Approach to a trauma patient - Advanced Trauma Life SupportParthasarathi Ghosh
Approach to a trauma patient from a Critical Care Medicine perspective with basics of Advanced Trauma Life Support.
References - ATLS Manual 10th Edition
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Approach to a trauma patient - Advanced Trauma Life SupportParthasarathi Ghosh
Approach to a trauma patient from a Critical Care Medicine perspective with basics of Advanced Trauma Life Support.
References - ATLS Manual 10th Edition
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Prehospital care in trauma is as important as in hospital care. The presentation addresses simple and basic approach to care a polytrauma victim in platinum 10 minutes based on BTLS.
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Detailed information on assessing the trauma patients with time dependent principle management and selection between early total care and damage control surgery.
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1. ATLS
Advanced Trauma Life Support
Supervised by: Prof. Mahmoud Abu-Ebeeleh
Done by: Dr. Faisal Rawagah
2. History
Dr James Styner, An orthopedic surgeon crashed his plane in February 1976
“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”
-Advanced Trauma Life Support Student Course Manual 10th edition
-Journal of Trauma Nursing April/June 2006, Volume :13 Number 2 , page 41 - 44
3. Do we Need ATLS?
ATLS Methods is accepted as a standard for the “first hour” of trauma care by
many who provide care for the injured.
5.8 million people die every year from unintentional injuries and violence.
Motor vehicle crashes alone case:
1.3 million deaths annually.
20 million to 50 million significant injuries.
Trauma the leading cause of death in persons 1 through 44 years of age in most
developed countries.
-Advanced Trauma Life Support Student Course Manual 10th edition
-https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries
4. The trimodal distribution of deaths
Classically:
Immediate (seconds to minutes)
Severe brain or high spinal cord injury
Rupture of the heart, aorta, or other large blood
vessels
Early (minutes to several hours)
Subdural and epidural hematomas,
Hemopneumothorax
Ruptured spleen, lacerations of the liver, pelvic
fractures.
Late (Several days to weeks)
sepsis and multiple organ system dysfunctions.
-Advanced Trauma Life Support Student Course Manual 10th edition
-Gunst M, Ghaemmaghami V, Gruszecki A, Urban J, Frankel H, Shafi S. Changing epidemiology of trauma deaths leads
to a bimodal distribution. Proc (Bayl Univ Med Cent). 2010 Oct;23(4):349-54. doi: 10.1080/08998280.2010.11928649.
PMID: 20944754; PMCID: PMC2943446.
5. The “initial assessment”
Timing is crucial, systematic approach that can be rapidly and accurately applied is essential
•• 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 postresuscitation monitoring and reevaluation
•• Definitive care
6. Preparation
Prehospital Phase
Airway maintenance, Control of external bleeding and shock.
Immobilization of the patient, and immediate transport to the closest appropriate facility.
Obtaining and reporting information needed for triage at the hospital.
Time of injury events related to the injury, and patient history.
Hospital Phase
Resuscitation area.
Properly functioning airway equipment.
Warmed intravenous crystalloid solutions (37c-40c) + appropriate monitoring devices.
Protocol to summon additional medical assistance + laboratory and radiology personnel.
Transfer agreements with verified trauma centers.
PPE- standard precautions (face mask, eye protection, water-impervious gown,and gloves)
7. Triage
based on the ABC
The severity of injury.
Ability to survive.
Available resources.
Multiple-casualty event
Mass-casualty event
-Advanced Trauma Life Support Student Course Manual 10th edition
-CDC, MMWR, Guidelines for Field Triage of Injured Patients:
Recommendations of the National Expert Panel on Field Triage, 2011
8. Primary Survey with
Simultaneous Resuscitation
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.
• Airway maintenance with restriction of cervical spine motion.
• Breathing and ventilation.
• Circulation with hemorrhage control.
• Disability(assessment of neurologic status).
• Exposure/Environmental control.
9. Airway maintenance with restriction of cervical
spine motion.
Asking the patient for his or her name, and asking what happened.
Inspecting for foreign bodies.
Identifying facial, mandibular, and/or tracheal/laryngeal fractures and other injuries that
can result in airway obstruction.
