this slide about principle, management

1. ATLS

2. ATLS has its origins in
the United States in
1976, when James K
Styner, an
Orthopedic surgeon
piloting a light aircraft,
crashed his plane into a
field in Nebraska. His wife
Charlene was killed
instantly and three of his
four children, Richard,
Randy, and Kim sustained
critical injuries.

3. His son Chris suffered a broken
arm. He carried out the initial
Triage of his children at the
crash site.
Dr.Styner had to flag down
a car to transport him to the
nearest hospital; upon arrival,
he found it closed. Even once
the hospital was opened and a
doctor called in, he found that
the emergency care provided at
the small regional hospital
where they were treated was
inadequate and inappropriate.

4. the initial ATLS course
which was held in 1978. In
1980, the
American College of Surgeons
Committee on Trauma
adopted ATLS and began US
and international
dissemination of the course.
Styner himself recently
recertified as an ATLS
instructor, teaching his
Instructor Candidate course
in Nottingham in the UK, July
2007

5. • The Advanced Trauma Life Support (ATLS) system
was therefore created initially in the USA and
rapidly taken up globally. At present, over 50
countries worldwide are actively providing the
ATLS course to their physicians

6. Triage
Triage is an important concept in modern health-
care systems, and three essential phases have
developed:
1 pre-hospital triage – in order to dispatch ambulance
and pre hospital care resources;
2 at the scene of trauma;
3 on arrival at the receiving hospital

7. 2 types of triage
1 Multiple casualties: Here, the number and severity of
injuries do not exceed the ability of the facility to render care.
Priority is given to the life-threatening injuries
2 Mass casualties: The number and severity of the injuries
exceed the capability and facilities available to the staff. In this
situation, those with the greatest chance of survival and the
least expenditure of time, equipment and supplies are
prioritized

8. Multiple causalities

9. Massive causalities

10. The steps in the ATLS philosophy
■ Primary survey with simultaneous resuscitation –
identify And treat what is killing the patient
■ Secondary survey – proceed to identify all other
injuries
■ Definitive care – develop a definitive
management plan

12. PRIMARY SURVEY AND RESUSCITATION
A – Airway maintenance and cervical
spine protection
B – Breathing and ventilation
C – Circulation with haemorrhage control
D – Disability: neurological status
E – Exposure: completely undress the
patient and assess for other injuries

14. 1. Airway
The airway must be evaluated first.
If there is vocal response from the patient, then the
patient’s airway is not immediately at risk, but
repeated assessment is prudent.
If there is no or limited response, then a rapid
investigation and assessment for signs of airway
obstruction should be undertaken. This includes
inspection for foreign bodies, maxillofacial or
mandibular fractures, tracheal or laryngeal injury or
oedema

15. 1. Airway

21. National Emergency X-radiography utilization
Study (NEXUS) Criteria

22. 2. Breathing
• Oxygen must be administered to all trauma patients,
usually at high flow and via a reservoir mask.
• Ventilation requires an adequately functioning chest wall,
lungs and diaphragm, and each must be systematically
evaluated.
• Signs of surgical emphysema, dilatation of the neck veins,
symmetry of the chest wall, respiratory effort and rate
should be evaluated and recorded.
• Percussion and auscultation should be performed both front
and back after log rolling

29. Flail Chest

30. This young man fell off his bike and landed on his left
side. His CXR shows a large left pneumothorax
(pleural line indicated by white arrows) with shift of
the trachea and mediastinum to the right side

31. 2. Breathing

40. Class % Blood Loss HR BP Urine pH MS Treatment
I
< 15%
(<750ml)
normal normal > 30 mL/hr normal anxious Fluid
II
15% to 30%
(750-1500ml)
> 100 bpm normal
20-30
mL/hr
normal
confused
irritable
combative
Fluid
III
30% to 40%
(1500-2000ml)
> 120 bpm decreased 5-15 mL/hr decreased
lethargic
irritable
Fluid &
Blood
IV
> 40% (life
threatening)
(>2000ml)
> 140 bpm decreased negligible decreased
lethargic
coma
Fluid &
Blood
Hemorrhagic Shock
Classification

41. Fluid Resuscitation
Introduction
• average adult (70 kg male) has an estimated 4.7 - 5 L of circulating blood
• average child (2-10 years old) has an estimated 75 - 80 ml/kg of
circulating blood
Methods of Resuscitation
• fluids
• crystalloid isotonic solution
• blood options
• O negative blood (universal donor)
• Type specific blood
• Cross-matched blood
• transfuse in 1:1:1 ratio (red blood cells: platelets: plasma)

43. Responder

44. Updated ATLS for Shock
•Class of haemorrhage table
amended: Base excess
•Early use of blood and blood
products
•Management of coagulopathy
•Tranexamic acid
•Trauma team

45. ATLS classification of
hypovolemic shock
*

46. Early use of blood and
blood products
Early resuscitation with blood and blood
products must be considered in patients
with evidence of class III and IV
hemorrhage.
Early administration of blood products at a
low ratio of packed red blood cells to
plasma and platelets can prevent the
development of coagulopathy and
thrombocytopenia.

