ATLS

Paleerat Jariyakanjana, MD

Emergency Physician, Naresuan University

outline

Initial Assessmentand Management Skill station

Adult Orotracheal Intubation Cervical collars Application of pelvic binder Needle thoracentesis Chest tube insertion FAST Principle of spine immobilization and logrolling

INITIAL ASSESSMENTAND MANAGEMENT

Initial assessment

Preparation Triage Primary survey (ABCDEs) Resuscitation Adjuncts to primary survey and resuscitation Consideration of the need for patient transfer Secondary survey (head-to-toe evaluation and patient

history) Adjuncts to the secondary survey Continued postresuscitation monitoring and reevaluation Definitive care

PRIMARY SURVEY

Airway maintenance with cervical spine protection Breathing and ventilation Circulation with hemorrhage control Disability Exposure/Environmental control

What is a quick, simple way to assess apatient in 10 seconds?

asking the patient for his or her name, and asking what happened no major airway compromise (ability to speak clearly) breathing is not severely compromised (ability to generate

air movement to permit speech) no major decrease in level of consciousness (alert enough

to describe what happened)

Airway maintenance with cervical spine protection

able to communicate verbally patent signs of airway obstruction

Secretion or blood per mouth/nose Stridor inspection for foreign bodies facial, mandibular, or tracheal/laryngeal fractures severe head injuries definitive airway

Airway maintenance with cervical spine protection

traumatic incident loss of stability of the cervical spine should be assumed protection of the patient’s spinal cord with appropriate

immobilization devices Evaluation and diagnosis of specific spinal injury,

including imaging, should be done later.

Breathing and ventilation

neck and chest assess jugular venous distention, position of the trachea,

and chest wall excursion Auscultation, Visual inspection and palpation,

Percussion Injuries

tension pneumothorax, flail chest with pulmonary contusion, massive hemothorax, and open pneumothorax

Simple pneumothorax or hemothorax, fractured ribs, and pulmonary contusion can compromise ventilation to a lesser degree and are usually identified during the secondary survey.

Circulation with hemorrhage control

The elements of clinical observation that yield important information within seconds are level of consciousness, skin color, and pulse.

Circulation with hemorrhage control

Bleeding external or internal External hemorrhage

direct manual pressure on the wound Tourniquets are

• effective in massive exsanguination• risk of ischemic injury • only be used when direct pressure is not effective

Hemostats: damage to nerves and veins

Circulation with hemorrhage control

Bleeding major areas of internal hemorrhage

chest, abdomen, retroperitoneum, pelvis, and long bones The source of the bleeding is usually identified by

physical examination and imaging (e.g., chest x-ray, pelvic x-ray, or focused assessment sonography in trauma [FAST]).

Management may include chest decompression, pelvic binders, splint application, and surgical intervention.

Disability (neurologic evaluation)

level of consciousness pupillary size and reaction lateralizing signs spinal cord injury level

Exposure and environmental control

completely undressed Keep warm

Warm blankets or an external warming device Warm Intravenous fluids and a warm environment (i.e.,

room temperature)

RESUSCITATION

Airway

Suction: rigid suctionjaw-thrust or chin-lift

maneuveroropharyngeal airway:

unconscious and has no gag reflex

definitive airwayprotection of the

cervical spine

Breathing, ventilation, and oxygenation

supplemental oxygen: mask-reservoir device with a flow rate of at least 11 L/min

tension pneumothorax chest decompression ICD

Open pneumothorax occlusive dressing ICD

Massive hemothorax: ICD

Circulation and hemorrhage control

2 large-caliber IV catheters, upper-extremity peripheral IV access

Warmed crystalloids, bolus of 1-2 L of isotonic solution If the patient is unresponsive to initial crystalloid therapy,

blood transfusion should be given.

baseline hematologic studies + G/M UPT Blood gases and/or lactate level: assess shock

ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION

Electrocardiographic monitoring urinary and gastric catheters other monitoring

ventilatory rate, arterial blood gas (ABG) levels, pulse oximetry, blood pressure

x-ray examinations

URINARY AND GASTRIC CATHETERS

Urinary Catheters C/I in urethral injury

Blood at the urethral meatus Perineal ecchymosis High-riding or nonpalpable prostate

Gastric Catheters C/I: cribriform plate fracture

X-RAY EXAMINATIONS ANDDIAGNOSTIC STUDIES

AP chest AP pelvis FAST/DPL

CONSIDER NEED FOR PATIENT TRANSFER

During the primary survey and resuscitation phase, the evaluating physician frequently obtains enough information to indicate the need to transfer the patient to another facility.

