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ADVANCE TRAUMA LIFE SUPPORT

ADVANCE TRAUMA LIFE SUPPORT. Jorge M. Concepcion, MD, FPCS Training Officer Department of Surgery The Medical City. ACCIDENTS ?. INJURIES?. OBJECTIVES. To discuss the concepts in ATLS. To provide the correct sequence of priorities in assessing multiply injured patient.

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ADVANCE TRAUMA LIFE SUPPORT

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  1. ADVANCE TRAUMA LIFE SUPPORT Jorge M. Concepcion, MD, FPCS Training Officer Department of Surgery The Medical City

  2. ACCIDENTS ? INJURIES?

  3. OBJECTIVES • To discuss the concepts in ATLS. • To provide the correct sequence of priorities in assessing multiply injured patient. • To introduce the principles in definitive trauma care

  4. INJURY(WHO definition) • a bodily lesion resulting from exposure • to energy Mechanical Thermal Radiation Electrical Chemical interacting with the body in the amounts that exceed the limits of physiologic tolerance.

  5. INJURIES “NOT ACCIDENTS” PREDICTABLE PREVENTABLE Not random events but occur in predictable patterns

  6. PREVENTION

  7. TRADITIONAL: HISTORY OF ILLNESS COMPLETE P.E. INITIAL IMPRESSION DIFFERENTIAL DIAGNOSIS DIAGNOSTIC TEST FINAL DIAGNOSIS TREATMENT

  8. TRAUMA MANAGEMENT RECOGNITION OF INJURY (P.E.) TREATMENT

  9. TRAUMA CONCEPTS: 1. TREAT THE GREATEST THREAT TO LIFE. 2. LACK OF DEFINITIVE DIAGNOSIS SHOULD NOT IMPEDE THE APPLICATION OF AN INDICATED TREATMENT. 3. DETAILED HISTORY IS NOT ESSENTIAL TO BEGIN THE EVALUATION OF AN ACUTELY INJURED PATIENT.

  10. APPROACH TO SEVERELY INJURED PATIENT 1. PRIMARY SURVEY 2. RESUSCITATION 3. SECONDARY SURVEY 4. DEFINITIVE MANAGEMENT 5. TERTIARY SURVEY REASSESSMENT

  11. PRIMARY SURVEY A - AIRWAY & C-SPINE CONTROL B - BREATHING C - CIRCULATION – HEMORRHAGE CONTROL D - DISABILITY (NEURO EXAM) E - EXPOSURE / ENVIRONMENT

  12. AIRWAY GUARANTEE PATENCY CLINICAL “WHAT IS YOUR NAME?” INTUBATE GCS 8 OR LESS OBSTRUCTED AIRWAY HEMORRHAGIC SHOCK COMBATIVE PATIENT

  13. AIRWAY RISK FACTORS • I nstability (hemodynamic) • N eck hematoma/trauma • T rauma to the face (maxillofacial) • U nresponsive (GCS < 8) • B leeding from oropharynx • A pnea • T hermal inhalational injury • E mesis/epistaxis/hemoptysis

  14. AIRWAY MAINTENANCE MEASURES • Finger sweep • Chin lift • Jaw thrust • Oro/nasopharyngeal airway • Laryngeal mask airway • Needle cricothyroidotomy

  15. DEFINITIVE AIRWAY CONTROL • Intubation • Orotracheal • Nasotracheal • Surgical airway • Cricothyroidotomy • Tracheostomy

  16. THINGS TO CONSIDER • TIMING – don’t delay • EQUIPMENT – scope, suction, suppplies • ANESTHEZISE • MONITOR • WEAR PROTECTION • OXYGENATE • REINFORCEMENT – ask for help • KEEP NECK PROTECTED

  17. C-SPINE CONTROL • ALL PATIENTS WITH BLUNT TRAUMA – PRESUME TO HAVE C-SPINE INSTABILITY • IMMOBILIZATION OF C-SPINE IS A PRIORITY • C-SPINE CLEARANCE IS NOT A PRIORITY

  18. C-SPINE CONTROL IN-LINE STABILIZATION CERVICAL COLLAR

  19. C-COLLAR SHOULD NOT INTERFERE WITH CLINICAL EXAM OF THE NECK • INTUBATION – REMOVE THE COLLAR AND DO IN-LINE STABILIZATION

  20. WHAT’S WRONG?

  21. BREATHING GUARANTEE ADEQUATE OXYGENATION AND VENTILATION GIVE SUPPLEMENTAL OXYGEN VENTILATION (LUNGS, CHEST WALL & DIAPHGRAM) ASSESS RESPIRATORY EFFORT, BREATH SOUNDS & OXYGEN DELIVERY

