advanced trauma life support[ATLS]

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1 : ATLS • A Advanced • T Trauma • L Life • S Support Dr. Zubair Ahmed Dept. of Internal Medicine ,Pulmonology & Critical Care Aware Global Hospitals Hyderabad
2 : ATLS Preparation 1. Prehospital phase 2. Inhospital phase Triage 1. Multiple casualties 2. Mass casualties
3 : ATLS Preparation & Triage Primary survey Resuscitation -Adjuncts to primary survey and resuscitation Secondary survey - Adjuncts to secondary survey - Post resuscitation monitoring and reevaluation Definitive care Tertiary survey
4 :
5 : TRIAGE The process of categorizing victims or mass casualty into different treatment and evacuation categories Its main goals are 1.Prevent avoidable deaths 2.Ensure proper initial medical treatment with a minimal time frame 3.Avoid misusing assets on hopeless cases
6 :
7 : PREHOSPITAL TRIAGE The first rescuers should perform initial triage starting with in order 1.self 2.scene 3.survivor asses the scene using the acronym ETHANE E-Exact location of accident T-Type of Incident [rail,road,chemical] H-Hazards,potential or actual A-Access direction of approach N-Number of casualties and their severity/type E-Emergency services [present and required]
8 :
9 : IN HOSPITAL TRIAGE TRIAGE IN EMERGENCY ROOM (AUSTRALIAN TRIAGE SCORE) Threat to life or deterioration-Immediate (ATS1) risk to the airways-impending arrest Respiratory rate <10/min Extreme respiratory distress BP <80[adult] or severely shocked child/infant Unresponsive or responds to pain only [GCS<9]
10 : IN HOSPITAL TRIAGE ATS 2 :Imminetly life threatening:10 min Airway risk-severe stridor or severe respiratory distress Circulatory compromise,severe blood loss, hypotension Very sever pain-any cause Drowsy,decreased responsivenes any cause[GCS <13] Major multi trauma Severe localised trauma
11 : IN HOSPITAL TRIAGE ATS 3-Potentially life threatening:30 min Moderately severe blood loss Moderate shortness of breath SaO2 90-95% Head injury with loss of consiousness[LOC}-now alert Moderately severe pain-any cause Moderate limb injury-deformity,severe laceration,crush Limb - altered sensation,acutely absent pulse Trauma-high risk history with no other high risk features
12 : IN HOSPITAL TRIAGE ATS 4:potentially serious or situational urgency:60 min Mild haemorrhage Chest injury without rib pain or respiratory distress Minor head injury,no LOC Moderate pain,some risk features Minor limb trauma-sprained ankle,possible #, uncomlicated laceration ATS 5:less urgent :120 min Minor wounds-small abrasions,minor lacerations[not requiring sutures
13 : Triage Tapes
14 : • Preparation The following protective devices are recommended • Goggles • Gloves • Fluid-impervious gowns or aprons • Shoes covers and fluid- impervious leggings • Mask • Head covering
15 : Primary survey Airway maintenance with cervical spine protection Asess for 1.Obstruction,foreign bodies,facial fractures or bleeding -begin measures to remove obstruction and establish airway 2.Patency may be compromised because of head injury,intoxication,or swelling Potential problems 1.Swelling leading to delayed airway collapse 2.if unable to control the airway ,surgical airway is must 3.Unknown laryngeal or tracheal disruption
16 : Primary survey B Breathing and ventilation Asess for 1. Adequate chest wall excursion not limited by rib fracture or pain or mental status 2. Loss of or diminished air entry on either side due to pneumothorax,hemothorax,pulmonary contusion or lung pathology 3. Evidence of bruising or laceration to chest 4. deviation of trachea from tension pneumothorax or neck haematoma Potential problems 1.Airway compromise may be difficult to discern from ventilatory failure 2.Massive pulmonary inuries may falsely seem to be airway related due to severe dyspnae 3.Airway placemant may worsen some pulmonary issues because of positive presssure [worsening pneumothorax]
17 : Primary survey C Circulation with hemorrhage control Assess for- 1.Blood volume and cardiac output a.mental state deteriorates with increasing amounts of blood loss and progression of haemorrhagic shock b.Ashen gray skin & poor refill imply poor circulation c.Pulses are markers of perfusion in young patients without vascular disease 2.Bleeding a.External blood loss is readily recognised and stopped by direct pressure b.Occult bleeding from internal haemorrhage should be suspected if patient has signs of shcok
18 : Primary survey Potential prblems 1.patients on beta blocker may not get tachycardia as a response to bleeing or anemia 2.Elderly patients have less reserve and may deompensate quickly 3.Children have less reserve and will not show signs of shock until severely volume depleted 4.Multiple occult sources for blood loss may exist in one patient
19 : Primary survey D Disability : Neurological status Neurologic • level of consciousness • pupillary size and response • motor and sensory signs • GCS Potential problems- 1.Intoxication masking or reproducing a closed head injury 2.Lucid interval can be seen before compromise from intracranial lesion
20 : Primary survey E Exposure/Environmental control completely Undress the patient, but prevent hypothermia as it worsens bleeding(deadly triad) and outcome in trauma
21 : Primary survey Resuscitation – Add high flow to oxygen to all patients and continued ventilation with hand bagging or a ventilator Pneumothorax or hemothorax should be released to permit adequate ventilation Shock management:Two large bore intravenous (14/16 G) lines,,if no peripheral consider a large bore[not triple lumen] catheter into major vein Warmed Ringer’s lactate solution 2 L in a adult patient/20-30ml/kg in peds. – Management of life-threatening problems identified in the primary survey is continued
22 : Adjuncts to primary survey and resuscitation X-rays and diagnostic studies • Chest • Pelvis • C-spine • DPL or FAST Send blood for Hb and cross matching – Urinary and gastric catheters – Monitoring • ABG analysis and ventilatory rate • End-tidal carbon dioxide •Continous12 lead EKG • Pulse oximetry • Blood pressure
23 : Secondary survey Secondary survey does not begin until the primary survey (ABCDEs) is completed, resuscitative efforts are well established, and the patient is demonstrating normalization of vital functions.
