Post on 08-Jul-2016
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ADVANCED TRAUMA AND LIFE SUPPORT (ATLS)
OBJECTIVE Identify the correct sequence of priorities
for assessment of a multiply injured pt. Apply the principles outlined in primary
and secondary evaluation surveys of ATLS.
Apply guidelines and techniques in the initial resusitative and definitive care phases of treatment.
ATLS PREPARATION AND TRIAGE. PRIMARY SURVEY RESUSITATION ADUNCTS TO PRIMARY SURVEY CONSIDER NEED FOR PATIENT TRANSFER SECONDARY SURVEY ADJUCTS TO SECONDARY SURVEY CONTINUED POSTRESUSITATION AND
REEVALUATION OF THE PATIENT. DEFINITIVE CARE.
PREPARATION
•PREHOSPITAL PHASE
•HOSPITAL PHASE
PREHOSPITAL PHASE:Coordination with the prehospital agency and personel can greatly fasten the treatment in the field. They inform the receiving hospital which mobilizes the trauma team to ED.
HOSPITAL PHASEAdvance planning for the trauma pt. beneficial. It saves time.
TRIAGE
The process of categorizing victims or mass casualties based on their need for treatment and the resources available.
ITS MAIN GOALS ARE. Prevent avoidable deaths. Ensure proper initial treatment with a
minimal time frame. Avoid misusing assests on hopeless cases.
Field Triage- Color Coding
Triage- sorting of patients by injury severity and need for transport
RED-most critically injured-immediate transfer to hospital
YELLOW-less critically injured-delayed transfer to hospital without endangering life
GREEN-No life/limb threatening injury- patient ambulatory-may not need IP treatment
BLACK- Dead patient
Multiple casualties No. of patients and the severity of their
injuries do not exceed the ability of the facility to provide care.
MASS CASUALTIES The no. of patients and the severity of
their injuries exceed the ability of the facility to provide care.
Roles of the Trauma Team
Roles of the Trauma TeamAirway
Nurse
BossAttending
Team Member
Team Member
Nurse
PRIMARY SURVEYWhat is the quick ,simple way to assess
the trauma patient in 10 seconds?A complete sentence spoken by pt. tells
us:
1. Airway is patent.2. Breathing intact.3. Good cerebral circulation.
AIRWAY MAINTAINENCE WITH C-SPINE PROTECTION
Assess for obstruction, foreign bodies, facial fractures, bleeding causing airway compromise… begin measures to establish airway.
PITFALLS
Recognize impending obstruction early before intubation becomes too difficult.
If unable to control airway surgical airway is must. Unknown tracheal or laryngeal disruption.
Simple maneuvers Chin lift Jaw thrust Suction Oropharyngeal and nasopharyngeal
airway Laryngeal mask airway Laryngeal tube airway Gum elastic bougie. Definitive airway Surgical airway.
INDICATIONS OF DEFINITIVE AIRWAY
UNCONCIOUS GCS <8 RISK OF ASPIRATION RISK OF IMPENDING OBSTRUCTION.
BREATHINGInspectionAuscultationPalpationPercussion Identify and manage life threatening problems first• Tension pneumothorax• Cardiac temponade• Massive hemothorax• Open pneumothorax• Flail chest with pulmonary contusion
maneuvers Bag and mask ventilation Needle thoracocentesis Pericardiocentesis Chest tube intubation
water seal drainage Definition Indication Purposes Site for chest tube insertion Type of water seal drainage
system FUNCTION OF PLEURAL DRAINAGE
SYSTEM PRINCIPLES OF THE CHEST TUBE Nursing Responsibilities
water seal drainage
Definition
Water seal drainage system is a closed chest drainage system used to allow air and fluid to escape from the plural space with each exhalation and to prevent their return flow with each inhalation
water seal drainage
water seal drainage
Water seal means that the water in the bottle seals off the atmospheric air thus prevents the entering of air or fluid back into the pleural space.
