advanced trauma and life support atls

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


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


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


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


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


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


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.


5. Maintenance of air tight drainage system Drainage system should be air tight with

stoppers and all the tubing should be taped well


6. Position of the client Fowler’s position So that fluid can be localized in lower pleural

space and can be drained out easily


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


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

advanced trauma and life support atls

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