Initial asessment and surveys

Initial assessment plan (8)

Re-evaluate and monitor at every step

Defintive care = or transfer

Concept of golden hour + platinum 10 mins

MCQS

Maximum time for primary survey is 7 mins

Hypoxia kills before hypovolumeia

Cerebral hypoxia rreversible after 7 minutes

ATLS approach (3)

Primary survey (resuscitation)

Secondary survey

Vertical ( human resource lacking, time consuming, stressful) and horizontal approach (well-equipped trauma center)

Primary survey

Purpose - idenitfy life-threatening conditions and simultaneously managed, use necessary interventions to eliminate the life threatening conditions

Conditions which kill the patient immediately

A Blocked Airway •B 5 x conditions •Tension pneumothorax •Open pneumothorax •Massive Haemothorax •Flail chest •Cardiac Tamponade •C blood loss

D Intra cranial Haemorrhage

E - Exposure

A: Airway maintainance with cervical spine protection (lungs)

B: Breathing and ventilation (lungs)

C: Circulation with haemorrhage control (cvs)

D: Disability (neurological status) (how ABC affect cerebral neuro)

E: Exposure / Environmenal control: Undress the patient & prevent hypothermia

Trauma team members

Trauma surgeon / emergency physician = team leader

anaesthetist

transfusion specialist

nursing staff

minor staff

Mechanism of Injury

Blunt

Penetrating

Thermal

• Blast

Where in the hospital should they be treated?

ETU/PCU/R.Room

OPD Area

Two types of injured

Those who need resuscitation => resuscitation area

Those who do not need resuscitation => OPD?

How triage done?

Evidence from the pre hospital transport •Mechanism of injuries •Physiological status on admission •By glimpse

Few criteria for major trauma

Mechanism RTA high speed -->60 kmh Ejection from a vehicle Fall from 3 meters high Penetrating Trauma Head/neck/torso ( not stab injury) Death of another passenger Rolling over/significant vehicle deformation Run over injury Fallen from train Extrication time more than 30min

Clinical

I.SBP 90 or less mmhg

II.Pulse < 50 or > 110 III.RR < 10 or > 30 IV.GCS < 13 I.Limb amputation proximal to knee or elbow V.Crushed chest/Dyspnoea VI.Major Pelvic injury VII.Obvious multiple injuries VIII.Paraplegia/ quadriplegia

Primary Survey

First thing asks name and make him talk. if can talk = airway obstruction no? + direct cerebral injury? + hypovolumeia?

Airway maintainanance with cervical spine protection

Open mouth and look for obvious stuff - clear secretions, assure that the patient can protect the airway to prevent aspiration, foreign bodies, facial, mandibular, tracheal, laryngeal fractures may result in airway obstruction - lift chin to maintain airway patency, jawthrust + suction, NO TRIBLE MANAEVURE AS NO HEAD TILT+ oropharngeal airway, laryngeal mask airway, cuffed endotracheal tube intubation,tracheostomy (surgical airway)

Tracheostomy indications

Assume C-spine always (multisystemic trauma, altered level of conciousness, blunt injury above clavicle) use philadelpia collar (as opening for tracheostomy)or MILS (manual in line stabilsation of neck)

Give 100% oxygen

Cervical spine injury – (suspect until proven otherwise) maintain manual in-line stabilization as early as possible, sandbags on side, collar and straps. Use spinal board if available

Apnea – {{c21:immediate orotracheal intubation with in-line stabilization. Rapid Sequence Induction (RSI) is appropriate in most patients when needed. Possible exceptions are airway obstruction and predicted difficult intubation. Consider awake intubation or urgent surgical airway under local anaesthesia}}.

Breathing and ventilation

Look for signs of respiratory distress. Management and assist ventilation. Look for the following life threatening conditions and treat early.

Diagnostic criteria- reduced chest movements and air entry, hyper resonance on percussion, deviated trachea, reduced blood pressure

If airway patent but oxygen satuuration (saturation probe) not imrpoved injury may acutely impair ventilation

1. Tension pneumothorax

Management- Immediate needle decompression (Insert 14g cannula at the second intercostal space mid clavicular line) followed by tube thoracostomy (Insert IC tube at the fourth or fifth intercostal space between the mid and the anterior axillary lines.)

