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ASSESSMENT AND MANAGEMENT OF MAJOR INJURIES AND ADVANCED TRAUMA LIFE SUPPORT[ATLS]

By; DR PAUL K NHIGA YEAR 2 OT RESIDENT KCMC

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BACKGROUND

• The Advanced Trauma Life Support[ATLS] course arose from the zeal and passion of a small group of surgeons intent on improving patient care.

• In 1976,when orthopedic surgeon Dr James Styner encountered a woefully inadquate response to the needs of his children injured in a light plane crash in rural Nebraska,he was compelled to take action.

• He spurred the development of an organized systematic approach to the evaluation and care of the injured patients

• Recently retired Director of Member Services for the American College of Surgeon,Paul “skip”Collicott MD,FACS,joined forces with his then colleague Dr Styner and the movement called “Advanced Trauma Life Support” was born.

• In short order,it was adopted by the committee on trauma and since then,the course has been developed and refined year after year,decade after decade,in that same spirit of dedication kindled by its founders.

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• In 1980,was the 1st exposure for David B.Hoyt,MD,FACS to ATLS as a resident.The instructor course was conducted by Paul “skip”Cllicott,MD,FACS and his fellow students.Over the next year or two,they trained everyone in Diego,and this became the language and glue for San Diego Trauma System.

• Also,The American College of Surgeons[ACS]was found to improve surgical patients care.

• The Committee on Trauma [COT],Sponsors and contributes to the continued development of ATLS Program,however,injured patients presents with a wide range of complex problems,The ATLS Presents a concise approach to assessing and managing multiply injured patients.

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PRIMARY SURVEY• Patients are assessed and treatments are initiated based on their

injuries,vitals signs and mechanisms of injuries.• In severely injured patients,logical and sequential treatment

priorities must be established based on overoll patient assessments• The pt’s vital functions must be assessed quickly and efficiently.This

consists of rapid primary survey,resuscitation of vital functions,a more detailed secondary survey and initiation of a definitive care

• It includes of A,B,C,D and Es• A-Airway maintanance with cervical spine protection• B-Breathing and Ventilation• C-Circulation with hemorrhage control• D-Disability-Neurological status• E-Exposure/Enviromental control;completely undress the patient but

prevent hypothermia

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What is a quick,simple way to assess a patient in 10 seconds?

• A quick assessment of the A,B,C,and D in a trauma patient can be conducted by identifying oneself,asking the patient for his or her name and asking what happened

• An appropiate response suggests that,there is no major airway compromise[ability to speak clearly],Breathing is not severely compromised[Ability to generate air movements to permit speech],and there is no major decrease in level of consciousness[alert enough to describe what happened]

• Failure to respond to these questions suggests abnormalities in A,B or C

• During the primary survey,life threatening conditions are identified in a prioritized sequence based on the effects of the injuries on the patients physiology because it is frequently not possible to initially identify the specific anatomic injuries.

• To perform effectively,the members of such a team must constantly communicate each other under a tea leader.

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SPECIAL POPULATIONS• These include;Children,Pregnant females,Older adults,Athletes and Obese patients.• Priorities of care of paediatrics patients are the same like those of adults,but differs in

anatomical and physiological aspects;the quantities of blood,fluids and medications;size of the child;degree and rapidity of heat loss and injury pattern may differ.The assessment and Management priorities are identical.

• Priorities for the care of pregnant woman are similar to those nonpregnant,but the anatomic and physiologic changes of pregnant can modify the patients response to injury.

• Trauma is common cause of death in the elderly,although CVD and Ca overtake the incidence of injury.The aging process diminishes the physiologic reserve of elderly trauma pts and chronic cardiac,respiratory and metabolic disease can impair their ability to respond to injury in a same manner like young patients.

• Comorbidities like DM,CHF,CAD,OPD,LIVER DISEASE,COAGULOPATHY AND PERIPHERAL VASCULAR DISEASE may adversly affect outcome during injury.

• Obese patients pose a particular challenge in the trauma setting,as their anatomy can make procedures like intubation difficult and hazardous

• Because of their excellent conditioning,Athletes may not manifest early signs of shock,such as Tachycardia and Tachypnoea.

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A.AIRWAY MAINTANANCE WITH CERVICAL SPINE PROTECTION

• Is the initial evaluation of a trauma pt,the airway must be assessed first to ascertain patency.

