TRAUMA

ATLS TRIAGE

Dr. Murali. U. M.S; M.B.A

Learning Outcomes• Trauma is the commonest cause of death in the Trauma

• Describe the principles & concepts of triage in management of injured patient based on the mechanisms of injury

• List the types & phases of triage

• Discuss the principles of primary & secondary surveys in the assessment & management of trauma

Introduction

• In all regions of the world, adults over the age of 70 years,particularly females, have significantly higher fall-related mortality rates than younger people.

• However, children account for the largest morbidity –almost 50% of the total number of disability adjusted

life-years (DALYs) lost globally to falls occur in children

under 15 years of age. .

Introduction

• With ever increasing population growth and increased life expectancy, the injury mortality and morbidity statistics are likely to be skewed towards the two ends of the age spectrum,

making the pediatric and the elderly very important with

respect to global health care and economics.

Trauma - Types

• In essence, trauma can be divided into two basic types:

• Serious and life-threatening injury

• Significant trauma requiring treatment but not

immediately life threatening.

• While it is acknowledged that the two can and often do overlap.

InTrauma - Types

* Multiple casualties - Here, the number and severity of injuriesdo not exceed the ability of the facility to render care. Priorityis given to the life-threatening injuries followed by those withpolytrauma.

* Mass casualties - The number and severity of the injuriesexceed the capability and facilities available to the staff. In thissituation, those with the greatest chance of survival and the least expenditure of time, equipment and supplies are prioritised.

Protocol

• The Advanced Trauma Life Support (ATLS) system was therefore created initially in the USA and rapidly taken up globally.

• At present, over 40 countries worldwide are actively providing the ATLS course to their physicians.

Mechanism of Trauma

• Blunt Trauma – Direct or indirect blunt injury can occur. Seat belt reduces the blunt injury in vehicles.

• Penetrating injury – severity depends on the extent of deeper injury.• Blast injury. • Crush injury – earthquake, industrial accidents, and train accidents –

causes crush syndrome, compartment syndrome. • Burn injury. • Injury in alcohol patients.

Concepts - Trauma Management

• Concept of “ golden hour “ to treat the trauma patient is important.

• Multidisciplinary approach

• Planning, setting up, organizing, team work.

• Assess respiratory system; circulation; breathing areas – as priority.

• Assess also whether patient is haemodynamically stable or unstable.

• Arrange fluids, blood, catheters, ventilator etc.

• Further definitive therapy depending on severity and site of injury.

TRIAGE

WHAT IS TRIAGE?

WHY DO WE DO IT?

PRINCIPLE GOAL OF TRIAGE IS:

TO DETERMINE , WHO SHOULD

BE SEEN FIRST!!!!

A second major goal

• Not just sort but also stream

• To get the right patients to the right resources in the right place , and at the right time….

Definition

a Process of prioritizing patients based on the severity of their condition.

OR

A medical classification process of priority of emergency care of simultaneous multiple patients in function of rear

available care resources.

ORIGINTerm comes from the

French verb

‘trier’,

Means to separate /sort / shift or select.

In Triage - Phases

• Triage is an important concept in modern health-care systems & three essential phases have developed:

* pre-hospital triage – in order to despatch

ambulance and prehospital care resources

* at the scene of trauma

* on arrival at the receiving hospital

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ADVANCE TRAUMA LIFE SUPPORT

Objective

• Identify the correct sequence of priorities for assessment of amultiple injured pt.

• Apply the principles outlined in primary and secondaryevaluation surveys of ATLS.

• Apply guidelines and techniques in the initial resuscitative anddefinitive care phases of treatment.

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T ADVANCE TRAUMA LIFE SUPPORT

Initial assessment

Primary survey

Secondary survey

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TA T L S

Initial assessment

Primary survey

Secondary survey

• Initial assessment of the casualty• Time interval• Then proceed to the basic ATLS

procedure i.e. (in short) ABCDE

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Initial assessment

Primary survey

Secondary surveyBreathing

AIRWAY

Circulation f

Disability

Exposure

•Confirmation • If patient talks normally, airway not compromised• Hoarse voice or audible breathing, suspicious

Assess the patient for airway obstruction (coma)Agitation--------------- hypoxiaCyanosis---------------- hypoxemia, secondary to inadequate oxygenationHoarseness,----------- suspected laryngeal fractures/c emphysema& palpable fracture

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Initial assessment

Primary survey

Secondary surveyBreathing

AIRWAY

Circulation f

Disability

Exposure

• Established maintenance of airway through either of the two---Head tilt-chin lift---Jaw thrust

JAW THRUST•Rescuer fingers are placed behind the posterior border of the ramus of the mandible•Displace the mandible forward, dislocating it while tilting the head backward•Retract the lower lip with the thump