2. Flail chest with pulmonary contusion

Diagnostic criteria –paradoxical chest movements, reduced air entry

Managementconsider mechanical ventilation if oxygenation is not adequate

3. Massive haemothorox

Diagnostic criteria-reduced chest movements and air entry, dull on percussion, deviated trachea

Management- Tube thoracostomy after fluid resuscitation.

4. Open pneumothorax

Diagnostic criteria- reduced chest movements and air entry, hyper resonant on percussion, Management- Close the opening immediately followed by tube thoracostomy as the definitive treatment

Consider Emergency room Thoracotomy when required if facilities are available. No radiological confirmation of the above mentioned conditions is necessary before treatmen

LOOK, FEEL, LISTEN

Inspection - paradoxical, chest movement,

Palpation- check tracheal deviation. Then chest/lung movements. Fracture in chest wall. Emphesyma.

Auscultate for air entry.

Percuss - if hyperresonanant air if not then fluid

IMMEDIATE MANAGEMENT

Correct A

100% oxygen

Needle thoracotomy - push wide bore canula, 2nd intercostal space in midclaviviular line (can create pneumothorax but cant miss)

IC tube - definitive on 5th IC space midaxillary line in safe triangle, widest 32 french gauge tube to underwater seal system

Look for thoracotomy indications - IC tube drainage more than 1000ml or every hour 250 ml for 3 consequently or ruptured bleeding (major visceral rupture) - rushed to theature

Circulation with haemorrhage control

assess blood volume and cardiac output (level of conciousness, skin colot, pulse) (BP, PP, pulse rate)

4 grades of haemorrhagic shock (remember his points)

bleeding control - direct manual pressure on the wound (bleeding on the floor) adjunct - IV tranexamic acid

thoracic (1000ml) , abdominal cavity - 2500ml(periotoneal (2.5L) -, pelvic (2500ml) , retroperitoneal (concealed -1000ml), thigh -1000 to 1500ml. So calculation based on fractures?, intracranial? - 500ml

Class IV (O negative blood unmatched)

2 wide bore cannula to two proximal veins (immediately before veins collapse)

Blood for basix Ix

Fluid management crystalloids maximum to 1L => hyperchloridemia => increased risk of DIC

Colloids => increased DIC (current guidelines no colloid place)

Blood (class 3 vs class 4)

ECg monitoring/ CVP/ BP/UOP

How to stop bleeding? (5)

Pressure •Elevate limbs •Bandage •Pack/plug •Clamp NO •Tourniquet last option

Insert two (preferably size 14) large bore cannulae, send blood for grouping, cross matching and basic investigations. Initial therapy should consist of isotonic crystalloid /colloid infusions/ blood.

Failure to respond or shock state that is difficult to correct should illicit a search for bleeding that requires operative control

Look for internal haemorrhage in patients with unrecordable blood pressure/absent pulses (radial pulse) and severe pallor. CONSIDER Uncross-matched blood –O negative or Group specific.

1 Cardiac Tamponade – Pericardiocentesis is required. Refer guidelines for chest injuries

Disability (neurological evaluation)

Expanding IC bleeding?

level of conciosness AVPU - Alert ot response to voice or response to pain or unresponsive

pupils?

pitfall (lucid interval - talk and die - EDH, frequent neurological revevaluaton can minimise this problem

prevent secondary brain injury (4 hypos - hypoglycaemia, hypoxiahypovolumeia, hypothermia

Exposure/Enviromental control

undress patient completely

protect from hypothermia (normal body temp needed for clot)

Front and back. Remove clothing, remove backboard when present. Log roll if necessary. Avoid hypothermia –Use blankets, warm fluids and warm room.

F for foley catheter?

...

Adjuncts to primary survey and resuscitation

Monitor -

Ventilatory rate and ABGs/ end-tidal CO2 (compative patients will bite endotracheal tude)

Pulse oximetry

ECG & BP monitor

Temperature

urine output

X ray and diagnostic studies (dont delay primary survey) (trauma sries- CXR, C-spine lateral view, pelvic AP view) + Sonography/FAST (4 quadrants -cardiac area for cardiac tamponade (eFAST) thocatomy! )

Tube in the stomach , OG Tube Tube in the bladder , catheter Splints Spinal boards/ Head block Analgesia Investigations –Lactic acid –Coagulation studies

Before secondary survey (3) - address and corrent non-life threatening injuries

Complete primary survery

Establish resuscitation

Normalisation of vital signs

Extra points

in paediatric no cuffed endotracheal tubes as ischaemic necrosis of trachea but will do

A negative or inadequate c-spine x-ray cant exclude spinal injury

Warm fluids and blood given

Secondary Survey

History taking (AMPLE, allergies, medications past illness, last meal, events/environment - rapid seqeuence induction if not fasting?)

