ATLS - Trauma Flashcards
ATLS
Multiple casualty
- More than one patient injured, but the number of patients
and the severity of injury does not exceed the capacity of the
hospital to render care - Those with life-threatening and multi-system injuries are
treated first
ATLS
Mass casualty
- Number of patients and severity of injury exceed capability of facility and staff
- Patients with the greatest chance of survival and requiring
the least expenditure of time, equipment and personnel are
treated first
ATLS
Triage
Involves the sorting of patients based on their needs for treatment and the resources available to provide that treatment
Primary triage
AKA
Triage sieve
Primary triage
Done in and the purpose
- Done at the site of the accident
- Seperate the dead from the walking and injured
Secondary triage
AKA
Triage sort
Secondary triage
Done at
the recieving station at the hospital bu the most senior doctor ( chief surgeon)
Secondary triage
The categories
- P1/T1/category 1/ RED
- P2/T2/Category 2/ YELLOW
- P3/T3/Category 3/ GREEN
- P4/T4/Category 4/ BLACK
Secondary triage
Category 1
Critical, cannot wait
Secondary triage
Category 2
Urgent, can wait for a short period of time ~30 minutes
Secondary triage
Category 3
Less serious injuries, can wait for a longer duration
Secondary triage
Category 4
Severe multi- system injury, not expected to survive
Trauma deaths
First peak causes of deaths
Lacerations on the
* Brain
* Brainstem
* Aorta
* Cord
* Heart
Trauma deaths
Second peak
- Epidural hemorrhage
- Subdural hemorrhage
- Hemopneumothorax
- Pelvic fractures
- Long bone fractures
- Abdominal injuries
Trauma deaths
Third peak
- Sepsis
- Multiple organ failure
Trauma deaths
Golden hour
can save 80% of patients
Trimodal pattern of trauma deaths
- 50% die within
- 30% die within
- 20% die within
- within seconds to mins
- within mins to hours
- within hours to days ( upto 6 weeks)
Trimodal pattern of trauma deaths
The main emphasis of Mx is on
the second peak - epidural, subdural, hemopneumothorax, pelvic fractures, long bone fractures, abd injuries
Trimodal pattern of trauma deaths
Main two goals in the second peak
- Prevent hypoxia
- Prevent hypovolemia
ATLS
The goals of the ATLS protocol
- To identify and treat most life threatening injuries first and treat
them as we identify itself - Lack of a definitive diagnosis and a detailed history should not slow
the application of indicated treatment for life threatening injury - Most time-critical interventions should be performed early
- Aims to maximize the window of golden hour
ATLS
Primary survery
cABCDE
ATLS
cABCDE
- Control of massive external haemorrhage
- Airway maintenance and cervical spine protection
- Breathing and ventilation
- Circulation with haemorrhage control
- Disability: Neurologic status
- Exposure/ Environmental control
Control of massive external hemorrhage
massive external hemorrhage?
Massive arterial bleeding
Control of massive external hemorrhage
Done how
- use packs and pressure directly on the bleeding wound
- if failed, use a tourniquet proximal to the wound
Tourniquet
How long can a tourniquet be used
maximum 6h. in surgery less than 2 hours
Airway Maintenance and Cervical Spine Protection
Types of patients that may require airway and C spine protection
- Unconscious patients with head injury
- Obtunded because of alcohol/ drugs
- thoracic injuries
- Gastric contents in the oropharynx
- Maxillo- facial trauma
- Blunt/ penetrating neck trauma
- Laryngeal/ tracheal trauma
Airway Maintenance and Cervical Spine Protection
How to assess the airway patency
Speaking to the patient- ask for his name, where he is, what happened
Airway Maintenance and Cervical Spine Protection
if the patient can speak clearly?
- No major airway compromise: Able to speak clearly
Airway Maintenance and Cervical Spine Protection
If the patient is able to generate air movement to permit speech?
Breathing is not severely compromised
Airway Maintenance and Cervical Spine Protection
If the patient is alert enough to describe what happened
no major decrease in level of confusion. brain perfusion is adequate
Airway Maintenance and Cervical Spine Protection
If no response after talking to the patient? the three steps
- look
- listen
- feel
Airway Maintenance and Cervical Spine Protection
LOOK
- Agitation- hypoxia
- Obtunded- hypercapnia
- SaO2- ear lobe, big toe, finger
- Cyanosis- nail bed, circumoral skin
- Use of accessory muscles
- Blood, vomitus, foreign body- suction, remove
Airway Maintenance and Cervical Spine Protection
Sites to check for saturation
Ear lobe
Big toe
Fingers
Airway Maintenance and Cervical Spine Protection
LISTEN
for movement of air.
