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Advanced trauma life support, management of a polytrauma patient
- 1. ATLS (Initial Assessment and Management) Dr. Lawrence Wambugu 02.02.2022
- 2. Objectives • Assess a patient’s condition rapidly and accurately. • Resuscitate and stabilize patients according to priority. • Determine whether a patient’s needs exceed the resources of a facility and/or the capability of a provider. • Arrange appropriately for a patient’s interhospital or intrahospital transfer. • Ensure that optimal care is provided and that the level of care does not deteriorate at any point during the evaluation, resuscitation, or transfer process.
- 3. ‘Golden Hour’ • To emphasize the urgency necessary for the successful treatment of the injured patient • The window of opportunity to have a positive impact on the morbidity and mortality of the patient • The time to identify life threatening injuries and institute life saving interventions. • The golden hour of care after injury is characterized by the need for rapid assessment and resuscitation
- 4. The Need
- 5. Distribution
- 7. • First peak occurs within seconds to minutes of injury (apnea, severe brain injury, rupture of heart/ great vessels) • The second peak occurs within minutes to several hours following injury (injuries associated with significant blood loss) • The third peak, which occurs several days to weeks after the initial injury (most often due to sepsis and multiple organ system dysfunctions)
- 8. Initial Assessment • Preparation • Triage • Primary survey (ABCDEs) with immediate resuscitation of patients with life- threatening injuries • Adjuncts to the primary survey and resuscitation • Consideration of the need for patient transfer • Secondary survey (head-to-toe evaluation and patient history) • Adjuncts to the secondary survey • Continued post-resuscitation monitoring and reevaluation • Definitive care
- 9. Preparation • Prehospital phase - set up to notify the receiving hospital before personnel transport the patient from the scene. • Hospital phase – include the following: • Trauma resuscitation area • Properly functioning airway equipment (laryngoscopes, ETT) • Warmed IV crystalloids • Protocol to summon additional medical assistance • Transfer agreements with verified trauma centers
- 10. Triage • Involves the sorting of patients based on the resources required for treatment and the resources that are actually available. • The order of treatment is based on the ABC priorities (airway with cervical spine protection, breathing, and circulation with hemorrhage control)
- 11. Primary Survey with Simultaneous Resuscitation • Patients are assessed, and their treatment priorities are established, based on their injuries, vital signs, and the injury mechanisms. • Airway maintenance with restriction of cervical spine motion • Breathing and ventilation • Circulation with hemorrhage control • Disability(assessment of neurologic status) • Exposure/Environmental control
- 12. Airway Maintenance with Restriction Of Cervical Spine Motion • Assess the airway to ascertain patency • Inspect for foreign bodies; identify facial, mandibular, and/or tracheal/laryngeal fractures and other injuries that can result in airway obstruction; • Suctioning to clear accumulated blood or secretions that may lead to or be causing airway obstruction. • Begin measures to establish a patent airway while restricting cervical spine motion. • Altered level of consciousness or a (GCS) score of 8 or lower usually require the placement of a definitive airway
- 13. Breathing and Ventilation • Ventilation requires adequate function of the lungs, chest wall, and diaphragm; therefore, clinicians must rapidly examine and evaluate each component. • Visual inspection and palpation can detect injuries to the chest wall that may be compromising ventilation • Inspect jugular venous distention, position of the trachea, and chest wall excursion • Perform auscultation to ensure gas flow in the lungs. • Use a pulse oximeter to monitor adequacy of hemoglobin oxygen saturation.
- 14. Circulation with Hemorrhage Control • Blood volume, cardiac output, and bleeding are major circulatory issues to consider • Rapid and accurate assessment of level of consciousness, skin perfusion, and pulse. • Identify the source of bleeding as external or internal. • External blood loss is managed by direct manual pressure on the wound or tourniquets • Major areas of internal hemorrhage are the chest, abdomen, retroperitoneum, pelvis, and long bones (examination and imaging)
- 15. • Management may include chest decompression, and application of a pelvic stabilizing device and/or extremity splints. • Definitive bleeding control is essential, along with appropriate replacement of intravascular volume (crystalloids). • Aggressive and continued volume resuscitation is not a substitute for definitive control of hemorrhage. • Identify the risk of coagulopathy which can be further potentiated by aggressive crystalloid resuscitation (role of preemptive tranexamic acid?)
