ATLS initial assessment 2019
- 1. Initial Assessment Trauma life support
- 2. WHAT ISTHIS? WHAT ISTHE FIRST STEPYOU DO?
- 3. OBJECTIVE Initial assessment of trauma patients Life saving maneuvers Practicing trauma skills
- 4. HISTORY ▪ 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 So ATLS is a system
- 5. TRAUMA SCENARIO ▪ MALE PATIENT 34YEARS OLD COMINGTO ER AFTER ROAD TRAFFIC ACCIDENT: HOARSNESSOFVOICE BP 90/50 RR 30 PULSE 130 ABRASION ON LT CHESY WHAT DOYOU DO?
- 8. Initial assessment of trauma patient Preparation Triage Primary survey (ABCDEs) Adjuncts to the primary survey and resuscitation Consideration of the need for patient transfer Secondary survey (head-to-toe evaluation and patient history) Adjuncts to the secondary survey monitoring and reevaluation Definitive care
- 9. Critical aspects of hospital preparation A resuscitation area is available for trauma patients. functioning airway equipment. Warmed intravenous crystalloid solutions. A protocol to summon additional medical assistance is in place,. Transfer
- 10. Standard Precautions Cap Gown Mask Shoe covers Goggles / face shield Check safety before start primary survey
- 11. Assess the patient in 10 seconds? Ask patient about his name
- 12. ➢ suggests that there is no major airway compromise (i.e., ability to speak clearly) ➢ breathing is not severely compromised (i.e., ability to generate air movement to permit speech) ➢ the level of consciousness is not markedly decreased (i.e., alert enough to describe what happened) MY NAME IS MOHAMED MEAN: Airway opened, clear Breathing adequate Conscious
- 13. Breathing / ventilation / oxygenation Circulation with hemorrhage control Disability Expose / Environment / body temp. Primary Survey Airway with c-spine protection
- 14. Airway GIVE HIGH FLOW O2TO ALL TRAUMA PATIENT IF EIGHT INTUBATE A opened clear maintained Chin lift Jaw thrust Oropharyngeal airway nasopharyngeal suction
- 16. CHIN LIFT
- 17. JAWTRUST
- 18. AIRWAY ADJUNCTS
- 19. SIZING •OPAs too large or too small may obstruct the airway. •NPAs sized incorrectly may enter the esophagus. •Always check for spontaneous respirations after insertion of either device.
- 22. ADVANCED AIRWAY
- 26. Sequence of air way maneuvers Chin lift&jaw trust Finger sweep& suction Airway adjuncts Oropharyngeal/ orotrachial tube LMA BMV Needle Cricothyroidotomy Surgical cricothyroidotomy Tracheostomy
- 28. C- SPINE PROTECTION ▪ INLINE IMMBOLIZATION ▪ NECK COLAR ▪ HEAD LOCK ▪ HARD BOARD ▪ BELLETS
- 30. pearls If the patient unconscious don’t remove neck coller and back board till proved radiographically that whole spine is intact
- 31. BREATHINGB ▪ Airway patency alone does not ensure adequate ventilation. Adequate gas exchange is required to maximize oxygenation and carbon dioxide elimination ▪ Every injured patient should receive supplemental oxygen. If the patient is not intubated, oxygen should be delivered by a mask-reservoir device to achieve optimal oxygenation
- 33. Our task is to identify ▪ Five life threatening thoracic conditions: ▪ Tension Pneumothorax ▪ Massive Pneumothorax ▪ Open pneumothorax ▪ Flail segment ▪ Cardiac tamponade
- 34. Abnormal Findings Un equality of chest movement Hyper resonance on percussion Decrease air entry Tachypenic Pneumo thorax chest tube
- 36. pearls A simple pneumothorax can be converted to a tension pneumothorax when a patient is intubated and positive pressure ventilation is provided before decompressing the pneumothorax with a chest tube.
