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Advanced Trauma Life Advanced Trauma Life SupportSupport

Dr Osama BawazirAssistant Professor , Consultant Pediatric surgeon

FRCSI, FRCS(Ed), FRCS (glas), FRCSC,FAAP,FACS.

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DEFINITION 0F TRAUMA

• A term derived from the Greek for “WOUND”• It refers to any bodily injury.• It defined as tissue injury due to direct effects of

externally applied energy. Energy may be mechanical, thermal, electrical, electromagnatic or nuclear.

• Included:burns, drowning, smoke, inhalation, • slip & fall.• Excluded: poisoning/toxic ingestion.

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TRIMODAL DISTRIBUTION OF TRAUMA DEATHS.

THE FIRST PEAK OF DEATHS OCCURS WITHIN FEW SECONDS TO MINUTES AFTER INJURY(50% OF ALL DEATHS). Virtually inevitable & very little can be done.

•THE SECOND PEAK OCCURS BETWEEN A FEW MINUTES AND AN HOUR AFTER INJURY. Can be reduced by prompt initial care in the pre-hospital phase,by early hospital resuscitation and by prompt and

competent definitive care.This period has been labelled as “THE GOLDEN HOUR”. Management at this time will affect the third peak of deaths.

•THE THIRD PEAKOCCURS SEVERAL DAYS OR WEEKS AFTER THE INITIAL INJURY.

The second and third peaks should be regarded as potentially preventable.

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GENERAL CATEGORIES OF TRAUMA.

DIVIDED INTO THREE CATEGORIES:

•IMMEDIATELY LIFE THREATENING.

AFFECT ABOUT 5%,ACCOUNT FOR 50% OF ALL IN-HOSPITAL TRAUMA DEATHS.

•URGENT.

COMPRISES APPROXIMATELY ABOUT 10-15 % OF ALL PATIENTS.

•NON-URGENT.

APPROXIMATELY 80 % OF ALL INJURIES.

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1. Preparation

2. Triage

3. Primary Survey (ABCDEs)

4. Resuscitation

5. Adjuncts to primary survey & resuscitation

6. Secondary Survey (head to toe evaluation & history)

7. Adjuncts to secondary survey

8. Continued post-resuscitation monitoring & re-evaluation

9. Definite care.

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1. PREPARATION1. PREPARATION

A Pre-hospital phase

Receiving hospital is notified first.

Send to the closest, appropriate facility.

B In Hospital Phase

Advanced planning for the trauma pt arrival.

Method to summon extra medical assistance

Transfer agreement with verified trauma center established.

Protect from communicable disease.

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2. TRIAGE2. TRIAGE

A A Multiple CasualtiesMultiple Casualties

no of severity & pt do not exceed the ability of the facility.

B Mass Casualties

no & severity of pt EXCEED the capability of the facility & staff.

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3. PRIMARY SURVEY3. PRIMARY SURVEY

A :A : Airway with cervical spine protect.

B :B : Breathing

C : C : Circulation --control external bleeding.

D :D : Disability or neurological status

E :E : Exposure (undress) & EEnvironment (temp control)

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PRIMARY SURVEYPriorities for the care of Adult , Pediatrics & Pregnancy women are all the same.

During the primary survey life threatening conditions are identified and management is instituted SIMULTANEOUSLY.

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A. Airway Maintenance with Cervical Spine A. Airway Maintenance with Cervical Spine Protection.Protection.

* GCS score of 8 or less require the placement of definite airway.

*Protection of the spine & spinal cord is the important management principle.

*Neurological exam alone does not exclude a cervical spine injury.

*Always assume a cervical spine injury in any pt with multi-system trauma, especially with an altered level of consciousness or blunt injury above the clavicle.

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B. Breathing & VentilationB. Breathing & Ventilation* Airway patency does not assure adequate ventilation.

C. Circulation with Hemorrhage Control.C. Circulation with Hemorrhage Control.

1. Blood Volume & Cardiac Output

a. level of consciousness.

b. skin color

c. Pulse.

