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Introduction to
Advanced Trauma Life Support
            ATLS
Objectives

●   Concepts of primary & secondary survey
●   Priorities & Life threatening conditions
●   Clinical & Surgical skills
Basic knowledge

●   Rapid assessment
●   Resuscitate & Stabilize (Prioritize)
●   Patient's needs & facility's capabilities
●   Appropriate transfer
●   Optimum care
Initial Assessment & Management

●   Preparation (Prehospital - Hospital)
●   Triage
●   Primary survey (ABCDE)
●   Resuscitation
●   Adjuncts to primary survey & resuscitation
●   ->
Initial Assessment & Management

●   Secondary survey
●   Adjuncts to the secondary survey
●   Postresuscitation monitoring
●   Definitive care
Primary Survey

●   Treatment priorities
●   A: Airway maintenance + C-spine protection
●   B: Breathing & Ventilation
●   C: Circulation & Hemorrhage control
●   D: Disability – Neuro
●   E: Exposure / Environment control
A

●   Airway
    –   Patency / Obstruction
    –   Severe head injury -> Definitive airway
Airway: Patency

●   Maxillofacial trauma
●   Neck trauma
●   Laryngeal trauma (Hoarseness, Subcutaneous
    emphysema, Palpable fracture)
A

●   C-spine protection
    –   Multiple system trauma
    –   Altered level of consciousness
    –   Blunt injury above clavicle
    –   Manual in-line stabilization
A: Nexus

●   Midline cervical tenderness
●   Altered level of consciousness
●   Evidence of intoxication
●   Neurologic abnormality
●   Presence of painful distracting injury
A

●   Trauma patient is dynamic
●   Repeated assessment
A: Resuscitation

●   Jaw thust / Chin lift / Head tilt
●   Naso / Oropharyngeal airway
●   Combitube, LMA
●   Definitive airway (Cuff in trachea)
    –   Oro / Naso tracheal intubation
    –   Surgical cricothyroidotomy
Endotracheal intubation

●   Indication
    –   Provide patent airway
    –   Deliver supplemental oxygen
    –   Support ventilation
    –   Prevent aspiration
Endotracheal intubation

●   Decision
    –   Apnea (orotracheal)
    –   Cannot maintain patent airway
    –   Protect aspiration / vomitus
    –   Impending compromise airway
    –   Closed head injury required assisted ventilation
    –   Inadequate oxygenation
Surgical Airway

●   Cricothyroidotomy / Tracheostomy
●   Indication
     – Unable to intubate (severe maxillofacial injury,
       failed intubation)
●   Contraindication
     – Airway transection
B: Breathing
B: Life Threatening Conditions

●   Tension pneumothorax
●   Flail chest with pulmonary contusion
●   Massive Hemothorax
●   Open pneumothorax
●   Cardiac tamponade
Thoracic Trauma: Primary survey

●   Looking, Palpation, Percussion,
    Listening
    –   Tension pneumothorax
    –   Open pneumothorax (sucking chest wound)
    –   Flail chest
    –   Massive hemothorax
    –   Cardiac tamponade
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
Thoracic Trauma: Primary survey

●   Open pneumothorax (sucking chest wound)
    –   > 2/3 of tracheal diameter
    –   3 sided dressing
    –   Chest tube insertion
Open Chest Wound: 3-Sided
Dressing
Thoracic Trauma: Primary survey

●   Flail chest
    –   >2 ribs fractures in 2 or more places
    –   Paradoxical chest wall movement
    –   Adequate ventilation
    –   Reexpand lungs: Intubation
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
Thoracic Trauma: Primary survey

●   Cardiac tamponade
    –   Penetrating injury
    –   Beck's triad
    –   DDx from Tension
        pneumothorax
    –   FAST / Echo
    –   Pericardiocentesis
B: Resuscitation

●   Supplemental oxygen
●   Tension pneumothorax decompression
C: Circulation & Hemorrhage
control
●   Circulation – Blood volume & Cardiac output
●   Level of consciousness
●   Skin color
●   Pulse
C

●   Hemorrhage control - External hemorrhage
    –   Manual pressure
    –   Splinting
    –   Tourniquet
    –   Hemostats
C: Resuscitation

