Intro To Atls Dr Jorge Concepcion

INITIAL ASSESSMENT & ABCs in TRAUMA Jorge M. Concepcion, MD,FPCS General Surgery & Trauma

Objectives At the end of this session, the participant is expected to be able to: • Discuss the social impact of trauma and the importance of trauma prevention. • Provide the correct sequence of priorities in assessing multiply injured patient. • Provide guidelines and techniques in the initial management of multiply injured patient.

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

INJURIES “NOT ACCIDENTS” PREDICTABLE PREVENTABLE VEHICULAR “VEHICULAR ACCIDENT CRASH”

Not random events but occur in predictable patterns

TRIMODAL PATTERN OF DEATH IN INJURY

THIRD PHASE 20 % SECOND PHASE FIRST PHASE

30 % 50 %

CRITICAL CARE & REHABILITATION TRAUMA SYSTEM PREVENTION

YEAR

MORTALITY RANK

MORBIDITY RANK

1980

7th

7th

1985

7th

6th

1990

9th

5th

1995

6th

5th

1998

5th

5th

2002

UNDERREPORTED??? 3rd 4th

Epidemiology TRAUMA IS A DISEASE!!!

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.

Approach To Severely Injured Patient 1. PRIMARY SURVEY 2. RESUSCITATION 3. SECONDARY SURVEY 4. DEFINITIVE MANAGEMENT 5. TERTIARY SURVEY REASSESSMENT

Primary Survey A

- AIRWAY & C-SPINE CONTROL

B

- BREATHING

C

- CIRCULATION – HEMORRHAGE CONTROL

D

- DISABILITY (NEURO EXAM)

E

- EXPOSURE / ENVIRONMENT

AIRWAY

Assessment of Airway Patency • Look • Listen • Feel

PCS Committee on Trauma

Look • • • • • • •

Apprehension Agitation/restlessness Unresponsiveness Sweating and pallor Cyanosis Dyspnea/tachypnea Rib retraction on inspiration

PCS Committee on Trauma

• Retracting cervical soft tissues • Use of accessory muscles of respiration • Alar flaring • Neck hematoma • Profuse bleeding • Gastric contents in oropharynx

Listen • • • •

Cough Hoarseness Stridor Decreased or absent breath sounds • Gurgling

PCS Committee on Trauma

• • • •

“I can’t breathe!” Snoring No air entry Wheezing

Feel • • • • •

Subcutaneous emphysema Tracheal deviation Chest wall deformity/crepitus No air flow on exhalation Diaphoretic skin

PCS Committee on Trauma

Factors Affecting Airway Patency • Maxillofacial trauma – Direct trauma – Hemorrhage – Aspiration of broken teeth, blood, dentures – Collapse of bony support – Soft tissue edema – Altered sensorium 2° to brain injury

PCS Committee on Trauma

Factors Affecting Airway Patency • Impaired sensorium – Due to associated brain injury or alcohol/drug intoxication – Absent gag/cough reflex – Aspiration of blood/gastric contents – Inadequate ventilatory drive/apnea

PCS Committee on Trauma

Factors Affecting Airway Patency • Cervical trauma – Hematoma/swelling compressing airway – Direct airway injury • Laryngeal fracture (e.g., direct blow, strangulation, clothesline injury) • Vocal cord paralysis

– Cervical spine precautions mandatory

PCS Committee on Trauma

Factors Requiring Airway Control • Resuscitation of trauma patients in impending arrest due to shock / hypoxia • Impaired ventilatory mechanics – Flail chest – Pneumo/hemothorax – Diaphragmatic breathing

• Transport/sedation requirements

PCS Committee on Trauma

Factors Requiring Airway Control • Continuing threats to airway patency – Soft tissue edema (eg, thermal inhalational injury, massive fluid resuscitation, local trauma) – Deteriorating sensorium – Aspiration risk: • Full stomach/abdominal distention • Continued bleeding/hemoptysis

PCS Committee on Trauma

Airway Risk Factors I nstability, hemodynamic N eck hematoma/trauma T rauma to the face (maxillofacial) U nresponsive (GCS < 8) B leeding from oropharynx A pnea T hermal inhalational injury E mesis/epistaxis/hemoptysis/ PCS Committee on Trauma

Airway Algorithm Trauma patient with airway risk factors Oxygenate Airway compromise Ventilate/Intubate with cervical in-line stabilization

No airway compromise

Y E S

Observe/reassess

Unable to intubate

Airway compromise?

Cricothyroidotomy

Continue monitoring patient’s progress

Reassess adequacy of ventilation

NO

Airway Maintenance Measures • • • • • •

Finger sweep Chin lift Jaw thrust Oropharyngeal/nasopharyngeal airway Laryngeal mask airway Needle cricothyroidotomy

PCS Committee on Trauma

Oropharyngeal Airway

Laryngeal Mask Airway

Definitive Airway Methods • Intubation – Orotracheal – Nasotracheal

• Surgical Airway – Cricothyroidotomy – Tracheostomy

PCS Committee on Trauma

Orotracheal Intubation

PCS Committee on Trauma

Cricothyroidotomy

PCS Committee on Trauma

Associated Skills • • • •

Assisted/bag-mask ventilation Esophageal compression Checking tube placement Anchoring

PCS Committee on Trauma

BREATHING • • • •

Guarantee adequate oxygenation and ventilation Give supplemental oxygen Ventilation (lungs, chest wall & diaphragm) Assess respiratory effort, breath sounds & oxygen delivery • Use of pulse oximetry

BREATHING: Problem Recognition • Objective Signs: • Inspection • Palpation • Percussion • Auscultation

Oxygenation Oxygen delivery Nasal cannula

Face mask Face mask w/ reservoir

L/min.

