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ATLS.ppt
- 1. •Initial management of polytrauma victim
- 2. Advanced trauma life support (ATLS)
- 3. • The Nebraska story • February 1976
- 4. • “When I can provide better care in the FIELD with limited resources than what my children and I received at the primary care facility, there is something wrong with the system and the system has to be changed”
- 5. • Today the ATLS method is accepted as a standard for the first hour of trauma care wherever the patient is being treated – be it an isolated rural area or the state of the art trauma centre.
- 6. Golden hour
- 7. Multiple injuries • Multiplicity of injuries • How to prioritize? –Alarming injuries may not be life threatening
- 8. Early management of trauma • Components of early management –Primary Survey & Resuscitation –Secondary Survey –Definitive management
- 9. Mechanisms predictive of serious injury • Fall from >20 feet • Pedestrian or cyclist hit by the car • Death of other occupant in the same vehicle • Ejection from the vehicle or bike • Vehicular roll over • Penetrating injury to head or torso • All shotgun injuries
- 10. Primary Survey & Resuscitation • A – Airway and cervical spine control • B - Breathing • C – Circulation and haemorrhage control • D – Dysfunction of the CNS • E - Exposure – (treat as soon as you diagnose)
- 11. Primary survey • It is essential that problems are anticipated rather than reacted to once they develop
- 12. AIRWAY • Rapid assessment – A patient who answers questions sensibly must have a clear airway, reasonable breathing, and reasonable cerebral perfusion. • Noisy airway is a compromised airway
- 13. Noisy airway • Snoring noises • Gurgling noises • Stridor • Hoarseness
- 14. Causes of airway problems in trauma • Soft tissues (tongue) • Oedema, haematoma and other swelling • Foreign bodies • Displaced facial bones • Aspiration of gastric contents
- 15. Airway compromise • Clear the airway – Suction – Removal with gloved fingers • Commonest cause of airway compromise is due the tongue falling back
- 16. Airway compromise- Initial management • Jaw thrust • Chin lift
- 17. Oropharyngeal airway • Indication – Absence of gag reflex • Technique of insertion • Guedel airway does not prevent aspiration
- 18. Airway compromise • When there is no gag reflex the only safe way of maintaining the airway is –Cuffed endotracheal intubation • Every patient with multiple injuries should receive 100% oxygen.
- 19. Breathing • Ensure that both sides are being ventilated – Equal movement on both sides – Auscultation both lungs • Auscultation – Both axillae – Epigastrium • Respiratory rate
- 20. Breathing -problems • Not breathing – To proceed to CPR • Breathing with difficulty – Dyspnoea – Tachypnoea
- 21. Immediately life threatening thoracic conditions 1. Open pneumothorax 2. Tension pneumothorax 3. Massive haemopneumothorax 4. Cardiac tamponade 5. Flail chest
- 22. Open chest wound • Why it is dangerous? • What is the immediate management? – Occlusive dressing which is taped on three sides only – Followed by ICD and definitive closure
- 23. Tension pneumothorax • Do not send the patient for X-ray • Act on clinical suspicion • How to differentiate simple from tension pneumothorax?
- 24. Tension pneumothorax • Immediate management – Needle / Cannula decompression – Midclavicular line in the 2nd intercostal space • Followed by ICD • What happens when you put a needle in the absence of pneumothorax?
- 25. Breathing • Respiratory rate and effort are very sensitive indicators of underlying lung pathology. They should therefore be monitored and recorded at frequent intervals
- 26. Circulation • Overt bleeding • Occult bleeding
- 27. Overt bleeding • How to stop? – Local pressure (pressure dressing) over the site of bleeding – Tourniquets are better avoided – Don’t plunge artery forceps in a pool of blood blindly
- 28. Sites of bleeding • Blood on the floor and four more –Chest –Abdomen and retroperitoneum –Pelvis –Long bone fractures
- 29. Hypovolaemia • Blood loss Class Symptoms • <750 ml I None • 750 –1500 II Cardiovascular,catecholamine release, thirst, weakness • 1500-2000 III Systolic BP falls • >2000 IV Systolic BP unreadable
- 30. BP in hypovolaemia • Class I II III IV • Sys = = - -- • Dia = + - --
- 31. Shock index • Pulse rate / Systolic BP • 0.6 – 0.8 is the normal value • 1 or more indicates shock
- 32. Hypovolaemia • How to detect occult loss into the –Thorax –Abdomen –Pelvis
- 33. Massive haemopneumothorax • Pale / hypotensive • Difficulty in breathing / tachypnoea • Tracheal / mediastinal shift to the opposite • Absent breath sounds • Empty neck veins
- 34. Cardiac tamponade • Hypotension • Neck veins distended • No tracheal shift • No difficulty in breathing • Pulses paradoxus
- 35. Rapid assessment of circulation • Skin colour • Carotid only palpable sys >60 mmHg • Femoral palpable sys >70 mmHg • Radial palpable sys >80 mmHg
- 36. Penetrating injuries • Below the 5th rib & • Above the gluteal fold –Abdominal organs can be involved • Do not remove the penetrating agent
- 37. Haemoperitoneum • Abdomen can hold 1500 – 2000 ml of fluid without any evidence of distension • When distension occurs in haemoperitoneum, the patient will be in profound shock
- 38. Haemoperitoneum • Diagnosis –Diagnostic peritoneal lavage –Four quadrant aspiration –Abdominal ultrasound • (The sonologist will only say freefluid in the peritoneal cavity)
- 39. Brain injury does not produce hypotension
- 40. • CNS dysfunction ( drowsiness / coma ) may be due to brain injury or hypovolaemia
- 41. A case history • 25 yr old male was stabbed in between the shoulder blades. He is hypotensive. What could be the cause for hypotension? – Massive haemopneumothorax – Haemoperitoneum – Tension pneumothorax – Cardiac tamponade – Neurogenic shock
- 42. CNS Dysfunction • Rapid assessment of Brain & Spinal Cord – Examine the pupils & • Ask the patient to – Put the tongue out – Move the toes – Squeeze your fingers • Later do GCS
- 43. Second accident • Hypoxia • Hypoperfusion
- 44. Exposure • Back • Perineum • Urethra
- 45. Secondary survey • Head to foot • Orderly, systematic and complete examination • Actively rule out fractures of cervical spine,ribs and pelvis • Explore every orifice