J.

Adv Dental Research All Right Res

REVIEW ARTICLE

Emergency Trauma Care: ATLS

Kiran DN * Anupama Kiran **
*M.D.S, Associate Professor, Department of Oral & Maxillofacial Surgery **M.D.S, Asst Professor, Department of Conservative & Endodontics, M.M .College of Dental Sciences and Research, Ambala, India. Email: kdn30673@gmail.com
Abstract: Advanced trauma life support orients doctors to the initial assessment and to provide emergency trauma care for the injured patient. It provides a safe, reliable method and also basic knowledge necessary to, 1. Assess the patients condition rapidly and accurately. 2. Resuscitate and stabilize according to priority. 3. Arrange appropriately for the patients inter hospital transfer (what, who, when and how). 5. Assure that optimum care is provided. The purpose of advanced trauma life support is to decrease morbidity and mortality, which is expected to be achieved by fast, systematic, and effective assessment and treatment of the injured patient. Key words: Trauma, ATLS, Life support, Emergency care, Trauma care Introduction The word Trauma comes from a Greek word meaning a wound, which implies, any serious injury to the body, often resulting from violence or an accident, or an event that causes great distress. (1) Trauma is a diverse disease in which, time, critical decisions and skills affect patient outcome. For every one patient who dies, there are three survivors with serious disabilities. (2, 3) The first peak of deaths occurs within minutes of the event from non-survivable injuries, even with the most advanced medical resources immediately to hand. The second peak may account for some 30% of deaths, in the first few hours after injury. Death is most often due to hypoxia and hypovolaemic shock. (4) This group stands to benefit the most from excellence in trauma care. The third peak, of up to 20% of trauma deaths, occurs late after the injury, from sepsis, multi-organ failure, and other complications.(5)

In developed countries there is a decrease in trauma mortality in recent decades due to a combination of injury prevention endeavours and improvement in trauma care.(6) The purpose of adequate trauma care is to decrease this morbidity and mortality, which is expected to be achieved by fast, systematic, and effective assessment and treatment of the injured patient. The maxillofacial skeleton is vulnerable to injury, and are commonly seen after assault, road traffic accidents, falls, and sporting injuries. These injuries require immediate first-aid treatment such as the establishment of a free airway, control of haemorrhage, treatment of shock, support of the facial structures and positioning of the patient face-downwards are the essential lifesaving measures. Advanced Trauma Life Support (ATLS) includes the initial assessment and management of trauma patients that aims to optimise initial care and reduce mortality and morbidity. The ATLS concept is also used in the prehospital phase of trauma patient care and has been adopted for non-trauma medical emergencies and implemented in resuscitation protocols around the world. History of ATLS Importance to the ATLS was established after a tragic plane crash in1976, an airplane with an orthopedic surgeon, J Styner in Nebraska. His wife and children crashed in a corn field, the wife died. The surgeon and three of his four children were seriously injured. Unfortunately for Dr Styner he found that the subsequent care received in the local hospital was inferior to what he was able to provide for 10 hours at the scene of the accident. And he decided to develop a system to improve the care for trauma victims, and thus, ATLS was born. (7) ATLS originally represented a state of the art training course on the care of major trauma.(8) A group of local surgeons and physicians, the Lincoln Medical Education Foundation, together with the University of Nebraska founded local courses aiming at teaching advanced trauma life support skills.(9) After the first ATLS course in 1978, it was taken up by the American College of Surgeons Committee on Trauma (ACS COT) in the next year and rapidly spread throughout the North, Central, and South America. Today ATLS is taught in over 42 countries and around half a million clinicians have completed the course. The concept has matured, has been

Serial Listing: Print ISSN(2229-4112) Online-ISSN (2229-4120) Bibliographic Listing: Index Copernicus. EBSCO Publishing Database. Proquest. J-Gate.

