430 SURGERY TEAM
Trauma Care
Yousef Almana
ATLS* Concept:
● ABCDE approach to evaluation and treatment
● Treat greatest threat o life first
t
Airway with c--‐spine protection
● Definitive diagnosis not immediately important Breathing / ventilation / oxygenation
● Time is of the essence Circulation: stop the bleeding!
● Do no further harm
*Advanced Trauma life support
Disability / Neurological status
Expose / Environment /Body temperature
Apply principles of “primary” and “secondary” surveys
● Identify management priorities
● Institute appropriate resuscitation and monitoring procedures
● Recognize the value of the patient history and biomechanics of injury
● Anticipate and manage “pitfalls”
________
Initial assessment:-
Primary survey and resuscitation of vital functions are done simultaneously using a team approach.
Primary survey: (ABCDE approach)
Airway: _____________________________________________________________________________________________________
Establish patent airway and protect c-spine
Basic Airway techniques:
Pitfalls:
Chin-lift maneuver occult air way injury
P jaw-thrust maneuver
progressive loss of airway
Equipment failure
r Advanced airway techniques: Inability to intubate
Orotracheal intubation
i
m Breathing:___________________________________________________________________________________________________
Assess and ensure adequate oxygenation and ventilation The Immediate life threatening injurie:
a ● Laryngeotracheal injury / Airway obstruction
● Respiratory rate ● Tension pneumothorax
Pitfalls:
r ● Chest movement Airway versus ventilation problem? ● Open pneumothorax
latrogenic pneumothorax or ● Flail chest and pulmonary contusion
y ● Air entry (by auscultation) tension pneumothorax? ● Massive hemothorax
● Oxygen saturation ● Cardiac tamponade
Circulation:__________________________________________________________________________________________________
s
Management
u ● Level of consciousness Pitfalls: ● Control hemorrhage
Elderly ● Restore volume (By 2 Large-bore peripheral lines to give 2L of Crystalloids
● Skin color and temperature Children
r Athletes OR Blood)
● Pulse rate and character Medication ● Reassess patient
v s
● Prevent the lethal triad (Coagulopathy, Hypothermia, Acidosis)
e
Disability:___________________________________________________________________________________________________
y Baseline neurologic evaluation: Caution:
● Glasgow Coma Scale score observe for neurologic deterioration
● Pupillary response (the only way to check for brain injury)
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Exposure / Environment:______________________________________________________________________________________
Completely undress the patient but prevent hypothermia!! Pitfalls:
Missed injuries
What is a quick simple way to assess a patient in 10 seconds?
1. Identify yourself A Patent airway
2. Ask the patient his or her name B Sufficient air reserve to permit speech
3. Ask the patient what happened C Sufficient perfusion to permit cerebration
D Clear sensorium
Adjuncts to primary Survey: X-ray (Cervical Spin, Chest X-ray, Pelvic X-ray)
ECG, ABG, Vital signs, Urinary Output, Pulse oximeter and CO2, urinary/gastric catheters unless contraindicated
Resuscitation
● Protect and secure airway
● Ventilate and oxygenate
● Stop the bleeding!
● Vigorous shock therapy
● Protect from hypothermia
Consider Early Transfer !! How do I minimize missed injuries?
● Use time before transfer for resuscitation ● High index of suspicion
● Frequent reevaluation and monitoring
● Do not delay transfer for diagnostic tests
With special considerations for: Pain management !
● Trauma in the elderly ● Relief of pain / anxiety as appropriate
● Pediatric trauma ● Administer intravenously
● Trauma in pregnancy ● Careful monitoring is essential
When should the transfer occur? Which patients do I transfer to a higher level of care?
As soon as possible after stabilization: Those whose injuries exceed institutional capabilities:
● Airway and ventilatory control ● Multisystem or complex injuries
● Hemorrhage control ● Patients with comorbidity or age extremes
Secondary survey:
After
The complete history and physical examination ● Primary survey is completed
S ● ABCDEs are reassessed
e ● History ● Vital functions are returning to normal
● Physical exam: Head to toe
c ● Complete neurologic exam
o ● Special diagnostic tests
● Reevaluation
n
d
History:
a Allergies
r Medications
Past illnesses
y Last meal
Events / Environment / Mechanism
Physical exam: Head to toe: Neurologic: Brain
● GCS (Glasgow Coma Scale score)
● Pupil size and reaction
Head
● External exam ● Lateralizing signs
● Scalp palpation ● Frequent reevaluation
● Comprehensive ● Prevent secondary brain injury >>>> by Early
●eye and ear exam neurosurgical consult !
Maxillofacial ● Including visual acuity
● Bony crepitus Neurologic: Spinal Assessment
Pitfalls !
● Deformity ● Whole spine
●Unconsciousness
● Malocclusion ● Tenderness and swelling
●Periorbital edem
Pitfall ! ●Occluded auditory canal ● Complete motor and sensory exams
Potential airway ● Reflexes
obstruction ● Imaging studies
Cribriform plate fracture
Frequently missed Pitfalls !
Altered sensorium
Neck (Soft Tissues) Inability to cooperate with
S Mechanism: Blunt vs penetrating
Symptoms: Airway obstruction, clinical exam
e hoarseness Neurologic: Spine and Cord
Findings: Crepitus, hematoma, stridor, Conduct an in-depth evaluation of the
bruit patient’s spine and spinal cord
c Early neurosurgical / orthopedic consult
Pitfalls:
o Delayed symptoms and signs Chest:
Progressive airway obstruction ● Inspect
Occult injuries
n ● Palpate
● Percuss
● Auscultate
d Abdomen:
● X-rays
● Inspect / Auscultate
a ● Palpate / Percuss
● Reevaluate The Potential life threatening injuries
● Special studies ● Blunt cardiac injury
r ● Traumatic aortic disruption
pitfalls ! ● Blunt esophageal rupture
y Hollow viscous injury ● Traumatic diaphragmatic injury
Retroperitoneal injury
Extremities
Pelvis: ● Contusion, deformity
s ● Pain on palpation ● Pain
● Leg length unequal ● Perfusion
u ● Instability ● Peripheral neurovascular status
● X-rays as needed ● X-rays as needed
r
Pitfalls !
Perineum
v Excessive pelvic manipulation
Contusions, hematomas, lacerations, urethral blood
Underestimating pelvic blood loss
Rectum.
e Sphincter tone, high-riding prostate, pelvic fracture,
rectal wall integrity, blood.
Musculoskeletal. Vagina.
y Blood, lacerations.
Pitfalls !
Potential blood loss Pitfalls !
Missed fractures Urethral injury
Soft tissue or ligamentous injury Pregnancy
Compartment syndrome (especially with
altered sensorium / hypotension)
Indications for Laparotomy_Blunt Trauma:
● Hemodynamically abnormal with Adjuncts to secondary survey:
●suspected abdominal injury (DPL / FAST) Special Diagnostic Tests as Indicated
● Free air
● Diaphragmatic rupture Pitfalls !
● Peritonitis Patient deterioration
● Positive CT Delay of transfer
Deterioration during transfer
Indications for Laparotomy_Penetrating Trauma: Poor Communication
● Hemodynamically abnormal
● Peritonitis
● Evisceration
● Positive DPL, FAST, or CT