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Advanced Trauma Life
Support
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DEFINITION 0F TRAUMA
A term derived from the Greek for WOUND It refers to any bodily injury.
It defined as tissue injury due to direct effects ofexternally applied energy Energy !ay "e!ec#anical$ t#er!al$ electrical$ electro!agnatic ornuclear
Included%"urns$ dro&ning$ s!o'e$ in#alation$
slip ( fall Excluded% poisoning)toxic ingestion
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TRIMODAL DISTRIBUTION OF TRAUMA DEATHS.
THE FIRST PEAK OF DEATHS OCCURS WITHIN FEW SECONDS
TO MINUTES AFTER INJURY(50% OF ALL DEATHS).Virtuallyinevitable & very little can be dne.
THE SECOND PEAK OCCURS BETWEEN A FEW MINUTES AND
AN HOUR AFTER INJURY. !an be reduced by "r#"t initial care in t$e"re%$"ital "$ae'by early $"ital reucitatin and by "r#"t and
c#"etent de(initive care.T$i "erid $a been labelled a )THE *OLDENHOUR+. Mana,e#ent at t$i ti#e -ill a((ect t$e t$ird "ea ( deat$.
THE THIRD PEAKOCCURS SEVERAL DAYS OR WEEKS AFTER
THE INITIAL INJURY.
The e!"#$ #$ &h'$ e* h"+,$ -e e$e$ "&e#&',,/ee#&-,e.
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GENERAL CATEGORIES OF TRAUMA.
DI*IDED INTO T+REE ,ATE-ORIE.:
I!DIA"!#$ #I%! "&'!A"!NING.
A%%!(" A)OU" *+,A((OUN" %O' *-+ O% A## IN&O/0I"A#
"'AUA D!A"&/.
U'G!N".
(O0'I/!/ A00'O1IA"!#$ A)OU" 2-2* + O% A## 0A"I!N"/.
NONU'G!N".
A00'O1IA"!#$ 3- + O% A## IN4U'I!/.
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1. Preparation
2. Triage
3. Primary Survey (ABCDEs
4. !esus"itation
#. A$%un"ts to primary survey & resus"itation
'. Se"on$ary Survey (ea$ to toe eva)uation & istory
*. A$%un"ts to se"on$ary survey
+. Continue$ post,resus"itation monitoring & re,eva)uation
-. Deinite "are.
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1. PREPARATION
A Pre-hospital phase Receiving hospital is notified first.
Send to the closest, appropriate facility.
B In Hospital Phase
Advanced planning for the trauma pt arrival.
Method to summon extra medical assistance
ransfer agreement !ith verified trauma center esta"lished.
Protect from communica"le disease.
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2. TRIAGE
A Multiple #asualties
no of severity $ pt do not exceed the a"ility of
the facility.B Mass #asualties
no $ severity of pt %%%' the capa"ility of
the facility $ staff.
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3. PRIAR! S"R#E!
A $Air!ay !ith cervical spine protect.
B $(reathing
% $ #irculation --control external "leeding.
& $'isa"ility or neurological status
E $%xposure )undress* $ Environment )temp control*
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PRIMAR+ SR%+Priorities for the care of Adult , Pediatrics$ Pregnancy !omen are all the same.
'uring the primary survey life threateningconditions are identified and management isinstituted SIMA/%0S+.
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A. Air'a( aintenance 'it) %ervica* SpineProtection.
1 2#S score of 3 or less re4uire the placement of definiteair!ay.
1Protection of the spine $ spinal cord is the importantmanagement principle.
1/eurological exam alone does not exclude a cervical spinein5ury.
1Al!ays assume a cervical spine in5ury in any pt !ith multi-system trauma, especially !ith an altered level of consciousness
or "lunt in5ury a"ove the clavicle.
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B. Breat)in+ , #enti*ation1 Air!ay patency does not assure ade4uate ventilation.
%. %ircu*ation 'it) -emorr)a+e %ontro*.
6. (lood olume $ #ardiac 0utput
a. level of consciousness.
". s7in color
c. Pulse.
8. (leeding
1external "leeding is identified $ controlled in the
primary survey.
1ourni4uets should not "e use.
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&. &ia/i*it( 0 Neuro*o+ica* Eva*uation
Simple Mnemonic to descri"e level of consciousnessA 9 Alert
9 Responds to ocal stimuli
P 9 Responds to Painful stimuli
9 nresponsive to all stimuli
/ot forget to use also 2lasco! #oma Scale.
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E. Epoure Environmenta* %ontro*
1It is the pt:s "ody temp that is most important, not hecomfort of the health care provider.
1Intravenous fluid should "e !arm.