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disseminated around the world and has become the standard of emergency care in trauma patients. (2) Originally, ATLS was designed for emergency situations where only one doctor and one nurse are present. Nowadays, ATLS is also accepted as the standard of care for the first (golden) hour in level-1 trauma centres. The priorities of emergency trauma care according to the ATLS principles are independent of the number of people caring for the patient. (10) Apart from the severity of injury, probably the single most important factor determining the outcome of a trauma patient is the time interval from the moment the injuries are received to the provision of definitive care. Definitive care for the trauma patient implies achieving a clear airway and effective ventilation, haemorrhage control and restoration of an adequate blood volume. In managing emergency trauma, treat the greatest threat to life first. A detailed history is not necessary to begin evaluation and treatment. Indicated treatment must be applied even when a definitive diagnosis is not yet established. Maxillofacial injuries are commonly seen after assault, road traffic accidents, falls, and sporting injuries in a ratio mandibular: zygoma: maxillary of 6:2:1.(11) As with all traumas, basic advanced trauma life support principles should be applied to the initial assessment of the casualty. This must include a primary and secondary survey. It is only after the secondary survey that definitive care begins. Primary survey; In the primary survey, the mnemonic ABCDE is used to remember the order of assessment with the purpose to treat first that kills first, A- Airway and Cervical spine stabilization B- Breathing C- Circulation D- Disability and E- Environment and Exposure(10) Airway obstruction kills quicker than difficulty of breathing caused by a pneumothorax, and a patient dies faster from bleeding from a splenic laceration then from a subdural hematoma. Injuries are diagnosed and treated according to the ABCDE sequence. A: Airway A recent retrospective study of pre-hospital trauma deaths in North Staffordshire reported that, on the basis of post-mortem evidence, airway obstruction had been present in two-thirds of those patients in whom death was judged not to have been inevitable. (12) The main cause of death in severe facial injury is airway obstruction. This may be because of the tongue falling back and obstructing the hypopharynx in an unconscious patient or may be secondary to uncontrolled haemorrhage drowning the airway. The airway is not compromised when the patient talks normally. A hoarse voice or audible breathing is suspicious. Patients in a coma are not capable of keeping their airway patent. Assess the patient for airway obstruction: Agitation suggests hypoxia, obtundation suggests hypercarbia, and cyanosis suggests hypoxemia secondary to inadequate oxygenation. Look for evidence of injury to the larynx and trachea, including crepitus of the soft tissues. Clinically the patient may have noisy breathing, snoring, gurgling, or croaking. Hoarseness, subcutaneous emphysema, and a palpable fracture are suggestive laryngeal fracture. (13) Establish and maintenance of the airway: Good suction is essential. The chin should be pulled forward either through chin lift or jaw thrust procedures. The jaw thrust and chin lift relieves soft tissue obstruction by pulling the tongue, anterior neck tissues, and epiglottis forward. Remove the debris (broken teeth, dentures) from the mouth with finger sweep technique or Yankauer suction. A Magills forceps may also be used for larger objects. (14) Airway compromise is uncommon in the conscious patient; however, it may occur in an unconscious patient, particularly those who have sustained bilateral parasymphyseal fracture. These patients may require forward repositioning of the mandible and tongue to prevent airway obstruction. A towel clip is useful to pull the tongue forward. If no foreign body is visible an endotracheal tube should be inserted. Endotracheal intubation with a cuffed tube will secure the airway. If the foreign body cannot be removed quickly or the vocal cords cannot be adequately visualised or endotracheal intubation is not possible it should be left and a surgical airway performed. A cricothyroidotomy is the preferred way to establish a surgical airway in the emergency. A recent study of 50 cricothyoidotomy attempts in trauma patients by paramedics in Indiana concluded that the procedure was successful in 47(97%). A 5 or 6 mm tube cuffed tracheostomy tube should be inserted through the cricothyroidotomy incision. A needle cricothyroidotomy is advised in children less than 12 years of age as there is a high risk of damaging the cricoid cartilage. As the cricoid cartilage is the only circumferential supporting structure that maintains patency of the upper trachea. Every patient sustaining significant blunt trauma, particularly above the clavicles, should be assumed to have a cervical spine injury until proved other-wise. These patients should have the cervical spine immobilized with a semi-rigid cervical collar and bilateral sandbags or block joined with tape or straps across the forehead. As long as the cervical spine is not cleared by physical examination, with or without diagnostic imaging, the spine should remain stabilized. B: Breathing Breathing is the second to be evaluated in trauma care. Tension pneumothorax, massive hemothorax, flail thorax accompanied by pulmonary contusion, and an open pneumothorax compromise breathing acutely and can be diagnosed with physical examination alone and should be treated immediately. Most clinical problems in B can be treated with relatively simple measures as endotracheal