●   2 large-caliber IV catheter
●   “warm” NSS, RLS
●   Blood
●   Control bleeding
    –   Direct pressure
    –   Operative control
●   Vasopressors
Shock

●   Inadequate tissue perfusion / oxygenation
●   Hemorrhagic / Non-hemorrhagic
Hemorrhagic shock

●   Most common cause of shock in trauma
●   External vs Internal hemorrhage
●   Blood volume = 7% of BW
●   Rx: Volume replacement
●   Shock Classification
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
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
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
Hemorrhagic shock classification

●   Class IV
    –   >40% blood loss
    –   P >140
    –   BP decreased
    –   PP decreased
    –   RR > 35
    –   Urine output ---
    –   Mental status: confused / lethargic
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
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
Response to fluid resuscitation

●   No response
    –   Immediate operative intervention
Non-hemorrhagic shock

●   Cardiogenic shock
●   Tension pneumothorax
●   Neurogenic shock
●   Septic shock
Cardiogenic shock

●   Cardiac contusion
●   Cardiac tamponade: “Beck's triad”
    –   Tachycardia
    –   Muffled heart sound
    –   Distended neck vein
●   Echo / FAST
Cardiac Tamponade

●   Penetrating injury
●   Beck's triad
●   DDx from Tension pneumothorax
●   FAST / Echo
●   Rx: Pericardiocentesis
Tension pneumothorax

●   One-way valve
●   Respiratory distress
●   Subcutaneous emphysema
●   Absent breath sound
●   Hyperresonance on percussion
●   Tracheal shift
●   Distended neck vein
●   Rx: Needle / Tube thoracostomy
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
D

●   Neurological status
    –   Level of consciousness (AVPU / GCS)
    –   Pupil size & Light reaction
    –   Lateralizing sign
    –   Spinal cord injury level
D

●   A: Alert
●   V: Verbal command
●   P: Painful stimuli
●   U: Unresponsive
D

●   Factors affect level of consciousness
    –   Oxygenation ( ABC )
    –   Ventilation ( ABC )
    –   Perfusion ( ABC )
    –   Hypoglycemia
    –   Drugs / Alcohol
D

●   Reevaluation
E

●   Uncloth patient
●   Logroll patient
●   Prevent hypothermia
    –   Warm blanket
    –   Warm IV fluid
E

●   Rectal examination
    –   Sphinctor tone
    –   Position of prostate (high-riding?) = urethral injury
    –   Gross blood (penetrating abdominal injury)
    –   Pelvic fractures
Primary survey: Adjuncts

●   Monitor
●   Diagnosis
Primary survey: Adjuncts: Monitor

●   EKG monitor
●   Foley's catheter
●   “Gastric” catheter
●   Respiratory rate
●   ABG
●   Pulse oximetry
Primary survey: Adjuncts:
Diagnosis
●   CXR, Pelvis AP, Lateral C-spine
●   DPL, FAST
●   Should not interrupt
    resuscitation process
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
Gastric tube

●   Relieve gastric dilatation
●   Decompress stomach before DPL
●   Reduce risk of aspiration
●   NG tube: contraindicated in basilar skull fracture
Secondary Survey

●   Not begin until primary survey is completed
●   History (AMPLE)
●   Head-to-toe evaluation
●   GCS
●   X-rays
Secondary Survey: Adjuncts

●   Specialized diagnostic tests (CT, US, scope)
●   Should not be performed until hemodynamic
    stabilization
Secondary Survey

●   History: AMPLE
    –   A: Allergies
    –   M: Medications
    –   P: Past illnesses / Pregnancy
    –   L: Last meal
    –   E: Events
Secondary Survey

●   Physical examination
●   Head-to-toe examination
Thoracic Trauma: Secondary Survey
●   Simple pneumothorax
●   Hemothorax
●   Pulmonary contusion
●   Tracheobronchial tree injury
●   Blunt cardiac injury
●   Traumatic aortic disruption
●   Traumatic diaphragmatic injury
●   Mediastinal transvering wound
Abdominal Trauma
Abdominal Trauma

●   External anatomy
    –   Anterion
    –   Flank
    –   Back
Abdominal Trauma

●   Internal anatomy
    –   Peritoneal cavity
    –   Pelvic cavity
    –   Retroperitoneal space
Abdominal Trauma

●   Mechanism of injury
    –   Blunt
    –   Penetrating
Abdominal Trauma: Assessment

●   History
●   Physical Exam
    –   Inspection, Auscultation, Percussion, Palpation
    –   Evaluation of penetrating wound
    –   Pelvic stability
    –   Penile, Perineal, Rectal exam
    –   Vaginal, Gluteal exam
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
Celiotomy: Indications (cont.)