JAW THRUST

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TA T L S

Initial assessment

Primary survey

Secondary surveyBreathing

AIRWAY

Circulation f

Disability

Exposure

• If debris ( broken tooth, dentures) is present, remove it by—Finger sweep

technique or--Yankauer suction or

-- Magill’s forceps (for large object)

• If ---no foreign body is visible, endotracheal tube should be used to secure theestablished airway

--- If the foreign body cannot be removed quickly or the vocal cords cannot beadequately visualized or endotracheal intubation is not possible, thencricothyroidotomy is indicated•

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Yankauersuction

Magill’s forcepsCRICOTHYROIDOTOMY

A T L S

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TA T L S

Initial assessment

Primary survey

Secondary surveyBreathing

AIRWAY

Circulation f

Disability

Exposure

• In patient sustaining significant blunt injury, should be assume to have cervical spine injury, until prove other-wise•--- such pt. should have cervical spineimmobilized with semi rigid cervical collar and bilateral sand bags or block joined with tapes or straps across the forehead

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semi rigid cervical collar

block joined with tapes or straps across the forehead

BREATHING

Airway

Circulation f

Disability

Exposure

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Initial assessment

Primary survey

Secondary survey

•Conditions that acutely compromised breathing are--

• Tension pneumothorax• Massive hemothorax• Flail thorax accompanied bypulmonary contusion• open pneumothorax compromise breathing

•Such condition can be diagnosed with physical examination & should be treated immediately•It can be treated with endotracheal intubation, mechanical ventilation, needle thoracocentesis, or tube thoracostomy.

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NEEDLE THORACOCENTESIS TUBE THORACOSTOMY

A T L S

Breathing

Airway

CIRCULATION

Disability

Environment & exposure

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Initial assessment

Primary survey

Secondary survey

•Circulatory problems in trauma patients are usually caused by hemorrhage•First action is to stop bleeding

•For ---Intra oral bleeding-----------------bite a cotton swapTongue laceration------------------deep suture across the lacerationBleeding from fracture-----------manually reducing and brittle wiring of the fracture fragments mandible endMobile maxilla---------------------rubber mouth gagsSoft tissues of head & neck----direct pressure on the bleeding siteTorrential bleeding from--------epistat tube with anterior and posterior balloonsthe nasopharynx region

Breathing

Airway

Circulation f

DISABILITY

Environment & exposure

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Initial assessment

Primary survey

Secondary survey

• Assessment of the neurological status. The Glasgow coma score (GCS)

• worst score is 3 points• GCS can be caused by a focal brain injury• Optimal oxygenation and circulation are important to prevent secondary injury to the brain • Impaired consciousness can be caused by hypoxia or hypotension for which ABC stabilization is essential

•Patients who open their eyes spontaneously, obey commands, and are normally oriented score a total of 15 points

Breathing

Airway

CIRCULATION f

Disability

EXPOSURE

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Initial assessment

Primary survey

Secondary survey

• Represent HypothermiaBurns, andPossible exposure to chemical and radioactive substance

Should beevaluated and treated

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Initial assessment

Primary survey

Secondary survey

• Under this the pt. is examined from head to toe• Appropriate additional radiographs of the thoracic and lumbar spine and the extremities are performed when indicated. • CT scans, when indicate

•Secondary survey mnemonics•Head/skull Has •Maxillofacial My •Cervical Spine Critical •Chest Care•Abdomen Assessed •Pelvis Patient's •Perineum Priorities •Orifices Or•Neurological Next •Musculoskeletal Management •Diagnostic tests/ Decision? Definitive care

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TRE-EVALUATION

IF, DURING THE SECONDARY SURVEY, THE PATIENT'S CONDITION DETERIORATES, THE PRIMARY SURVEY SHOULD BE REPEATED

BEGINNING WITH “A”.

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ADVANCE TRAUMA LIFE SUPPORT

Analgesia

Documentation & Legal

Definitive care

Triage at an accident scene is performed by a paramedic or an emergency physician,using the four-level scale of

Cannot wait

Has to waitCan wait

LostNo chance of survival

category meaning consequences examples

T1 (I) acute danger for lifeimmediate treatment, transport as soon as

possible

arterial lesions, internal haemorrhage, major

amputations

T2 (II) severe injuryconstant observation and rapid treatment,

transport as soon as practical

minor amputations, flesh wounds, fractures

and dislocations

T3 (III) minor injury or no injurytreatment when practical, transport and/or

discharge when possibleminor lacerations, sprains, abrasions

T4 (IV) no or small chance of survivalobservation and if possible administration of

analgesics

severe injuries, uncompensated blood loss,

negative neurological assessment

T5 (V) deceasedcollection and guarding of bodies,

identification when possible

dead on arrival, downgraded from T1-4, no

spontaneous breathing after clearing of airway

References

• Bailey & Love’s - Short Practice of Surgery

26th edition.

• Internet websites.