24 : Secondary survey • Head-to-toe evaluation • Complete history and physical examination • Reassessment of all vital signs
25 : Secondary survey Secondary survey – Total patient evaluation • history : AMPLE physical examination – Complete neurologic examination – Head and skull – Maxillofacial – Neck – Chest – Abdomen – Perineum/rectum/vagina – Musculoskeletal – Tubes and fingers in every orifice!
26 : Secondary survey History –A Allergies –M Medications currently used –P Past illnesses/Pregnancy –L Last meal –E Events/Environment related to the injury
27 : Secondary survey History – Blunt trauma – Penetrating trauma – Injuries due to burns and cold – Hazardous environment
28 : GCS
29 : Secondary survey Physical examination – Head • Scalp • Fractures CSF leak from ears,nose or mouth • Eyes edema – Visual Acuity - Pupil size - Penetrating injury – Hemorrhage of conjunctivae,fundi – Contact lenses - Dislocation of lenses – Ocular entrapment
30 : Secondary survey Physical examination– Maxillofacial • airway obstruction , major bleeding • # of mid maxilla beware of NG tube insertion • need frequent reassessment
31 : Secondary survey Secondary survey • Physical examination- Cervical spine and neck • Head injury pt.keep in mind of cervical spine injury • Absence of neurologic deficit does not exclude spine injury • Inspection , palpation , auscultation , cervical spine tenderness , subcutaneous emphysema , tracheal deviation , laryngeal fracture • Protection of C-spine injury , helmet removing
32 : Technique of removal of helmet
33 : Secondary survey • Physical examination – Chest • Visual evaluation of anterior and posterior chest – open pneumothorax – flail chest • Pain , dyspnea , hypoxia • Cardiac tamponade , tension pneumothorax – distended neck veins – distant heart sound
34 : Secondary survey Physical examination– Abdomen • closed observation and frequent reevaluation • unexplained hypotension • neurologic injury(unconcious) • equivocal abdominal finding
35 : Secondary survey Physical examination– Perineum/rectum/vagina • contusion , hematoma , laceration , urethral bleeding • rectal examination : blood , high-riding prostate , integrity of rectal wall , sphincter tone • female : – Vg exam.: blood , Vg laceration , Vg laceration – pregnancy test
36 : Secondary survey Physical examination– Musculoskeletal • inspection : contusion , deformity • palpation : tenderness , abnormal movement • pelvic #: ecchymosis on iliac wings , pubis , labia ,scrotum , pain on palpation of pelvic ring , Pelvi CompressionTest • assessment of peripheral pulses Beaware of compartment syndrome of exremity • patient’s back examination-logroll
37 : Secondary survey Adjuncts to secondary survey – hemodynamic status • CT scan • Contrast x-ray studies • Extremitry x-ray • Endoscopy and ultrasonography
39 : Post resuscitation monitoring and reevaluation – reevaluation for new findings or overlooked – continuous monitoring of vital signs , urinary output(0.5-1 ml/kg/hr) – ABG , EKG , pulse oximetry – effective analgesia
40 : Definitive care – After identifying the patient’s injuries – Managing life-threatening problems – Obtaining special studies • Transfer – If the patient’s injuries exceed the institution’s treatment capabilities
41 : TAKE HOME MESAGES 1. To improve survival, injury management must be prioritized in the multiply injured patient 2.The order of priority among injuries is related to time and degree of life threat posed by each injury. 3.Immediate priority is given to airway control and to maintenance of ventilation, oxygenation, and perfusion. 4.Cervical spine protection is crucial during airway intubation. 5.A trauma team leader is important to coordinate management in the multiply injured patient.
42 : TAKE HOME MESAGE 5.Complete familiarity with techniques for airway control, chest decompression and the establishment of intravenous access is essential in management of multiple trauma . 6. Complete in-depth assessment of the multiply injured patient is required only after immediately life-threatening injuries have been treated. 7. Repeated assessment is necessary to diagnose and treat injuries that are not obvious on initial presentation.
43 : Thank You


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approach to trauma patient[ATLS]
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