Transcript definitive management

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.
 To introduce the principles in definitive
trauma care
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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.
INJURIES
“NOT ACCIDENTS”
PREDICTABLE
PREVENTABLE
Not random events but occur in
predictable patterns
PREVENTION
TRADITIONAL:
HISTORY OF ILLNESS
COMPLETE P.E.
INITIAL IMPRESSION
DIFFERENTIAL DIAGNOSIS
DIAGNOSTIC TEST
FINAL DIAGNOSIS
TREATMENT
TRAUMA MANAGEMENT
RECOGNITION OF INJURY (P.E.)
TREATMENT
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.
APPROACH TO SEVERELY
INJURED PATIENT
1. PRIMARY SURVEY
2. RESUSCITATION
3. SECONDARY SURVEY
4. DEFINITIVE MANAGEMENT
5. TERTIARY SURVEY
REASSESSMENT
PRIMARY SURVEY
A
- AIRWAY & C-SPINE CONTROL
B
- BREATHING
C
- CIRCULATION – HEMORRHAGE CONTROL
D
- DISABILITY (NEURO EXAM)
E
- EXPOSURE / ENVIRONMENT
AIRWAY
GUARANTEE PATENCY
CLINICAL
“WHAT IS YOUR NAME?”
INTUBATE
GCS 8 OR LESS
OBSTRUCTED AIRWAY
HEMORRHAGIC SHOCK
COMBATIVE PATIENT
AIRWAY RISK FACTORS
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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
AIRWAY MAINTENANCE
MEASURES
Finger sweep
 Chin lift
 Jaw thrust
 Oro/nasopharyngeal airway
 Laryngeal mask airway
 Needle cricothyroidotomy
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DEFINITIVE AIRWAY CONTROL
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Intubation
– Orotracheal
– Nasotracheal
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Surgical airway
– Cricothyroidotomy
– Tracheostomy
THINGS TO CONSIDER
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TIMING – don’t delay
EQUIPMENT – scope, suction,
suppplies
ANESTHEZISE
MONITOR
WEAR PROTECTION
OXYGENATE
REINFORCEMENT – ask for help
KEEP NECK PROTECTED
C-SPINE CONTROL

ALL PATIENTS WITH BLUNT TRAUMA –
PRESUME TO HAVE C-SPINE INSTABILITY
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IMMOBILIZATION OF C-SPINE IS A PRIORITY
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C-SPINE CLEARANCE IS NOT A PRIORITY
C-SPINE CONTROL
IN-LINE STABILIZATION
CERVICAL COLLAR
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C-COLLAR SHOULD NOT INTERFERE
WITH CLINICAL EXAM OF THE NECK
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INTUBATION – REMOVE THE COLLAR
AND DO IN-LINE STABILIZATION
WHAT’S WRONG?
BREATHING
GUARANTEE ADEQUATE OXYGENATION AND
VENTILATION
GIVE SUPPLEMENTAL OXYGEN
VENTILATION (LUNGS, CHEST WALL & DIAPHGRAM)
ASSESS RESPIRATORY EFFORT, BREATH SOUNDS &
OXYGEN DELIVERY
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 Inspection
 Palpation
 Percussion
 Auscultation
Objective Signs
OXYGENATION
Oxygen delivery
Nasal cannula
Face mask
Face mask w/
reservoir
L/min.