●   Penetrating trauma with Bleeding from stomach,
    rectum, GU
●   Peritonitis
●   Free air, retroperitoneal air, ruptured
    hemidiaphragm after blunt trauma
●   Ruptured hollow viscus
Diagnostic Studies

●   Diagnostic peritoneal lavage: DPL
●   FAST
●   CT scan
●   Urethrography, Cystography, IVP
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
Diagnostic Peritoneal Lavage:DPL

●   Contraindications
    –   Existing indication for celiotomy
●   Relative contraindications
    –   Previous abdominal operations
    –   Morbid obesity
    –   Advanced cirrhosis
    –   Coagulopathy
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
Head injury
Head Injury

●   Classification
    –   Mechanism (Blunt, Penetrating)
    –   Severity (mild, moderate, severe)
    –   Morphology (Skull fractures, Intracranial)
Head Injury: Severity

●   Mild: GCS 13-15
●   Moderate: GCS 9-12
●   Severe: GCS 3-8
Head Injury: Morphology

●   Skull fractures
●   Intracranial
    –   Epiduralhematoma
    –   Subdural hematoma
    –   Intracerebral hematoma
    –   Diffuse brain injury
Skull fractures

●   Cranium
●   Maxillofacial
●   Basilar skull fractures
Basilar skull fracture

●   Raccoon's eyes
●   Battle's sign
●   CSF rhinorrhea / otorrhea
Epidural Hematoma

●   Arterial origin (middle
    meningeal a.)
●   CT: lenticular shape
Subdural Hematoma

               ●   Venous origin
               ●   CT: Crescent shape
Intracerebral Hematoma

                 ●   Brain laceration
Head Injury: Management

●   Mild HI (GCS 13-15)
    –   Observe
    –   CT:
         ●   Lost of conscious > 5 min
         ●   Amnesia
         ●   Severe headache
         ●   Focal neurological deficit
Head Injury: Management

●   Moderate HI (GCS 9-12)
    –   CT brain
    –   Admit observe neurosigns
    –   F/U CT brain 12-24 h
Head Injury: Management

●   Severe HI (GCS < 9)
    –   Prompt diagnosis & treatment
    –   Don't delay patient transfer to obtain CT scan
Monro-Kellie Doctrine
Brain resuscitation

●   Maintain adequate
    –   Cerebral Perfusion Pressure (CPP)
    –   Oxygenation
    –   Normocapnia
Cerebral Perfusion Pressure

●   CPP = MAP – ICP
    –   MAP = Mean Arterial Pressure
    –   ICP = Intracranial Pressure
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
Brain resuscitation

●   Oxygenation
    –   Oxygen supplement
    –   Anticonvulsants
●   Normocapnia
    –   Hyperventilation -> CO2 -> Cerebral vasoconstriction
        -> CPP
Conclusions

●   Initial Assessment (Primary survey, Secondary
    survey)
●   Adjuncts
●   Priority: Life threatening first
●   Knowledge & Skills for specific conditions
●   DOs & DON'Ts
Q?
http://www.slideshare.net/narenthorn/introduction-to-atls-presentation/