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intubation, mechanical ventilation, needle thoracocentesis, or tube thoracostomy. Injuries, like a simple pneumothorax or hemothorax, rib fractures, and pulmonary contusion, are often more difficult to appreciate with physical examination. Because these conditions have less effect on the clinical condition of the patient, they can be identified in the secondary survey. C: Circulation Circulatory problems in trauma patients are usually caused by haemorrhage. The first action should be to stop the bleeding. If there is no evidence of damage to the major vessels of the neck or middle third of facial fractures blood loss is usually insufficient to cause hypovolumic shock problems, but may cause problems with establishing and maintaining an airway. Bleeding from the soft tissues of the head and neck may be controlled with direct pressure on the bleeding site. If conscious, ask the patient to sit upright as this allows blood and secretions to drain out of the mouth. Intra oral bleeding may be controlled by getting the patient to bite on a swab. Bleeding from a tongue laceration can be torrential, in such cases deep sutures across the laceration are advised to achieve haemostasis, as pressure alone will not stop the bleeding. Bleeding from fractured mandible ends may be arrested by manually reducing and brittle wiring of the fracture fragments. In a patient with a mobile maxilla, the use of rubber mouth gags is advisable. The mouth gags, which act as a splint compressing the maxilla between the skull base and the mandible. In cases where there is also a mobile mandible fracture a cervical collar may be used as a temporary form of mandibular splint. Torrential bleeding from the region of the nasopharynx can be difficult to control. An epistat tube with anterior and posterior balloons that can be inflated to tamponade any bleeding can be very useful in these situations. Foley catheters may also be used. (14) D: Disability This includes assessment of the neurological status. The Glasgow coma score (GCS) is used to evaluate the severity of head injury. This score is arrived at by scoring eye opening, best motor response, and best verbal response. Patients who open their eyes spontaneously, obey commands, and are normally oriented score a total of 15 points. The worst score is 3 points. A decreased GCS can be caused by a focal brain injury, such as an epidural hematoma, a subdural hematoma, or a cerebral contusion, and by diffuse brain injuries ranging from a mild contusion to diffuse axonal injury. To prevent secondary injury to the brain, optimal oxygenation and circulation are important. Also, impaired consciousness can be caused or aggravated by hypoxia or hypotension for which ABC stabilization is essential. E: Environment and exposure Environment and exposure represent hypothermia, burns, and possible exposure to chemical and radioactive substances and should be evaluated and treated. At the end of the primary survey, before continuing with the secondary survey, the ABCDEs should be re- evaluated and confirmed. Secondary survey: An injury may be missed or its significance may not be recognised in the trauma resuscitation scenario, particularly in the unconscious or unstable patient. The secondary survey starts only after the ABCDE primary survey is complete and the patient responds to resuscitation. The secondary survey can be haphazard, poorly recorded, and, in the aftermath of a more dramatic initial resuscitation, may be less thorough. There can be a substantial delay between the primary and secondary survey if immediate treatment or surgery is indicated. During the secondary survey, the patient is examined from head to toe, and appropriate additional radiographs of the thoracic and lumbar spine and the extremities are performed when indicated. CT scans, when indicated, are also done in the secondary survey. Table 1 Secondary survey mnemonic (15) Mnemonic Has My Critical Care Assessed Patients Priorities Or Next Management Decision? Secondary survey Head/skull Maxillofacial Cervical Spine Chest Abdomen Pelvis Perineum Orifices (PR/PV)* Neurological Musculoskeletal Diagnostic tests/ definitive care

