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    Advanced Trauma Life Support

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    azlanajaib
    1) Advanced Trauma Life Support (ATLS) protocol follows the DRS ABCDE mnemonic for the primary survey to assess and treat life-threatening conditions within 10 minutes. The primary goals are to establish an open airway, ensure adequate breathing and ventilation, and attend to circulation issues and severe bleeding. 2) The secondary survey involves a more thorough head-to-toe examination including assessment for injuries that may have been overlooked initially such as pulmonary contusions, aortic disruptions, tracheobronchial tears, myocardial contusions, esophageal trauma, and diaphragmatic ruptures. 3) Key interventions during the primary survey include cervical spine immobilization, needle decompression for suspected tension

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    Advanced Trauma Life Support

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    azlanajaib
    773 views8 pages
    1) Advanced Trauma Life Support (ATLS) protocol follows the DRS ABCDE mnemonic for the primary survey to assess and treat life-threatening conditions within 10 minutes. The primary goals are to establish an open airway, ensure adequate breathing and ventilation, and attend to circulation issues and severe bleeding. 2) The secondary survey involves a more thorough head-to-toe examination including assessment for injuries that may have been overlooked initially such as pulmonary contusions, aortic disruptions, tracheobronchial tears, myocardial contusions, esophageal trauma, and diaphragmatic ruptures. 3) Key interventions during the primary survey include cervical spine immobilization, needle decompression for suspected tension

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    1) Advanced Trauma Life Support (ATLS) protocol follows the DRS ABCDE mnemonic for the primary survey to assess and treat life-threatening conditions within 10 minutes. The primary goals are to establish an open airway, ensure adequate breathing and ventilation, and attend to circulation issues and severe bleeding. 2) The secondary survey involves a more thorough head-to-toe examination including assessment for injuries that may have been overlooked initially such as pulmonary contusions, aortic disruptions, tracheobronchial tears, myocardial contusions, esophageal trauma, and diaphragmatic ruptures. 3) Key interventions during the primary survey include cervical spine immobilization, needle decompression for suspected tension

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    © All Rights Reserved
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    Download as docx, pdf, or txt
    773 views8 pages

    Advanced Trauma Life Support

    Uploaded by

    azlanajaib
    1) Advanced Trauma Life Support (ATLS) protocol follows the DRS ABCDE mnemonic for the primary survey to assess and treat life-threatening conditions within 10 minutes. The primary goals are to establish an open airway, ensure adequate breathing and ventilation, and attend to circulation issues and severe bleeding. 2) The secondary survey involves a more thorough head-to-toe examination including assessment for injuries that may have been overlooked initially such as pulmonary contusions, aortic disruptions, tracheobronchial tears, myocardial contusions, esophageal trauma, and diaphragmatic ruptures. 3) Key interventions during the primary survey include cervical spine immobilization, needle decompression for suspected tension

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    Advanced Trauma Life Support (ATLS)

    Primary Survey
    *Primary survey: Aim: To find and treat life-threatening condition (within 10 minutes)
    Mnemonic : DRS ABCDE
    DANGER
    -

    Assess danger of the surrounding


    Wear proper PPE (goggles, mask, glove and apron)

    RESPONSE - Tap the shoulder and ask Are you ok,sir/madam/miss?

