emergency management in stepwise approach according to ATLS guideline

1. Major Trauma Emergency
approach
Moderator: DR.RAM NEUPANE

2. A 22 year old female brought in ER within 20
minutes of alleged history of RTA hit by truck.the
patient was unconciouness, has feeble pulse,
and swallow breath,on examination B.P = 80/60,
HR =120/min.
1.what is your emergency response.
2. What is primary and secondary survey.

3. Emergency Response(PT –PRACS-ACD)
1. Preparation
2. Triage
3. Primary survey (ABCDEs)
4. Resuscitation
5. Adjuncts to primary survey and resuscitation

4. 6. Consideration of the need for patient transfer
7. Secondary survey (head-to-toe evaluation and
patient history)
8. Adjuncts to the secondary survey
9. Continued post resuscitation monitoring and
Reevaluation
10. Definitive care

5. preparation
• Prehospital phase
• Hospital Phase

6. TRIAGE

8. Primary survey and resuscitation
1. A
2. B
3. C
4. D
5. E

9. Airway and Resuscitation
• Clear the upper airway by direct visualization
• Suction and removal of any foreign bodies
• Insertion of an oropharyngeal or
nasopharyngeal
• jaw-thrust manoeuvre
– nasopharyngeal airway can be hazardous in
patients with a fracture of the cribriform plate
– Chin lift is not recommended additional
movement of the cervical spine.

11. • Consider c spine in all major trauma patients
OR
– Neck pain or neurological symptoms
– Altered level of consciousness
– Significant blunt injury above the level of the
clavicles
– Multiple system trauma
– Unable to active flexion of neck

12. Manual in line stabilisation of
neck(MILS)

16. Bag Valve Mask
• Difficult BVM = MOANS
– mask
– Obese/obstruction
– Aged/eldery
– No teeth
– Sleep Apnea / Snoring/stifness

18. INDICATIONS FOR INTUBATION IN
MAJOR TRAUMA
• Faciltate oxygenation and ventilation
• Airway protection
• prevent impending, or overcome, airway
obstruction
• neuroprotection (e.g. targeted PCO2
management)

19. Difficult intubation = LEMON
• Look externally
• Evaluate 3-3-2 rule
• Mallampati score
• Obstruction
• Neck Mobility

24. Position the patient with ear-to-sternal notch
alignment (also known as the HELP aka Head
Elevated Laryngoscopy Positioning)

25. Rapid sequence intubation(RSI)
1. Plan
2. Preparation (drugs, equipment, people, place)
3. Protect the cervical spine
4. Positioning (some do this after paralysis and induction)
5. Preoxygenation
6. Pretreatment (optional; e.g. atropine, fentanyl and
lignocaine)
7. Paralysis and Induction
8. Placement with proof
9. Postintubation management

28. CORMACK-LEHANE CLASSIFICATION

29. Practicle tips
1. cricoid pressure is controversial – it is contra-
indicated in laryngeal trauma and may worsen
laryngeal visualisation or cause airway
obstruction
2. suspected base of skull fracture is contra-
indication to nasopharyngeal airway insertion
3. endotracheal intubation via the oral route may
be impossible due to mechanical trismus or
airway trauma

30. 4.Emergency surgical airways are more difficult, due
to local swelling and deformity
5.Suxamethonium is contra-indicated >48 hours
after burns or spinal injury (due to risk of
hyperkalaemia)
6.Haemodynamic instability may occur post-
intubationa vagal response in neurogenic shock
may result in severe bradycardia or asystole (treat
with atropine)
7.Hypotension may result from induction agents,
haemorrhagic shock or neurogenic shock

34. Breathing and ventilation
• Do not confuse airway problem for ventilation
problem.
• Patent airway does not equal adequate
ventilation.
• Need good gas exchange –
• Oxygen in – CO2 out

35. Rapid assessment and resuscitation:
• RR
• SPO2
• TRACHEA
• CHEST EXPANSION
• PERCUSSION
• AUSCULTATION

36. Breathing and ventilation
• The patient’s neck and chest should be exposed
to adequately assess jugular venous distention,
position of the trachea, and chest wall excursion
• inspection and palpation can detect injuries to
the chest wall that may compromise ventilation.
• Percussion of the thorax can also identify
abnormalities,but during a noisy resuscitation
this may be difficult to produce unreliable results.
• Auscultation

37. Severe life threatening condition
• Tension pnuemothorax
• Massive hemothorax
• Open pneumothorax
• Flail chest

38. Tension pnuemothorax(clinical
diagnosis)
• Tachypnoea
• Tracheal deviation away from the affected
hemithorax,
• Diminished ipsilateral breath sounds,
diminished compliance,
• Oxygen desaturation and hypotension.