Diagnosis & consult

SECONDARY SURVEY

complete history and physical examination head-to-toe evaluation

History

Allergies Medications currently used Past illnesses/Pregnancy Last meal Events/Environment related to the injury

ADJUNCTS TO THE SECONDARY SURVEY

Specialized diagnostic tests Additional x-ray examinations of the spine and extremities CT scans of the head, chest, abdomen, and spine Contrast urography and angiography transesophageal ultrasound Bronchoscopy Esophagoscopy other diagnosticprocedures

REEVALUATION

Continuous monitoring of vital signs and urinary output relief of severe pain TT, antibiotic

SKILL STATION

Adult Orotracheal Intubation

Direct an assistant to manually immobilize the head and neck.

The patient’s neck must not be hyperextended or hyperflexed during the procedure.

Take off the collar

Cervical collars

maintains cervical immobilization measures the pt for proper size selection

Measure the distance from the bottom of the pt’s mandible to the top of the pt’s clavicle

Measure the same distance on the premarked cervical collar

Select the appropriate size or adjust the collar Apply the cervical collar Ensure that the collar is properly sized and firmly in

position

TECHNIQUES TO REDUCE BLOOD LOSSFROM PELVIC FRACTURES

Internally rotate the lower legs to close an open-book type fracture reduce a displaced symphysis, decrease the pelvic

volume, and serve as a temporary measure until definitive treatment can be provided

Apply a pelvic binder.

Needle Thoracentesis

2th ICS, midclavicular line

over-the-needle catheter (minimum 16 gauge, 2 in. [5 cm] long)

Prepare for a chest tube insertion.

Chest Tube Insertion

nipple level (5th ICS), just anterior to the midaxillary line 2- to 3-cm transverse (horizontal) incision bluntly dissect through the subcutaneous tissues, just

over the top of the rib Puncture the parietal pleura with the tip of a clamp Finger exploration Clamp the proximal end of the thoracostomy tube and

advance it into the pleural space to the desired length. directed posteriorly, medially, and superiorly

Chest Tube Insertion

Look for “fogging” of the chest tube with expiration or listen for air movement.

Connect the end of the thoracostomy tube to an underwater-seal apparatus.

Suture the tube in place. Apply an occlusive dressing and tape the tube to the

chest. Obtain a chest x-ray film.

Focused Assessment Sonography in Trauma (FAST)

Start with the subxiphoid or the parasternal view

Focused Assessment Sonography in Trauma (FAST)

RUQ view sagittal view in the

midaxillary line, at approximately the 10th or 11th rib space

hepatorenal fossa (Morrison’s pouch)

Focused Assessment Sonography in Trauma (FAST)

LUQ view sagittal view in the

midaxillary line, at approximately the 8th or 9th rib space

splenorenal fossa

Focused Assessment Sonography in Trauma (FAST)

suprapubic view transverse view optimally obtained prior to placement of a

Foley catheter

Subxiphoid view

RUQ view

RUQ view

LUQ view

LUQ view

Suprapubic view

Suprapubic view

Principles of Spine Immobilization and Logrolling

4 people 1 person to maintain manual, inline immobilization of the

patient’s head and neck 1 for the torso (including the pelvis and hips) 1 for the pelvis and legs 1 to direct the procedure and move the spine board

Apply gentle, inline manual immobilization to the patient’s head and apply a semirigid cervical collar.

Principles of Spine Immobilization and Logrolling

Principles of Spine Immobilization and Logrolling

cautiously logroll the patient as a unit toward the two assistants at the patient’s side, but only to the least degree necessary to position the board under the patient.

Place the spine board beneath the patient Padding and tape the patient’s head and neck straps

across the patient’s thorax just above the iliac crests across the thighs just above the ankles

used only for transferring the patient

Take home message

Primary survey (ABCDEs) Resuscitation Adjuncts to primary survey and resuscitation Consideration of the need for patient transfer

Reference

ATLS 9th Student Manual EMS -- A Practical Global Guidebook by Tintinalli,

Cameron, and Holliman

ANY QUESTIONS?