- 37. Abnormal Findings Un equality of chest movement Hyper resonance on percussion Decrease air entry ,tachypenic Deviated trachea ,congested neck vein Tension Pneumo thorax Needle decompression & chest tube
- 40. Abnormal Findings Un equality of chest movement Dullness on percussion Decrease air entry Tachypenic heamothorax chest tube
- 41. heamothorax
- 42. heamothorax
- 43. Abnormal Findings Un equality of chest movement Dullness on percussion Normal air entry ,muffled heart sounds Tachypenic, congested neck veins Cardiac tamponade pericardiocentesis
- 44. ▪ (almost always seen with a penetrating wound) ▪ Beck’s triad: Hypotension distended neck veins Muffled heart sounds Pulsus paradoxus
- 49. Skills in B Needle de compression Chest tube pericardiocentesis
- 58. pearls
- 59. circulation Check : ▪ Bp ▪ Pulse ▪ Capillary refill ▪ Search for External bleeding ▪ Search for Internal bleeding ▪ 2 wide bore cannula ▪ Blood sample for ABO compatibility, creatinine,urea,ABG ▪ GIVE 2 liters warmed crystalloid C
- 60. pearls European and American military studies demonstrate improved survival when tranexamic acid is administered within 3 hours of injury.When bolused in the field follow up infusion is given over 8 hours in the hospital
- 61. ▪ Hemorrhage is the predominant cause of preventable deaths after injury. ▪ Tachycardia in a cold patient indicates shock ▪ Causes of shock following injury: ▪ Hypovolemic ▪ Cardiogenic ▪ Neurogenic ▪ Septic
- 63. Aggressive and continued volume resuscitation is not a substitute for definitive control of hemorrhage. Shock associated with injury is most often hypovolemic in origin. In such cases, initiate IV fluid therapy with crystalloids.All IV solutions should be warmed either by storage in a warm environment (i.e., 37°C to 40°C, or 98.6°F to 104°F) or administered through fluid warming devices. A bolus of 1 L of an isotonic solution may be required to achieve an appropriate response in an adult patient. If a patient is unresponsive to initial crystalloid therapy, he or she should receive a blood transfusion pearls
- 64. ▪ Adults- 2 lit of Ringer lact solu as initial fluid challenge ▪ Children- 20mg/kg of body wt Response to initial fluid challenge: ▪ Immediate & sustained return of vital signs. ▪ Transient response with later deterioration ▪ No improvement.
- 65. ▪ Urine output – ▪ 0.5ml/kg/hr in adults ▪ 1ml/kg/hr in children ▪ 2ml/kg/hr in infants
- 66. Skills in C ▪ Direct compression in site of external bleeding ▪ Splint of long bone fractures ▪ Pelvic binder ▪ FAST( E- FAST) ▪ X-ray chest , pelvis ▪ Consult surgeon
- 67. Blood in the floor and 4 more Chest Abdomen Pelvis femur
- 70. Disability ▪ Determine Glasgow coma scale ▪ Check pupil for (equality- reactivity) ▪ Signs of lateralization ▪ Neurological assessment D A.-Alert V.-Responds to Voice P.-Responds to Pain U.-Unresponsive Pupil.-Size and reaction
- 74. Exposure ▪ Remove clothes ▪ Log roll ▪ Prevent hypothermia E
- 75. Hypothermia can be present when the patient arrives, or it may develop quickly in the ED if the patient is uncovered and undergoes rapid administration of room-temperature fluids or refrigerated blood. Because hypothermia is a potentially lethal complication in injured patients, tak aggressive measures to prevent the loss of body heat and restore body temperature to normal pearls
- 78. ADJUNCTS Vital signs ABGs Pulse oximeter and CO2 Urinary / gastric catheters unless contraindicated Urinary output ECG
- 79. Physiologic parameters for adequcy of resuscitation such as pulse rate, blood pressure, pulse pressure, ventilatory rate, ABG levels, body temperature, and urinary output are assessable measures that reflect the adequacy of resuscitation
- 81. CONSIDER EARLY PATIENT TRANSFER ➢Do not delay transfer for diagnostic tests ➢Use time before transfer for resuscitation
- 83. The secondary survey does not begin until the primary survey (ABCDE) is completed, resuscitative efforts are under way, and improvement of the patient’s vital functions has been demonstrated Secondary Survey
- 84. Secondary Survey AMPLE History Allergies Medications Past illnesses Last meal Events / Environment
- 87. HEAD ▪ Inspection ▪ Palpation ▪ Signs of fracture base ▪ Eye (PUPIL,visual acuity) ▪ Nose (RHINORRHEA) ▪ Maxilla (FRACTURE) ▪ Mouth ▪ Ear(HAEMOTYPMANUM
- 88. Fracture base skull ▪ Haemotympnym ▪ Otorrhea ▪ Rhinorrhea ▪ Rakon eyes ▪ Battle s signs
- 93. NECK ▪ Inspection (abrasion-cut wounds) ▪ Palpation (mass , surgical emphysema ,trachea , carotid pulse -Cervical spine fractures) Auscultation carotid bruit
- 94. ▪ The finding of active arterial bleeding, an expanding hematoma, arterial bruit, or airway compromise usually requires operative evaluation. ▪ Unexplained or isolated paralysis of an upper extremity should raise the suspicion of a cervical nerve root injury and should be accurately documented.
