Trauma-Atls Advanced Trauma Life Support

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1 Advanced Trauma Life Support Patrick Cheah, MD Li-Shin Hospital Emergency Department

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2 1. Preparation 2. Triage 3. Primary Survey (ABCDEs) 4. Resuscitation 5. Adjuncts to primary survey & resuscitation 6. Secondary Survey (head to toe evaluation & history) 7. Adjuncts to secondary survey 8. Continued post-resuscitation monitoring & re-evaluation 9. Definite care.

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3 1. PREPARATION 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. Protect from communicable disease.

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4 2. TRIAGE 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.

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5 3. PRIMARY SURVEY A : Airway with cervical spine protect. B : Breathing C : Circulation --control external bleeding. D : Disability or neurological status E : Exposure (undress) & Environment (temp control)

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6 PRIMARY SURVEY Priorities for the care of Adult , Pediatrics & Pregnancy women are all the same. During the primary survey life threatening conditions are identified and management is instituted SIMULTANEOUSLY.

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7 A. Airway Maintenance with Cervical Spine Protection. * GCS score of 8 or less require the placement of definite airway. *Protection of the spine & spinal cord is the important management principle. *Neurological exam alone does not exclude a cervical spine injury. *Always assume a cervical spine injury in any pt with multi-system trauma, especially with an altered level of consciousness or blunt injury above the clavicle.

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8 B. Breathing & Ventilation * Airway patency does not assure adequate ventilation. C. Circulation with Hemorrhage Control. 1. Blood Volume & Cardiac Output a. level of consciousness. b. skin color c. Pulse. 2. Bleeding *external bleeding is identified & controlled in the primary survey. *Tourniquets should not be use.

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9 D. Disability ( Neurological Evaluation) Simple Mnemonic to describe level of consciousness A : Alert V : Responds to Vocal stimuli P : Responds to Painful stimuli U : Unresponsive to all stimuli Not forget to use also Glascow Coma Scale.

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10 E. Exposure / Environmental Control *It is the pt’s body temp that is most important, not he comfort of the health care provider. *Intravenous fluid should be warm. *Warm environment (room tem) should be maintained. *early control of hemorrhage.

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11 4. RESUSCITATION A. Airway *definite airway if there is any doubt about the pt’s ability to maintain airway integrity. B. Breathing /Ventilation/Oxygenation *every injured pt should received supplement oxygen C. Circulation *control bleeding by direct pressure or operative intervention * minimum of two large caliber IV should be established *pregnancy test for all female of child bearing age. * Lactated Ringer is preferred & better if warm.

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12 5. ADJUNCT TO PRIMARY SURVEY & RESUSCITATION A. Electro-cardiographic Monitoring B. Urinary & Gastric Catheter 1. Urinary catheter. Urethral injury should be suspected if *Blood at the penile meatus *Perineal ecchymosis *Blood in the scrotum *High riding or nonpalpable prostate *Pelvic fracture

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13 C. Monitoring 1. Ventilatory rate & ABG 2. Pulse oximetry does not measure ventilation or partial O2 pressure 3. Blood pressure poor measure of actual tissue perfusion. D. X-Ray & Diagnostic Studies C-spine, CXR, Pelvic film Essential x-ray should not be avoid in pregnant pt. *** Consider the need for patient transfer.

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14 6 SECONDARY SURVEY Does not begin until the primary survey (ABCDEs) is completed, resuscitative effort are well established & the pt is demonstrating normalization of vital sign. * Head to Toe evaluation & reassessment of all vital signs. * A complete neurological exam is performed including a GCS score. * Special procedure is order.

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15 History A : Allergies. M : Medication currently used. P : Past illness/ Pregnancy. L : Last Meal E : Events/Environment related to the injury. *blunt trauma/penetrating trauma/injuries due to cold & burn/hazardous environment?

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16 PHYSICAL EXAMINATION 1. Head Visual acuity Pupillary size Hemorrhage of conjunctiva and fundi Penetrating injury Contact lenses(remove before edema occurs) Dislocation of lens Ocular movement

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17 2. Maxillofacial Injury no NG tube, definite airway? 3. Cervical Spine & Neck *Pt with maxillofacial or head trauma should be presumed to have and unstable cervical spine. 4. Chest *elderly pt are not tolerant of even relatively minor chest injury. *Children often sustain significant injury to the intrathoracic structure without evidence of thoracic skeletal trauma.

