ● Penetrating injury ● Beck's triad ● DDx from Tension pneumothorax ● FAST / Echo ● Rx: Pericardiocentesis
  41. 41. Tension pneumothorax ● One-way valve ● Respiratory distress ● Subcutaneous emphysema ● Absent breath sound ● Hyperresonance on percussion ● Tracheal shift ● Distended neck vein ● Rx: Needle / Tube thoracostomy
  42. 42. 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
  43. 43. D ● Neurological status – Level of consciousness (AVPU / GCS) – Pupil size & Light reaction – Lateralizing sign – Spinal cord injury level
  44. 44. D ● A: Alert ● V: Verbal command ● P: Painful stimuli ● U: Unresponsive
  45. 45. D ● Factors affect level of consciousness – Oxygenation ( ABC ) – Ventilation ( ABC ) – Perfusion ( ABC ) – Hypoglycemia – Drugs / Alcohol
  46. 46. D ● Reevaluation
  47. 47. E ● Uncloth patient ● Logroll patient ● Prevent hypothermia – Warm blanket – Warm IV fluid
  48. 48. E ● Rectal examination – Sphinctor tone – Position of prostate (high-riding?) = urethral injury – Gross blood (penetrating abdominal injury) – Pelvic fractures
  49. 49. Primary survey: Adjuncts ● Monitor ● Diagnosis
  50. 50. Primary survey: Adjuncts: Monitor ● EKG monitor ● Foley's catheter ● “Gastric” catheter ● Respiratory rate ● ABG ● Pulse oximetry
  51. 51. Primary survey: Adjuncts: Diagnosis ● CXR, Pelvis AP, Lateral C-spine ● DPL, FAST ● Should not interrupt resuscitation process
  52. 52. 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
  53. 53. Gastric tube ● Relieve gastric dilatation ● Decompress stomach before DPL ● Reduce risk of aspiration ● NG tube: contraindicated in basilar skull fracture
  54. 54. Secondary Survey ● Not begin until primary survey is completed ● History (AMPLE) ● Head-to-toe evaluation ● GCS ● X-rays
  55. 55. Secondary Survey: Adjuncts ● Specialized diagnostic tests (CT, US, scope) ● Should not be performed until hemodynamic stabilization
  56. 56. Secondary Survey ● History: AMPLE – A: Allergies – M: Medications – P: Past illnesses / Pregnancy – L: Last meal – E: Events
  57. 57. Secondary Survey ● Physical examination ● Head-to-toe examination
  58. 58. Thoracic Trauma: Secondary Survey ● Simple pneumothorax ● Hemothorax ● Pulmonary contusion ● Tracheobronchial tree injury ● Blunt cardiac injury ● Traumatic aortic disruption ● Traumatic diaphragmatic injury ● Mediastinal transvering wound
  59. 59. Abdominal Trauma
  60. 60. Abdominal Trauma ● External anatomy – Anterion – Flank – Back
  61. 61. Abdominal Trauma ● Internal anatomy – Peritoneal cavity – Pelvic cavity – Retroperitoneal space
  62. 62. Abdominal Trauma ● Mechanism of injury – Blunt – Penetrating
  63. 63. Abdominal Trauma: Assessment ● History ● Physical Exam – Inspection, Auscultation, Percussion, Palpation – Evaluation of penetrating wound – Pelvic stability – Penile, Perineal, Rectal exam – Vaginal, Gluteal exam
  64. 64. 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
  65. 65. Celiotomy: Indications (cont.) ● Penetrating trauma with Bleeding from stomach, rectum, GU ● Peritonitis ● Free air, retroperitoneal air, ruptured hemidiaphragm after blunt trauma ● Ruptured hollow viscus
  66. 66. Diagnostic Studies ● Diagnostic peritoneal lavage: DPL ● FAST ● CT scan ● Urethrography, Cystography, IVP
  67. 67. 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
  68. 68. Diagnostic Peritoneal Lavage:DPL ● Contraindications – Existing indication for celiotomy ● Relative contraindications – Previous abdominal operations – Morbid obesity – Advanced cirrhosis – Coagulopathy
  69. 69. 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
  70. 70. Head injury
  71. 71. Head Injury ● Classification – Mechanism (Blunt, Penetrating) – Severity (mild, moderate, severe) – Morphology (Skull fractures, Intracranial)
  72. 72. Head Injury: Severity ● Mild: GCS 13-15 ● Moderate: GCS 9-12 ● Severe: GCS 3-8
  73. 73. Head Injury: Morphology ● Skull fractures ● Intracranial – Epiduralhematoma – Subdural hematoma – Intracerebral hematoma – Diffuse brain injury
  74. 74. Skull fractures ● Cranium ● Maxillofacial ● Basilar skull fractures
  75. 75. Basilar skull fracture ● Raccoon's eyes ● Battle's sign ● CSF rhinorrhea / otorrhea
  76. 76. Epidural Hematoma ● Arterial origin (middle meningeal a.) ● CT: lenticular shape
  77. 77. Subdural Hematoma ● Venous origin ● CT: Crescent shape
  78. 78. Intracerebral Hematoma ● Brain laceration
  79. 79. Head Injury: Management ● Mild HI (GCS 13-15) – Observe – CT: ● Lost of conscious > 5 min ● Amnesia ● Severe headache ● Focal neurological deficit
  80. 80. Head Injury: Management ● Moderate HI (GCS 9-12) – CT brain – Admit observe neurosigns – F/U CT brain 12-24 h
  81. 81. Head Injury: Management ● Severe HI (GCS < 9) – Prompt diagnosis & treatment – Don't delay patient transfer to obtain CT scan
  82. 82. Monro-Kellie Doctrine
  83. 83. Brain resuscitation ● Maintain adequate – Cerebral Perfusion Pressure (CPP) – Oxygenation – Normocapnia
  84. 84. Cerebral Perfusion Pressure ● CPP = MAP – ICP – MAP = Mean Arterial Pressure – ICP = Intracranial Pressure
  85. 85. 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
  86. 86. Brain resuscitation ● Oxygenation – Oxygen supplement – Anticonvulsants ● Normocapnia – Hyperventilation -> CO2 -> Cerebral vasoconstriction -> CPP
  87. 87. Conclusions ● Initial Assessment (Primary survey, Secondary survey) ● Adjuncts ● Priority: Life threatening first ● Knowledge & Skills for specific conditions ● DOs & DON'Ts
  88. 88. Q?
  89. 89. http://www.slideshare.net/narenthorn/introduction-to-atls-presentation/
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