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Introduction To ATLS

  • 2. Objectives ● Concepts of primary & secondary survey ● Priorities & Life threatening conditions ● Clinical & Surgical skills
  • 3. Basic knowledge ● Rapid assessment ● Resuscitate & Stabilize (Prioritize) ● Patient's needs & facility's capabilities ● Appropriate transfer ● Optimum care
  • 4. Initial Assessment & Management ● Preparation (Prehospital - Hospital) ● Triage ● Primary survey (ABCDE) ● Resuscitation ● Adjuncts to primary survey & resuscitation ● ->
  • 5. Initial Assessment & Management ● Secondary survey ● Adjuncts to the secondary survey ● Postresuscitation monitoring ● Definitive care
  • 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. A ● Airway – Patency / Obstruction – Severe head injury -> Definitive airway
  • 8. Airway: Patency ● Maxillofacial trauma ● Neck trauma ● Laryngeal trauma (Hoarseness, Subcutaneous emphysema, Palpable fracture)
  • 9. A ● C-spine protection – Multiple system trauma – Altered level of consciousness – Blunt injury above clavicle – Manual in-line stabilization
  • 10. A: Nexus ● Midline cervical tenderness ● Altered level of consciousness ● Evidence of intoxication ● Neurologic abnormality ● Presence of painful distracting injury
  • 11. A ● Trauma patient is dynamic ● Repeated assessment
  • 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. Endotracheal intubation ● Indication – Provide patent airway – Deliver supplemental oxygen – Support ventilation – Prevent aspiration
  • 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. Surgical Airway ● Cricothyroidotomy / Tracheostomy ● Indication – Unable to intubate (severe maxillofacial injury, failed intubation) ● Contraindication – Airway transection
  • 17. B: Life Threatening Conditions ● Tension pneumothorax ● Flail chest with pulmonary contusion ● Massive Hemothorax ● Open pneumothorax ● Cardiac tamponade
  • 18. Thoracic Trauma: Primary survey ● Looking, Palpation, Percussion, Listening – Tension pneumothorax – Open pneumothorax (sucking chest wound) – Flail chest – Massive hemothorax – Cardiac tamponade
  • 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. Thoracic Trauma: Primary survey ● Open pneumothorax (sucking chest wound) – > 2/3 of tracheal diameter – 3 sided dressing – Chest tube insertion
  • 21. Open Chest Wound: 3-Sided Dressing
  • 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. 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. Thoracic Trauma: Primary survey ● Cardiac tamponade – Penetrating injury – Beck's triad – DDx from Tension pneumothorax – FAST / Echo – Pericardiocentesis
  • 25. B: Resuscitation ● Supplemental oxygen ● Tension pneumothorax decompression
  • 26. C: Circulation & Hemorrhage control ● Circulation – Blood volume & Cardiac output ● Level of consciousness ● Skin color ● Pulse
  • 27. C ● Hemorrhage control - External hemorrhage – Manual pressure – Splinting – Tourniquet – Hemostats
  • 28. C: Resuscitation ● 2 large-caliber IV catheter ● “warm” NSS, RLS ● Blood ● Control bleeding – Direct pressure – Operative control ● Vasopressors
  • 29. Shock ● Inadequate tissue perfusion / oxygenation ● Hemorrhagic / Non-hemorrhagic
  • 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. 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. 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. 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. Hemorrhagic shock classification ● Class IV – >40% blood loss – P >140 – BP decreased – PP decreased – RR > 35 – Urine output --- – Mental status: confused / lethargic
  • 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. 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. Response to fluid resuscitation ● No response – Immediate operative intervention
  • 38. Non-hemorrhagic shock ● Cardiogenic shock ● Tension pneumothorax ● Neurogenic shock ● Septic shock
  • 39. Cardiogenic shock ● Cardiac contusion ● Cardiac tamponade: “Beck's triad” – Tachycardia – Muffled heart sound – Distended neck vein ● Echo / FAST
  • 40. Cardiac Tamponade ● Penetrating injury ● Beck's triad ● DDx from Tension pneumothorax ● FAST / Echo ● Rx: Pericardiocentesis
  • 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. 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. D ● Neurological status – Level of consciousness (AVPU / GCS) – Pupil size & Light reaction – Lateralizing sign – Spinal cord injury level