- 96. pearls
- 99. pearls
- 100. Search for potentially life threatening injuries ▪ Pulmonary complication ▪ Myocardial contusion ▪ Aortic tear ▪ Diaphragmatic tear ▪ Oesophageal tear ▪ Tracheobronchial tear ▪ Early thoracotomy if initial ▪ haemorrhage > 1500 ml
- 101. ABDOMEN ▪ Inspection ▪ Auscultation ▪ Palpation ▪ percussion
- 102. PELVIS ➢ Pelvic fractures can be suspected by the identification ▪ of ecchymosis over the iliac wings, pubis, labia, or ▪ scrotum. ➢ Clinical assessment of stability ▪ X-ray ▪ stabilize pelvis with fixator/clamps –pelvic binder ▪ urethral injury is suspected when high up prostate in PR ▪ blood in meatus ▪ perineal haematoma
- 103. pearls
- 104. Perineum, Rectum, andVagina ▪ The perineum should be examined for contusions, hematomas, lacerations, and urethral bleeding. ▪ A rectal examination may be performed to assess for the presence of blood within the bowel lumen, integrity of the rectal wall, and quality of sphincter tone. ▪ Vaginal examination should be performed in patients who are at risk of vaginal injury. The clinician should assess for the presence of blood in the vaginal vault and vaginal lacerations. In addition, pregnancy tests should be performed on all females of childbearing age.
- 105. Inspection •Wounds •Swelling •contusion •Source of bleeding Palpation •Peripheral pulsation •Click of fracture •Compartmental syndrome EXTERMITIES
- 109. diagnostic tests may be performed during the secondary survey to identify specific x-ray examinations of the spine and extremities CT scans of the head, chest, abdomen, and spine contrast urography and angiography transesophageal ultrasound; bronchoscopy esophagoscopy; and other diagnostic procedures ADJUCANTS
- 110. Reevaluation Trauma patients must be reevaluated constantly to ensure that new findings are not overlooked and to discover any deterioration in previously noted findings. Continuous monitoring of vital signs, oxygen saturation, and urinary output is essential. For adult patients, maintenance of urinary output at 0.5 mL/kg/h is desirable. In pediatric patients who are older than 1 year, an output of 1 mL/kg/h is typically adequate. PeriodicABG analyses and end-tidalCO2 monitoring are useful in some patients.
- 111. Definitive care ▪ Whenever the patient’s treatment needs exceed the capability of the receiving institution, transfer is considered. ▪ This decision requires a detailed assessment of the patient’s injuries and knowledge of the capabilities of the institution, including equipment, resources, and personnel.
- 112. Forensic Evidence ▪ If criminal activity is suspected in conjunction with a patient’s injury, the personnel caring for the patient must preserve the evidence. ▪ All items, such as clothing and bullets, are saved for law enforcement personnel. ▪ Laborator determinations of blood alcohol concentrations and other drugs may be particularly pertinent and have substantial legal implications.
- 113. Trauma team
- 115. Work up of any case of trauma: LAB ▪ 1-cbc ▪ 2-blood chemistry (renal-liver-cardiac-electrolyte) ▪ 3-coagulation profile ▪ 4- Blood group, cross matching if multiple trauma patient ▪ IMAGING: ▪ 1-x ray cervical vertebra ▪ 2-x ray chest ▪ 3-x ray pelvis ▪ 4-Abd U/S ( FAST) ▪
- 116. INDICATION OF CT INTRAUMA PATIENT: ▪ ▪ CT HEAD FOR HEAD TRAUMA IF: ▪ 1-old age more than 65 ▪ 2- Patient on warfarin ▪ 3- Loss of conscious level after trauma ▪ 4-GCS less than 15 for 2 hours ▪ 5-suspected depressed skull fracture ▪ 6-signs of basal skull fracture ▪ 7-pediatric with signs of increase ICT ▪ 8-convulsion after trauma ▪ 9-dangerous trauma ▪ 10-polytraumatized patient
- 117. ▪ CT CHEST IF: ▪ 1-chest pain after trauma ▪ 2-chest contusion ▪ 3-decrease air entry ▪ 4-any change in o2 sat ▪ 5-suspecting rib fracture ▪ 6-polytraumatized patient
- 118. CT abdomen must be with contrast if: ▪ 1- positive FAST scan ▪ 2- Cullen sign ▪ 3- turner sign ▪ 4- abdominal Contusion ▪ 5- unexplained shock ▪ 6- Part from pan scan of multiple trauma patient
- 119. TRAUMA SCENARIO ▪ MALE PATIENT 34YEARS OLD COMINGTO ER AFTER ROAD TRAFFIC ACCIDENT: HOARSNESSOFVOICE BP 90/50 RR 30 PULSE 130 ABRASION ON LT CHESY WHATYOU DO?
- 121. THANKYOU