39. management
• Temporary : needle (no.14-16) at second
intercostal space ,midclavicular line
• ICD : fifth intercostal space ,midaxillary line

40. Massive hemothorax
• 32 Fr or larger intercostal catheter, positioned
in the fifth or sixth intercostal space in the
mid-axillary line on the affected side.
• The use of suction (20 cm H2O) facilitates
drainage.
• Bleeding is usually self-limiting following
drainage.
• Blood transfusion

41. Indication of Thoracotomy
• Drainage of more than 1500 mL following
initial intercostal catheter insertion (massive
hemothorax) or a loss of more than 200 mL/h
for more than 2 h

42. Flail chest
• paradoxical movement of the associated
unanchored chest wall segment.
• Clinical features of a flail segment may also be
masked by positive-pressure ventilation,
which splints the chest wall internally. Elderly
patients have a less compliant chest wall and
are at greater risk of developing a flail
segment.

43. • maintaining oxygenation, ventilation and
euvolaemia.
• Adequate analgesia with intercostal nerve
blocks or epidural analgesia.
• Hypoxia may be managed with non-invasive
ventilation.
• Mechanical ventilation is required if non-
invasive ventilation is contraindicated or
unsuccessful.

44. CARDIAC TAMPONADE
• common in penetrating thoracic trauma than
blunt trauma
• As little as 75 mL of blood.

45. Recognition
• Anxiety and agitation
• Obstructive shock — tachycardia, hypotension,
cool peripheries
• Beck’s triad: muffled heart sounds, hypotension
and distended neck veins —!
• Pulsus paradoxus (drop in systolic blood pressure
>10 mmHg on inspiration)
• Very hard to differentiate clinically from tension
• EFAST exam leading to formal echocardiography

46. management
• High flow oxygen to maintain SpO2 target (e.g.
15L/min via non-rebreather mask)
• May transiently respond to fluid challenge
• Needle pericardiocentesis, preferably ultrasound
guided, may be lifesaving but may fail due to
clotted blood
• Pericardotomy is definitive treatment
• Emergency thoracotomy may be necessary in the
event of cardiac arrest

47. Open pneumothorax

48. Recognition
1. Open wound on chest wall
2. Anxiety and agitation
3. Respiratory distress
4. Tachycardia
5. Decreased chest movement ipsilaterally
6. Hyper-resonance ipsilaterally
7. Decreased breath sounds ipsilaterally
8. Bedside EFASTcan rapidly confirm
pneumothorax

49. management
1. High flow oxygen to maintain SpO2 target (e.g.
15L/min via nonrebreather mask)
2. Cover with occlusive 3-sided dressing to form a
‘flutter valve’ that allows the egress of air
through the wound but prevents ‘sucking in’.
3. Place formal catheter in separate intercostal
space
4. Will need formal exploration prior to closing

51. circulation
• Rapid and accurate assessment of an injured
patient’s hemodynamic status is essential.
• The elements of clinical observation that yield
important information within seconds
– level of consciousness
– skin color
– pulse

52. Pulse palpation as guide to BP

53. SOURCE OF HAEMORRHAGE
(SCALPeR)
It is convenient to consider injuries to 6 regions which may
account for major blood loss: “FIND the bleeding, STOP the
bleeding”
1. scalp and external sources (especially small children)
2. Chest
3. Abdomen
4. Long bones (especially femurs)
5. Pelvis
6. Retroperitoneum

56. Classificaton of stages of hemorragic
shock

57. approach to hemorrhage control:
1. Find the cause
2. Initial measures:
Direct pressure and elevation
Adrenaline soaked gauze, hemostatic dressings
3. Reduce and splint long bone and pelvic
fractures
4. Tourniquets

58. Invasive measures, such as:
1. Sutures
2. tamponade, by packing or foley catheter with
balloon inflated
3. tie off vessels
4. Cautery
5. interventional radiology
6. damage control surgery
7. Correct coagulopathy

59. Choice of fluid
• Replace that which is lost, at the rate at which
it is lost.
• commonest choice in the emergency situation
remains ‘isotonic’ 0.9% normal saline.

60. Fluid administration
• between 10 and 40 mL/kg (averaging 20
mL/kg) stat over minutes are recommended.
• Cannulae sized 16 and 20 gauge may achieve
flow rates of 1 L over 5 and 10 minutes,
respectively .
• In the emergency situation, hand-pump
infusion lines or gravity or pressure bag-driven
infusion will deliver volumes effectively.

61. • The use of the antifibrinolytic agent
tranexamic acid has been shown to decrease
mortality in trauma patients at risk of major
bleeding.