    Sign of
    airway
    obstructio
    n
    - Stridor
    - Cyanosis

    SHOUT FOR HELP/ASK TO PREPARE AIRWAY, BREATHING AND CIRCULATION


    Airway: ETT, adjunct airway (OPA/NPA), laryngoscope, stylet etc
    Breathing: Oxygen, SpO2
    Circulation: Insert two large bore branulas and run 1 L of warm NS, send blood for investigation,
    vital signs monitoring (blood pressure, heart rate)
    AIRWAY & CERVICAL IMMOBILISATION
    - Open airway & suction [remove foreign body, blood, secretion, check gag reflex]; no gag
    reflex, insert OPA (use appropriate size to avoid blocking the airway)
    *always make sure the cervical spine is protected
    *open airway via jaw thrust, chin lift (no head tilt in trauma, prevent cervical spine injury)
    *jaw thrust: hand at angle of mandible and lift the mandible forward
    - Give O2 [ ~ 10-15L / min ] (can give high flow oxygen via ambu bag mask without positive
    pressure ventilation)
    *you may check for neck swelling, laceration, haematoma & JVP before any immobilization
    device in place
    - Protect cervical spine by immobilization [manual inline immobilization, apply cervical collar,
    head immobilizer at spinal board]
    *cervical collar measured from angle of mandible to base of neck
    - Check SpO2
    *if normal/acceptable range and airway patent: put HFMO2
    *intubate if presence of inhalation injury or other airway compromise
    Lethal 6 assessment:
    1) Airway Obstruction

    LETHAL 6
    Airway obstruction
    Tension pneumothorax
    Open pneumothorax
    Massive haemothorax
    Flail Chest
    Cardiac tamponade

    Prepared by Leow Zhe Eu Group 4 Year 5


    2014/2015

    BREATHING AND VENTILATION


    INSPECT Observe breathing, chest movement, Wounds, JVP, Tracheal tug
    PALPATE

    Tracheal deviation
    tension pneumothorax
    Chest spring (anterior, lateral)
    rib fracture
    *Careful if visible chest wound/flail chest
    Crepitus
    emphysema

    PERCUSSION Hyperresonance (pneumothorax) / Dull (haemothorax)


    AUSCULTATION - Breath sound. Muffled heart sound in cardiac tamponade with distended
    neck vein, hypotension.
    Lethal 6 assessment:
    Inspection
    2) Open pneumothorax
    3) Flail chest
    Percussion/auscultation
    4) Tension pneumothorax
    5) Massive hemothorax
    Auscultation
    6) Cardiac tamponade

    Tension pneumothorax
    S : Tracheal deviation
    : Reduce chest expansion
    : Reduce air entry
    : Hyperresonance
    : Dyspnoea & tachypnea
    : Hypotension
    : Mediastinal shift
    Mx: Needle thoracocentesis
    immediately (temporary
    measure)
    *2nd ICS, mid-clavicular line
    *Green needle and above
    : Chest tube (definitive)

    Open pneumothorax
    S: Bubbling at wound site
    : Open wound >2/3 of
    trachea size or 2 cm [N=
    ~3cm]

    Mx: 3-sided occlusive


    dressing
    (temporary)
    : Chest tube (definitive)

    Massive haemothorax
    S: : Reduce breath sound
    : Unequal chest rise
    : Dull percussion
    Blood drained
    : 300ml/h for 2 hours
    : 200ml/h for 3 hours
    : 600ml / 6 hours
    : 600ml / 1 hour
    : 1.5L one go
    clamp chest tube if more 1L
    for tamponade effect, prevent
    further blood loss,
    decompression acute
    pulmonary oedema
    *200-300ml blunt
    costophrenic angle in CXR

    Prepared by Leow Zhe Eu Group 4 Year 5


    2014/2015

    Mx: Chest tube insertion


    : Refer cardiothoracic
    Flail chest
    S: > 2 segmental # with > 2
    ribs
    *may injure lung parenchyma
    Mx: Analgesia
    (morphine/fentanyl
    infusion)
    *BP lowfentanyl
    *NO NSAIDS > bleeding risk
    : Oxygen
    : Chest tube if indicated

    Cardiac tamponade
    S : Becks triad
    -Hypotension
    -Elevated JVP
    -Muffled heart sound

    Extras
    Intra-pleural pressure
    :Inspiration = ~ -8 mmHg
    :Expiration = ~ -5 mmHg

    Mx: Pericardiocentesis
    (ultrasound-guided vs blind)
    *withdraw about 50-80ml
    A: Left lateral subxiphoid
    *gray needle and above or
    angiocath
    : Aim 45o to tip of left
    shoulder
    : Advance with continual
    aspiration
    : if ECG shows ST
    changes/artifact,
    pull back as needle is
    touching myocardium