2. Bleeding

*external bleeding is identified & controlled in the

primary survey.

*Tourniquets should not be use.

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D. Disability ( Neurological Evaluation)D. Disability ( Neurological Evaluation)

Simple Mnemonic to describe level of consciousness

A : Alert

V : Responds to Vocal stimuli

P : Responds to Painful stimuli

U : Unresponsive to all stimuli

Not forget to use also Glascow Coma Scale.

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E. Exposure / Environmental ControlE. Exposure / Environmental Control

*It is the pt’s body temp that is most important, not he comfort of the health care provider.

*Intravenous fluid should be warm.

*Warm environment (room tem) should be maintained.

*early control of hemorrhage.

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4. RESUSCITATION4. RESUSCITATIONA. Airway

*definite airway if there is any doubt about the pt’s ability to maintain airway integrity.

B. Breathing /Ventilation/Oxygenation

*every injured pt should received supplement oxygen

C. Circulation

*control bleeding by direct pressure or operative intervention

* minimum of two large caliber IV should be established

*pregnancy test for all female of child bearing age.

* Lactated Ringer is preferred & better if warm.

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5. 5. ADJUNCT TO PRIMARY SURVEY &ADJUNCT TO PRIMARY SURVEY &

RESUSCITATIONRESUSCITATION

A. Electro-cardiographic Monitoring

B. Urinary & Gastric Catheter

1. Urinary catheter.

Urethral injury should be suspected if

*Blood at the penile meatus

*Perineal ecchymosis

*Blood in the scrotum

*High riding or nonpalpable prostate

*Pelvic fracture

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C. Monitoring

1. Ventilatory rate & ABG

2. Pulse oximetry

does not measure ventilation or partial O2 pressure

3. Blood pressure

poor measure of actual tissue perfusion.

D. X-Ray & Diagnostic Studies

C-spine, CXR, Pelvic film

Essential x-ray should not be avoid in pregnant pt.

*** Consider the need for patient transfer.

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6 6 SECONDARY SURVEYSECONDARY SURVEY Does not begin until the primary survey (ABCDEs)

is completed, resuscitative effort are well established

& the pt is demonstrating normalization of vital sign.

* Head to Toe evaluation & reassessment of all vital

signs.

* A complete neurological exam is performed including

a GCS score.

* Special procedure is order.

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History

A : Allergies.

M : Medication currently used.

P : Past illness/ Pregnancy.

L : Last Meal

E : Events/Environment related to the injury.

*blunt trauma/penetrating trauma/injuries due to cold & burn/hazardous environment?

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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION1. Head

Visual acuity

Pupillary size

Hemorrhage of conjunctiva and fundi

Penetrating injury

Contact lenses(remove before edema occurs)

Dislocation of lens

Ocular movement

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2. Maxillofacial Injury

no NG tube, definite airway?

3. Cervical Spine & Neck

*Pt with maxillofacial or head trauma should be presumed to have and unstable cervical spine.

4. Chest

*elderly pt are not tolerant of even relatively minor chest injury.

*Children often sustain significant injury to the intrathoracic structure without evidence of thoracic skeletal trauma.

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5. Abdomen

*excessive manipulation of the pelvic should be avoided.

6. Perineum/rectum/vagina

7. Musculoskeletal

8. Neurologic

* Protection of spinal cord is required at all times until a

spine injury excluded, especially when the pt is transfer.

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7. 7. ADJUNCT TO THE SECONDARY SURVEYADJUNCT TO THE SECONDARY SURVEY

include additional x-ray and all other special procedure.

8. 8. RE-EVALUATIONRE-EVALUATION

Adult urine output 0.5ml/kg/hr

Pediatric urine output 1mg/kg/hr

*Pain relief -- IM should be avoid.

