When does ATLS start and what is important
Time of injury
Platinum 10 minutes
Golden hour
What is important to know pre-hospital
Mechanism of injury
If RTA - where sitting / where they thrown?
Time of injury
Suspected serious injuries - LOC / head injury / neck pain
Vital signs
Any interventions
What is put out
Trauma call to all teams Anaesthetist ED ITU Surgical Radiology
What is important in the history
AMPLE Allergies Medication PMH / pregnancy Last meal Events / environment relating to injury
What is the primary assessment
CABCDE
Restart if any changes
C
Catastrophic haemorrhage control
- Tourniquet
- Pressure
A
Airway with C-spine control
Always stabilise C-spine and never put into recovery if suspect injury
Always assume C-spine injury in major trauma till proven otherwise
- Triple mobilisation with collar, block and tape
- May not need collar if able to cooperate and keep head still
- Beware of patient with AS when immobilisation C-spine due to subluxation and risk of fracture and nerve damage
What do you look for in A
Noises
- Speech suggest patent
- Stridor = worrying so DEAL
Visual
- Any swelling / deformity / blood / vomit
- Can suction away any visible foreign body
How do you manage airway
Chin lift jaw thrust Oropharyngeal airway - guedel Nasopharyngeal airway Endotracheal intubation Needle / surgical cricothyroidectomy Intubation
What do you avoid in trauma and why
Nasopharyngeal
Incase of basal skull fracture
When do you intubate
If reduced GCS <8
Requires anaesthetic
Continuous capnograpy after
Tension pneumothorax will get worse after ventilation
What requires urgent aesthetic assessment
Impending obstruction
What do you do for C-spine
Consider early on
Immobilise
When do you assume C-spine injury
Dangerous mechanism
Reduced GCS
Injury above clavicle
Any neurology
B
Breathing
What do you look for in B
Look and felt chest including posterior aspect
- Want to see if any stab areas / open wound
- Any bruising
- Look for distended or flat neck veins
- Distended = tamponade / SVC obstruction
- Flat = hypo
Work and effort of breathing
- Use of accessory / abdominal
Chest expansion Tracheal position - should be central JVP fdifficult to do in trauma Palpate and percuss Ausculate O2 sats Get CXR
What is important to look for
Any flair segment or signs of pneumothorax
- Tracheal deviation = late sign in tension
- Decreased movement / unequal expansion / no air entry / hypo and low sats and look unwell = suggestive
- Will go into cardiac arrest
Underlying fracture
- Subcut emphysema - crepitus on palpation (due to pneumothorax or gas producing infection)
- Pneumothorax
- Flail chest
Bruising or open wounds
What are 6 main causes of breathing problems in trauma
ATOMFC
Airway obstruction
Tension pneumothorax
Open pneumothorax / Sucking Chest injury
Massive haemothroax
Flail chest
- 2+ rib broken next to each other in 2 places causing portion of rib cage to be separated from the chest wall
- Get parodical movement of flail / bruising when chest moves
Cardiac tamponade
How do you manage B
15l O2 non-breath for all trauma Decompress pneumothorax - Wide bore cannula into 2nd IC space midclavicular will decompress - Need chest drain if in hospital Decompress haemothorrax with chest drain if in hospital High flow O2 - 15l non-rebreath O2 monitoring ABG CXR
C
Circulation + haemorrhage control
What is shock in a trauma patient
Hypovolaemic until proven otherwise
How do you assess and what imaging
HR Pulse Pulse pressure CRT BP Urine output Confusion Colour and temp Hb and lactate on VBG will give good idea USS / CT
What are common sites of blood loss
Floor and 4 more Haemothorax - Will detect on chest exam / CXR Abdomen - Peritonism / rigid + shock Pelvis Long bones - femur - Look swollen / brusised / tender
Options for haemorrhage control
Direct pressure
Pelvic binder if pelvic fracture
Thomas splint for femur fracture
How do you value replace
IV access - 2 large bore Get bloods - can see Hb drop X-match Catheter to see UO O2 Fluid resus Massive transfusion protocol
If can’t get vein what are options
