ART OF LIFE SUPPORT

ART OF LIFE SUPPORT: 

ART OF LIFE SUPPORT BY Hosam Mohamad Hamza , Msc Assistant lecturer of GI Surgery & Endoscopy Minia School Of Medicine Minia –Egypt

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Trauma is the 3 rd leading cause of death in people aged 1-44 years, and a leading cause of disability. WHO data suggest that 1 in 10 deaths worldwide is a result of trauma. Serious multi-system injuries occur in 10-15% of PTP.

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Trauma related mortality may be: Late Death Early Death Immediate death 20% 30% 50% % days or weeks 1st few hrs ( golden hrs) soon or within min. Time after injury -Sepsis. -M.O.F. - Airway obst. -disruption of Breathing mech. - Circulation failure. -major brain injury. -high cord injury. -major airway disruption. Causes Proper patient follow-up. Training about ABC resuscitation programs. Community education about trauma- preventing programs (seat belts, head protection,…etc) Prevention

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I. Trauma Team Patients with major trauma are best treated by a well-organized trauma team. Each team member should be assigned a specific task or tasks so each of these can be performed simultaneously.

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II. Trauma System Recently, many protocols were introduced for management of multi injured patients including : ATLS → A dvanced T rauma L ife S upport. followed by: ATNC → A dvanced T rauma N ursing C ourse. and more recently: PHTLS → P re- H ospital T rauma L ife S upport .

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LIFE SUPPORT Definition: Several techniques used to maintain life when essential body systems are not sufficiently functioning to sustain life unaided. B asic L ife S upport ( B.L.S. ) A specific level of prehospital medical care provided by trained responders, including emergency medical technicians , in the absence of advanced medical care.

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A dvanced T rauma L ife S upport ( A.T.L.S. ) In 1970s, an air crash lead to the death of the wife and serious injuries of the three children of James Styner; an American orthopedic surgeon. An event that had forced him to introduce a structured trauma management program which was soon adopted by The American Collage of Surgeons and developed the Advanced Trauma Life Support (ATLS) protocol or EMST (Early Management of Severe Trauma) as known in the UK.

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Philosophy of ATLS: “ Treat the lethal injuries first, then reassess and treat again” Components of ATLS: 1- Primary Survey identify what is fatal and treat it. 2- Secondary Survey proceed to discover all other injuries. 3- Definitive Care develop a definitive management plan.

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Primary survey and Resuscitation identify and treat any life threatening condition. - starts at the scene of accident by trained ambulance personnel. - must be repeated any time a patient's status changes. - Steps : ( stepwise approach ) history : (AMPLE ) A irway, no procedures are initiated until the airway is secured B reathing C irculation D isability (N. Dysfunction) E xposure / E nvironment F racture

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1- AIRWAY & SPINE CONTROL (1ry survey) Lack of an airway is one of the few situations in medicine in which seconds count. * assess : -esp. in : disturbed conscious level ?? ± vomition. maxillo-facial trauma. neck trauma. nasal or oral bleeding. * maintain : * protect (clear) : * provide : @ endotracheal @ surgical ×

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AIRWAY & SPINE CONTROL (continued)

AIRWAY & SPINE CONTROL (continued) : 

AIRWAY & SPINE CONTROL (continued)

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AIRWAY & SPINE CONTROL (continued) indications of ETE in trauma: 1.Apnea (as part of CPR). 2.Respiratory insufficiency. 3.Risk of aspiration (dcl w vomition) 4.Impending upper airway compromise (inhalation, maxillo- facial injuries). 5.Closed head injuries. (hyperventilation).

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Tracheostomy (tracheotomy)

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Cricothyroidotomy (cricothyrotomy, mini-tracheostomy, laryngostomy) Types : -needle cricothyrotomy -surgical cricothyrotomy

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? - cricothyroidotomy is more simple and faster and nowadays is gaining popularity over tracheostomy. - needle cricothyroidotomy is a temporary method not suitable for proper ventilation. - surgical cricothyroidotomy can be used for ventilation for only 30-45 minutes. -cricothyroidotomy (esp. surgical) is not suitable for children < 10 years.

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? - cervical spine should be considered unstable until proved otherwise by radiology (at least 3 views). - esp. in : * Altered level of consciousness *Blunt injury above the clavicle. *Cervical bony abnormalities or tenderness. *Maxillofacial trauma. - Immobilization : Backboard and rigid neck collar, sand bags and fore head tape. If a collar is not available, manual in line immobilization is necessary.

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2- BREATHING (1ry survey) % Having a patent airway is not necessarily associated with normal respiration. % Abnormal resp. after trauma may be : § Central (severe head trauma, RC depression) § Peripheral ( Suction pneumothorax, Tension pneumothorax, Tension hameothorax, flail chest)

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2- BREATHING (1ry survey) * assess : Inspection :- chest wall bulge or retraction. chest expansion. wounds. respiratory rate . tracheal shift. use of accessory muscles of respiration. Palpation :- surgical emphysema. Tenderness. fracture click. flail segments. Auscultation :- air entry at different lung fields on both sides. Percussion :- (less commonly used ) for hyperresonance or dullness over different lung fields on both sides.