- 16. Disability (Neurologic Evaluation) • Rapid neurologic evaluation establishes the patient’s level of consciousness and pupillary size and reaction; identifies the presence of lateralizing signs; and determines spinal cord injury level, if present. • GCS score • Hypoglycemia, alcohol, narcotics, and other drugs can also alter a patient’s level of consciousness.
- 17. Exposure and Environmental Control • Completely undress the patient, usually by cutting off his or her garments to facilitate a thorough examination and assessment. • Cover the patient with warm blankets or an external warming device • Warm intravenous fluids and maintain a warm environment
- 18. Adjuncts to the Primary Survey with Resuscitation • Electrocardiographic (ECG) monitoring (continuous) • Pulse Oximetry – monitoring oxygenation in injured patients. • Ventilatory rate, capnography, and ABG measurements to assess the adequacy of respirations and perfusion • Urinary and gastric catheters • Xray examinations (chest and pelvic xrays) and diagnostic studies (FAST, eFAST, DPL )
- 19. Consider Need for Patient Transfer • Frequently obtain sufficient information to determine the need to transfer the patient to another facility for definitive care. • It is important not to delay transfer to perform an in-depth diagnostic evaluation. • Only undertake testing that enhances the ability to resuscitate, stabilize, and ensure the patient’s safe transfer.
- 20. Special Populations • Pediatric patients • Pregnant women • Elderly • Obese patients • Athletes
- 21. Secondary Survey • The secondary survey does not begin until the primary survey (ABCDE) is completed, resuscitative efforts are under way, and improvement of the patient’s vital functions has been demonstrated. • Head-to-toe evaluation of the trauma patient—that is, a complete history and physical examination, including reassessment of all vital signs. • Minimizes the potential for missing an injury or failing to appreciate the significance of an injury • Must in no way interfere with the performance of the primary survey
- 22. History • AMPLE history • Allergies • Medications currently used • Past illnesses/Pregnancy • Last meal • Events/Environment related to the injury • Every complete medical assessment includes a history of the mechanism of injury
- 24. Physical Examination • Follows the sequence of head, maxillofacial structures, cervical spine and neck, chest, abdomen and pelvis, perineum/rectum/vagina, musculoskeletal system, and neurological system.
- 25. Adjuncts to the Secondary Survey • Specialized diagnostic tests during the secondary survey to identify specific injuries • Include additional x-ray examinations of the spine and extremities; CT scans of the head, chest, abdomen, and spine; contrast urography and angiography; transesophageal ultrasound; bronchoscopy; esophagoscopy; • Requires a high index of suspicion
- 26. Reevaluation • Trauma patients must be reevaluated constantly to ensure that new findings are not overlooked and to discover any deterioration in previously noted findings. • Continuous monitoring of vital signs, oxygen saturation, and urinary output is essential. • Periodic ABG analyses and end-tidal CO2 monitoring are useful in some patients • The relief of severe pain is an important part of treatment for trauma patients through effective analgesia.
- 27. Definitive Care • Whenever the patient’s treatment needs exceed the capability of the receiving institution, transfer is considered
- 28. References • American College of Surgeons; ATLS (Advanced Trauma Life Suppport)
- 29. End Questions?
Editor's Notes
- Demonstrate the concepts and principles of the primary and secondary patient assessments. Establish management priorities in a trauma situation. Initiate primary and secondary management necessary for the emergency management of acute life threatening conditions in a timely manner.
- The concept of the “golden hour” emphasizes the urgency necessary for successful treatment of injured patients and is not intended to represent a fixed time period of 60 minutes. Rather, it is the window of opportunity during which doctors can have a positive impact on the morbidity and mortality associated with injury. The ATLS course provides the essential information and skills for doctors to identify and treat life-threatening and potentially life-threatening injuries under the extreme pressures associated with the care of these patients in the fast-paced environment and anxiety of a trauma room.
- According to the most current information from the World Health Organization (WHO) and the Centers for Disease Control (CDC), more than nine people die every minute from injuries or violence, and 5.8 million people of all ages and economic groups die every year from unintentional injuries and violence (n FIGURE 1).