  22. Objective Signs • Inspection • Palpation • Percussion • Auscultation

  23. Oxygen delivery L/min. Approx. FiO2 Nasal cannula Face mask Face mask w/ reservoir 1 2 4 6 5-6 6-7 7-8 6 8 10 0.24 0.28 0.35 0.42 0.40 0.50 0.60 0.60 0.80 1.00 OXYGENATION

  24. Ventilation Mouth to pocket face mask Bag-valve-mask ( 2 person technique) Pleural Decompression Needle thoracentesis Closed-tube thoracostomy Three-sided dressing MANAGEMENT

  25. CIRCULATION ASSURE ADEQUATE OXYGEN DELIVERY AND CONTROL BLEEDING ASSESS VITAL SIGNS CONTROL BLEEDING DIRECT PRESSURE REDUCTION OF FRACTURES IN LONG BONES AND PELVIS

  26. RECOGNITION OF SHOCK • Tachycardia • Cutaneous vasoconstriction • Hypotension • Narrowed pulse pressure

  27. ETIOLOGY OF SHOCK • Hemorrhagic • Nonhemorrhagic • Cardiac compressive • tension pneumothorax • cardiac tamponade • Cardiogenic • Neurogenic • Septic

  28. CLASSES OF HEMORRHAGE

  29. CLASSES OF HEMORRHAGE • 70 kg male with gunshot wound in the RUQ • Vital signs: • BP 80/40 • HR 116/min • RR 22/min • Class III hemorrhage • EBL= 1470 mL • 70 kg x 7% x 30%

  30. INITIAL MANAGEMENT • Recognize shock • Stop the bleeding! • Replace effective circulating volume • Restore tissue perfusion

  31. FLUID THERAPY • Warmed crystalloid solution • Rapid fluid bolus • Adult 2 liters • Child 20 mL/kg • “3 for 1 rule” • Monitor response to therapy

  32. ELECTROLYTES 140 109 4 21

  33. Size of needle in relation to a flow of 1 liter IVF Time Size (gauge) 12 min. 18 9 min. 16 7 min. 14

  34. RESPONSE TO FLUID RESUSCITATION • Rapid response • Transient response • Minimal or no response

  35. RESPONSE TO FLUID RESUSCITATION

  36. CIRCULATION • Hypovolemia most common cause of shock • Recognition of its presence 1st step • Control of bleeding • Restoration of intravascular volume • Monitor patient’s response

  37. DISABILITY ASSESS GCS, PULSES, SENSORY AND MOTOR FUNCTIONS GCS BEST MOTOR RESPONSE – 6 BEST VERBAL RESPONSE – 5 EYE OPENING – 4 3 - 15 ? V = ? M = 4 E = 3 GCS = 7 V = M(0.5) + E(0.4) V = 4 (0.5) = 2 + 3 (0.4) = 1.2 V = 2 + 1.2 = 3.2 V = 3 M = 4 E = 3 GCS = 10

  38. EXPOSURE AND ENVIRONMENTAL CONTROL UNDRESS ( CUT CLOTHING ) KEEP PATIENT WARM LOGROLL OFTEN MISSED INJURIES AXILLA PERINEUM BACK

  39. SECONDARY SURVEY HISTORY A - ALLERGIES M- MEDICATIONS P – PAST ILLNESSES L – LAST MEAL E– EVENTS PRECEEDING THE INCIDENT

  40. PHYSICAL EXAMINATION DETAILED, METICULOUS HEAD TO TOE EXAM FINGER AND TUBES IN ALL ORIFICES LOOK, LISTEN, FEEL EVERYWHERE

  41. DEFINITIVE MANAGEMENT TERTIARY SURVEY

  42. DEFINITIVE MANAGEMENT • PENETRATING NECK • PENETRATING CHEST • BLUNT CHEST • PENETRATING ABDOMEN • BLUNT ABDOMEN • EXTREMITIES

  43. DO’s PRIMUM NON NOCERE SPLINT PATIENTS WHERE THEY LIE COMFORT THE PATIENT ALLEVIATE PAIN HONE YOUR SKILLS ASK FOR HELP

  44. DON’TS PANIC INSERT NGT IN PATIENT WITH SUSPECTED FACIAL FRACTURE REMOVE IMPALED OBJECTS FORGET TO WARM THE PATIENT (ESP. CHILDREN) INSERT A FOLEY CATHETER IN PATIENTS SUSPECTED OF URETHRAL INJURY OVERLOOK THE PERINEUM, BACK AND AXILLA

  45. Thank you

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