    Pathophysiology
    1) Tension pneumothorax
    - T.P. Compress or distort large vessels in the thorax Decrease Cardiac output
    Hypotension
    2) Cardiac tamponade
    - Right ventricle affect first due to low pressure system
    - Pericardial fluid accumulates and impedes RV Decrease venous return
    Decrease preloadDecrease CO
    -

    CIRCULATION AND HAEMORRHAGE CONTROL


    Insert 2 large bore IV branula and run 1 L of warm NS
    Check BP and HR
    Blood for investigation
    Look for source of bleeding Scalp (check using hand swipe)
    - Facial fracture
    - Neck swelling, haematoma, laceration
    - Chest (done in breathing)

    Blood loss
    # UL 1-2 L
    # LL 2-3 L
    # Hip 3-4 L
    # pelvic drain all
    blood

    Prepared by Leow Zhe Eu Group 4 Year 5


    2014/2015

    Abdomen (distended/tender)FASTif massive


    intraabdominal bleeding, get GXM 4 pint PC, DIVC regime,
    refer surgery
    Genitalia (begin with pelvic spring, blood in external meatus,
    perineum)
    Check for #, open bleeding, feel for pulse
    Upper limbs
    volume and hand swipe for posterior part,
    Lower limbs
    (also check posterior part of trunk during
    log roll)

    *scalp bleed a lot due to presence of vessels and loose tissue/no tamponade effect
    hypovolemic shock Mx: Hemostatic Suture
    - STOP bleeding Compression [ technique: spiral or figure of 8 ]
    - Suture if at scalp
    - Torniquet if amputated limb/unsalvageable or 30mins for severe bleed
    (* Cx: Damage blood vessels; limb ischaemia, Rhabdomyolysis Renal
    failure)

    Priapism: spinal injury vessels cant vasoconstrict (symphatetic


    disruption) pooling of blood priapism
    Destot sign: Scrotal/perineal haematoma indicating pelvic #

    DISABILITY AND NEUROLOGICAL


    - GCS (done in primary survey according to ATLS 7th Edition) GCS 8, prepare for intubation for
    cerebral protection during 2 survey if no airway/ventilation problem)
    - Pupil
    *Constricted: bleeding at pons causing irritation affect craniosacral outflow (parasympathetic)
    at pons CN III constriction
    *Fixed, dilated: brain death
    Bleeding no blood supply to pons pons dead no inhibition from parasympathetic
    outflow Increase in sympathetic activation (thoracolumbar outflow) fixed, dilated
    EXPOSURE AND ENVIRONMENT
    - Look and treat for injury
    - Log-roll to check posterior Head/scalp
    - Spine (tenderness, stepping sign)
    - Laceration wound/ open pneumothorax at back
    - Bleeding/ hematoma (may suggest retroperitoneal bleed)
    - Muscle tear
    - Do Per-rectal Anal tone, High riding prostate, bleeding
    Decrease anal tone spinal cord injury loss of anal sphincter lumbosacral
    injury
    Prepared
    by Leow
    Eu Group
    4 Year 5
    If lax, proceed with bulbocavernous reflex
    [tugging
    on anZhe
    indwelling
    Foley
    2014/2015
    catheter ]

    - Maintain temperature Blanket, give warmer to prevent hypothermia prevent coagulopathy

    ADJUNCT (can be done at any time during primary survey)

    2+2+2+2

    2 Tubes

    : Ryles tube (via mouth, do not insert via nose in suspected skull/facial bone #)
    : CBD (do not insert in suspected urethral injury refer Uro, may need SPC)

    2 Imaging

    : Chest
    : Pelvic
    : *Cervical if suspected (AP, lateral (swimmers view)

    2 Investigations

    : ECG
    : FAST (Focused Assessment with Sonography of Trauma)

