MANAGEMENT OF TRAUMA UNDER ATLS PROTOCOL

MODERATOR – PROF. SYED AMJAD ALI RIZVI

M.S., F.R.C.S.(Edin.)

PRESENTORS - DR. NITIN P. KULSHRESTHA

DR. Md. SHAHID ALAM

JUNIOR RESIDENTS

DEPT. OF SURGERY , J.N.M.C.H., A.M.U. ALIGARH, INDIA

INTRODUCTION:

• TRAUMA, a Greek word meaning :- a wound, currently defined as a mechanical injury to tissues by an external physical cause.

• R Adams Cowley, Professor Of Thoracic Surgery “Father Of Trauma Medicine”.

• Advanced Trauma Life Support is a training program for medical providers in the management of acute trauma cases, developed by the American College of Surgeons. 

HISTORY OF ATLS

• ATLS has its origins in the United States in 1976,  James K. Styner, an orthopedic surgeon.

•  Styner and his colleague Paul 'Skip' Collicott, with assistance from advanced cardiac life support personnel and the Lincoln Medical Education Foundation, produced the initial ATLS course which was held in 1978. In 1980, the American College of Surgeons Committee on Trauma adopted ATLS and began US and international dissemination of the course.

PREPARATION

• An effective trauma system needs the teamwork of EMS, emergency medicine, trauma surgery, and subspecialists.

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.

Development of pre-hospital Emergency Medical Services (EMS) with three purposes:

Get to the patient quickly. Fix what we can fix . Quickly get the patient to the right hospital.

Trimodal distribution of trauma deaths:

Golden Hour = 80% of trauma deaths in first hour after injury Rapid trauma care has greatest level of impact in these patients

6

Immediately

Hours

Days/Week

50%

30% 20%

GOLDEN HOUR

• The "Golden Hour" concept, the period of 60 minutes or less following injury when immediate definitive care is crucial to a trauma patient's survival.

TRIAGE

CATEGORIZATION

• A. Multiple 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.

Color Codes Triage Tag

RED : Most critic

al injur

y.

YELLOW : Less critic

al injured.

GREEN : No life

threatened injury

.

BLACK :

Death or

obviously fatal

injury.

TRAUMA TEAM

RADIOGRAPHER

ANAESTHESIST

NURSE 1

GENERAL SURGEON

ED PHYSICIAN

ORTHO REGISTRAR

WARDS PERSON

NURSE 2

TEAM LEADER

ANAESTHETIC ASST.

• ANATOMICAL

• PHYSIOLOGICAL

• MECHANISM

TRAUMA TEAM ACTIVATION CRITERIA

TRAUMA TEAM ACTIVATION CRITERIA

ANATOMICAL

• INJURY TO 2/ MORE BODY REGIONS

• FRACTURE 2/ MORE LONG BONES

• SPINAL CORD INJURY

• AMPUTATION OF LIMB

• PENETRATING INJURY TO HEAD, NECK TORSO/ PROX. LIMB

• BURNS> 15% IN ADULTS, >10% IN CHILDREN, AIRWAY BURNS

• AIRWAY OBSTRUCTION

TRAUMA TEAM ACTIVATION CRITERIA

• PHYSIOLOGICAL

• SBP<90mm Hg/ PR- >130 per min.

• RR<10/ >30 PER MIN

• DEPRESSED CONSCIOUSNESS

• AGE>70YR WITH CHEST INJURY

• PREGNANCY>24 WEEKS WITH TORSO INJURY

MECHANISM

• BIKER/ PEDESTRIAN HIT BY VEHICLE>30KM/HR

• FALL>5 METRE

• FATALITY IN SAME VEHICLE

• MOTOR VEHICLE CRASH WITH EJECTION

TRAUMA TEAM ACTIVATION CRITERIA

TEAM LEADER CHECKLIST

• Trauma team activation prior to arrival• Name tags worn• Universal precaution in place• Lead gowns in place• X-ray cassette in place• Warmed i.v fluids hanging• O-neg blood ready, blood warmer and rapid infuser ready• Trauma surgeon notified if SBP<90mm Hg• Theatre notified• Radiology notified

APPROACH TO A TRAUMA PATIENT:

• PRIMARY SURVEY:

• Airway maintenance with cervical spine protection.• Breathing and ventilation.• Circulation with hemorrhage control.• Disability: Neurologic status.• Exposure/Environmental control.

