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A.T.L.S.
By
Dr. Sayed Adel
Dr. Kareem Sabry
Lecturers Of General
Surgery
Unit 6 (B) Surgery
Ain Shams University
History
•Globally, about 16,000 people die of
injures ever day and about 5.8 million
people die every year.
•WHO data shows that 1 in 10 deaths
worldwide is the result of an injury.
Causes of trauma
1st peak: Severe brain lacerations
Brain stem injuries
High spinal cord injuries
Heart & Aorta injuries
2nd peak: Airway obstruction
Hemopneumothorax
Internal Hge.
Epidural or subdural Hge.
3rd peak: Sepsis
Organ failure
Pulmonary embolism
TRAUMA SYSTEM
 Trauma system approach is the integration
of all aspects of trauma care to achieve the
best outcome
 Components of the trauma system
a) Pre-hospital care
b) In-hospital care
c) Rehabilitation
d) Prevention
e) Education
f) Research.
Pre-hospital care
 Airway
 Breathing
 Circulation
 Keeping the patient immobilised.
 Keeping time at the scene to a minimum.
 Co-ordination and communication with the
receiving hospital
Trauma triage
 Trauma triage is the use of trauma assessment for
prioritising of patients for treatment or transport
according to their severity of injury , given the
limitations of the current situation, the mission, and
available resources
 Triage occurs at every level of care, starting with medic
care, extending through the OR, the ICU, and the
evacuation system.
 Triage Categories:
Immediate: Treatable life threatening injury.
Delayed: Serious but not life threatening injuries.
Minimal: Walking, wounded.
Expectant: Dead or fatally injured.
Minimise mortality &
morbidity by
• Critical decision-making and planning
• Cellular protection
• Liberal communication
• Definitive surgical procedures
• ICU/HDU level care in major trauma
• Appropriate medical support
• Rehab assessment and planning
•Primary survey
•Resuscitation
•Secondary survey
•Definitive care
Primary survey
•Assessment: Look
Listen
Feel
•Management: Oral toilet
Jaw thrust
Oropharyngeal airway
Cricothyroidotomy, tracheostomy &
endotracheal intubation
•Cervical spine collar
Breathing
 Assessment: Look
Listen
Feel
 Management:
 100% O2
 Assisted ventilation by Ambu bag
 Urgent needle decompression for
tension pneumothorax
Intercostal tube + under water seal for
hemo- pneumothorax
Circulation
 Assessment:
• Vital data
• UOP
• Class of shock
 Management:
•2 I.V. Wide bore cannulae
•Give 2 litres of crystalloids
(preferably Ringer’s Lactate)
•Stop external bleeding
•Pericardiocentesis if there is cardiac
tamponade
Disability (neurological)
Pupillary size and reaction
A V P U
Glasgow coma scale
+
Splinting of fractures
Exposure
Undress the patient, but prevent
hypothermia.
Clothes may need to be cut off but.
After examination, attention to prevention of
heat loss with warming devices, warmed
blankets.
Adjuncts to 1ry survey
Monitoring
Urinary catheter and NGT
X-ray cervical spine, chest and pelvis
Ressuscitation
Exposure
Baseline Monitoring
Venous Cut Down
Blood Transfusion
Reassess Oxygenation
Hge. Control
Splinting of The Fractures
Dressing of The Wounds
Drugs: Analgesics, Antibiotics,antitetanic
Serum and Corticosteroids.
Secondary survey
Continue monitoring
Examination of the body by region
Complete neurological examination
including GCS
History taking:
A = Allergies
M = Medication currently used
P = Past illnesses/Pregnancy
L = Last meal
E = Events/Environment related to injury
Basic X-rays
Definitive care
Goals of Definitive Care
1. Prevent early death
2. Minimise morbidity
• sepsis
• multi-organ failure
• disability
• length of stay
3. Maximise function
•Thoracic injuries (specially penetraring
wounds of the heart, tension and open
pneumothorax, hemothorax and flail chest)
•Abdominal injuries (specially involving
Aorta and IVC)
•Cerebral injuries (N.B. Skull # not associated
with IC Hge. are dealt with after more critical
thoracic and abdomenal injuries)
•Urological injuries
•Long bone fractures
•Contaminated wounds
Concepts related to
trauma
Early Cellular Protection
• Airway maintenance
• Optimise oxygenation/ventilation
• Stop the bleeding
• Support circulation
• Prevent raised ICP
• Control contamination/sepsis (<3
hours)
• Debridement (<6 hours)
• Fracture stabilization
Hypotensive resuscitation:
Keep systolic pressure at 85 – 90.
This is sufficient for vital organ perfusion
Prevent BP overshoot and risk of increased Hge.
FUST / FAST:
Focused Abdominal Sonogram for Trauma
Assess: liver, spleen, pelvic or abdomenal free
collection, pleural effusion or hemopericardial
Advantages
Disadvantages
Special setuations
Pregnant trauma patient
 Maternal resuscitation and survival is key to fetal survival.
 The fetus may be in distress despite a well appearing mother.
