You are on page 1of 34

Advanced Trauma Life Support

Patrick Cheah, MD Li-Shin Hospital Emergency Department

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.
2

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.
3

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.


4

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)
5

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.

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 multisystem trauma, especially with an altered level of consciousness or blunt injury above the clavicle.
7

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.
8

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.

E. Exposure / Environmental Control


*It is the pts 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.

10

4. RESUSCITATION
A. Airway
*definite airway if there is any doubt about the pts 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.
11

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
12

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.


13

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.


14

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?
15

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
16

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.
17

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.

18

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

19

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
20

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 : Class II Hemorrhage : Class III Hemorrhage : up to 15% loss 15-30% loss 30-40% loss

Class IV Hemorrhage :

>40% loss

21

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

22

Initial Fluid Therapy


Lactated Ringer is preferred

* For adult 1-2 liters bolus * For child 20ml/kg bolus


23

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.

24

Head Injury Classification:


Mild Severe : GCS 14-15 : GCS 3-8

Moderate : GCS 9-13

Coma = GCS score of 8 or less


25

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
26

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

27

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

28

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.
29

30

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

31

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
32

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

33

Priorities with multiple injuries


1. Thoracic trauma or tamponade

2.
3.

Abdominal hemorrhage
Pelvic Hemorrhage

4.
5. 6.

Extremity Hemorrhage
Intra-cranial Injury Acute Spinal Cord Injury
34