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18 5. Abdomen *excessive manipulation of the pelvic should be avoided. 6. Perineum/rectum/vagina 7. Musculoskeletal 8. Neurologic * Protection of spinal cord is required at all times until a spine injury excluded, especially when the pt is transfer.

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19 7. ADJUNCT TO THE SECONDARY SURVEY include additional x-ray and all other special procedure. 8. RE-EVALUATION Adult urine output 0.5ml/kg/hr Pediatric urine output 1mg/kg/hr *Pain relief -- IM should be avoid. 9. DEFINITE CARE

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20 Indication For Definite Airway * Unconscious * Severe maxillo-facial fracture * Risk for aspiration : Bleeding/ vomiting * Risk for obstruction : neck hematoma/laryngeal,tracheal injury/ stridor * Apnea : Neuromuscular paralysis/unconscious * Inadequate respiratory effort: tachypnea/hypoxia/hypercapnia/cyanosis * Severe closed head injury need for hyperventilation

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21 Normal Blood Amount: Normal adult blood volume : 7% of body weight Normal blood volume for child : 8-9% of body weight Hemorrhage Classification : Class I Hemorrhage : up to 15% loss Class II Hemorrhage : 15-30% loss Class III Hemorrhage : 30-40% loss Class IV Hemorrhage : >40% loss

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22 3 for 1 Rule a rough guideline for the total amount of crystalloid volume acutely is to replace each ML of blood loss with 3 ML of crystalloid fluid, thus allowing for restitution of plasma volume lost into the interstitial & intracellular space

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23 Initial Fluid Therapy Lactated Ringer is preferred * For adult 1-2 liters bolus * For child 20ml/kg bolus

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24 Intraosseous Puncture/Infusion Children less than 6 y/o for IV access is impossible due to circulatory collapse or for whom percutaneous peripheral venous cannulation had failed on two attempt.

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25 Head Injury Classification: Mild : GCS 14-15 Moderate : GCS 9-13 Severe : GCS 3-8 Coma = GCS score of 8 or less

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26 Diagnostic Peritoneal Lavage Indication A. Change in sensorium--Head injury/alcohol/drug. B. Change in sensation--Spinal cord injury. C. Injury to adjacent structure(indicating abd injury)--lower ribs/pelvic/lumbar spine. D. Equivocal physical examination. E. Prolong loss of contact with patient anticipated. *** Positive Test: >100,000 RBC/mm3, >500 WBC/mm3 or Gram Stain with bacteria

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27 Determining the level of quadriplegia a. Raise elbow to level of shoulder -- Deltoid C5 b. Flexes the forearm -- Biceps C6 c. Extend the forearm -- Triceps C7 d. Flexes wrist & finger -- C8 e. Spread finger -- T1

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28 Determine the level of paraplegia a. Flexes the hip -- Iliopsoas L2 b. Extend knee -- Quadriceps L3 c. Dorsiflexes ankle -- Tibialis anterior L4 d. Plantar flexes ankle -- Gastrocnemius S1

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29 Thoracic Trauma 8 lethal Injury 1. Simple pneumothorax 2. Hemothorax 3. Pulmonary contusion 4. Tracheo-bronchial tree injury 5. Blunt cardiac injury 6. Traumatic aortic disruption 7. Traumatic diaphragmatic injury 8. Mediastinal traversing wounds.

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30

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31 Fluid Therapy in 2nd or 3rd Degree Burn Total amount of first 24 hours: 4 ml of Ringer lactate x BW(kg) x BSA * give 1/2 in first 8 hrs * 1/2 in remaining 16 hrs

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32 Referral to Burn Center * 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y/o * 2nd or 3rd degree burn > 20% BSA in other age group * 2nd or 3rd degree burn of face/eye/ear/hands/feet/ genitalia/perineum or major joints * 3rd degree burn >5% in any age group * Significant electrical/lightning injury * Significant chemical burn * Inhalation injury

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33 Color Codes Triage Tag RED : Most critical injury YELLOW : Less critical injured GREEN : No life or limb threatened injury BLACK : Death or obviously fatal injury

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34 Priorities with multiple injuries 1. Thoracic trauma or tamponade 2. Abdominal hemorrhage 3. Pelvic Hemorrhage 4. Extremity Hemorrhage 5. Intra-cranial Injury 6. Acute Spinal Cord Injury