ATLS principles Flashcards
Airway (assessment)
Talking Foreign bodies Maxilla facial trauma Neck trauma GCS Listen for air entry at the nose, mouth and lung fields
ATLS Procedure
Preparation Triage Primary survey Resuscitation Adjuncts to primary survey, and resuscitation Consider need for transferral Secondary survey Adjuncts to secondary survey Continued post resuscitative monitoring and evaluation Definitive care
Breathing (assessment)
Inspection, including chest rise
Percussion
Palpation
Auscultation
Circulation (assessment)
Blood volume/CO - GCS - skin - pulse - pulse pressure External hemorrhage
Disability (assessment)
Consciousness/ GCS
Pupils
Lateralising signs
Spinal cord injury
Adjuncts to the primary survey
Urinary and gastric catheters ABG Ventilatory rate Sats Blood pressure ECG Chest and pelvis X-ray Fast scan DPL Urinalysis
Breathing (resuscitation)
Needle decompression
Ventilation
Oxygenation (and sats monitoring)
Airway (resuscitation)
Chin lift and jaw thrust
Intermediate airways
Intubation
Surgical airway
Circulation (resuscitation)
2 large bore IV lines (min 16 gauge) Fluid resuscitation (Ringer's lactate) Control hemorrhage Transfusion Blood tests (Hb, crossmatch, pregnancy)
Fluid resuscitation
Ringer’s lactate or normal saline
Loading dose: 1-2L (adults); 20ml/kg (kinders) - observe 3 to 1 rule
Blood transfusion - options
Depends on response to fluid resuscitation:
Rapid - order fully cross matched blood if necessary (1 hour)
Transient - typed blood (10 minutes)
Poor - O negative, although typed blood preferred if possible (immediate)
Secondary survey
History: AMPLE (BEST) and MIST Head and eyes Neck Thorax Abdomen Perineum, vagina and rectum Musculoskeletal Neurological
Post resuscitative monitoring
Vital signs Urinary output (0.5ml/kg/hour in adults, 1ml/kg/hour in paeds) ABG Cardiac monitoring devices Pulse oximetry End tidal volume carbon dioxide Analgesia and anxiolysis
Adjuncts to secondary survey
X-ray CT Urography Angiography Specialized ultrasound Bloods (Hb, U&E, b-hCG, BAC, amylase, INR, compat, troponin)
Circulation (monitoring)
BP, pulse pressure, and pulse rate suggest perfusion is returning
Urine output and CVP are better indicators
- 0.5ml/kg/hour (adults)
- 1ml/kg/hour (kinders)
- 2ml/kg/hour (infants)
Lactate and base excess give an indication of severity of shock
Hematocrit, Hb
CNS function and skin colour may also be applied as markers of recovery
Airway and breathing (monitoring)
Pulse oximetry
Respiratory rate
ABG
Thoracic trauma - primary survey
Airway obstruction - control airway with c-spine protection
Tension pneumothorax - immediate decompression
Open pneumothorax (wound >2/3 diameter of trachea - 1.5c,) - flutter valve dressing
Flail chest and pulmonary contusion - judicious use of fluids, analgesia, intubation and ventilation
Massive hemothorax - initial drainage, consultation with surgeon for thoracotomy
Cardiac tamponade - thoracotomy, with pericardiocentesis as a temporizing manouevre
Thoracic trauma - secondary survey
Simple pneumothorax - tube thoracostomy
Hemothorax - tube thoracostomy
Pulmonary contusion - judicious fluid resuscitation and selective intubation
Tracheobronchial tree injury - operative repair
Blunt cardiac injury
Traumatic aortic disruption - surgical consult
Traumatic diaphragmatic disruption - laparotomy
Blunt esophageal rupture - surgical consult
Fracture of first three ribs, sternum, or thoracic vertebrae
Blunt cardiac injury
Manifestations of severe thoracic trauma
Subcutaneous emphysema - airway or lung injury
Crush injuries (petechia and plethora of the head, neck and upper torso) - brain injury and cerebral edema
