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PROGRAM GOALS

A Safe and reliable method to :


Assess condition rapidly, accurately
Resuscitate/ stabilize via ABC
priorities
Determine if needs exceed
capabilities
Arrange for interhospital transfer
Assure optimum care is provided

COURSE OBJECTIVES

Demonstrate concepts and principles of


primary and secondary assessment.
Establish management priorities in a
trauma situation
Initiate primary and secondary
management
Demonstrate live-saving skills to assess
and manage the trauma patient

THE NEED

Trauma is the leading cause of death


in first four decades of life

When I can provide better care in the


field with limited resources than what
my children and I received at the
primary care facility there is
something wrong with the system and
the system has to be changed
James styner, MD FACS - 1977

ATLS CONCEPT

ABCs-approach to evaluation,
treatment
Treat greates threat to life first
Do no further harm

ATLS CONCEPT
A
B
C
D
E

Airway with c-spine control


Breathing
Circulation
Disability / Neurologic status
Exposure / Environment

Transfer

Injury

Stabilization

Initial Assesment
(Primary Survey)
First Hour
and

Re-Evaluation

Live-saving
Intervention

Head to-toe Evaluation


(Secondary Survey)

ATLS
EDUCATION FORMAT

Lectures
Demonstration
Group Discussions
Practical live-saving skills
Simulated patient scenarios
Tests

SUMMARY
Premise : Appropriate and timely care
can improve patient outcome
Provides : Safe, reliable method of
trauma care in the first hour

OBJECTIVES

Identify correct sequence of priorities


Outline primary and secondary surveys
Identify and discuss history and injury
mechanisms
Explain treatment guidelines used during
resuscitation and definitive care phases
Conduct assessment and management
surveys on simulated patients

CONCEPTS OF
INITIAL ASSESSMENT

Rapid primary survey


Resusctitation
Detailed secondary survey
Re-evaluation
Initiate definitiv care

PRIMARY SURVEY
AND RESUSCITATION
OF VITAL FUNCTION
ARE DONE SIMULTANEOUSLY

PREPARATION
Prehospital

: Closest, appropriate
facility
Inhospital
:
Preplanning essential
Equipment, personnel, services
Communicable disease protection
Transfer agreements

TRIAGE

Sorting of patients according to ABCs


and available resources

PRIMARY SURVEY
Adult / pediatric priorities same
A Airway with c-spine control
B Breathing
C Circulation with hemorrhage control
D Disability : Neurologic status
E Exposure / Environment

PRIMARY SURVEY
Establish Patent Airway

CAUTION

Servical spine injury

PRIMARY SURVEY
Assume C-spine Injury
Multisytem trauma
Alteredlevel of consciousness
Blunt injury above clavicle

PRIMARY SURVEY
Breatching
Assess
Oxygenate
Ventilate

PRIMARY SURVEY
Circulation
Assess blood volume loss and
cardiac output
Level of consciousness
Skin color
Pulse

PRIMARY SURVEY
Disabilty (Neurological Evaluation)
Level of consciousness
A
Alert
V
Responds to voice
P
Responds to pain
U
Unresponsive
Pupils

PRIMARY SURVEY
Exposure / environment
Undress patient completely
Protect from hypothermia

RESUSCITATION
Protect / Secure airway
Ventilate / oxygenate
Vogorous shock therapy
Protect from hypothermia
Urinary / gastric catheters
CAUTION
Unless contraindicated

RESUSCITATION
Monitor

Vital sign
Urinary output
ABGs

*
*
*

ECG
Temperatur
Pulse oxymetry

End-tidal CO2

RESUSCITATION

Manage life-threatening injuriesin


sequence and as identified
Consider need for transfer:
Physician-to-physician communication

BEFORE SECONDARY SURVEY

Complete primary survey


Initiate resuscitation
Reassess ABCs

SECONDARY SURVEY

Head to toe evaluation


Complete neurologic exam
Roentgenograms
Special procedures
Tubes and fingers in every orifice
Re-evaluation

SECONDARY SURVEY
History
A
Allergies
M Medication
P
Pass Illnesses
L
Last meal
E
Events / Environment

SECONDARY SURVEY
Mechanism of injury : Blunt
Direction of impact determines injury
pattern
History / Description of event
Age factors

SECONDARY SURVEY
Mechanism of injury: Penetrating
Anatomic factors
Energy transfer factors
* Velocity and caliber of bullet
* Trajectory
* Distance