Suctioning to clear accumulated blood or secretions.
Jaw-thrust or chin-lift.
Oropharyngeal airway.
Establish a definitive airway.
Cervical In-line stabilization.
Cervical collar.
-Advanced Trauma Life Support Student Course Manual 10th edition
-Austin N, Krishnamoorthy V, Dagal A. Airway management in cervical spine injury. Int J Crit Illn Inj Sci.
2014 Jan;4(1):50-6. doi: 10.4103/2229-5151.128013. PMID: 24741498; PMCID: PMC3982371.
10. Breathing and ventilation
Expose the patient’s neck and chest
Assess jugular venous distention.
Position of the trachea
Chest wall excursion
Tension pneumothorax, Massive hemothorax, Open pneumothorax, and tracheal or
bronchial injuries.
O2 mask-reservoir device.
Pulse oximeter to monitor.
Ask but do not stop at; Portable CXR.
NOT in Primary Survey: Simple pneumothorax, simple hemothorax, fractured ribs, flail
chest, and pulmonary contusion.
11. Circulation with hemorrhage control.
cABCDE; Catastrophic Haemorrhage Control.
Blood Volume and Cardiac Output
If there is no tension pneumothorax then consider that hypotension following injury is
due to blood loss until proven otherwise.
Evaluation:
Level of Consciousness
Skin Perfusion
Pulse
BP
Bleeding
Blood on the floor and four more
12. External hemorrhage is identified and controlled during the primary survey.
Direct manual pressure
Tourniquet: carry a risk of ischemic injury
Do NOT do Blind clamping.
Internal hemorrhage; Four More
Physical examination and imaging;
Chest x-ray, Pelvic x-ray, focused assessment with sonography for trauma [FAST], or diagnostic
peritoneal lavage [DPL].
Chest decompression, and application of a pelvic stabilizing device and/ or extremity splints.
Definitive management may require surgical or interventional radiologic treatment and pelvic and
long-bone stabilization.
Definitive bleeding control is essential, along with appropriate replacement of intravascular
13. Vascular access
Two large-bore peripheral venous catheters (g16 cannula)
Send 5 Blood samples
CBC
Blood gases and/or lactate level
Blood Group/ Xmach
Pt Ptt INR
Toxicology
+/- pregnancy test
Peripheral sites cannot be accessed
Intraosseous infusion, central venous access(Cordis catheter), or venous cutdown.
-Advanced Trauma Life Support Student Course Manual 10th edition
-Schwartz’s Principles of Surgery Eleventh Edition: chapter 7, page 183- 249
14. Aggressive and continued volume resuscitation is NOT a substitute for definitive
control of hemorrhage.
Bolus of 1 L warm (37°C to 40°C) normal saline IV
Unresponsive; activate massive blood transfusion protocol (1:1:1)
Your target is permissive hypotension
Tranexamic acid; best within 1 h of trauma, up to 3 h, followed by 2nd dose infusion
over 8 hours in the hospital.
15. Disability(assessment of neurologic status).
Patient’s level of consciousness and pupillary size and reaction.
Identifies the presence of lateralizing signs.
Determines spinal cord injury level, if present.
GCS
Decrease in a patient’s level of consciousness may indicate:
Decreased cerebral oxygenation and/or perfusion,
Direct cerebral injury
Hypoglycemia, alcohol, narcotics, and other drugs
Call neurosurgeon once a brain injury is recognized
Your main goal to Prevent secondary brain injury by maintaining adequate oxygenation and
perfusion.
16. Exposure/Environmental control
Cutting off his or her garments
Examine the anterior surface
Examine areas that not easy to access; axilla, perineum
Log rolling maneuver; Examine the back, PR.
Cover the patient with warm blankets or an external warming device.
Use only warm IV fluids.
Hypothermia one of the trauma’s lethal triad.
17. Adjuncts to the Primary Survey with
Resuscitation
Physiologic parameters such as pulse rate, blood pressure, pulse pressure,
ventilatory rate, ABG levels, body temperature, and urinary output are assessable
measures that reflect the adequacy of resuscitation. Values for these parameters
should be obtained as soon as is practical during or after completing the
primary survey, and reevaluated periodically.