Injuries to upper 3 ribs, scapulae and sternum - underlying head, spine and cardiothoracic injury
Indications for thoracotomy
Cardiac tamponade Hemothorax Tracheobronchial injury Aortic rupture Esophageal rupture SBP < 70 despite adequate resuscitation Diminished peripheral pulses with thoracic inlet injury
Indications for ER thoracotomy
Cardiac arrest in penetrating injury
SBP < 70 despite active resuscitation in any injury
Indications for operative management of hemothorax
> 1000-1500ml blood immediately drained
240ml/hour for 4 hours
100ml/hour for 10 hours
If blood transfusion is required
Diagnostic peritoneal lavage - method
If gross blood (>10ml) or gastrointestinal content not aspirated, perform lavage:
- 1000ml warmed saline (10ml/kg in kinders)
- ensure adequate mixing
- withdraw, inspect for obvious blood or gastric content
- laboratory tests if microscopic matter suspected:
>100000 RBCs/ mm^3
>500 WBCs/mm^3
Bacteria on Gram staining
Raised amylase
Indications for chest tube drain in the trauma patient
Pneumothorax Hemothorax Patient transfer, especially by air General anesthesia Positive pressure ventilation
Life saving measures in burns
Identify and manage inhalation injury
Stop the burning (remove clothing and jewellery, cold water, wash chemicals)
IV lines
Indications for laparotomy
Hemodynamic abnormality in abdominal trauma
Clinical evidence of intraperitoneal bleeding
Positive FAST scan
Positive DPL
Gunshot wound (high velocity, trams abdominal, close range shotgun, peppering)
Peritoneal irritation (indicating rupture of hollow viscus)
Signs of fascial penetration
Positive finding on wound exploration
Evisceration
Gastrointestinal or genitourinary bleeding
Free air, retroperitoneal air, rupture of hemidiaphragm
Positive finding on CT
Assessment of burns
History
Body surface area affected
Depth of burns
Body surface area in burns
Adults
- rule of 9: head, each upper limb, anterior lower limb, posterior limb
- 18%: anterior torso, posterior torso
- 1%: perineum
Kinders
- rule of 9: anterior head, posterior head, each upper limb
- 18%: anterior torso, posterior torso (each butt cheek 2.5%)
- 7%: anterior lower limb, posterior lower limb
Inhalation injury - 10-20%
Burn depth
1st degree: erythema, pain, no vesicles
2nd degree: erythema or mottled, swelling and vesicles, wet and exudative, painfully sensitive
3rd degree: dark, leathery, dry, waxy white, mottled, translucent, painless
Primary and secondary survey conditions in burns
Primary survey:
- inhalation injury
- chemical injury to lungs
- CO poisoning
- fluids: 2-4ml/kg/%BSA, half in first 8hrs after injury, half in next 16hrs
Secondary survey:
- physical examination
- documentation
- baseline investigations (CXR, FBC, U&E, glucose, HbCO, compat, ABG, BhCG)
- wound care
- antibiotics as indicated
- analgesia
- tetanus prophylaxis
- nasogastric tube
- peripheral circulation (remove constricting clothing and jewelry, assess peripheral perfusion, escharotomy and fasciotomy as indicated)
Special considerations in the primary survey of a child
Airway: position, alternative insertion of oropharyngeal airway contraindicated, atropine prior intubation, needle cricothyroidotomy
Breathing: increased risk of barotrauma (tidal volume 6-8ml/kg); smaller chest tube and needle for decompression
Circulation: occult intracranial or intraabdominal hemorrhage, subtle signs of shock, increased compensatory ability, 20ml/kg fluid boluses, 10ml/kg RBCs, intraosseous infusion, urine output
Disability: increased compliance of bones means fewer fractures
Thermoregulation: increased surface area
Acute deterioration of the intubated child