SECONDARY SURVEY
Mechanism of injury: Burns / Cold
Burns
Inhalation / CO complication
Associated injury
Event history

COLD
Local or systemic
Event history

SECONDARY SURVEY
Mechanism of injury: Hazardous Materials
Risk to patient and care providers
Event history

SECONDARY SURVEY
Head
Pupils
Visual acuity
Injury

SECONDARY SURVEY
Maxillofacial
No airway obstruction or bleeding-treat later
Midfacial fracture cribriform plate fracture
Assume c-spine injury

SECONDARY SURVEY
C-spine and neck
Maintain immobilization
Complete evaluation
Cautious helmet removal
Penetrating : operation

SECONDARY SURVEY
Abdoment
Inspect, auscultate, palpate, end percuss
Re-evaluate frequently
Special studies

SECONDARY SURVEY
Perineum : Contusions, hematomas,
lacerations, urethral blood
Rectum

: Sphincter tone, high-riding


prostate, pelvic fracture,
rectal wall integrity, blood

Vagina

: Blood, laceration

SECONDARY SURVEY
Muskuloskeletal
Extremities/ Contusions, deformity,
Pelvis
: pain, crepitation,
abnormal movement
Vascular
: Assess all peripheral
pulses
Spine
: Physical findings,
mechanism of injury

SECONDARY SURVEY
Neurologic
Determine GCS Score
Re-evaluate pupils
Sensory / motor evaluation
Maintain immobilization
Prevent secondary CNS injury
Early neurosurgical consultation

RE-EVALUATION

New findings / deterioration /


Improvement
High index of suspicion
Continuous monitoring
Pain relief after surgical consultation

DEFITIVE CARE

Trauma centre or
Closest appropriate hospital

RECORDS AND LEGAL


CONSIDERATION

Concise, chronologic documentation


Consent for treatment
Forensic evidence

SUMMARY
Initial Assessment
Primary survey
Resuscisation
Secondary survey
Definitive care

OBJECTIVES

Recognize airway obstruction


Identify clinical settings in which
airway compromise occurs
Explain airway management
techniques
Discuss definitive airway and related
management procedures
Demonstrate basic and advanced
techniques of airway intervention

AIRWAY MANAGEMENT
First priority
Secure airway
oxygenate and ventilate

AIRWAY MANAGEMENT
Preventable Deaths
Failure to recognize airway need
Delay in establishing adequate
ventilation
Technical difficulties
Aspiration of gastric contents

AIRWAY COMPROMISE
Increased Risk
Head injury
Direct Airway injury
Facial fractures
Thoracic injury
Drugs / Alcohol

AIRWAY OBSTRACTION
Objective Sign
A Mental status
Retraction

Air movement
Cyanosis
Noisy breathing
Tracheal position

VENTILATORY COMPROMISE
Increased Risk
Airway obstruction
Impaired ventilation mechanics
CNS depresion

VENTILATORY COMPROMISE
Objective Sign
Chest asymmetry
Labored breathing tachyipnea

or absent breath sounds

MANAGEMENT APPROACH
Adequate Oxygenation Requires
Airway
Maintenance * Ventilation
Techniques
or
Definitive
Airway
* Ventilation

CAUTION

Maintain c-spine alignment


During airway management

DEFINITIVE AIRWAY

Cuffed tube in trachea


Ventilation
Tube secured in place
Types :
Endotracheal intubation
Surgical airway

DEFINITIVE AIRWAY
Indications

Apnea
Risk of aspiration
Impending airway compromise
Insecure airway
Closed head injury
Poor oxygenation

DEFINITIVE AIRWAY

Based on urgency
Oximetry helpful during tube
placement

DEFINITIVE AIRWAY
Surgical airway
Inability to intubate
Immediate need for airway

OXYGENATION / VENTILATION

Goal : Achieve maximum cellular


oxygenation
Oxygen at 10 12 L/minute
Tight-fitting O2 reservoir mask
Ventilate
Avoid prolonged attempts at
intubation without ventilation

OXYGENATION / VENTILATION
Pulse Oximetry
Difficult intubation
Adequacy of oxygenation
Transport

OXYGENATION / VENTILATION
Pulse oximetry
Measures O2, saturation not
partial pressure of oxygen (PaO2)

SUMMARY

Suspect airway compromise


Protect c-spine
Open airway and ventilate

SUMMARY

If in doubt
Definitive airway
Type of definitive airway based on
Urgency of need
Physicians clinical judgment / skill