Airway Maintenance and Cervical Spine Protection
Noisy breathing
partial obstruction of the pharynx or larynx- stridor
Airway Maintenance and Cervical Spine Protection
FEEL
- air coming out of the nostrils?
- Is the trachea in the midline
- palpate for facial, laryngeal/ tracheal, mandibular fractures which can obstruct the airway- check for crepitus (katas katas sound)
Airway Maintenance and Cervical Spine Protection
Maneuvers
- Chin lift
- Jaw thrust
Airway Maintenance and Cervical Spine Protection
when is the head tilt done
after C spine injury is excluded
Airway Maintenance and Cervical Spine Protection
Temporary airways
- Oro- pharyngeal tube (MC)
- Naso- pharyngeal tube
- Extra- glottic and supra- glottic devices - LMA
Airway Maintenance and Cervical Spine Protection
Naso- pharyngeal tubes are not inserted during
suspected basal skull #
Airway Maintenance and Cervical Spine Protection
When are laryngeal mask airways used
during difficult or failed intubation
Airway Maintenance and Cervical Spine Protection
Definitive airways
A tube placed in the trachea with the cuff inflated below the vocal cords, the tube connected to oxygen enriched assisted ventilation
Airway Maintenance and Cervical Spine Protection
The cuff of definitive airways are inflated…
below the vocal cords
Airway Maintenance and Cervical Spine Protection
Types of definitive airways
- Orotracheal tube ( ET tube)
- Nasotracheal tube
- Surgical airways- Crico- thyroidotomy, tracheostomy
Airway Maintenance and Cervical Spine Protection
MC temporary airway and definitive airway
- definitive- ET tube
- temporary- Oro-pharyngeal tube
Airway Maintenance and Cervical Spine Protection
2nd most common definitive airway
Tracheostomy
Airway Maintenance and Cervical Spine Protection
Indications for definitive airway- main two categories
- Need for airway protection
- Need for ventilation of oxygenation
Indications for definitive airway
Need for airway protection
- Severe maxillo- facial fractures
- Risk for obstruction- Neck hematoma, Laryngeal of tracheal injury, Stridor
- Risk for aspiration- bleeding, vomiting
- Unconsciousness patients with GCS 8 or less
Indications for definitive airway
Need for ventilation of oxygenation
- Inadequate respiratory efforts- tachypnea, hypoxia, hypercapnia, cyanosis
- Massive blood loss and need for volume resuscitation
- Severe closed head injury with need for brief hyperventilation if acute neurological deterioration occurs
- Apnea- neuro muscular paralysis, unconsciousness
Difficulty of intubation
LEMON
- Look externally
- Evaluate the 3-2-3 rule
- Mallampati score
- Obstruction
- Neck mobility
LEMON
L
- Facial trauma
- Large incisors
- Beard
- Large tongue
LEMON
E
- The distance between the patient’s incisor teeth should be at least 3
finger breadths (3)- vertically put your fingers - The distance between the hyoid bone and the chin should be at least
3 finger breadths (3) - The distance between the thyroid notch and floor of the mouth
should be at least 2 finger breadths (2)
LEMON
M
Mallampati score visualizes the hypopharynx- it will tell us if it easy or difficult to intubate the patient. It is an indicator of how much space is at the back
LEMON
O
Obstruction- epiglottis, peri- tonsillar abscess
LEMON
N
Neck mobility
Ventilation
two types
- Ambu ventilation
- Mechanical ventilation
Closed head injury
Why hyperventilate in closed head injury
To wash out CO2. Reduced CO2 means cerebral vasoconstriction and reduced cerebral edema. Reduced chance of brain to herniate.
