1. ADVANCE TRAUMA LIFE SUPPORT Jorge M. Concepcion, MD, FPCS Training Officer Department of Surgery The Medical City

2. ACCIDENTS ? INJURIES?

3. OBJECTIVES To discuss the concepts in ATLS. To discuss the concepts in ATLS. To provide the correct sequence of priorities in assessing multiply injured patient. To provide the correct sequence of priorities in assessing multiply injured patient. To introduce the principles in definitive trauma care To introduce the principles in definitive trauma care

4. INJURY (WHO definition) -a bodily lesion resulting from exposure to energy Mechanical Thermal Electrical Chemical interacting with the body in the amounts that exceed the limits of physiologic tolerance. Radiation

5. INJURIES “NOT ACCIDENTS” PREDICTABLE PREVENTABLE Not random events but occur in predictable patterns

6. PREVENTION

7. TRADITIONAL: HISTORY OF ILLNESS COMPLETE P.E. INITIAL IMPRESSION DIFFERENTIAL DIAGNOSIS DIAGNOSTIC TEST FINAL DIAGNOSIS TREATMENT

8. TRAUMA MANAGEMENT RECOGNITION OF INJURY (P.E.) TREATMENT

9. TRAUMA CONCEPTS: 1. TREAT THE GREATEST THREAT TO LIFE. 2. LACK OF DEFINITIVE DIAGNOSIS SHOULD NOT IMPEDE THE APPLICATION OF AN INDICATED TREATMENT. 3. DETAILED HISTORY IS NOT ESSENTIAL TO BEGIN THE EVALUATION OF AN ACUTELY INJURED PATIENT.

10. APPROACH TO SEVERELY INJURED PATIENT 1. PRIMARY SURVEY 2. RESUSCITATION 3. SECONDARY SURVEY 4. DEFINITIVE MANAGEMENT REASSESSMENT 5. TERTIARY SURVEY

11. A - AIRWAY & C-SPINE CONTROL B - BREATHING C - CIRCULATION – HEMORRHAGE CONTROL D - DISABILITY (NEURO EXAM) E - EXPOSURE / ENVIRONMENT PRIMARY SURVEY

12. AIRWAY CLINICAL GUARANTEE PATENCY “WHAT IS YOUR NAME?” GCS 8 OR LESS OBSTRUCTED AIRWAY HEMORRHAGIC SHOCK COMBATIVE PATIENT INTUBATE

13. AIRWAY RISK FACTORS I nstability (hemodynamic) I nstability (hemodynamic) N eck hematoma/trauma N eck hematoma/trauma T rauma to the face (maxillofacial) T rauma to the face (maxillofacial) U nresponsive (GCS < 8) U nresponsive (GCS < 8) B leeding from oropharynx B leeding from oropharynx A pnea A pnea T hermal inhalational injury T hermal inhalational injury E mesis/epistaxis/hemoptysis E mesis/epistaxis/hemoptysis

14. AIRWAY MAINTENANCE MEASURES Finger sweep Finger sweep Chin lift Chin lift Jaw thrust Jaw thrust Oro/nasopharyngeal airway Oro/nasopharyngeal airway Laryngeal mask airway Laryngeal mask airway Needle cricothyroidotomy Needle cricothyroidotomy

15. DEFINITIVE AIRWAY CONTROL Intubation Intubation –Orotracheal –Nasotracheal Surgical airway Surgical airway –Cricothyroidotomy –Tracheostomy

16. THINGS TO CONSIDER TIMING – don’t delay TIMING – don’t delay EQUIPMENT – scope, suction, suppplies EQUIPMENT – scope, suction, suppplies ANESTHEZISE ANESTHEZISE MONITOR MONITOR WEAR PROTECTION WEAR PROTECTION OXYGENATE OXYGENATE REINFORCEMENT – ask for help REINFORCEMENT – ask for help KEEP NECK PROTECTED KEEP NECK PROTECTED

17. C-SPINE CONTROL ALL PATIENTS WITH BLUNT TRAUMA – PRESUME TO HAVE C-SPINE INSTABILITY ALL PATIENTS WITH BLUNT TRAUMA – PRESUME TO HAVE C-SPINE INSTABILITY IMMOBILIZATION OF C-SPINE IS A PRIORITY IMMOBILIZATION OF C-SPINE IS A PRIORITY C-SPINE CLEARANCE IS NOT A PRIORITY C-SPINE CLEARANCE IS NOT A PRIORITY

18. C-SPINE CONTROL IN-LINE STABILIZATION CERVICAL COLLAR

19. C-COLLAR SHOULD NOT INTERFERE WITH CLINICAL EXAM OF THE NECK C-COLLAR SHOULD NOT INTERFERE WITH CLINICAL EXAM OF THE NECK INTUBATION – REMOVE THE COLLAR AND DO IN-LINE STABILIZATION INTUBATION – REMOVE THE COLLAR AND DO IN-LINE STABILIZATION

20. WHAT’S WRONG?

21. BREATHING GUARANTEE ADEQUATE OXYGENATION AND VENTILATION VENTILATION (LUNGS, CHEST WALL & DIAPHGRAM) ASSESS RESPIRATORY EFFORT, BREATH SOUNDS & OXYGEN DELIVERY GIVE SUPPLEMENTAL OXYGEN

22. Objective Signs Objective Signs  Inspection  Palpation  Percussion  Auscultation

23. OXYGENATION Oxygen deliveryL/min.Approx. FiO 2 Nasal cannula Face mask Face mask w/ reservoir 1 2 4 6 5-6 6-7 7-8 6 8 10 0.24 0.28 0.35 0.42 0.40 0.50 0.60 0.80 1.00