 History: Mechanism
 Last menstrual period (LMP)
 Uterine contractions
 Fetal movement
 Premature rupture of membranes
 Vaginal bleeding
 SBP decrease by 2-4 mm Hg, DBP decreases by 5-15 mm Hg
in mid-trimester. Heart rate increases by 10-15 B/M.
 Obstetric assessment
Work up
 Lap. Work: Plasma volume increases by 50%, average
hematocrit level is 32-34% , Pregnancy-induced
leukocytosis , electrolyte and glucose.
 Imaging Studies: Usually, adverse effects are not
expected until the dose is 5-10 rad. Shielding the patient
with lead decreased the radiation exposure by 50 to 75%.
2 view chest 0.00007 rads, CT scan head <0.05 rads,
chest CT<0.1 rads
 Others: CTG
Management
 Position: The patient should be tilted 15° to the
left.
 Airway and breathing: All pregnant trauma
patients should receive supplemental oxygen
because the fetus is extremely sensitive to
hypoxia. If a chest tube is placed, enter the chest 1
or 2 interspaces higher than usual.
 Circulation: the relative hypervolemia of
pregnancy allows for a 30-35% loss of blood
volume before hypotension develops.
Trauma in the elderly
The aging process and the presence of chronic
diseases results in decreased functional reserve
which may produce a diminished physiologic
response to adjust to traumatic injuries.
Airway: increased risk of aspiration
Dentures
Intubation may be difficult due to temporomandibular
arthritis.
Cervical spine disease results in more difficulty with
airway management.
Breathing: There is a reduction of the efficiency of
ventilation with age.
Circulation : The normal tachycardic and
vasoconstrictor response to hypovolaemia may be
blunted.
Disability: In case of decline in intellectual or cognitive
function, decreased sensory input, and altered
mentation by medication the neurological assessment
may be difficult.
Paediatric Trauma
 Smaller body size in children often makes them
more prone to poly traumatic injury.
 A child's weight to surface area ratio is lower than
an adult's and thus have a higher risk of
becoming hypothermic.
 Infants and children are at special risk of
becoming dehydrated and hypoglycemic
 Among children, the CNS is the most commonly
injured isolated system.
 Shaken baby syndrome
Management
 Airway: A child has a shorter neck, smaller and anterior
larynx, floppy epiglottis, short trachea, and large tongue.
 Breathing: children are primarily diaphragmatic breathers;
hence any compromise of diaphragmatic movement
significantly limits the child's ability to ventilate.
 Circulation: Obvious signs of shock, such as hypotension
or a decrease in urinary output, may not occur until more
than 30% of blood volume has been lost. Initial fluid
resuscitation should consist of a bolus of 20 mL/kg.
Children with evidence of hemorrhagic shock who fail to
response to fluid resuscitation should also receive blood
(10 mL/kg) and be evaluated by a pediatric surgeon for
possible operative intervention.
Thank
you

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Trauma lecture

  • 1. A.T.L.S. By Dr. Sayed Adel Dr. Kareem Sabry Lecturers Of General Surgery Unit 6 (B) Surgery Ain Shams University
  • 3. •Globally, about 16,000 people die of injures ever day and about 5.8 million people die every year. •WHO data shows that 1 in 10 deaths worldwide is the result of an injury.
  • 5. 1st peak: Severe brain lacerations Brain stem injuries High spinal cord injuries Heart & Aorta injuries 2nd peak: Airway obstruction Hemopneumothorax Internal Hge. Epidural or subdural Hge. 3rd peak: Sepsis Organ failure Pulmonary embolism
  • 6. TRAUMA SYSTEM  Trauma system approach is the integration of all aspects of trauma care to achieve the best outcome  Components of the trauma system a) Pre-hospital care b) In-hospital care c) Rehabilitation d) Prevention e) Education f) Research.
  • 7. Pre-hospital care  Airway  Breathing  Circulation  Keeping the patient immobilised.  Keeping time at the scene to a minimum.  Co-ordination and communication with the receiving hospital
  • 8. Trauma triage  Trauma triage is the use of trauma assessment for prioritising of patients for treatment or transport according to their severity of injury , given the limitations of the current situation, the mission, and available resources  Triage occurs at every level of care, starting with medic care, extending through the OR, the ICU, and the evacuation system.  Triage Categories: Immediate: Treatable life threatening injury. Delayed: Serious but not life threatening injuries. Minimal: Walking, wounded. Expectant: Dead or fatally injured.
  • 9. Minimise mortality & morbidity by • Critical decision-making and planning • Cellular protection • Liberal communication • Definitive surgical procedures • ICU/HDU level care in major trauma • Appropriate medical support • Rehab assessment and planning
  • 12. •Assessment: Look Listen Feel •Management: Oral toilet Jaw thrust Oropharyngeal airway Cricothyroidotomy, tracheostomy & endotracheal intubation •Cervical spine collar
  • 13. Breathing  Assessment: Look Listen Feel  Management:  100% O2  Assisted ventilation by Ambu bag  Urgent needle decompression for tension pneumothorax Intercostal tube + under water seal for hemo- pneumothorax
  • 14. Circulation  Assessment: • Vital data • UOP • Class of shock  Management: •2 I.V. Wide bore cannulae •Give 2 litres of crystalloids (preferably Ringer’s Lactate) •Stop external bleeding •Pericardiocentesis if there is cardiac tamponade
  • 15. Disability (neurological) Pupillary size and reaction A V P U Glasgow coma scale + Splinting of fractures
  • 16. Exposure Undress the patient, but prevent hypothermia. Clothes may need to be cut off but. After examination, attention to prevention of heat loss with warming devices, warmed blankets.