IO access for max 48 hours
Tibial tuberosity
Proximal humerus
Distal femur
What type of fluid do you give
Want to replace blood lost with blood and clotting
4 units O neg blood in ED
Whilst waiting for blood can give crystalloid resus but will eventually dilute and won’t clot
Need to replace clotting to prevent DIC
Give tranexamic acid
How do you monitor replacement and response
Vital signs Want high enough BP to perfuse organs UO hourly Lactate Repeat gas
What is lethal triad of haemorrhage
Coagulopathy
Acidosis
Hypothermia
Wha scan to look of bleeding
FAST
- Focussed assessment with sonography in trauma
D
Disability
What do you assess
Neuro - C-spine / head injury - AVPU - GCS - PEARL - Tone / reflex - Log roll DONT FORGET GLUCOSE
E
Environment / exposure - Prevent hypothermia - Warm blanket - Log roll for injuries to back Temperature Abdo exam PR exam
What is secondary survey
Identify all injuries once patient stable
What can you do
FAST scan will show blood in abdo or cardiac tamponade
- Don’t do if delays CT
CT = definite imaging in trauma (NOT if unstable)
Blood gas
Urine dip
ECG
What is further management
Theatre
Interventional radiology
ITU for ICP monitoring
What should you always check in long bone fracture
Hb
What causes tension pneumothorax
External injury e.g. stab
Internal injury to lung e.g. from rib fracture
How does if form
Air can pass into pleural space but can’t move out
Pressure builds up
Everything is pushed away
What are signs
Hyper-expanded chest Absent movement due to pressure Reduce or absent breath sound Hyper-resonant Trachea and apex deviated Distended neck vein Shock and hypoxia
How do you Rx in emergency
Needle thoracocentesis
Place grey cannula into 2IC space midclavicular line
Advanced and aspirate till your hear air
or
Finger thoracotomy
Cut a slice and put finger in and remove and should hear air
What is role of this
Equlibrate pressure so become simple pneumothorax
What is definite Rx
Chest drain
What is safe triangle
Lateral border of pec major Base of axilla 5th IC space Lat edge of lat dorsi Go along top of the rib NOT underneath
What is an open pneumothorax
Chest wound which allows air movement in on respiration
How does it present
Like tension pneumothorax
How do you treat
3 sided dressing
Stops air getting in but allows air out when breath
How do you definitely treat
Drain
How does a massive haemothorax present
Reduced breath sounds Dull to percuss Flat neck veins due to shock or distended if SVC is obstructed Shock and hypoxia Normal movement Trachea central
How do you Rx
Chest drain to see how much blood lost
Volume resus
Thoracotomy or sternotomy if continue to bleed
If patient is shocked in trauma what do you think
Could it be tamponade
How does it present R
Raised JVP
Muffled heard sounds
Kausmaull
- Rise of JVP on inspiration (should decrease)
Distended neck vein as fluid builds up in pericardium and heard can’t fill and expand
How do you Rx
Volume resus - any but ideally blood
Thoracotomy
Pericardiocentesis
What are other risks of trauma
PE
Fat embolism
If haemodynamically compromised
No CT etc
Straight to theatre
What is the triad of significant bleed
Coagulopathy as use up coag factors
Hypothermia as not moving warm blood which further impacts coagulation
Acidosis due to initial trauma + lactic acidosis as not perfusing
If major bleed
Recognise early
Get access and bloods send
Senior help
What bloods
FBC, U+E, LFT
VBG
Lipase
Clotting / INR
Major haemorrhage
If >4 units RBC within 1 hour or replacing >50% blood volume in 3 hours
ATLS class of haemorrhage shock
4 classes
Look to see if any drugs that could be masking signs e.g. BB
If minimal bleed with no harm-dynamic compromise what do you do
Conservative
If BP low but overload what do you d
Bolus vs adrenaline to vasoconstrict
HYpovolaemic and cariogenic shock
Decreased CO and BP
Increased HR and SVR
Rx
Fluid
Septic shock
Normal CO
Decreased BP
Increased HR
Decreased SVR as vasodilate
Rx
Fluid
May need adrenaline to vasoconstrictor
Neurogenic shock
Decreased sympa or increased para
Vasoconstrictor used to return vascular tone