24. MANAGEMENT Ventilation Ventilation –Mouth to pocket face mask –Bag-valve-mask ( 2 person technique) Pleural Decompression Pleural Decompression –Needle thoracentesis –Closed-tube thoracostomy –Three-sided dressing

25. CIRCULATION ASSURE ADEQUATE OXYGEN DELIVERY AND CONTROL BLEEDING ASSESS VITAL SIGNS CONTROL BLEEDING DIRECT PRESSURE REDUCTION OF FRACTURES IN LONG BONES AND PELVIS

26. RECOGNITION OF SHOCK Tachycardia Tachycardia Cutaneous vasoconstriction Cutaneous vasoconstriction Hypotension Hypotension Narrowed pulse pressure Narrowed pulse pressure

27. ETIOLOGY OF SHOCK Hemorrhagic Hemorrhagic Nonhemorrhagic Nonhemorrhagic –Cardiac compressive  tension pneumothorax  cardiac tamponade –Cardiogenic –Neurogenic –Septic

28. CLASSES OF HEMORRHAGE Class I Class II Class III Class IV Blood Loss (ml) Up to 750 750-15001500-2000>2000 Blood Loss (% blood volume) Up to 15% 15-30%30-40%>40% Pulse Rate <100>100>120>140 Blood Pressure normalnormaldecreaseddecreased Pulse Pressure normal or decreased decreaseddecreaseddecreased Respiratory Rate 14-2020-3030-40>35 Urine Output (mL/hr) >3020-305-15negligible CNS/mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic

29. CLASSES OF HEMORRHAGE 70 kg male with gunshot wound in the RUQ 70 kg male with gunshot wound in the RUQ Vital signs: Vital signs: –BP 80/40 –HR 116/min –RR 22/min Class III hemorrhage Class III hemorrhage EBL= 1470 mL EBL= 1470 mL –70 kg x 7% x 30%

30. INITIAL MANAGEMENT Recognize shock Recognize shock Stop the bleeding! Stop the bleeding! Replace effective circulating volume Replace effective circulating volume Restore tissue perfusion Restore tissue perfusion

31. FLUID THERAPY Warmed crystalloid solution Warmed crystalloid solution Rapid fluid bolus Rapid fluid bolus –Adult2 liters –Child20 mL/kg “3 for 1 rule” “3 for 1 rule” Monitor response to therapy Monitor response to therapy

32. ELECTROLYTES 140 109 4 21

33. Size (gauge) Time 18 16 14 12 min. 9 min. 7 min. Size of needle in relation to a flow of 1 liter IVF

34. RESPONSE TO FLUID RESUSCITATION Rapid response Rapid response Transient response Transient response Minimal or no response Minimal or no response

35. RESPONSE TO FLUID RESUSCITATION Rapid Response Transient Response No response Vital Signs Return to normal Transient improvement Remain abnormal Estimated blood loss Minimal (10-20%) Moderate and ongoing (20-40%) Severe (>40%) Need for more fluids LowHighHigh Need for blood Low Moderate to high Immediate Blood preparation Type and crossmatch Type specific Emergency blood release Need for surgery PossiblyLikely Highly likely Early presence of surgeon YesYesYes

36. CIRCULATION Hypovolemia most common cause of shock Hypovolemia most common cause of shock Recognition of its presence 1 st step Recognition of its presence 1 st step Control of bleeding Control of bleeding Restoration of intravascular volume Restoration of intravascular volume Monitor patient’s response Monitor patient’s response

37. DISABILITY ASSESS GCS, PULSES, SENSORY AND MOTOR FUNCTIONS GCS BEST MOTOR RESPONSE – 6 BEST VERBAL RESPONSE – 5 EYE OPENING – 4 3 - 15 V = ? M = 4 E = 3 GCS = 7 V = M(0.5) + E(0.4) V = 4 (0.5) = 2+ 3 (0.4) = 1.2 V = 2 + 1.2 = 3.2 V = 3 M = 4 E = 3 GCS = 10 ?

38. EXPOSURE AND ENVIRONMENTAL CONTROL LOGROLL KEEP PATIENT WARM UNDRESS ( CUT CLOTHING ) OFTEN MISSED INJURIES AXILLA PERINEUM BACK

39. SECONDARY SURVEY HISTORY A - ALLERGIES M - MEDICATIONS P – PAST ILLNESSES L – LAST MEAL E – EVENTS PRECEEDING THE INCIDENT

40. PHYSICAL EXAMINATION DETAILED, METICULOUS HEAD TO TOE EXAM FINGER AND TUBES IN ALL ORIFICES LOOK, LISTEN, FEEL EVERYWHERE

41. DEFINITIVE MANAGEMENT TERTIARY SURVEY

42. DEFINITIVE MANAGEMENT PENETRATING NECK PENETRATING NECK PENETRATING CHEST PENETRATING CHEST BLUNT CHEST BLUNT CHEST PENETRATING ABDOMEN PENETRATING ABDOMEN BLUNT ABDOMEN BLUNT ABDOMEN EXTREMITIES EXTREMITIES

43. DO’s SPLINT PATIENTS WHERE THEY LIE COMFORT THE PATIENT ALLEVIATE PAIN HONE YOUR SKILLS ASK FOR HELP PRIMUM NON NOCERE

44. DON’TS PANIC INSERT NGT IN PATIENT WITH SUSPECTED FACIAL FRACTURE FORGET TO WARM THE PATIENT (ESP. CHILDREN) OVERLOOK THE PERINEUM, BACK AND AXILLA REMOVE IMPALED OBJECTS INSERT A FOLEY CATHETER IN PATIENTS SUSPECTED OF URETHRAL INJURY

45. Thank you