47. Management of coagulopathy
Uncontrolled blood loss can occur in patients
taking antiplatelet or anticoagulant medications.
Prevention
• Obtain medication list as soon as possible.
• Administer reversal agents as soon as possible.
• Where available, monitor coagulation with
thromboelastography (TEG) or rotational
thromboelastometry (ROTEM).
• Consider administering platelet transfusion,
even with normal platelet count.

48. Tranexamic acid (TXA)
European and American military studies
demonstrate improved survival when
TXA is administered over 10 minutes
within 3 hours of injury.
When bolused in the field, follow up
infusion TAX 1 gram over 8 hours in
the hospital.

49. Indicators of adequate
resuscitation
• urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
• serum lactate levels (normal < 2.5 mmol/L)
• gastric mucosal pH (>7.3)
• base deficit
• normal -2 to +2

57. DCO

58. Early Total Care vs Damage
Control Orthopaedic
• Early Total Care (ETC): a concept implying the
primary definitive management of all major
injuries within 24 hours after the trauma
• Damage Control Ortopaedics (DCO): minimally
invasive surgical techniques are used for the
primary stabilization of all major fractures. Based
upon the patient’s physiological status, temporary
stabilization with external fixation for certain
fracture is used.

59. Damage Control Orthopaedic
• Design to avoid worsening patient’s condition
due to “second hit” phenomenon
• Delay definitive surgery until patient’s
condition is optimized
• Focuses in hemorrhagic control, management
of soft tissue injury and provisional fracture
stability
• Consist 4 phase
• Acute phase, life saving procedure
• Control of hemorrhage, temporary stabilization of major skeletal
fractures and management soft tissue injuries
• Monitoring period in ICU
• Definitive fracture fixation

60. First hit and second hit
phenomena

62. Timing for Definitive Surgery

63. Parameters that help decide who
should be treated with DCO
• ISS >40 (without thoracic trauma)
• ISS >20 with thoracic trauma
• GCS of 8 or below
• multiple injuries with severe pelvic/abdominal
trauma and hemorrhagic shock
• bilateral femoral fractures
• pulmonary contusion noted on radiographs
• hypothermia <35 degrees C
• head injury with AIS of 3 or greater
• IL-6 values above 500pg/dL

64. Injury Severity Scale (ISS)
• First scoring system to be based on
anatomic criteria
• ISS = sum of squares for the highest
AIS grades in the three most severely
injured body regions
ISS = A2+B2+C2
• Score ranged from 1-75
• ISS >15 associated with mortality of 10%
(severe trauma patient)

65. Abbreviated Injury Scale (AIS)
Value Injury Description
0 No injury
1 Minor
2 Moderate
3 Severe ( Not-life threatening)
4 Severe (life threatening,
survival probable)
5 Severe (Critical, survival
uncertain)
6 Maximal, possibly fatal
Single score of 6 on any AIS region results in automatic score of 75

66. ISS Calculation
Region Injury Description AIS Grades Top 3 squared AIS
Grade
Head
Face
Neck
Thorax
Abdominal and Pelvic
Content
Spine
Upper Exteremity
Lower Extermity
External
ISS SCORE

68. DCO
therefore only potentially life-threatening injuries should
be treated in DCO including
• unstable pelvic fracture
• compartment syndrome
• fractures with vascular injuries
• unreduced dislocations
• traumatic amputations
• unstable spine fractures
• cauda equina syndrome
• open fractures

69. Stabilization and Definitive treatment
• To minimize trauma, initial stabilization should
be performed
• Definitive treatment delayed for 7-10 days

70. MESS

71. Mangled Extremity Severity Score (MESS)
• Used to predict necessity of amputation after lower
extremity trauma
• Variables
• skeletal and soft tissue injury
• limb ischemia
• shock
• age
• Calculation
• score determined by adding scores of components in four categories
• Interpretation
• score of >7 is predictive of amputation

72. MESS SCORE

73. THANK YOU