*Tubes and fingers in every orifice. Include AMPLE history. If, during the secondary survey, the patients condition deteriorates, the primary survey should be repeated beginning with A. Conclusion: Trauma continues to be the most common cause of death in first four decades of life. In that, Maxillo-facial injuries require immediate first-aid for the establishment of a free airway, control of hemorrhage, and treatment of shock. The facial structures must always be supported and the patient kept in a face-downward position. From its tragic origin ATLS has become an icon in medical education. There is no doubt that ATLS is at a crossroads in its development. To do nothing runs the risk of a schism developing. Alternatively it could adapt to become a truly international course. Either option will require trauma

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enthusiasts wishing to develop a more effective course for patients. ATLS is a systematic approach for the assessment of trauma patients. In multidisciplinary trauma care, it is beneficial and, maybe, even mandatory for effective communication that all members of the trauma team, speak the same ATLS language, so that the mortality will be reduced. References: 11. 1. Rowe Norman Lester. History of maxillofacial trauma. Annals of Royal College of surgery. 1971; 49: 329 349. American College of Surgeons Committee on Trauma Advanced trauma life support program for doctors, 7th edn. American College of Surgeons, 2004. World Health Organization (2007) Detailed data files of WHO mortalitydatabase, 2003. WHO, the Netherlands. http://www.who.int/whosis/database/mort/table1.cfm. Cited May 10, 2007 Alexander RH, Proctor HJ, eds. Committee on trauma: resource document 1: trauma prevention. In Advanced trauma life support. American College of Surgeons, 1993. Jon Clasper. David Rew. Trauma life support in conflict. British Medical Journal. 2003;327:11789 Roudasri Bahman S., Nathens Avery B. Emergency Medical Service (EMS) systems in developed and developing countries Injury, Int. J. Care Injured. 2007; 38: 1001 1013. P Driscoll, J Wardrope. ATLS: past, present, and future - Emerg Med J 2005; 22:2-3 8. Nolan JP. Advanced trauma life support in the United Kingdom: time to move on. Emerg Med J. 2005; 22:3 4. M R Carmont. The Advanced Trauma Life Support course: a history of its development and review of related literature. Postgrad Med J 2005; 81:8791. Digna R. Kool & Johan G. Blickman Advanced Trauma Life Support. ABCDE from a radiological point of view Emerg Radiol (2007) 14:135141 Jacobson LE, Gomez GA, Sobieray RJ, Rodman GH, Soltkin KC, Misinski ME, Surgical crichothyroidotomy in trauma patient: analysis of its use by paramedics in the field. Journal of Trauma 1996; 41: 15-20. Haug RH, Prather J, Indresano AT. An epidemiologic survey of facial fractures and concomitant injuries. J Oral Maxillofac Surg 1990; 48:926. Hussain LM. Redmond AD. Are pre-hospital deaths from accidental injury preventable? British Medical Journal 1994; 308: 1077-1080. P O Ceallaigh, K Ekanaykaee, C J Beirne, D W Patton Diagnosis and management of common maxillofacial injuries in the emergency department. Part 1: advanced trauma life support. Emerg Med J 2006; 23:796797. S C A Hughes Letters. Emerg Med J 2006; 23:661 663.

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Source of Support: Nil Conflict of Interest: Not Declared Received: November 2010 Accepted: December 2010

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Journal of Advanced Dental Research Vol II : Issue I: January, 2011

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