1;arm environment )room tem* should "e maintained.
1early control of hemorrhage.
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4. RES"S%ITATIONA. Air'a(
1definite air!ay if there is any dou"t a"out the pt:s a"ility tomaintain air!ay integrity.
B. Breat)in+ #enti*ationO(+enation
1every in5ured pt should received supplement oxygen
%. %ircu*ation
1control "leeding "y direct pressure or operative intervention
1 minimum of t!o large cali"er I should "e esta"lished
1pregnancy test for all female of child "earing age.
1 actated Ringer is preferred $ "etter if !arm.
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5. A&6"N%T TO PRIAR! S"R#E! ,
RES"S%ITATION
A. E*ectro7cardio+rap)ic onitorin+ B. "rinar( , Gatric %at)eter
6. rinary catheter.
rethral in5ury should "e suspected if
1(lood at the penile meatus
1Perineal ecchymosis
1(lood in the scrotum
1High riding or nonpalpa"le prostate 1Pelvic fracture
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%. onitorin+
6. entilatory rate $ A(2
8. Pulse oximetry
does not measure ventilation or partial 08 pressure
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: SE%ON&AR! S"R#E!
'oes not "egin until the primary survey )A(#'%s* is completed, resuscitative effort are !ell esta"lished
$ the pt is demonstrating normali=ation of vital sign.
1 Head to oe evaluation $ reassessment of all vital
signs.
1 A complete neurological exam is performed including
a 2#S score.
1 Special procedure is order.
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History
A 9 Allergies.
M 9 edication currently used.
P 9 Past illness>Pregnancy.
9 Last Meal
% 9 Events>Environment related to the in5ury.
1"lunt trauma>penetrating trauma>in5uries due
to cold $ "urn>ha=ardous environment?
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PH+SI#A %&AMI/AI0/
1. -ead isual acuity
Pupillary si=e
Hemorrhage of con5unctiva and fundi
Penetrating in5ury
#ontact lenses)remove "efore edema occurs*
'islocation of lens
0cular movement
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2. ai**ofacia* In;ur(
no /2 tu"e, definite air!ay?
3. %ervica* Spine , Nec7g>hr
Pediatric urine output 6mg>7g>hr
1Pain relief -- IM should "e avoid.
?. &E@INITE %ARE
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Indication @or &efinite Air'a(1 nconscious
1 Severe maxillo-facial fracture
1 Ris7 for aspiration 9 (leeding> vomiting
1 Ris7 for o"struction 9 nec7 hematoma>laryngeal,tracheal
in5ury> stridor1 Apnea 9 /euromuscular paralysis>unconscious
1 Inade4uate respiratory effort9 tachypnea>hypoxia>hypercapnia>cyanosis
1 Severe closed head in5ury need for hyperventilation
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Norma* B*ood Amount$
/ormal adult "lood volume 9 BC of "ody !eight/ormal "lood volume for child 9 3-DC of "ody !eight
-emorr)a+e %*aification $
#lass I Hemorrhage 9 up to 6C loss#lass II Hemorrhage 9 6-
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3 for 1 Ru*e
a rough guideline for the total amount ofcrystalloid volume acutely is to replace each
Mof "lood loss !ith < Mof crystalloidfluid, thus allo!ing for restitution of plasmavolume lost into the interstitial $intracellular space
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Initia* @*uid T)erap(
actated Ringer is preferred
1 Gor adult 6-8 liters "olus 1 Gor child 8@ml>7g "olus
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Intraoeou PunctureInfuion
#hildren less than y>o for I access isimpossi"le due to circulatory collapse or
for !hom percutaneous peripheral venouscannulation had failed on t!o attempt.
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Head In5ury #lassification9
Mild 9 2#S 6E-6
Moderate 9 2#S D-6< Severe 9 2#S
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&ia+notic Peritonea* Lava+e Indication
A. #hange in sensorium--Head in5ury>alcohol>drug.
(. #hange in sensation--Spinal cord in5ury.
#. In5ury to ad5acent structure--lo!er
ri"s>pelvic>lum"ar spine.
'. %4uivocal physical examination.
%. Prolong loss of contact !ith patient anticipated.
111 Poitive Tet$ F6@@,@@@ R(#>mmmm
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&eterminin+ t)e *eve* of uadrip*e+ia
a. Raise el"o! to level of shoulder -- 'eltoid #
". Glexes the forearm -- (iceps #
c. %xtend the forearm -- riceps #B
d. Glexes !rist $ finger -- #3
e. Spread finger -- 6
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&etermine t)e *eve* of parap*e+ia
a. Glexes the hip -- Iliopsoas 8
". %xtend 7nee -- Juadriceps