SECONDARY SURVEY:

• AMPLE history.

Allergies

Medications (Anticoagulants, insulin and cardiovascular medicine).

Past medical/surgical history

Last oral meal (Time)

Events /Environment surrounding the injury.

TERTIARY SURVEY: • The tertiary survey is a repeat clinical examination along the lines

of the primary and secondary surveys.

• It is performed with the aim of identifying injuries that have been missed during initial assessment.

• This survey consists of a structured and comprehensive re-examination that takes place within 48-72 hours.

PRIMARY SURVEY

Airway Maintenance with Cervical Spine Protection.

• GCS score of 8 or less.

• Inappropriate verbal response.

• Protection of the spine.

Cervical Spine & Neck:

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

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

Airway Interventions Maintenance of Airway

Patency– Suction of Secretions– Chin Lift/Jaw thrust– Nasopharyngeal Airway– Definitive Airway

Airway Support– Oxygen 100%– Bag Valve Mask

Definitive Airway– Endotracheal Intubation

In-line cervical stabilization

– Surgical Crichothyroidotomy

CHIN LIFT

JAW THURST

OROPHARYNGEAL AIRWAY

NASOPHARYNGEAL AIRWAYS

BAG VALVE MASK AIRWAY

ENDOTRACHEAL INTUBATION….

DIFFICULT INTUBATION

• LEMON Assessment for Difficult Intubation– Look externally– Evaluate 3-3-2 rule–Mallampati

classification– Obstruction– Neck mobility

MALLAMPATTI CLASSIFICATION

Airway Management in C-spine Injury

• To secure the airway with direct laryngoscopy, manual in-line stabilization (MILS) of the neck is the standard care of these patients in the acute stage.• MILS is best accomplished by

having two operators in addition to the physician who is actually managing the airway.

SURGICAL CRICOTHYROIDOTOMY

STEPS

BREATHING AND VENTILATION

• Do not confuse airway problem for ventilation problem• Patent airway does not equal adequate ventilation.• Need good gas exchange

• Oxygen in• CO2 out

Rapid assessment of• RR• SPO2• TRACHEA• CHEST EXPANSION• PERCUSSION• AUSCULTATION

BREATHING WITH SUPPLEMENTAL OXYGEN

• INSPECT:Equal chest rise,paradoxical chest movements,contusion,sucking chest

wound,distended neck veins

• PALPATE:Trachea,chest wall tenderness,subcutaneous emphysema,sternal and

rib fracture

• PERCUSS:dullness,hyperresonance

• AUSCULTATE: equal breath sounds,absence of breath sounds

TENSION PNEUMOTHORAX

• Respiratory Distress• Hyperinflated Chest• Deviated Trachea• Decreased Movement• Decreased Breathsound• Tachycardia• Hypotension

NEEDLE THORACOSTOMY VIA 2ND ICS IN MCLFOLLOWED BY DEFINITIVE CHEST TUBE (4TH- 5TH ICS JUST ANTERIOR TO MAL

CONNECTED TO WATER UNDER SEAL DRAIN)

MASSIVE HEMOTHORAX

• Signs Similar To Tension Pneumothorax Except Dullness On Percussion• Shock• T/T- Tube Thoracostomy• Thoracotomy In• >1500ml DRAIN IMMEDIATELY• >200ml/Hr FOR 4 HOURS

• Contact CTVS Early.