1
2
4
6
5-6
6-7
7-8
6
8
10
Approx. FiO2
0.24
0.28
0.35
0.42
0.40
0.50
0.60
0.60
0.80
1.00
MANAGEMENT
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Ventilation
– Mouth to pocket face
mask
– Bag-valve-mask ( 2
person technique)
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Pleural Decompression
– Needle thoracentesis
– Closed-tube
thoracostomy
– Three-sided dressing
CIRCULATION
ASSURE ADEQUATE OXYGEN DELIVERY AND
CONTROL BLEEDING
ASSESS VITAL SIGNS
CONTROL BLEEDING
DIRECT PRESSURE
REDUCTION OF FRACTURES IN LONG BONES
AND PELVIS
RECOGNITION OF SHOCK
Tachycardia
 Cutaneous vasoconstriction
 Hypotension
 Narrowed pulse pressure
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ETIOLOGY OF SHOCK
Hemorrhagic
 Nonhemorrhagic
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– Cardiac compressive
 tension pneumothorax
 cardiac tamponade
– Cardiogenic
– Neurogenic
– Septic
CLASSES OF HEMORRHAGE
Class I
Class II
Class III
Class IV
Blood Loss (ml)
Up to 750
750-1500
1500-2000
>2000
Blood Loss (% blood
volume)
Up to 15%
15-30%
30-40%
>40%
<100
>100
>120
>140
Blood Pressure
normal
normal
decreased
decreased
Pulse Pressure
normal or
decreased
decreased
decreased
decreased
14-20
20-30
30-40
>35
>30
20-30
5-15
negligible
Slightly
anxious
Mildly
anxious
Anxious,
confused
Confused,
lethargic
Pulse Rate
Respiratory Rate
Urine Output
(mL/hr)
CNS/mental status
CLASSES OF HEMORRHAGE
70 kg male with gunshot wound in the
RUQ
 Vital signs:
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– BP 80/40
– HR 116/min
– RR 22/min
Class III hemorrhage
 EBL= 1470 mL
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– 70 kg x 7% x 30%
INITIAL MANAGEMENT
Recognize shock
 Stop the bleeding!
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Replace effective circulating volume
 Restore tissue perfusion
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FLUID THERAPY
Warmed crystalloid solution
 Rapid fluid bolus
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– Adult
– Child
2 liters
20 mL/kg
“3 for 1 rule”
 Monitor response to therapy
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ELECTROLYTES
140 109 4
21
Size of needle in relation to a flow of 1 liter IVF
Size (gauge)
Time
18
12 min.
16
9 min.
14
7 min.
RESPONSE TO FLUID
RESUSCITATION
Rapid response
 Transient response
 Minimal or no response
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RESPONSE TO FLUID
RESUSCITATION
Rapid Response
Transient Response
No response
Vital Signs
Return to normal
Transient
improvement
Remain abnormal
Estimated blood
loss
Minimal (10-20%)
Moderate and
ongoing (20-40%)
Severe (>40%)
Need for more
fluids
Low
High
High
Need for blood
Low
Moderate to high
Immediate
Blood preparation
Type and
crossmatch
Type specific
Emergency blood
release
Need for surgery
Possibly
Likely
Highly likely
Early presence of
surgeon
Yes
Yes
Yes
CIRCULATION
Hypovolemia most common cause of
shock
 Recognition of its presence 1st step
 Control of bleeding
 Restoration of intravascular volume
 Monitor patient’s response
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DISABILITY
ASSESS GCS, PULSES, SENSORY AND
MOTOR FUNCTIONS
GCS
?
BEST MOTOR RESPONSE – 6
BEST VERBAL RESPONSE – 5
EYE OPENING – 4
V=?
M=4
E=3
3 - 15
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
EXPOSURE AND
ENVIRONMENTAL CONTROL
UNDRESS ( CUT CLOTHING )
KEEP PATIENT WARM
LOGROLL
OFTEN MISSED INJURIES
AXILLA
PERINEUM
BACK
SECONDARY SURVEY
HISTORY
A - ALLERGIES
M - MEDICATIONS
P – PAST ILLNESSES
L – LAST MEAL
E – EVENTS PRECEEDING THE INCIDENT
PHYSICAL EXAMINATION
DETAILED, METICULOUS HEAD TO
TOE EXAM
FINGER AND TUBES IN ALL ORIFICES
LOOK, LISTEN, FEEL EVERYWHERE
DEFINITIVE MANAGEMENT
TERTIARY SURVEY
DEFINITIVE MANAGEMENT
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PENETRATING NECK
PENETRATING CHEST
BLUNT CHEST
PENETRATING ABDOMEN
BLUNT ABDOMEN
EXTREMITIES
DO’s
PRIMUM NON NOCERE
SPLINT PATIENTS WHERE THEY LIE
COMFORT THE PATIENT
ALLEVIATE PAIN
HONE YOUR SKILLS
ASK FOR HELP
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
Thank you