It is important not to delay transfer to perform an indepth diagnostic evaluation.
19. 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.
History (Allergies, Medications, Past illnesses/Pregnancy, Last meal,
Events/Environment)
Blunt Trauma
Penetrating Trauma
Thermal Injury
Hazardous Environment
20. Physical Examination
Head
Maxillofacial Structures
Cervical Spine and Neck
Chest
Abdomen and Pelvis
Perineum, Rectum, and Vagina
Musculoskeletal System
Neurological System
29. -Resuscitative endovascular balloon occlusion of the aorta: current evidence Open Access Emerg Med. 2019; 11: 29–38. Published online 2019 Jan 14. doi: 10.2147/OAEM.S166087
-Sridhar, Srikanth MD*; Gumbert, Sam D. MD*; Stephens, Christopher MD*; Moore, Laura J. MD†; Pivalizza, Evan G. MBChB, FFASA* Resuscitative Endovascular Balloon Occlusion of the Aorta: Principles, Initial Clinical Experience, and Considerations for
the Anesthesiologist, Anesthesia & Analgesia: September 2017 - Volume 125 - Issue 3 - p 884-890 doi: 10.1213/ANE.0000000000002150
Resuscitative endovascular
balloon occlusion of the
aorta (REBOA)
30. ABDOMINAL AND PELVIC TRAUMA
Blunt
Spleen (40% to 55%)
Liver (35% to 45%)
Small bowel (5% to 10%)
Retroperitoneal hematoma
Pelvic Fractures
Penetrating
Stab wounds
Liver (40%), Small bowel (30%),
Diaphragm (20%), colon (15%)
High-energy low-energy
gunshot wounds
small bowel (50%), colon (40%),
liver (30%), and abdominal
vascular structures (25%).
33. References
Advanced Trauma Life Support Student Course Manual 10th edition
Journal of Trauma Nursing April/June 2006, Volume:13 Number 2 , page 41-44
https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries
Gunst M, Ghaemmaghami V, Gruszecki A, Urban J, Frankel H, Shafi S. Changing epidemiology of trauma deaths leads to a bimodal distribution. Proc
(Bayl Univ Med Cent). 2010 Oct;23(4):349-54. doi: 10.1080/08998280.2010.11928649. PMID: 20944754; PMCID: PMC2943446.
CDC, MMWR, Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage, 2011
Austin N, Krishnamoorthy V, Dagal A. Airway management in cervical spine injury. Int J Crit Illn Inj Sci. 2014 Jan;4(1):50-6. doi: 10.4103/2229-5151.128013.
PMID: 24741498; PMCID: PMC3982371.
Schwartz’s Principles of Surgery Eleventh Edition: chapter 7, page 183- 249
Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC,
Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan
1;80(1):6-15. doi: 10.1227/NEU.0000000000001432. PMID: 27654000.
Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension N Engl J Med 2016; 375:1119-1130, DOI: 10.1056/NEJMoa1605215
https://www.grepmed.com/images/2422/echocardiogram-tamponade-clinical-cardiac-pocus
Resuscitative endovascular balloon occlusion of the aorta: current evidence Open Access Emerg Med. 2019; 11: 29–38. Published online 2019 Jan
14. doi: 10.2147/OAEM.S166087
Sridhar, Srikanth MD*; Gumbert, Sam D. MD*; Stephens, Christopher MD*; Moore, Laura J. MD†; Pivalizza, Evan G. MBChB, FFASA* Resuscitative
Endovascular Balloon Occlusion of the Aorta: Principles, Initial Clinical Experience, and Considerations for the Anesthesiologist, Anesthesia & Analgesia:
September 2017 - Volume 125 - Issue 3 - p 884-890 doi: 10.1213/ANE.0000000000002150
34. Thank you
Supervised by:
Prof. Mahmoud Abu-Ebeeleh
Cardiothoracic surgery consultant
Done by:
Dr. Faisal Rawagah
Critical Care Fellow
Jordan University Hospital 17.03.2022