Indication1. Traumatic pneumothorax2. Hemopneumothorax3. Spontaneous pneumothorax4. Iatrogenic pneumothorax5. Broncho-pleural fistula6. Emphysema7. Malignancy8. Pleural effusion9. Thoracic or thoraco-abdominal surgeries
water seal drainage
water seal drainagePurposes
To permit drainage of air and fluid from the pleural cavity
To establish normal negative pressure in the pleural cavity for lung expansion
To equalize pressure on both sides of the thoracic cavity
To provide continuous suction to prevent tension pneumothorax
water seal drainageSite for chest tube insertion
1. Thoracic surgery. 2 chest tube are inserted –
Anterior chest tube Posterior chest tube
water seal drainageSite for chest tube insertion
Anterior chest : Upper/anterior chest wall Inserted in the 2nd Intercostal space to remove the air
arising from the pleural cavityPosterior chest tube : Placed at the posterior chest in the 8th or 9th Intercostal
space at the mid-Axillary line. Indication to remove sero-sangeneous fluid at the lower
area of pleural cavity Diameter of tube in the lower section is wider or longer
compare to the upper tube.
water seal drainageSite for chest tube
insertion2. Pneumothorax : Tube placed at the 2nd
or 3rd Intercostal space along mid-clavicle or anterior Axillary line.
water seal drainageSite for chest tube
insertion(ATLS,2012) : Nipple level (5th intercostal
space), anterior to mid-axillary line) just over the top of the rib
water seal drainageSTEPS
(ATLS,2012) : After identifying the insertion
site, sterile draping and locally anesthetize skin until rib periosteum
2-3 cm transverse incision (through the rib)
Puncture parietal pleura with the tip of clamp. With gloved finger avoiding injury to other organs and clearing any adhensions, clots.
water seal drainageSTEPS
(ATLS,2012) : Advance the tube entering into
pleural space with clamp (directed posteriorly)
Connect the end of the tube to underwater-seal apparatus
Suture the tube (can be performed earlier before entering tube)
Evaluate (see aftertreatment)
water seal drainage
Chest Drainage System
1 bottle 2 bottles 3 bottles Pleurovac
water seal drainageTYPES OF SYSTEM - 1 BOTTLE DRAINAGE
TYPES OF SYSTEM - 2 BOTTLE DRAINAGE
water seal drainage
TYPES OF SYSTEM - 3 BOTTLE DRAINAGE
water seal drainage
FUNCTION OF PLEURAL DRAINAGE SYSTEM
water seal drainage
Inspiration
Intrapleural pressure
Air and fluid move into bottle
Pleural space becomes negative
Lungs reexpand
water seal drainagePRINCIPLES OF THE CHEST TUBE
1. Gravity
2. Under water seal
3. Suction
water seal drainagePRINCIPLES OF THE
CHEST TUBE1. Gravity
Enhances flow from high to low
Chest drain is placed below client’s bed
water seal drainagePRINCIPLES OF THE CHEST TUBE
2. Under Water Seal Is a barrier to prevents backflow into pleural
space. Rod – depth determines the negative
pressure Air bubbles is released through the rod Air vent – to allow drained air to escape to
prevent pressure build up
water seal drainagePRINCIPLES OF THE CHEST TUBE
3. Suction Is a pull force MUST be in another bottle
Purpose for the suction is, when :i. - gravity drainage is not enough.ii. - patient’s respiration and cough are too weakiii. - air leak is fast into the pleural spaceiv. - need to speed up removal from pleural space
water seal drainageFactors affecting water seal drainage
1. Proper placement of chest catheter2. Proper placement of chest drainage apparatus3. Length of drainage tubing4. Patency of chest tubing5. Maintenance of air tight drainage system6. Position of the client7. Application of mechanical suction8. Activity of the client
water seal drainageFactors affecting water seal drainage
1. Proper placement of chest catheter
• 2 & 3rd intercostal space and 8 &9th intercostal space
• These catheter should be connected to the separate bottle
• When there is single tube it is usually placed in lower intercostal space
water seal drainageFactors affecting water seal drainage
2.Proper placement of drainage apparatus Drainage apparatus should be placed at
lower level then the chest It helps in gravity and also prevent the back
flow of air and fluid into pleural cavity While transferring patient apparatus should
be placed over the bed or trolley after clamping the tubing at two places
water seal drainageFactors affecting water seal drainage
3. Length of drainage tubing Drainage tubing neither too short nor too long It should fall in straight line to the drainage
system There should not be any loop of drainage tubing Too short drainage tubing may restrict the
movement of patient on bed or it may get disconnected from the catheter
water seal drainageFactors affecting water seal drainage
4. Patency of chest tubing Patency of chest tube should be checked frequently Any kink or pressure over chest tubing may obstruct
the flow from pleural space Ensure that patient is not lying over the tubing Any clot or mucus plug in pleural space may also
obstruct the flow Milking the tube helps to dislodge the plug Never clamp the tubing until it is necessary.