  • 17. Adjuncts to 1ry survey Monitoring Urinary catheter and NGT X-ray cervical spine, chest and pelvis
  • 19. Exposure Baseline Monitoring Venous Cut Down Blood Transfusion Reassess Oxygenation Hge. Control Splinting of The Fractures Dressing of The Wounds Drugs: Analgesics, Antibiotics,antitetanic Serum and Corticosteroids.
  • 21. Continue monitoring Examination of the body by region Complete neurological examination including GCS History taking: A = Allergies M = Medication currently used P = Past illnesses/Pregnancy L = Last meal E = Events/Environment related to injury Basic X-rays
  • 23. Goals of Definitive Care 1. Prevent early death 2. Minimise morbidity • sepsis • multi-organ failure • disability • length of stay 3. Maximise function
  • 24. •Thoracic injuries (specially penetraring wounds of the heart, tension and open pneumothorax, hemothorax and flail chest) •Abdominal injuries (specially involving Aorta and IVC) •Cerebral injuries (N.B. Skull # not associated with IC Hge. are dealt with after more critical thoracic and abdomenal injuries) •Urological injuries •Long bone fractures •Contaminated wounds
  • 26. Early Cellular Protection • Airway maintenance • Optimise oxygenation/ventilation • Stop the bleeding • Support circulation • Prevent raised ICP • Control contamination/sepsis (<3 hours) • Debridement (<6 hours) • Fracture stabilization
  • 27. Hypotensive resuscitation: Keep systolic pressure at 85 – 90. This is sufficient for vital organ perfusion Prevent BP overshoot and risk of increased Hge. FUST / FAST: Focused Abdominal Sonogram for Trauma Assess: liver, spleen, pelvic or abdomenal free collection, pleural effusion or hemopericardial Advantages Disadvantages
  • 29. Pregnant trauma patient  Maternal resuscitation and survival is key to fetal survival.  The fetus may be in distress despite a well appearing mother.  History: Mechanism  Last menstrual period (LMP)  Uterine contractions  Fetal movement  Premature rupture of membranes  Vaginal bleeding  SBP decrease by 2-4 mm Hg, DBP decreases by 5-15 mm Hg in mid-trimester. Heart rate increases by 10-15 B/M.  Obstetric assessment
  • 30. Work up  Lap. Work: Plasma volume increases by 50%, average hematocrit level is 32-34% , Pregnancy-induced leukocytosis , electrolyte and glucose.  Imaging Studies: Usually, adverse effects are not expected until the dose is 5-10 rad. Shielding the patient with lead decreased the radiation exposure by 50 to 75%. 2 view chest 0.00007 rads, CT scan head <0.05 rads, chest CT<0.1 rads  Others: CTG
  • 31. Management  Position: The patient should be tilted 15° to the left.  Airway and breathing: All pregnant trauma patients should receive supplemental oxygen because the fetus is extremely sensitive to hypoxia. If a chest tube is placed, enter the chest 1 or 2 interspaces higher than usual.  Circulation: the relative hypervolemia of pregnancy allows for a 30-35% loss of blood volume before hypotension develops.
  • 32. Trauma in the elderly The aging process and the presence of chronic diseases results in decreased functional reserve which may produce a diminished physiologic response to adjust to traumatic injuries.
  • 33. Airway: increased risk of aspiration Dentures Intubation may be difficult due to temporomandibular arthritis. Cervical spine disease results in more difficulty with airway management. Breathing: There is a reduction of the efficiency of ventilation with age. Circulation : The normal tachycardic and vasoconstrictor response to hypovolaemia may be blunted. Disability: In case of decline in intellectual or cognitive function, decreased sensory input, and altered mentation by medication the neurological assessment may be difficult.
  • 34. Paediatric Trauma  Smaller body size in children often makes them more prone to poly traumatic injury.  A child's weight to surface area ratio is lower than an adult's and thus have a higher risk of becoming hypothermic.  Infants and children are at special risk of becoming dehydrated and hypoglycemic  Among children, the CNS is the most commonly injured isolated system.  Shaken baby syndrome
  • 35. Management  Airway: A child has a shorter neck, smaller and anterior larynx, floppy epiglottis, short trachea, and large tongue.  Breathing: children are primarily diaphragmatic breathers; hence any compromise of diaphragmatic movement significantly limits the child's ability to ventilate.  Circulation: Obvious signs of shock, such as hypotension or a decrease in urinary output, may not occur until more than 30% of blood volume has been lost. Initial fluid resuscitation should consist of a bolus of 20 mL/kg. Children with evidence of hemorrhagic shock who fail to response to fluid resuscitation should also receive blood (10 mL/kg) and be evaluated by a pediatric surgeon for possible operative intervention.