• For signs of airway obstruction,asssessment includes suctioning,inspection for foreign bodies and fractures of face,mandibles and trachea or larynx.Measures to keep the air way patenty must be established while protecting the cervical spine.

• If the patient is able to communicate verbally,the airway is not likely to be in immediate jeopardy,but assessment must be done repeatdly.

• Pts with severe head injury,GCS<8,usually require the placement of a definitive airway[secured tube in trachea]

• In children,knowledge of the unique anatomic features of the position and size of the larynx as well as special equipments is required.

• Avoid excessive movements of the cervical spine and the patients head and neck shouldn’t be hyperextended,hyperflexed or rotated

• Neurological examination alone doesn’t exclude cervical spine injury but imaging like MRI and CT Scan and spine xrays can support the dignosis

• Initially,protection of the patients spinal cord with appropriate immobilisation devices must be accomplished and maintained.

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B.BREATHING AND VENTILATION

• Adquate gas exchange is required to maximize oxygenation and co2 elimination.

• Ventilation requires adquate functioning of the lungs,chest wall and diaphragm.

• Each component must be rapidly examined and evaluated.• Pts neck and chest should be exposed to adquately assess jugular venous

distension,position of the trachea and chest wall• Auscultation should be performed to ensure gas flow in the lungs.• Visual inspection and palpation can detect injuries to the chest which can

compromise ventilation.• Injuries that severely impair ventilation in the short term includes TENSION

PNEUMOTHORAX,FLAIL CHEST WITH PULMONARY CONTUSION,MASSIVE HEMOTHORAX AND OPEN PNEUMOTHORAX.

• These injuries should be identified during the primary survey and they may need immediate attention.

• Simple hemo or pneumothorax,fractured ribs and pulmonary contusion can compromise ventilation to a lesser degree and are usually identified during the secondary survey.

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C.CIRCULATION WITH HEMORRHAGE CONTROL

• Circulatory compromise in trauma patients can results from many different injuries.Blood volume,Cardiac Output and bleeding are major issues to consider.

• 1.BLOOD VOLUME AND CO• After injury,hemorrhage is the predominant cause of preventable deaths.• Identifying and stopping hemorrhage are therefore crucial steps in the assessment

and management of such pts.• Rapid and accuracy assessment of an injured pts hemodynamic status is essential• The elements of clinical observation that yield important information within seconds

are level of consciousness,skin colour and pulse.

• A.LEVEL OF CONSCIOUSNESS• Low blood volume=Low cerebral perfusion=Altered levels of counsciosness• However,a consciuos pt also may have lost a significant amount of blood

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2.BLEEDING

• The source of bleeding can either be internal or external• External hemorrhage is identified and managed during the primary

survey• Rapid,external blood loss is managed by direct manual pressure to

the wound• Tourniquets are effective in massive exsanguination from an

extremity but carry a risk of ischemic injury to that extremity and should only be used when direct pressure is not effective

• The use of hemostats can result in damage nerves and veins• The major areas of internal hemorrhage are the

chest,abdomen,pelvis,retroperitoneum and long bones.• The source of bleeding are identified by physical exams and

imaging eg CXR,PELVIC XRAY AND USS• RX is chest compresion,pelvic bindres,splint application and surgical

means

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D.DISABILITY[NEUROLOGICAL EVALUATION]

• Perfomed at the end of the primary survey• It establishes the patients level of

consciousness,pupillary size and reaction,lateralizing signs and spinal cord injury level.

• The GCS is a simple and quick method for determining the level of consciousness

• Low GCS=Low level of consciousness=Low cerebral oxygenation or perfusion=Brain injury

• This needs immediate re-evaluation of the pt oxygenation,ventilation and perfusion status.

• Prevention of secondary brain injury by maintaining adquate oxygenation and perfusion are the main goals of initial managements.

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E.EXPOSURE AND ENVIROMENT CONTROL

• The pt should be completely undressed’usually by cutting off his/her garments to facilitate a thorough exam and assessment

• After undressing the pt and the assessment is done,the pt should be covered with warm clothes or warm devices to prevent hypothermia.

• IV fluids should be warmed before being given to the pt and a warm enviroment must be maintained.

• The pts body temp is more important than the comfort of the health care providers.

