ATLS initial management Dr. Khalid Abdulwahid CABS, FRCS(England) Al Bashir teaching hospital Tri model death distribution • First peak: within seconds to minutes of injury, result of apnea(brain or high spinal cord), rupture heartaorta-large vessel • Second peak: within minutes to several hours, result of subdural-epidural hematomas, hemopneumthorax, rupture spleen, liver laceration, fracture pelvic. • Third peak: several days to weeks after injury, result of sepsis and multi organ dysfunction History Initial assessment • Treatment of seriously injured patient requires rapid assessment of injury and institution of life preserving therapy. Because time is of the essence, a systemic approach includes: 1- Preparation 2- Triage 2-Primary survey (ABCDE) and resuscitation 3- adjunct to primary survey and resuscitation 4-secondary survey and resuscitation 5-definitive care Preparation • Pre hospital phase: pre hospital agency and personnel, maintain airway, control bleeding, immobilization, transport contact. Record of injury: time, events related to injury, patient history, mechanism of injury • Hospital phase: hospital informed, equipment ready; airway, tubes, warmed IVF, protection (mask, gloves, aprons, glasses) Triage • Sorting of patients based on there need for treatment and resources available to provide that treatment. Two types present: • 1- multiple casuality: No. of patients and severity don not exceed the ability of the facility to render care. Patient with life threatening problems and mutiple system injuries treated first. • 2- mass casuality: No. of patients and severity of their injury exceeds the capability of the facility and staff. Patient with greatest chance of survival, least expenditure of time , equipment and personnel treated first. Primary survey • • • • • 1- Airway and cervical spine 2- Breathing and ventilation 3- Circulation and hemorrhage control 4- Disability: neurologic status 5- Exposure/ Environment control: completely undress the patient but prevent hypothermia • During primary survey life threatening conditions identified and managed simultaneously. Primary survey Airway and cervical spine protection: inspection F.B, facial- mandibular-tracheal fractures, do chin lift jaw thrust to open airway. prevent excessive movement of cervical spine, use cervical collar. Primary survey • Breathing and ventilation Assess chest wall excursion and auscultation visual inspection, palpation and percussion looking for; tension pneumothorax, flail chest, pulmonary contusion, massive hemothorax or open pneumothorax. Primary survey • Circulation and hemorrhage control Look for hypotension, tachycardia, altered level of consciousness, pale cold skin. External bleeding identified and controlled during primary survey. • Disability: neurologic status Level of consciousness, pupillary size and reaction, lateralizing signs and spinal cord injury level. GCS Primary survey • Exposure/ Environment control: Undress , complete assessment, cover with warm blankets, warm IVF, Resuscitation • Airway : protect airway; jaw thrust or chin lift, oral airway, definitive airway( tube, tracheotomy) • Breathing : treatment of hemo or pneumothorax • Circulation : IVF, blood,2 large peripheral( or central line or cut down) IV cannula fixed with infusion of 12 liters of warmed crystalloid solution(37-40 c). control of external or internal bleeding by pressure, suture ligation, cautery, operation, angioembolization, fracture fixation…etc Adjunct to primary survey • ECG monitoring: tachycardia, dysrhythmia, pulseless electrical activity: cardiac temponade, tension pneumothorax. • Urinary and gastric catheter • Ventilatory rate and ABG • Pulse oximetry • Blood pressure • X ray and diagnostic tests: FAST and DPL, but not CT. • Consider transport Secondary survey • • • • • • HEAD TO TOE EXAMINATION AMPLE history A: allergies M: medications P: past illness/ pregnancy L: last meal E : events/ environment related to the injury Secondary survey • Adjunct to secondary survey: Spinal X-ray CT head, chest, abdomen, and or spine Contrast urography Angiography Extremity X-ray Transesophageal US Bronchoscopy esophagoscopy • Definitive care? Question:1 • A 22-year-old man is hypotensive and tachycardic after a shotgun wound to the left shoulder. His blood pressure is initially 80/40 mm Hg. After 2 liters of crystalloid solution his blood pressure increases to 122/84 mm Hg. His heart rate is now 100 beats per minute and his respiratory rate is 28 breaths per minute. His breath sounds are decreased in the left hemithorax, and after initial IV fluid resuscitation, a closed tube thoracostomy is performed for decreased left breath sounds with the return of a small amount of blood and no air leak. After chest tube insertion, the most appropriate next step is • • • • • A) reexamine the chest. B) perform an aortogram. C) obtain a CT scan of the chest. D) obtain arterial blood gas analyses E) perform transesophageal echocardiography Question:2 • In managing the head-injured patient, the most important initial step is to • A) secure the airway. • B) obtain c-spine film. • C) support the circulation • D) control scalp hemorrhage. • E) determine the GCS Score. Question:3 • A 7-year-old boy is brought to the emergency • • • • • department by his parents several minutes after he fell through a window. He is bleeding profusely from a 6-cm wound of his medial right thigh. Immediate management of the wound should consist of A) application of a tourniquet. B) direct pressure on the wound. C) packing the wound with gauze. D) direct pressure on the femoral artery at the groin. E) debridement of devitalized tissue. Question:4 • • • • • • Which one of the following findings in an adult should prompt immediate management during the primary survey? A) Distended abdomen. B) Glasgow Coma Scale Score of 11. C) Temperature of 36.5°آC (97.8°آF). D) Heart rate of 120 beats per minute. E) Respiratory rate of 40 breaths per minute. Question:5 Thank you • • • • • • The most important, immediate step in the management of an open pneumothorax is A) endotracheal intubation. B) operation to close the wound. C) placing a chest tube through the chest wound. D) placement of an occlusive dressing over the wound. E) initiation of 2, large-caliber IVs with crystalloid solution.
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