Hyoid bone site
Face ends and the neck starts site
Thyroid notch
Extend the neck and can feel a prominence on the neck
BURP maneuver
BURP
- Backwards
- Upwards
- Rightwards
- Pressure on the thyroid cartilage
BURP maneuver
uses
maneuver to aid visualization of the vocal cords
Difficult intubation
If BURP fails
- Try with Gum elastic bougie (GEB)
Gum Elastic Bougie
Blindly put this and try to scrape upwards. if you feel a smooth feeling, you are in the esophagus. But if you feel clicking- like feeling it’s the tracheal cartilages. Then put the ET tube through the bougie and take it out
Hard cervical collar
only protect C1- C7
Philadelphia collar
Protect the cranio- cervical junction
Difficult intubation
If BURP and GEB fails
Surgical airway- crico- thyroidotomy, tracheostomy
Assessment of position of the tube
Proper placement is suggested by
- Hearing equal breath sounds B/L on auscultation
- No borborygmi in the epigastrium ( rumbling or gurgling noises)
- Detection of CO2 in exhaled air
Assessment of position of the tube
Proper placement is best confirmed by
Chest X-ray (after excluding oesophageal intubation with the above measures)
Assessment of the Cervical Spine
High Risk Factors
- Sixty five (Age >65 years)
- Fast drive (Dangerous mechanism)-RTA, fall, rolled over
- Sense deprive (Paresthesia in extremities)
- IMAGE (X-RAY) IF ALIVE
Assessment of the Cervical Spine
Low risk factors
* Slow wreck** (Simple rear-end RTA)
* Slow neck (Delayed onset of neck pain)
* Sitting down (Patient sitting in the emergency department
* Walking around (Ambulatory at any time)
* C Spine maybe fine (Absence of midline neck tenderness
posteriorly)
* ROTATE THE SPINE
Assessment of the Cervical Spine
After rotating
- If you can look both ways, you can cross the road (Can rotate 45
degrees to the left and right) - WITHOUT IMAGING (X-RAY)
Assessment of the Cervical Spine
The imaging
C spine Lat X Ray
Cervical Spine Protection
Types of C spine protective methods
- Manual in-line neck stabilization
- Sand bags snd tapes
- Blocks
- Definitive measures-Hard cervical collar, Philadelphia collar
Philadelphia collar
A section comes up to the face, shoulder
Breathing and ventilation
Types of problem
- Direct trauma to the chest-Rib fractures causes pain, leading to rapid shallow breathing and hypoxaemia
- Elderly patients
- Patients with pre-existing pulmonary dysfunction
- Intra-cranial injury
- Cervical spinal cord injury
Assesment of breathing
Look, Listen
- Look
* Symmetrical rise and fall of the chest
* Adequate chest wall expansion
* Labored breathing - Listen- movement of air
* Reduced or absent breath sounds
Life threatening thoracic conditions
- Airway obstruction
- Tension pneumothorax
- Open pneumothorax
- Massive haemothorax
- Flail chest with pulmonary contusion
- Cardiac tamponade
Management of breathing
- O2 At least 11L/min
- Ambu ventilation
- Mechanical ventilation
- Monitor saturation
Circulation with Haemorrhage Control
Blood loss we can’t see
One on the floor and four more
Circulation with Haemorrhage Control
the predominant cause of preventable post-injury deaths
Hemorrhage
Circulation with Haemorrhage Control
Hypotension is due to………. until proven otherwise
Hypovolemia
Circulation with Haemorrhage Control
Hypovolaemic shock is caused by
significant blood loss
Circulation with Haemorrhage Control
Sites of major haemorrhage
Chest, abdomen, pelvis, long bones, external
haemorrhage (One on the floor and four more)
classes of blood loss
Class 1
* Volume
* % of blood loss
* PR
* SBP
* PP
* RR
* UOP
* Mental status
- Volume- <750mL
- % Blood loss- <15%
- PR<100/min
- SBP- Norm
- PP- Norm
- RR- Norm
- UOP- Norm
- Mental status- Norm
Classes of blood loss
Class 2
* Volume
* % of blood loss
* PR
* SBP
* PP
* RR
* UOP
* Mental status
- Volume- 750- 1500 mL
- % Blood loss- 15- 30%
- PR-120/min
- SBP- Norm
- PP- narrow
- RR- 20-30
- UOP- Norm/ little reduced
- Mental - anxious
Classes of blood loss
Class 3
* Volume