Complete neurological exam

Head-to-toe evaluation

Special procedure

Tubes and fingers in every orifice

Re-evaluate (can deteriorate to primary survey) - new findings, high index of suspicion, continous monitoring, pain relief

Head to toe exam, front and back including internal examination. (PR and VE) 1. Head/Maxillofacial 2. Neck 3. Chest. 4. Abdomen 5. Pelvis 6. Extremities 7. Full neurological examination which includes GCS.

4 people for a log roll to examine back and spine)

high riding prostrate - pevic fracture, sphinture tone - spinal injury

Pelvic binder for pelvic fracture (rectopelvic venous plexus main reason for bleeding + 10% arterial + bone) - to stop bleeding

GLASGOW COMA SCALE

GCS < 8 (8 or less) then endotracheal intubation

Records and legal considerations

Records - concide, chronologic, documetation

consent for treatment

forensic evidence

Investigations

1. Radiological: Three basic x-rays i.e. Cervical spine (AP/Lateral/ Open Mouth), Chest and Pelvis and any other as required.-CT

2. FAST scan-when available.

Procedures to be consider at this stage

a. Naso/orogastric tube – consider placement in all trauma victims. b. Catheter – place after rectal exam, unless deemed unnecessary by team leader.

After Stabilization:

1. Determine disposition: OT, ICU, HDU/Ward

2. Determine need and sequence of advanced radiographic studies. (plain film, CT, angiography.)

3. Consult specialty services.

4. Re-evaluation and assessment

Summary

Initial assessment & management of multiple inured persons

Primary survey

Resuscitation & monitor

Secondary survey

Definitive care

ATLS MCQ POINTS

management of cervical spine injury is managed in secondary survey (but suspected in pirmary survery) C2-C3 subluxation

if after primary survey, haemodynamically unstable => theatre?

hyperbaric oxygen should not be given because can rupture lung contusion

in a child blood volume is 8% of blood volume 80ml/kg

pulse oximeter has nothing to do with haemorrhage

for every trauma patient 1L of crystalloid and then plasma expanders? but limited to 1L so then give colloid preferably blood

crystalloids are saline, hartmanns (other stuff so not preferred), dextrose - others are colloids including blood and blood products. no synthetic colloids are in the latest guidelines (hexta starrch shit)

lethal triad in trauma - hypothermia, coagulopathy, acidosis (ROTEM stuff)

blood transfusion needs wide bore canula (green canula)

bradycardia - cushing's reflex (with hypertension), paradoxical bradycardia, arrythmia, spinal shock sundrome (all drops)

hypotension + muffled heart sounds + distended veins = cardiac tamponade

any major trauma keep patient fasting

more than 92% on air is okay in trauma

5% dextrose useless coz intracellular oedema - cerebral oedema will worsens so 100% contraidicated in trauma and brain injury

urethral injury - membranous urethra highly injured to trauma. partial- blood in tip of urethra (urethral catheterisation is contraindicated so supra-pubic) Ix - reverse cystourethralgram - where dye goes? complete - enlarged scrotum Ix-CT

pulse measurement - disappearnce of pulse (femoral more than 90,60-90 radial, 60- carotid pulse) - due to classes

arterial cannulation - radial artery

total paraenteral nutrition and ionotrophs (norendranaline) - dont give through peripheral veins

if cant find peripheral and central then venous cut up - cubital vein |+ some leg vein? intraosseus

chest traumas can give rise to haemoperitonoeum - commonest intraabdominal ruoture is splenic which can be conserved conservatively according to grade - unless it is shattered through hilum - cam be excluded with FAST scan and then Ct scan to see how bad if stable - but in day 7-10 can have a rerupture even after haemotoma can discharge so -

FAST scan - solid...diagnostic peritoneal lavage...hollow organ injury - 4Bs - bile, bladder, bowel

diaphragmatic rupture (mimics a penumothorax always a surgery) most common in left side as no major organ to protect => therefore if stable do chest x ray before IC tube insertion as bowel can be there as mediastinitis