• RESUSCITATION• Resuscitation and the management of life threatening injuries as they are identified are

essential to maximize pt survival• It also follows the ABCs sequence.

• ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION• Adjuncts that are used during the primary survey includes ELECTROCARDIOGRAPHIC

MONITORING,URINARY AND GASTRIC CATHETERS• Other monitoring are VENTILATORY RATE,ARTERIAL BLOOD GAS LEVELS,PULSE

OXIMETRY,BLOOD PRESSURE AND XRAY EXAMINATIONS.

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CONSIDER NEED FOR PATIENT TRANSFER

• During the primary survey and resuscitation phase,the physician obtains enough information to indicate the need to transfer the pt to the another facility

• This can also be initiated by the administrative personnel received the order from the physician who is by that time on resuscitation sessions

• After confirming the transfer issues,communication between the reffering and receiving doctors is essential.

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SECONDARY SURVEY• This doesn’t begin until the primary survey[ABCDEs]is

completed,resuscitative efforts are underway and the normalization of vital functions has been demonstrated

• When additional personnel are available,part of the secondary survey may be conducted while the other personnel attend to the primary survey

• Is a head to toe evaluation of the trauma pt,that is,a complete history and physical exam,including reassessment of all vital signs.

• Each region of the body is completely examined• Missing or failure to appreciate an injury is common especially in

unresponsive or unstable pts.• A complete neurological exam,xrays and special procedures and lab

studies are repeated.• Complete pt evaluation requires repeated examinations

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B.SKIN COLOUR

• Helps in assessment to an injured patient with hypovolemia• A pt with pink skin,especially in the face and extremeties,rarely has

a critical hypovolemia after injury.• Patient with hypovolemia may have ashen,gray facial skin and pale

extrimities.

• C.PULSE• The pulse,typically an easilly accessible central pulse eg femoral

or carotid artery,should be assessed bilaterally for quality,rate, and regularity

• Full,slow and regular peripheral pulses are usually signs of normovolemia=not taking beta blockers

• A rapid,thready pulse=hypovolemia,but a normal pulse rate doesn’t necessarily mean nomovolemia

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HISTORY• Every complete medical assessment includes a history of the mechanism of injury.Often,such a history cant be obtained from patient sustained a traumaPrehospital and family personnels are consulted to obtain the

information that can enhance the understanding of pts physiological status.

The AMPLE history is a useful mnemonic for this purposeA=AllergiesM=Medications currently usedP=Past illnesses/PregnancyL=Last mealE=Events/Environment related to the injury

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PHYSICAL EXAMINATION• Follows the sequence ofhead,maxillofacial structures,cervical spine and

neck,chest,abdomen,perineum/rectum/vagina,musculoskeletal system,and neurological system.

• 1.HEAD• It begins with evaluating the head and identifying all related neurologic

injuries and other significant injuries• The entire scalp and head should be examined for lacerations,contusions

and evidence of fractures.• Because edema around the eyes can later preclude an in depth

examination,the eyes should be re evaluated for ;• Visual acuity• Pupillary size• Hemorrhage of the conjuctiva or fundi• Penetrating injury• Contact lenses • Dislocation of the lens• Ocular intrapment

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2.MAXILLOFACIAL STRUCTURES

• Examination of the face should include palpation of all bony structures, assessment of occlusion, intraoral examination,and assessment of soft tissues.

• 3.CERVICAL SPINE AND NECK• Pts with maxillofacial or head trauma should be

presumed to have an unstable cervical spine injury eg fracture or ligament injury

• The neck should be immobilized until all aspects of the cervical spine have been adquately studied and an injury has been excluded.

• The neck should be inspected,palpated and auscultated.

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4.CHEST

• Visual evaluation of the chest,both anterior and posterior can identify conditions such as open pneumothorax and large flail segments

• A complete evaluation of the chest wall requires palpation of the entire chest cage like clavicles,ribs and sternum

• Sternal pressure can be painful if the sternum is fractured

• Significant chest injury can manifest with pain, dyspnea and hypoxia

• Evaluation includes auscultation of the chest and chest xray.