- The burden of injury is even more significant, accounting for 18% of the world’s total diseases. Motor vehicle crashes (referred to as road traffic injuries in n FIGURE 2) alone cause more than 1 million deaths annually and an estimated 20 million to 50 million significant injuries; they are the leading cause of death due to injury worldwide. Improvements in injury control efforts are having an impact in most developed countries, where trauma remains the leading cause of death in persons 1 through 44 years of age. Significantly, more than 90% of motor vehicle crashes occur in the developing world. Injury-related deaths are expected to rise dramatically by 2020, and deaths due to motor vehicle crashes are projected to increase by 80% from current rates in lowand middle-income countries.
- First peak occurs within seconds to minutes of injury; During this early period, deaths generally result from apnea due to severe brain or high spinal cord injury or rupture of the heart, aorta, or other large blood vessels. Very few of these patients can be saved because of the severity of their injuries. Only prevention can significantly reduce this peak of trauma-related deaths. The second peak occurs within minutes to several hours following injury. Deaths that occur during this period are usually due to subdural and epidural hematomas, hemopneumothorax, ruptured spleen, lacerations of the liver, pelvic fractures, and/or multiple other injuries associated with significant blood loss. The golden hour of care after injury is characterized by the need for rapid assessment and resuscitation, which are the fundamental principles of Advanced Trauma Life Support. The third peak, which occurs several days to weeks after the initial injury, is most often due to sepsis and multiple organ system dysfunctions. Care provided during each of the preceding periods affects outcomes during this stage. The first and every subsequent person to care for the injured patient has a direct effect on long-term outcome.
- The primary and secondary surveys are repeated frequently to identify any change in the patient’s status that indicates the need for additional intervention.
- During the prehospital phase, providers emphasize airway maintenance, control of external bleeding and shock, immobilization of the patient, and immediate transport to the closest appropriate facility, preferably a verified trauma center
- Multiple-casualty incidents are those in which the number of patients and the severity of their injuries do not exceed the capability of the facility to render care. In such cases, patients with life-threatening problems and those sustaining multiple-system injuries are treated first. In mass-casualty events, the number of patients and the severity of their injuries does exceed the capability of the facility and staff. In such cases, patients having the greatest chance of survival and requiring the least expenditure of time, equipment, supplies, and personnel are treated first.
- Clinicians can quickly assess A, B, C, and D in a trauma patient (10-second assessment) by identifying themselves, asking the patient for his or her name, and asking what happened. An appropriate response suggests that there is no major airway compromise (i.e., ability to speak clearly), breathing is not severely compromised (i.e., ability to generate air movement to permit speech), and the level of consciousness is not markedly decreased (i.e., alert enough to describe what happened). During the primary survey, life-threatening conditions are identified and treated in a prioritized sequence based on the effects of injuries on the patient’s physiology, because at first it may not be possible to identify specific anatomic injuries
- Initially, the jaw-thrust or chin-lift maneuver often suffices as an initial intervention. If the patient is unconscious and has no gag reflex, the placement of an oropharyngeal airway can be helpful temporarily. Establish a definitive airway if there is any doubt about the patient’s ability to maintain airway integrity. While assessing and managing a patient’s airway, take great care to prevent excessive movement of the cervical spine. Based on the mechanism of trauma, assume that a spinal injury exists.
- Adequate gas exchange is required to maximize oxygenation and carbon dioxide elimination. Injuries that significantly impair ventilation in the short term include tension pneumothorax, massive hemothorax, open pneumothorax, and tracheal or bronchial injuries Every injured patient should receive supplemental oxygen Simple pneumothorax, simple hemothorax, fractured ribs, flail chest, and pulmonary contusion can compromise ventilation to a lesser degree and are usually identified during the secondary survey.
- Once tension pneumothorax has been excluded as a cause of shock, consider that hypotension following injury is due to blood loss until proven otherwise. When circulating blood volume is reduced, cerebral perfusion may be critically impaired, resulting in an altered level of consciousness. A patient with pink skin, especially in the face and extremities, rarely has critical hypovolemia after injury. Conversely, a patient with hypovolemia may have ashen, gray facial skin and pale extremities. A rapid, thready pulse is typically a sign of hypovolemia. Assess a central pulse (e.g., femoral or carotid artery) bilaterally for quality, rate, and regularity. Absent central pulses that cannot be attributed to local factors signify the need for immediate resuscitative action. Use a tourniquet only when direct pressure is not effective and the patient’s life is threatened. The source of bleeding is usually identified by physical examination and imaging (e.g., chest x-ray, pelvic x-ray, focused assessment with sonography for trauma [FAST], or diagnostic peritoneal lavage [DPL]).