water seal drainageFactors affecting water seal drainage
5. Maintenance of air tight drainage system Drainage system should be air tight with
stoppers and all the tubing should be taped well
water seal drainageFactors affecting water seal drainage
6. Position of the client Fowler’s position So that fluid can be localized in lower pleural
space and can be drained out easily
water seal drainageFactors affecting water seal drainage
7. Application of mechanical suctionContinuous and gentle suction is used when :i. - gravity drainage is not enough.ii. - patient’s respiration and cough are too
weakiii. - air leak is fast into the pleural spaceiv. - need to speed up removal from pleural
space
water seal drainageFactors affecting water seal drainage
8. Activity of the client Movement of the patient on bed helps the fluid
to drain from chest. Patient should be encouraged to cough and
deep breath Which helps in rising the intra-pleural and
intra-pulmonary pressure
water seal drainageAFTER TREATMENT : Observe for the fluctuating movement of
fluid inside the tubing Observe the chest drainage Watch for bubbling in water seal bottle Obtain chest x-ray, SaO2, BGA (if
necessary)
CIRCULATION AND HEMORRHAGE CONTROL
Assess for: Shock External bleeding Occult bleeding Estimate the blood loss on initial
presentation of patient and the signs and symptoms
Replace fluid accordingly, 2 litres of warm crystalloid solution.
DISABILITY Glasgow Coma Scale (Eye, Verbal,
Motoric) Pupillary reaction and size
EXPOSURE Undress the patient completely, but
prevent hypothermia (ex: warm infusion) Log-rolling and looking for back of the
pt. is very important.
LOG-ROLLING
ADJUNCTS TO PRIMARY SURVEY AND RESUSSITATION ECG PULSE OXIMETRY Xray chest AP view Xray pelvis AP view URINARY CATHETER GASTRIC CATHETER BLOOD PRESSURE Blood Gas Analysis FAST DPL
NEED TO TRANSFER or REFER?
SECONDARY SURVEYSecondary survey does not begin until the primary survey is
completed,resuscitative efforts are established and patient is demonstrating normalization of vital functions.
It includes: Head to toe evaluation AMPLE history
• Allergy• Medications currently taking• Past illness• Last meal• Event/environment related to injury.
physical examination Reassessment of all vital organs (IMPORTANT Re-
Evaluate Patient General Condition)
Adjucts to secondary survey CT SCAN (brain CT-scan) CONTRAST STUDIES (ex:
arteriography) EXTREMITY X-RAY ENDOSCOPY ULTRASONOGRAPHY (FAST)
POSTRESUSITATION MONITORING AND REEVALUATION
Reevaluation for new finding or overlooked IMPORTANT
Continous monitoring of vital signs. Effective analgesia.
DEFINITIVE CARE AFTER identifying the patients injury. Managing life threatening problems Obtaining special studies. If the patients injuries exceed the
capabilities of the institution refer
Take home message1. ABCDE APPROACH.2. TREAT GREATEST THREAT TO LIFE.3. DEFINITIVE DIAGNOSIS IS NOT
IMMEDIATELY IMPORTANT.4. TIME IS THE ESSENCE.5. DO NO FURTHER HARM THE
PATIENT
THANK YOU