65. Transfusion reactions and problems
• TRALI / TACO
• Acute / delayed haemolytic transfusion reaction
• Non-febrile haemolytic transfusion reaction
• Bacterial / viral infection
• Anaphylaxis if IgA deficient
• GVHD
• Storage lesion effects

67. DAMAGE CONTROL RESUSCITATION
• Damage control resuscitation (DCR) is a
systematic approach to the management of the
trauma patient with severe injuries that starts in
the emergency room and continues through the
operating room and the intensive care unit (ICU)
• DCR aims to maintain circulating volume, control
haemorrhage and correct the ‘lethal triad’ of
coagulopathy, acidosis and hypothermia until
definitive intervention is appropriate

68. DCR has 3 components:
• Permissive hypotension (aka minimal
normotension) (this is controversial)
• Early haemostatic
• Resuscitation
• Damage control surgery

69. Disability/neuro evaluation
• Patient’s level of consciousness,
• Pupillary size and reaction
• Lateralizing signs
• Spinal cord injury level.

70. Brief neurologic examination
A – Alert
V – Responds to Vocal stimuli
P – Responds to Painful stimuli
U – Unresponsive
– Pupillary size & reaction ➣ More detailed
evaluation - during the secondary survey
– Spinal cord injury level

72. Hypoglycemia,
alcohol,narcotics,drug
alter the patient’s level of consciousness if these
factors are excluded, changes in the level of
consciousness should be considered to be of
traumatic central nervous system origin until
proven otherwise.
.

73. Stage of brain herniation
Early –
– Ipsilateral pupillary dilation
– Progressive decrease in mental status
– Respiratory pattern changes (Chyne-Strokes)

74. Stage of brain herniation
Progressing
– Decreasing level of consciousness –
– Hyperventilation - Contralateral hemiplegia -
Decerebrate posturing - Pupillary constriction

75. Stage of brain herniation
• Advanced –
– Biliateral decerebrate rigidity (uncal herniation) –
– Irregular respiration –
– Flaccidity (central herniation) - Death

76. Exposure
HYPOTHERMIA PREVENTION AND TREATMENT
Prevent and treat hypothermia with the following:
– Aggressive resuscitation with blood products
– Use warmed fluids (e.g. Level 1 Fluid Warmer)
– Bair Hugger or warm blankets
– Minimise exposure
– Increase ambient temperature
– Continuous temperature monitoring

77. To prevent lethal triad
LETHAL TRIAD AND ACUTE COAGULOPATHY OF TRAUMA/
SHOCK
The lethal triad is:
– Hypothermia
– Coagulopathy
– Acidosis
These three factors both cause, and contribute to,
acute coagulopathy of trauma/ shock (ACoTS) which
leads to, and result from, major hemorrhage.

78. Secondary survey

79. Secondary survey
• Head to toe examination
• if awake take AMPLE history
• exclude (FATAL TRAUMA):

80. Secondary survey

81. Secondary survey

82. Abdomen
• Abdominal pain, localized tenderness (LUQ)
• Possible hemorrhagic shock
• CT abdomen with IV contrast is the
investigation of choice in visceral solid organ
with hemoperitenum

83. Splenic injury

84. • Grades I to III injury : hemodynamically stable
can be managed non-operatively
• Grade IV or V Injuries involving the hilum or
avulsion often require surgery
• hemodynamic instability is the only real
contra-indication to conservative
management

85. Angiography with embolization should be
considered if:
— grade > III
— moderate hemoperitoneum is present
— evidence of ongoing bleeding
Patients with functional asplenism will need
immunisations and follow up similar to post-
splenectomy patients

86. Hepatic injury
American Association for Surgery of Trauma
Organ Injury Scale based on:
– haematoma size (% surface area)
– laceration size (parenchymal depth)
– vessel involvement
– integrity of liver
– vascular status

87. Hepatic injury

88. MANAGEMENT
Hemodynamically stable injuries can be
managed non-operatively
Angiography with embolization should be
considered if evidence of ongoing bleeding

89. Renal injury

90. Treatment modality
• Grades I to III, and most Grade IV injuries can be
managed conservatively, as they tend to heal
spontaneously
• Surgical repair is needed for urinary extravasation
or if ongoing bleeding or hemodynamic instability
due to renal injury
• interventional radiology to embolise bleeding
vessels or to stent dissected renal arteries
• Grade V injuries (avulsed kidneys) need operative
intervention and often require nephrectomy

91. Vertebrae examination
• back: deformity, haematoma, open # (when
logged rolled)
• perineal: anal sensation and tone
• PR examination

92. c- Spine injury

94. Pelvic fracture

98. Adjunct to secondary survey
• Missed injuries can be minimized by
maintaining a high index of suspicion and
providing continuous monitoring of the
patient’s status.
• Specialized diagnostic tests may be
performed during the secondary survey to
identify specific injuries.
• Trauma series, CT scan, urography and
angiography,endoscopy

99. • Definative care

100. • Thank you