- Definitive management may require surgical or interventional radiologic treatment and pelvic and long-bone stabilization. Initiate surgical consultation or transfer procedures early in these patients. Vascular access must be established typically two large-bore peripheral venous catheters are placed to administer fluid, blood, and plasma. Alternatively, intraosseous infusion, central venous access, or venous cutdown Blood samples for baseline hematologic studies are obtained, including a pregnancy test for all females of childbearing age and blood type and cross matching. To assess the presence and degree of shock, blood gases and/or lactate level are obtained. If a patient is unresponsive to initial crystalloid therapy, he or she should receive a blood transfusion. Fluids are administered judiciously, as aggressive resuscitation before control of bleeding has been demonstrated to increase mortality and morbidity.
- A decrease in a patient’s level of consciousness may indicate decreased cerebral oxygenation and/or perfusion, or it may be caused by direct cerebral injury. An altered level of consciousness indicates the need to immediately reevaluate the patient’s oxygenation, ventilation, and perfusion status. Until proven otherwise, always presume that changes in level of consciousness are a result of central nervous system injury. Remember that drug or alcohol intoxication can accompany traumatic brain injury. Patients with evidence of brain injury should be treated at a facility that has the personnel and resources to anticipate and manage the needs of these patients.
- Because hypothermia is a potentially lethal complication in injured patients, take aggressive measures to prevent the loss of body heat and restore body temperature to normal
- Dysrhythmias—including unexplained tachycardia, atrial fibrillation, premature ventricular contractions, and ST segment changes—can indicate blunt cardiac injury or hypothermia Pulseless electrical activity (PEA) can indicate cardiac tamponade, tension pneumothorax, and/or profound hypovolemia. Bradycardia, aberrant conduction, and premature beats are present, hypoxia and hypoperfusion should be suspected immediately Ventilation can be monitored using end tidal carbon dioxide levels. End tidal CO2 can be detected using colorimetry, capnometry, or capnography Urinary output is a sensitive indicator of the patient’s volume status and reflects renal perfusion ( transurethral bladder catheterization is contraindicated for patients who may have urethral injury) blood from meatus and perineal ecchymosis A gastric tube is indicated to decompress stomach distention, decrease the risk of aspiration, and check for upper gastrointestinal hemorrhage from trauma. If a fracture of the cribriform plate is known or suspected, insert the gastric tube orally to prevent intracranial passage. FAST (focused assessment with sonography for trauma) and Efast – peritoneal, pericardial fluids, pneumo and hemothorax
- Pediatric patients have unique physiology and anatomy; The quantities of blood, fluids, and medications vary with the size of the child: the injury patterns and degree and rapidity of heat loss differ. Children typically have abundant physiologic reserve and often have few signs of hypovolemia, even after severe volume depletion. The anatomic and physiologic changes of pregnancy can modify the patient’s response to injury. The aging process diminishes the physiologic reserve of these patients, and chronic cardiac, respiratory, and metabolic diseases can impair their ability to respond to injury in the same manner as younger patients. Comorbidities such as diabetes, congestive heart failure, coronary artery disease, restrictive and obstructive pulmonary disease, coagulopathy, liver disease, and peripheral vascular disease are more common in older patients and may adversely affect outcomes following injury. Long-term use of medications can alter the usual physiologic response to injury and frequently leads to over-resuscitation or under-resuscitation Obese patients pose a particular challenge in the trauma setting, as their anatomy can make procedures such as intubation difficult and hazardous. Diagnostic tests such as FAST, DPL, and CT are also more difficult; many obese patients have cardiopulmonary disease, which limits their ability to compensate for injury and stress. Because of their excellent conditioning, athletes may not manifest early signs of shock, such as tachycardia and tachypnea. They may also have normally low systolic and diastolic blood pressure.
- Knowledge of the mechanism of injury can enhance understanding of the patient’s physiologic state and provide clues to anticipated injuries.
- As initial life-threatening injuries are managed, other equally life-threatening problems and less severe injuries may become apparent, which can significantly affect the ultimate prognosis of the patient. A high index of suspicion facilitates early diagnosis and management. For adult patients, maintenance of urinary output at 0.5 mL/kg/h is desirable. In pediatric patients who are older than year, an output of 1 mL/kg/h is typically adequate.