• Chest xray may confirm the presence of hemothorax or simple pneumothorax

• Ribs fracture may be present

• A widened mediasternum or other radiographic signs can suggest an aortic rupture

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5.ABDOMEN• Abdominal injuries must be identified and treated aggressively.• The specific diagnosis is not as important as recognising that an injury exists that

requires surgical intervention• A close observation by the same observer is important as changes can occur at

anytime in blunt injuries• Early involvement of a surgeon is essential• Fractures of pelvis and lower rib cage can hinder accurate • diagnostic exam of the abdomen• Abdominal ultrasonography or CT can be the diagnostic tools.

• 6.PERINEUM,RECTUM AND VAGINA• Should be examined for Contusions, lacerations or hematomas and urethral bleeding• Rectal exam may be performed before placing a urinary catheter• A physician should assess for presence of blood within bowel lumen,a high riding

prostate, pelvic fracture the integrity of the rectal wall and the quality of sphincter tone• Vaginal examinations should be performed in pts who are at high risk of vaginal

injury, including all women with a pelvic fracture• Presence of blood in vagina vault and vagina lacerations should be examined• Pregnant tests should be performed on all females of chil bearing age.

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6.MUSCULOSKELETAL SYSTEM

• Should be inspected for contusions and deformities

• Pelvic fractures can be suspected by ecchymosis over the iliac wings ,pubis, labia or scrotum

• Pain on palpation of the pelvic ring is an important finding in an alert pt

• Assessment of peripheral pulses can identify vascular injuries

• Significant extremity injuries can exit without fractures being evident on exam or x-rays

• Ligament ruptures produce joint instabilities

• Nerve injuries or ischemia may impaire sensation or loss of voluntary muscles

• Thoracic and lumbar spine fractures or neurologic injuries must be considered based on physical exam and mechanisms of injury

• The musculoskeletal examination is not compete without an examination of the back

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7.NEUROLOGICAL SYSTEM

• The GCS Score facilitates detection of early changes and trends in the neurological status

• Early consultation with a neurosurgeon is required for pts with head injury

• Pts should be closely monitored for a deterioration in level of consciousness and changes in the neurological examination.

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ADJUNCTS TO A SECONDARY SURVEY

• How can I minimize missed injuries?• By maintaining high index of suspicion and providing continous monitoring

of the patients status• By specialized diagnostic tests to identify specific injuries

• REEVALUATION• Trauma pts must be reevaluated constantly to ensure that new findings are

not overlooked and to discover deterioration in previously noted findings• A high index of suspicion facilitates early diagnosis and management• Continuous monitoring of vital signs and urinary out put is essential

• DEFINITIVE CARE• Which patients do i transfer to a higher level of care?when should the

transfer occur?• Transfer should be considered whenever the patients treatment needs

exceed the capability of the receiving institution• This decision requires a detailed assessment of the patients injuries and

capabilities of the institution,including equipments ,resources and personnel

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DISASTER

• Frequently overwhelm local and regional resources

• Plans for managements of such conditions must be developed,reevaluated and rehearsed frequently to enhance the possibility of saving the maximum no.of injured patients

• ATLS providers should understand their role in disaster managements

• They should also remember the principles of ATLS relevant to pts care.

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RECORDS AND LEGAL CONSIDERATIONS

• Specific legal considerations,including records,consent for tretment and forensic evidence are relevant to ATLS providers

• RECORDS• Includes documenting the time for all events• Helps the practitioner to evaluate the pts needs and

clinical status• Helps during resuscitation• Helps during medicolegal problems arise• Helps the attending doctor to assess changes in the

patients condition quickly

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CONSENT FOR TREATMENT

• Is sought before treatment if possible• During emergencies,it is done after treatment

• FORENSIC EVIDENCE• If criminal activity is suspected,the personnel

caring the patient must preserve the evidence• All items,such as clothes and bullets must be

saved for law enforcement personnels• Lab determinations of blood alcohol

concentrations and other drugs may have legal implications.

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TEAMWORK

• In many centers, trauma pts are assessed by a team ,the size and composition of which varies from one institution to another

• In order to perform effectively, one team member should assume the role of a team leader.

• The team leader supervises, checks and directs the assessment.

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REFERENCES

• 1.AMERICAN COLLEGE OF SURGEONS COMMITTEE ON TRAUMA,2006

• 2.ADVANCED TRAUMA LIFE SUPPORT STUDENTS COURSE MANUAL,9TH EDITION

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• THANK YOU FOR YOUR ATTENTION