  • 44. D ● A: Alert ● V: Verbal command ● P: Painful stimuli ● U: Unresponsive
  • 45. D ● Factors affect level of consciousness – Oxygenation ( ABC ) – Ventilation ( ABC ) – Perfusion ( ABC ) – Hypoglycemia – Drugs / Alcohol
  • 46. D ● Reevaluation
  • 47. E ● Uncloth patient ● Logroll patient ● Prevent hypothermia – Warm blanket – Warm IV fluid
  • 48. E ● Rectal examination – Sphinctor tone – Position of prostate (high-riding?) = urethral injury – Gross blood (penetrating abdominal injury) – Pelvic fractures
  • 49. Primary survey: Adjuncts ● Monitor ● Diagnosis
  • 50. Primary survey: Adjuncts: Monitor ● EKG monitor ● Foley's catheter ● “Gastric” catheter ● Respiratory rate ● ABG ● Pulse oximetry
  • 51. Primary survey: Adjuncts: Diagnosis ● CXR, Pelvis AP, Lateral C-spine ● DPL, FAST ● Should not interrupt resuscitation process
  • 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. Gastric tube ● Relieve gastric dilatation ● Decompress stomach before DPL ● Reduce risk of aspiration ● NG tube: contraindicated in basilar skull fracture
  • 54. Secondary Survey ● Not begin until primary survey is completed ● History (AMPLE) ● Head-to-toe evaluation ● GCS ● X-rays
  • 55. Secondary Survey: Adjuncts ● Specialized diagnostic tests (CT, US, scope) ● Should not be performed until hemodynamic stabilization
  • 56. Secondary Survey ● History: AMPLE – A: Allergies – M: Medications – P: Past illnesses / Pregnancy – L: Last meal – E: Events
  • 57. Secondary Survey ● Physical examination ● Head-to-toe examination
  • 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
  • 60. Abdominal Trauma ● External anatomy – Anterion – Flank – Back
  • 61. Abdominal Trauma ● Internal anatomy – Peritoneal cavity – Pelvic cavity – Retroperitoneal space
  • 62. Abdominal Trauma ● Mechanism of injury – Blunt – Penetrating
  • 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. 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. 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. Diagnostic Studies ● Diagnostic peritoneal lavage: DPL ● FAST ● CT scan ● Urethrography, Cystography, IVP
  • 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. Diagnostic Peritoneal Lavage:DPL ● Contraindications – Existing indication for celiotomy ● Relative contraindications – Previous abdominal operations – Morbid obesity – Advanced cirrhosis – Coagulopathy
  • 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
  • 71. Head Injury ● Classification – Mechanism (Blunt, Penetrating) – Severity (mild, moderate, severe) – Morphology (Skull fractures, Intracranial)
  • 72. Head Injury: Severity ● Mild: GCS 13-15 ● Moderate: GCS 9-12 ● Severe: GCS 3-8
  • 73. Head Injury: Morphology ● Skull fractures ● Intracranial – Epiduralhematoma – Subdural hematoma – Intracerebral hematoma – Diffuse brain injury
  • 74. Skull fractures ● Cranium ● Maxillofacial ● Basilar skull fractures
  • 75. Basilar skull fracture ● Raccoon's eyes ● Battle's sign ● CSF rhinorrhea / otorrhea
  • 76. Epidural Hematoma ● Arterial origin (middle meningeal a.) ● CT: lenticular shape
  • 77. Subdural Hematoma ● Venous origin ● CT: Crescent shape
  • 78. Intracerebral Hematoma ● Brain laceration
  • 79. Head Injury: Management ● Mild HI (GCS 13-15) – Observe – CT: ● Lost of conscious > 5 min ● Amnesia ● Severe headache ● Focal neurological deficit
  • 80. Head Injury: Management ● Moderate HI (GCS 9-12) – CT brain – Admit observe neurosigns – F/U CT brain 12-24 h
  • 81. Head Injury: Management ● Severe HI (GCS < 9) – Prompt diagnosis & treatment – Don't delay patient transfer to obtain CT scan
  • 83. Brain resuscitation ● Maintain adequate – Cerebral Perfusion Pressure (CPP) – Oxygenation – Normocapnia
  • 84. Cerebral Perfusion Pressure ● CPP = MAP – ICP – MAP = Mean Arterial Pressure – ICP = Intracranial Pressure
  • 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. Brain resuscitation ● Oxygenation – Oxygen supplement – Anticonvulsants ● Normocapnia – Hyperventilation -> CO2 -> Cerebral vasoconstriction -> CPP
  • 87. Conclusions ● Initial Assessment (Primary survey, Secondary survey) ● Adjuncts ● Priority: Life threatening first ● Knowledge & Skills for specific conditions ● DOs & DON'Ts
  • 88. Q?