9. DEFINITE CARE9. DEFINITE CARE

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Indication For Definite Airway* Unconscious

* Severe maxillo-facial fracture

* Risk for aspiration : Bleeding/ vomiting

* Risk for obstruction : neck hematoma/laryngeal,tracheal injury/ stridor

* Apnea : Neuromuscular paralysis/unconscious

* Inadequate respiratory effort: tachypnea/hypoxia/hypercapnia/cyanosis

* Severe closed head injury need for hyperventilation

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Normal Blood Amount:Normal Blood Amount:Normal adult blood volume : 7% of body weight

Normal blood volume for child : 8-9% of body weight

Hemorrhage Classification :Hemorrhage Classification :

Class I Hemorrhage : up to 15% loss

Class II Hemorrhage : 15-30% loss

Class III Hemorrhage : 30-40% loss

Class IV Hemorrhage : >40% loss

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3 3 for 1 Rulefor 1 Rule

a rough guideline for the total amount of crystalloid volume acutely is to replace each ML of blood loss with 3 ML of crystalloid fluid, thus allowing for restitution of plasma volume lost into the interstitial & intracellular space

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Initial Fluid TherapyInitial Fluid Therapy

Lactated Ringer is preferredLactated Ringer is preferred

* For adult 1-2 liters bolus

* For child 20ml/kg bolus

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Intraosseous Puncture/InfusionIntraosseous Puncture/Infusion

Children less than 6 y/o for IV access is impossible due to circulatory collapse or for whom percutaneous peripheral venous cannulation had failed on two

attempt.

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Head Injury Classification:

Mild : GCS 14-15

Moderate : GCS 9-13

Severe : GCS 3-8

Coma = GCS score of 8 or less

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Diagnostic Peritoneal Lavage Indication

A. Change in sensorium--Head injury/alcohol/drug.

B. Change in sensation--Spinal cord injury.

C. Injury to adjacent structure--lower

ribs/pelvic/lumbar spine.

D. Equivocal physical examination.

E. Prolong loss of contact with patient anticipated.

*** Positive Test: >100,000 RBC/mm3, >500 WBC/mm3

or Gram Stain with bacteria

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Determining the level of quadriplegia

a. Raise elbow to level of shoulder -- Deltoid C5

b. Flexes the forearm -- Biceps C6

c. Extend the forearm -- Triceps C7

d. Flexes wrist & finger -- C8

e. Spread finger -- T1

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Determine the level of paraplegia

a. Flexes the hip -- Iliopsoas L2

b. Extend knee -- Quadriceps L3

c. Dorsiflexes ankle -- Tibialis anterior L4

d. Plantar flexes ankle -- Gastrocnemius S1

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Thoracic Trauma8 lethal Injury

1. Simple pneumothorax

2. Hemothorax

3. Pulmonary contusion

4. Tracheo-bronchial tree injury

5. Blunt cardiac injury

6. Traumatic aortic disruption

7. Traumatic diaphragmatic injury

8. Mediastinal traversing wounds.

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Fluid Therapy in 2nd or 3rd Degree Burn

Total amount of first 24 hours:

4 ml of Ringer lactate x BW(kg) x BSA

* give 1/2 in first 8 hrs

* 1/2 in remaining 16 hrs

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Referral to Burn Center

* 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y/o

* 2nd or 3rd degree burn > 20% BSA in other age group

* 2nd or 3rd degree burn of face/eye/ear/hands/feet/genitalia/perineum or major joints

* 3rd degree burn >5% in any age group

* Significant electrical/lightning injury

* Significant chemical burn

* Inhalation injury

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Color Codes Triage Tag Color Codes Triage Tag

RED : Most critical injury

YELLOW : Less critical injured

GREEN : No life or limb threatened injury

BLACK : Death or obviously fatal injury

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Priorities with multiple injuriesPriorities with multiple injuries

1. Thoracic trauma or tamponade

2. Abdominal hemorrhage

3. Pelvic Hemorrhage

4. Extremity Hemorrhage

5. Intra-cranial Injury

6. Acute Spinal Cord Injury