* % of blood loss
* PR
* SBP
* PP
* RR
* UOP
* Mental status
- Volume- 1500- 2000mL
- % of blood loss- 30- 40%
- PR- 130/min
- ** SBP- decreased**
- PP- Narrow
- RR- 30-40
- UOP- reduced
- Mental status- confused
Classes of blood loss
Class 4
* Volume
* % of blood loss
* PR
* SBP
* PP
* RR
* UOP
* Mental status
- Volume- >2000mL
- % of blood loss- >40%
- PR- >140/min
- SBP- Decreased
- PP- narrow
- RR- >35
- UOP- Negligible
- Mental status- lethargic
Classes of blood loss
Choice of fluid for class 1 blood loss
Crystalloid
Classes of blood loss
Choice of fluid for class 2 blood loss
Crystalloid
Classes of blood loss
Choice of fluid for class 3 blood loss
Crystalloid and group specific blood
Classes of blood loss
Choice of fluid for class 4 blood loss
Crystalloid and Group specific blood or
O –ve blood
Resuscitation
The main target
Maintain perfusion of vital organs which can be temporarily achieved with a target systolic BP of 70-90 mmHg
Resuscitation
Target if head injury is suspected
Maintain systolic BP >90mmHg
Resuscitation
Steps
- Minimize blood loss
- Gain iv access on both arms
- Take blood for Ix
- Start Iv fluids
- Tranaxemic acid
- Connect to cardiac monitor, saturation probe
- Catheterize and maintain IP/OP chart
- Maintain vitals
- Give blood
Resuscitation
Minimize blood loss
- Apply direct pressure over the bleeding site
- Elevate the limb
- Use a tourniquet if the bleeder is in a periphery
- Use Pelvic binders in all hemodynamically unstable patients
Resuscitation
Why is pelvic binders used
used in all hemodynamically unstable patients following blunt trauma until a pelvic fracture is excluded
Resuscitation
Getting IV access
- 2 large bore (14G/16G) cannulae to 2 large veins of the forearms
- Venous cutdown- basilic V/ Greater saphenous V
- Prepare the equipments, expertise for a central venous access
Resuscitation
If the peripheral circulation is constricted
Venous cutdown or get a central venous line
Resuscitation
Venous cutdown
- Small surgical incision at the basilic V of the elbow or the greater saphenous V of the lower limb until the vein is reached
- Directly cut the vein and cannulate
Resuscitation
Blood Ix after getting iv access
- Blood grouping, DT
- FBC, Sr.Cr, SE, PT/INR, venous lactate
Resuscitation
Colour of the 14G cannula
Orange
Resuscitation
Colour of the 16G cannula
Grey
Resuscitation
All iv fluids should be warmed to….
39 celcius
Resuscitation
IV fluids used
- Crystalloids- NS, Ringer lactate
- Colloids generally avoided
Resuscitation
Amount of IV fluids given
upto 2L ( 500mL bolus takes 20min)
Resuscitation
Colloids avoided?
- ADRS
- Anaphylaxis
- Allergies
Resuscitation
Crystalloids
3/4 leak into the interstitium and only 1/4 remain in the circulation
Resuscitation
Colloids
NO LEAKING INTO THE INTERSTITIUM
Resuscitation
Generally the limit of iv fluids given
until blood arrives to the saline tube
Resuscitation
Venous lactate
new test to find the degree of anaerobic respiration
Resuscitation
Excessive crystalloids or colloids can lead to
hemodilution and coagulopathy
Resuscitation
Tranexamic acid uses
stop the bleeding and reduce the mortality
Resuscitation
Tranexamic acid should be given during
during the first 3 hours of admission to all patients suspected with significant hemorrhage (SBP <100mmHg, PR>110/min)
Resuscitation
Tranexamic acid dose
1g over 10 minutes followed by 1g over 8 hours
Resuscitation
Ideal UOP
> 0.5- 1mL/kg/h
Resuscitation
monitor vital signs
- BP
- PR
- RR
- SaO2
- UOP
- CVP (optional)
Resuscitation
Blood is given to
Class 3 and class 4 hemorrhages
Resuscitation
In massive transfusions what should be given along with RCC packs
RCC:Plt: FFP in 1:1:1 ratio
Resuscitation
Massive transfusions
> 10 packs of RCC
Resuscitation
Occult blood loss sites
- Chest
- Abdomen
- Pelvis
- Long bones
Blood loss
Difference between class 1 and 2
Pulse pressure (norm ~40mmHg) is normal is class 1 and narrow in class 2
Blood loss
Only abnormality in class 1
PR is low
Blood loss