Approx. FiO2

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 0.60 0.80 1.00

Management • Ventilation – Mouth to pocket face mask – Bag-valve-mask – ( 2 person technique)

• Pleural Decompression – Needle thoracentesis – Closed-tube thoracostomy – Three-sided dressing

BREATHING

Bag Mask Ventilation

PCS Committee on Trauma

Needle Thoracentesis • Indication Tension Pneumothorax

Complications: Local hematoma Pneumothorax Lung laceration

Closed Tube Thoracostomy • Indications – Simple Pneumothorax – Massive Hemothorax – Tension Pneumothorax – Open Pneumothorax

Closed Tube Thoracostomy Complications: Laceration or puncture of thoracic & abdominal organs Pleural infection Damage to intercostals nerves, artery or vein Incorrect tube position Chest tube kinking, clogging or dislodging

Three-sided Dressing • Indications – Open pneumothorax

Pulse Oximetry • The pulse oximeter is designed to measure oxygen saturation and pulse rate in peripheral circulation.

CIRCULATION

CIRCULATION • Assure adequate oxygen delivery and control bleeding • Assess vital signs • Control bleeding by direct pressure • Reduction of fractures in long bones and pelvis

Recognition of Shock • Tachycardia • Cutaneous vasoconstriction • Narrowed pulse pressure • Hypotension

Pitfalls of Shock Recognition • • • •

Extremes of age Athletes Pregnancy Medications – beta blockers – pacemakers

• Hypothermia

Classes of Hemorrhage Class I

Class II

Class III

Class IV

Blood Loss (ml)

Up to 750

750-1500

1500-2000

>2000

Blood Loss (% blood volume)

Up to 15%

15-30%

30-40%

>40%

<100

>100

>120

>140

Blood Pressure

normal

normal

decreased

decreased

Pulse Pressure

normal or decreased

decreased

decreased

decreased

14-20

20-30

30-40

>35

>30

20-30

5-15

negligible

Slightly anxious

Mildly anxious

Anxious, confused

Confused, lethargic

Pulse Rate

Respiratory Rate Urine Output (mL/hr) CNS/mental status

Initial Management • Recognize shock • Stop the bleeding! • Replace effective circulating volume • Restore tissue perfusion

Initial Management • Physical examination – ABCDEs – gastric and bladder decompression

• Vascular access – basic principles – initial blood tests

• Fluid therapy – isotonic fluid

Hemorrhage Control Techniques • • • •

Direct pressure Inflow occlusion Tourniquets Reduction of pelvic volume maneuvers • Application of folded sheets • PASG

Severe Pelvic Fractures

C-CLAMP

Vascular Access • 2 large bore peripheral IV lines • Venous cutdown – saphenous vein

• Central access – femoral – jugular – subclavian

• Intraosseous • Obtain blood for type and cross matching

Fluid Therapy • Warmed crystalloid solution • Rapid fluid bolus – Adult – Child

2 liters 20 mL/kg

• “3 for 1 rule” • Monitor response to therapy

Fluid Therapy Size (gauge)

Time

18

12 min.

16

9 min.

14

7 min.

Response to Fluid Resuscitation • Rapid response • Transient response • Minimal or no response

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

Low

High

High

Need for blood

Low

Moderate to high

Immediate

Blood preparation

Type and crossmatch

Type specific

Emergency blood release

Need for surgery

Possibly

Likely

Highly likely

Early presence of surgeon

Yes

Yes

Yes

Disability Assess GCS, pulses, sensory and motor functions GCS BEST MOTOR RESPONSE – 6 3 - 15 BEST VERBAL RESPONSE – 5 EYE OPENING – 4 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

Exposure and Environmental Control • • • •

Undress (cut clothing!) Keep patient warm Logroll Often missed injuries Axilla Perineum Back

Resuscitation

EXPLORATORY LAPAROTOMY

X-FIX

CHEST TUBE PERICARDIOCENTESIS INSERTION

ED THORACOTOMY

IV ACCESS

Secondary Survey • History A - ALLERGIES M - MEDICATIONS P - PAST ILLNESSES L - LAST MEAL E - EVENTS PRECEEDING THE INCIDENT

Secondary Survey • Physical Examination Detailed, meticulous head-to-toe exam Finger and tubes in all orifices Look, listen, feel everywhere

DEFINITIVE MANAGEMENT

TERTIARY SURVEY

DON’T PANIC INSERT NGT IN PATIENT WITH SUSPECTED FACIAL FRACTURE REMOVE IMPALED OBJECTS FORGET TO WARM THE PATIENT (ESP. CHILDREN) INSERT A FOLEY CATHETER IN PATIENTS SUSPECTED OF URETHRAL INJURY OVERLOOK THE PERINEUM, BACK AND AXILLA

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

Summary 1. Rapid but thorough assessment. 2. Treat the greatest threat to life: a. Control airway b. Provide oxygen and adequate ventilation c. Control bleeding and restore blood volume

3. Continuously monitor patient’s condition: treat continuing threats to life and limb 4. Prompt definitive treatment