ATLSPaleerat Jariyakanjana, MD

Emergency Physician Naresuan University

13 Dec 2015

outlineInitial Assessment and ManagementSkill station

Cervical collars Needle thoracentesis Chest tube insertion FAST Application of pelvic binder Adult Orotracheal Intubation 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 ventilationCirculation with hemorrhage controlDisabilityExposure/Environmental control

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

asking the patient for his/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 devicesEvaluation and diagnosis of specific

spinal injury, including imaging, should be done later.

Breathing and ventilationneck and chest

jugular venous distention, position of the trachea, and chest wall excursion

Auscultation, visual inspection, palpation, and percussion

Injuries tension pneumothorax flail chest with pulmonary contusion massive hemothorax open pneumothorax

Breathing and ventilation

Tension Pneumothoraxhyperresonant note on percussion,

deviated trachea, and absent breath sounds over the affected hemithorax

Open Pneumothorax (Sucking Chest Wound)≥2/3 of the diameter of the trachea

Breathing and ventilation

Flail Chest and Pulmonary Contusion≥2 adjacent ribs fractured in ≥2

placesparadoxical motion

Massive Hemothorax>1500 mL of blood or ≥1/3 of the

patient’s blood volume 200 mL/hr for 2-4 hours

Breathing and ventilationSimple pneumothorax or

hemothorax, fractured ribs, and pulmonary contusion can compromise ventilation to a lesser

degree usually identified during the secondary survey

Circulation with hemorrhage control

level of consciousnessskin colorpulse

Circulation with hemorrhage control

BleedingExternal/internalExternal hemorrhage

direct manual pressure Tourniquets

• 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

Bleedingmajor areas of internal hemorrhage

chest, abdomen, retroperitoneum, pelvis, and long bones

identified by physical examination and imaging

Management: as cause

Disability (neurologic evaluation)level of consciousnesspupillary size and reactionlateralizing signsspinal cord injury level

Exposure and environmental control

completely undressedKeep warm

Warm blankets or an external warming device Warm intravenous fluids and a warm

environment

Resuscitation

AirwaySuction: rigid

suctionjaw-thrust or

chin-lift maneuver

oropharyngeal airway: unconscious and has no gag reflex

definitive airway

Airway

Breathing, ventilation, and oxygenation

supplemental oxygen: mask-reservoir device ≥11 L/min

Breathing, ventilation, and oxygenation

tension pneumothorax Immediate

decompression ICD

Breathing, ventilation, and oxygenation

Open pneumothorax occlusive dressing ICD

Breathing, ventilation, and oxygenation

Massive hemothorax ICD

Flail Chest and Pulmonary Contusion adequate oxygenation administer fluids judiciously provide analgesia

Circulation and hemorrhage control

2 large-caliber (minimum of 16G in an adult) IV catheters, upper-extremity peripheral IV access

Warmed crystalloids, bolus of 1-2 L of isotonic solution

unresponsive to initial crystalloid therapy: blood transfusion

Circulation and hemorrhage control

baseline hematologic studies + G/MUPTBlood gases a/o lactate level: assess

shock

Adjuncts to primary survey and resuscitation

Electrocardiographic monitoringurinary and gastric cathetersother monitoring

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

x-ray examinations

URINARY AND GASTRIC CATHETERS

Urinary CathetersC/I: urethral injury

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

Gastric CathetersC/I: cribriform plate fracture

X-RAY EXAMINATIONS ANDDIAGNOSTIC STUDIES

AP chestAP pelvisFAST/DPL

Consider Need for Patient Transfer

Diagnosisconsult

Secondary Survey

complete history and physical examination

head-to-toe evaluation

HistoryAllergiesMedications currently usedPast illnesses/PregnancyLast mealEvents/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 diagnostic procedures

Reevaluation

Continuous monitoring of vital signs and urinary output

relief of severe painTetanus toxoid, antibiotic

Skill station

Cervical collarsmaintains cervical immobilizationmeasures the pt for proper size

selection bottom of mandible - top of clavicle Measure the same distance on the

premarked cervical collar Select the appropriate size or adjust the

collarApply the cervical collar

Cervical collars

http://www.rch.org.au/clinicalguide/guideline_index/Cervical_Spine_Injury/

Needle Thoracentesis2th ICS, midclavicular lineover-the-needle catheter (minimum

16G, 2 in. [5 cm] long)Prepare for a chest tube insertion.

Chest Tube Insertionnipple level (5th ICS), just anterior to

the midaxillary line2-3 cm transverse (horizontal)

incisionbluntly dissect through the

subcutaneous tissues, just over the top of the rib

Puncture the parietal pleura with the tip of a clamp

Digital assessment

Chest Tube InsertionClamp the proximal end of the

thoracostomy tube (36/40 Fr) and advance it into the pleural space

directed posteriorly, medially, and superiorly

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.

Chest Tube InsertionSuture 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-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-9th rib space

splenorenal fossa

Focused Assessment Sonography in Trauma (FAST)

suprapubic view transverse view optimally obtained prior to

placement of a Foley catheter

Focused Assessment Sonography in Trauma (FAST)

Focused Assessment Sonography in Trauma (FAST)

Focused Assessment Sonography in Trauma (FAST)

Focused Assessment Sonography in Trauma (FAST)

Focused Assessment Sonography in Trauma (FAST)

Focused Assessment Sonography in Trauma (FAST)

Focused Assessment Sonography in Trauma (FAST)

Techniques to reduce blood lossfrom pelvic fractures

Internally rotate the lower legsApply a pelvic binder

Techniques to reduce blood lossfrom pelvic fractures

Adult Orotracheal IntubationDirect 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

Adult Orotracheal Intubation

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

Principles of Spine Immobilization and Logrolling

Principles of Spine Immobilization and Logrolling

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

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

Principles of Spine Immobilization and Logrolling

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

Take home messagePrimary survey (ABCDEs)ResuscitationAdjuncts to primary survey and

resuscitationConsideration of the need for patient

transfer

ReferenceATLS 9th Student ManualEMS -- A Practical Global Guidebook

by Tintinalli, Cameron, and Holliman

Any questions?