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*test : 1- Pulse oximetry ( ?unreliable) 2-ABG sampling 3- Diagnostic Thoracocentesis (Diagnostic Aspiration = in respiratory distress) -site : -result :

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4-Imaging

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Flail chest Hypoxia 1- Rib fracture pain may cause the patient to hold the chest still. 2- Pulmonary contusion (if present) causes extravasation of fluid and blood into the alveoli. 3- Paradoxical respiration .

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Tension pneumothorax is a clinical diagnosis. do not wait for radiographs if suspecting Classic signs : -respiratory distress. -cyanosis. -chest pain. -refractory shock . -decreased breath sounds. -tympany of the affected lung. -jugular venous distension. -tracheal deviation to the opposite side

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Tension (Massive) hemothorax is defined as 1500 mL of blood in the chest cavity . Patient who continues to bleed (a flow of 200 mL / h for 2-4 hours) may require thoracotomy to control bleeding.

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3- CIRCULATION (1ry survey) Failure of peripheral circulation is known as SHOCK. causes of SHOCK with trauma : 1 - hypovolaemic (hgic) : commonest . 2- neurogenic : severe pain . 3- cardiogenic : haemopericarcardium or cardiac trauma . 4- septic : late and rare .

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* assess : - fatigue . - altered mentality . - cold pale clammy skin with slow capillary refill and collapsed veins. - vital signs : weak rapid pulse. hypotension. hypothermia. hunger to air (tachypnea). - oliguria: ↓ urine output < 0.5 ml/kg/hour in adults.

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* estimate : (amount of blood loss) - clinically : - external blood loss : (WTa –WTb x 1.5 -2) - internal blood loss : ¤ type of injury : hematoma in closed fracture tibia → 500 – 1500 ml. hematoma in closed fracture femur →500 –2000 ml. hematoma in closed fracture pelvis →2000 –3000 ml. ¤ abdominal US or CT scan .

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Class I Class II Class III Class IV Blood loss Up to 15% 15 – 30% 30 – 40% > 40% Mental state Normal to Anxious Anx. to Restless Aggressive or Drowsy Drowsy to unconscious Pulse / min < 100 100 - 120 100 – 140 140 Systolic BP Normal Normal (supine) ↓ ↓ Diastolic BP Normal ↑ ↓ ↓ Pulse P. Normal ↓ ↓ ↓ Cap. refill Normal > 2 sec > 2 sec > 2 sec R.R. 14 - 20 20 - 30 30 - 35 >35 Skin Normal Pale & cold Pale &colder P &very cold Urine (ml/h) 0 - 10 10 - 20 20 - 30 > 30

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* treat : - define & treat the cause . - 4 tubes :

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*Resuscitate with : two large-bore (14- to 16-gauge) I.V. catheters warmed fluids. packed RBCs if necessary. *Control hemorrhage. *Use the left lateral position for all pregnant patients at more than 20 weeks of gestation.

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4- DISABLITY (1ry survey) * causes : head injury, shock , hypoxia and intoxication. * assess : AVPU method A lert and responsive . V ocal stimulus elicits response. P ainful stimulus is needed to elicit a response . U nresponsive .

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Response SCORE Eye opening response Spontaneous 4 To voice 3 To pain 2 None 1 Best verbal response Oriented 5 Confused 4 Inappropriate speech 3 Incomprehensible speech 2 None 1 Best motor response Obeys commands 6 Localizes pain 5 Withdraws to pain 4 Flexes to pain 3 Extends to pain 2 None 1 TOTAL 3 - 15

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5- EXPOSURE / ENVIRONMENT (1ry survey) All clothes are removed using large sharp scissors. Keep the emergency room warm and use blankets to prevent hypothermia.

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Some cases may require transfer to another hospital with higher facilities or to another department in the same hospital. The level of care MUST not be allowed to DROP during the transfer .

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Summary of the primary survey Airway - Airway opened, airway obstruction treated, possible definitive airway placed Breathing - Breathing assessed, treat threats. Circulation - Blood circulation and tissue perfusion assessed, intravascular volume loss replaced with fluids and blood, external hemorrhage controlled. Disability - Neurologic status assessed Exposure/environment - Patient fully undressed and environment controlled to protect from hypo or hyperthermia Consider transfer - For higher level of care if necessary. Adjuncts - Trauma radiographs, laboratory studies, urinary or gastric catheters, temperature monitoring, consider blood transfusion

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Secondary Survey -starts once resuscitation efforts are underwent and preliminary X rays have been evaluated. -steps : * examine the patient from head to toe and from front to back. * complete and integrate all data (clinical, laboratory and radiological) . * Formulate a management plan .

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Definitive Care * after identification of the cause & region of injury . * Patients with multiple injuries require the attention of a number of specialists. * The most appropriate person to take the primary responsibility in such cases is usually the general surgeon. * Patients require repeated evaluation as some injuries may present late e.g. delayed splenic injuries, retroperitoneal duodenal injuries and subdural hematomas.

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THANK U olympusminia@yahoo.com