Dislodgement of endotracheal tube
Obstruction of endotracheal tube
Tension pneumothorax
Equipment failure
Pediatric verbal score
5 - appropriate words, social smile, fixes and follows 4 - cries, but consolable 3 - persistently irritable 2 - restless, agitated 1 - none
Resuscitation, monitoring, and re-evaluation
Oxygen saturation monitor applied
2 wide bore lines, Ringers lactate IVI at maximum speed
Arterial blood gas collected
ECG monitor connected
Logroll, rectal and perineal examination. While logrolling, a rapid secondary survey of the back can be performed
Remove all clothing and then cover
Urinary catheter if perineum intact
Nasogastric (or orogastric) tube if required
Analgesia and sedation
X-ray chest (all cases) and pelvis(in blunt trauma)
Repeat the Primary Survey to re-evaluate the response to resuscitation
Clinically clearing C-spine
Patient fully awake and orientated (co-operative)
No abnormal neurology related to spinal trauma
No discomfort/pain related to spinal column
No distracting injury in the vicinity, e.g. above clavicle, paraspinal area
No tenderness, step-deformities, bruising or induration over spine
Collar and other immobilizing devices removed, and patient capable of gently moving each element without any discomfort or new neurology
If it: CT or X-ray (lateral, AP, and open mouth)
Injuries in blunt abdominal trauma
Liver, spleen, kidney Small bowel rupture Diaphragm rupture Duodenum and pancreas Bladder rupture Retroperitoneal hematoma
Injuries in stab abdomen
Liver
Small bowel
Colon
Diaphragm
Indications for intubation
SBP < 70mmHg
GCS < 8
Burns inhalation injury
Clinically compromised airway
Indication for thoracotomy in hemothorax
Chest drains >1.5L initially
Chest drains >200ml/h for 4 hours
Chest drains >100ml/h for 10 hours
Repeat CXR reveals persistent hemothorax
Special considerations in burns
Circumferential burns - neurovascular compromise (escharotomy)
CO inhalation - monitor CO level, 100% oxygen, intubate and ventilate
Chemical burns - brush dry chemicals off, rinse wet chemicals
Electrical burns - rhabdomyolysis, demyelinisation, fractures, and arrhythmia
Triage sieve
Injured Walking Breathing Resp rate Circulation (pulse, capillary refill)
Green - walking
Red - only breathing with airway manoeuvre, RR > 30 or 120, capillary refill >2 seconds
Yellow - not walking, but not red
Triage sort
GCS
Resp rate
SBP
Green
- SBP >90
- RR 10-30
- GCS 13-15
Yellow - ONE of
- SBP 75-90
- RR > 30
- GCS 9-12
Red - not green or yellow
Management goals in head injury
MAP > 90 Normovolemia PO2 80-100 SATS > 95 PCO2 30-35 Mannitol Temp 35-37 Phenytoin No steroids Early enteral feeding Sucralfate DVT prophylaxis (NB brain bleeds) Pressure sore prevention Drain mass lesions \+/- ICP monitoring
Musculoskeletal injuries
Life threatening
- unstable pelvic fracture
- major arterial hemorrhage
- crush syndrome
Limb threatening
- open fractures
- joint injuries
- vascular injuries
- compartment syndrome
- neurological injury
Other
- contusion and laceration
- fracture
- joint injury
Secondary survey of extremity injuries
Look, feel and move - assess skin, bone, muscle, neurovascular, and joints
Adjuncts: Pelvic X-rays X rays of injured limbs U/S for large hematomas Assess perfusion Full neurological examination Differential Doppler pressures Compartment pressures Angiography and arteriography
Chest drain cocktail
400ml saline
1000iu heparin
Chest drain removal - indications
No bubbling for 24 hours
Draining les than 150ml per day
Indications for chest drain in simple pneumothorax
>2 cm lung collapse Respiratory distress General anesthetic Positive pressure ventilation Transfer