OPEN PNEUMOTHORAX

• Chest Tube At Site Separate To Defect• Cover Wound With 3 Sides

Gauze• Definitive Debridement In OT

FLAIL CHEST

• >2 Rib Fractures In 2 Or More Places• Paradoxical Chestwall

Movement• Adequate Ventilation• Reexpand Lungs: Intubation,,

CTVS Consultation

PERICARDIAL TAMPONADE

• Penetrating Injury• Becks Triad• Echo/ FAST• Pericardiocentesis.• Emergency Room Thoracotomy/

Urgent Thoracotomy

HYPOTENSION

DISTENDED NECK VEINS

MUFFLED HEART SOUND

CIRCULATION AND HEMORRHAGE CONTROL

• Assess-• Pulse .• Skin Colour And Temperature• Conscious Level(GCS)• Capillary Refill Time• Decreased Urine Output• Hypotension-a Late Sign When≥ 30% Blood Volume Lost.

• Stopping The Bleeding : Most Important Priority

IDENTIFY

• External hemorrhage• Apply direct pressure• No tourniquets except for traumatic amputations

• Be aware of possible sources of internal bleeding both from blunt and penetrating trauma• Chest• Abdomen• Pelvic Fractures• Long Bone Fractures

Primary Survey - CirculationTable 251-4 Estimated Fluid and Blood Losses Based on Patient's Initial Presentation Class I Class

I I Class I I I

Class IV

Blood loss (mL)* Up to 750 750–1500 1500–2000 >2000

Blood loss (percent blood volume)

Up to 15 15–30 30–40 40

Pulse rate <100 100–120 120–140 >140

Blood pressure Normal Normal Decreased Decreased

Pulse pressure (mm Hg) Normal or increased

Decreased Decreased Decreased

*Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.

MANAGEMENT OF CIRCULATION

• Control bleeding with direct pressure • Splint limb fractures• Insert 2 large bore IV cannulas in adults or cut down on long

saphenous v• Send off blood-cross match,coagulation screen,Hb,

Hct,biochemistry,blood alcohol level if req• Intraosseous needle in children upto 10 yrs

• Fluid replacement:adults upto 2-3 Lt crystalloid/colloid, • Children- 20 ml/kg• Blood replacement•O neg group specific or fully cross matched packed cells• Remember other blood product requirements: FFP, cryoppt, platelets

PITFALLS IN CIRCULATION

• Elderly - limited ability to increase HR• BP often has little correlation to Cardiac output

• Children - abundant reserve, appear stable then crash• Medication use (Beta Blockers)

Disability ( Neurological Evaluation):

• Abbreviated neurological exam :

• Level of consciousness

• Pupil size and reactivity

• GCS

• Simple Mnemonic to describe level of consciousness• A : Alert• V : Responds to Vocal stimuli• P : Responds to Painful stimuli• U : Unresponsive to all stimuli

Disability Interventions:

• Spinal cord injury• High dose steroids if within 8 hours.

• ICP monitor- Neurosurgical consultation.• Elevated ICP• Head of bed elevated• Mannitol• Hyperventilation• Emergent decompression

EXPOSE

You can’t treat what you don’t find!

If you don’t look, you won’t see!

EXPOSURE

FOLEY’S CATHETER

• CONTRAINDICATED IN URETHRAL INJURY

• SUSPECT URETHRAL INJURY

• INABILITY TO VOID

• UNSTABLE PELVIC FRACTURE

• BLOOD AT MEATUS

• SCROTAL HEMATOMA

• PERINEAL ECCHYMOSIS

• HIGH RIDING PROSTATE

GASTRIC TUBE

• Relieve Gastric Dilatation• Decompress Stomach • Reduce Risk Of Aspiration• N.G Tube – C.I. In Basal skull #

PRIMARY SURVEY ADJUNCTS:- DIAGNOSIS

• CXR• PELVIS AP• LATERAL C-SPINE• DPL• FAST

SECONDARY SURVEY:

The secondary survey does not begin until the primary survey (ABCDEs) is completed, resuscitative efforts are underway, and the normalization of vital functions has been demonstrated.• Head to Toe evaluation & reassessment of all vital signs.• AMPLE history

• A complete neurological exam is performed including a GCS score.

Quick Systemic Assesment

• Thoracic Trauma.

• Abdominal and Pelvic Trauma.

• Head Trauma with TBI.

A GOOD BEGINNING ALMOST ASSURES SUCCESS!!!

EMERGENCIES DON’T GIVE US A SECOND CHANCE…..