    2 Drugs : Anti-tetanus toxoid (2 drugs not included in primary survey but still important)
    : Analgesia

    LETHAL TRIAD OF TRAUMA


    ACIDOSIS
    HYPOTHERMIA

    cause decrease myocardial contractility


    - Hypoxia/tissue hypoperfusion is the No. 1 cause of acidosis
    - Disrupt cellular metabolism (<36.2C), causing coagulopathy
    - usually iatrogenic (cold ER, saline)

    COAGULOPATHY - Transfuse blood/packed cell if massive bleeding


    - DIVC Regime
    : 4 Fresh frozen plasma (all coagulation factors)
    : 4 platelet concentrates (some center only give if platelet <50)
    : 6 cryoprecipitates (contain labile factors eg F 5,8,13)
    -give IV Tranexamic acid 1g if no contraindication

    Prepared by Leow Zhe Eu Group 4 Year 5


    2014/2015

    Secondary Survey: Examine from head to toe


    also look for HIDDEN 6 (PATMET)
    PULMONARY CONTUSION
    Mechanism
    Signs
    Investigations
    Management

    Blunt trauma direct impact or # ribs(flail chest) haemorrhage into


    lung parenchyma HYPOXEMIA ( worsen over 24-48 hours )
    - Haemoptysis
    - Blood in ET tube
    - Chest Xray findings delayed (can take up to 5 hours post injury)
    - Contrast-enhanced CT scan
    Mild : Oxygen
    : Analgesia
    : Aggressive pulmonary toilet
    Severe : Mechanical ventilation
    : Prevent fluid overload pulmonary edema/ARDS

    AORTIC DISRUPTION
    Mechanism
    Signs
    Investigations
    Management

    - Automobile collision
    - Fall from great height
    - BP discrepancy between left and right arm/ UL & LL
    - Widened pulse pressure
    - Chest wall contusion
    - Erect Chest X-ray widened mediastinum
    - Immediate open operative intervention
    - Conservation(for physiologically unstable patient eg trauma elsewhere)
    - Control systolic pressure > 100 mmHg

    TRACHEOBRONCHIAL DISRUPTION
    Mechanism
    Signs
    Investigations
    Management

    Severe subcutaneous emphysema with respiratory compromise


    - Large air leak at chest tube
    - Collapse lung fail to re-expand
    Diagnostic bronchoscopy
    Intubation of unaffected bronchus operative repair

    Prepared by Leow Zhe Eu Group 4 Year 5


    2014/2015

    MYOCARDIAL CONTUSION
    Mechanism
    Signs
    Investigations
    Management

    Blunt cardiac injury


    - Chest pain
    - Palpitation
    - Hypotension/ hypoxia
    - 12-lead ECG to monitor for 24 hrs for dysrhythmias
    - ECHO
    - Cardiac markers
    Haemodynamic stabilisations

    ESOPHAGEAL TRAUMA
    Mechanism
    Signs

    Investigations
    Management

    Penetrating injuries
    - Odynophagia
    - Subcutaneous/mediastinal emphysema
    - Pleural effusion
    - Retro-esophageal air
    - Unexplained fever in 24 hours
    Esophagram in decubitus position + esophagoscopy
    Operative

    TRAUMATIC DIAPHRAGMATIC RUPTURE


    Mechanism
    Signs

    Investigations
    Management

    - Stab wound below nipple line


    - Blunt diaphragm rupture often miss due to associated injuries
    *normal expiration diaphragm rise up to 5th ICS
    - Difficulty in breathing
    - Tracheal deviation
    - Asymmetrical chest expansion
    - Absence of breath sound dt lung displacement
    - Bowel sound during auscultation over chest
    - CXR after NG tube insertion
    - CT scan
    Operative repair

    CREDITS
    I would like to express our gratitude and appreciation to Dr Ariff Arithra and Dr Junainah
    Nor for their guidance and teachings throughout resuscitation week for Year 5 2014/2015.
    Special thanks to Tan Chung Yung from Group 5 for his assistance in preparing these
    notes. Thanks to all who had assisted directly and indirectly.
    Prepared by Leow Zhe Eu Group 4 Year 5
    2014/2015

    Prepared by Leow Zhe Eu Group 4 Year 5


    2014/2015

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