Advanced Trauma Life Support

Patrick Cheah, MD Li-Shin Hospital Emergency Department

1. Preparation

2. Triage
3. Primary Survey (ABCDEs) 4. Resuscitation 5. Adjuncts to primary survey & resuscitation 6. Secondary Survey (head to toe evaluation & history) 7. Adjuncts to secondary survey 8. Continued post-resuscitation monitoring & re-evaluation

9. Definite care.
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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

Transfer agreement with verified trauma center established. Protect from communicable disease.
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2. TRIAGE
A Multiple Casualties no of severity & pt do not exceed the ability of the facility. B Mass Casualties

no & severity of pt EXCEED the capability of the facility & staff.

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3. PRIMARY SURVEY
A : Airway with cervical spine protect.
B : Breathing

C : Circulation --control external bleeding.

D : Disability or neurological status E : Exposure (undress) & Environment (temp control)
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PRIMARY SURVEY
Priorities for the care of Adult , Pediatrics & Pregnancy women are all the same. During the primary survey life threatening conditions are identified and management is instituted SIMULTANEOUSLY.

A. Airway Maintenance with Cervical Spine Protection.

* GCS score of 8 or less require the placement of definite airway. *Protection of the spine & spinal cord is the important management principle.

*Neurological exam alone does not exclude a cervical spine injury.

*Always assume a cervical spine injury in any pt with multisystem trauma, especially with an altered level of consciousness or blunt injury above the clavicle.
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B. Breathing & Ventilation

* Airway patency does not assure adequate ventilation.

C. Circulation with Hemorrhage Control.

1. Blood Volume & Cardiac Output
a. level of consciousness. b. skin color

c. Pulse.
2. Bleeding *external bleeding is identified & controlled in the primary survey. *Tourniquets should not be use.
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D. Disability ( Neurological Evaluation)

Simple Mnemonic to describe level of consciousness A : Alert V : Responds to Vocal stimuli P : Responds to Painful stimuli

U : Unresponsive to all stimuli

Not forget to use also Glascow Coma Scale.

E. Exposure / Environmental Control

*It is the pts body temp that is most important, not he comfort of the health care provider. *Intravenous fluid should be warm. *Warm environment (room tem) should be maintained. *early control of hemorrhage.

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4. RESUSCITATION
A. Airway
*definite airway if there is any doubt about the pts ability to maintain airway integrity.

B. Breathing /Ventilation/Oxygenation
*every injured pt should received supplement oxygen

C. Circulation
*control bleeding by direct pressure or operative intervention * minimum of two large caliber IV should be established *pregnancy test for all female of child bearing age. * Lactated Ringer is preferred & better if warm.
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5. ADJUNCT TO PRIMARY SURVEY & RESUSCITATION

A. Electro-cardiographic Monitoring

B. Urinary & Gastric Catheter

1. Urinary catheter. Urethral injury should be suspected if

*Blood at the penile meatus

*Perineal ecchymosis *Blood in the scrotum

*High riding or nonpalpable prostate

*Pelvic fracture
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C. Monitoring
1. Ventilatory rate & ABG 2. Pulse oximetry does not measure ventilation or partial O2 pressure 3. Blood pressure poor measure of actual tissue perfusion.

D. X-Ray & Diagnostic Studies

C-spine, CXR, Pelvic film
Essential x-ray should not be avoid in pregnant pt.

*** Consider the need for patient transfer.

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6 SECONDARY SURVEY
Does not begin until the primary survey (ABCDEs) is completed, resuscitative effort are well established & the pt is demonstrating normalization of vital sign. * Head to Toe evaluation & reassessment of all vital

signs.
* A complete neurological exam is performed including a GCS score.

* Special procedure is order.

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History
A : Allergies.

M : Medication currently used.

P : Past illness/ Pregnancy. L : Last Meal E : Events/Environment related to the injury. *blunt trauma/penetrating trauma/injuries due to cold & burn/hazardous environment?
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PHYSICAL EXAMINATION
1. Head

Visual acuity
Pupillary size Hemorrhage of conjunctiva and fundi

Penetrating injury
Contact lenses(remove before edema occurs) Dislocation of lens Ocular movement
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2. Maxillofacial Injury no NG tube, definite airway?

3. Cervical Spine & Neck

*Pt with maxillofacial or head trauma should be presumed to have and unstable cervical spine.

4. Chest
*elderly pt are not tolerant of even relatively minor chest injury.

*Children often sustain significant injury to the intrathoracic structure without evidence of thoracic skeletal trauma.
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5. Abdomen *excessive manipulation of the pelvic should be avoided. 6. Perineum/rectum/vagina 7. Musculoskeletal 8. Neurologic

* Protection of spinal cord is required at all times until a spine injury excluded, especially when the pt is transfer.

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7. ADJUNCT TO THE SECONDARY SURVEY

include additional x-ray and all other special procedure.

8. RE-EVALUATION
Adult urine output 0.5ml/kg/hr Pediatric urine output 1mg/kg/hr *Pain relief -- IM should be avoid.

9. DEFINITE CARE

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Indication For Definite Airway

* Unconscious

* Severe maxillo-facial fracture

* Risk for aspiration : Bleeding/ vomiting * Risk for obstruction : neck hematoma/laryngeal,tracheal injury/ stridor * Apnea : Neuromuscular paralysis/unconscious * Inadequate respiratory effort: tachypnea/hypoxia/hypercapnia/cyanosis * Severe closed head injury need for hyperventilation
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Normal Blood Amount:

Normal adult blood volume : 7% of body weight

Normal blood volume for child : 8-9% of body weight

Hemorrhage Classification :
Class I Hemorrhage : Class II Hemorrhage : Class III Hemorrhage : up to 15% loss 15-30% loss 30-40% loss

Class IV Hemorrhage :

>40% loss

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3 for 1 Rule
a rough guideline for the total amount of crystalloid volume acutely is to replace each ML of blood loss with 3 ML of crystalloid fluid, thus allowing for restitution of plasma volume lost into the interstitial & intracellular space

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Initial Fluid Therapy

Lactated Ringer is preferred

* For adult 1-2 liters bolus * For child 20ml/kg bolus

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Intraosseous Puncture/Infusion
Children less than 6 y/o for IV access is impossible due to circulatory collapse or for whom percutaneous peripheral venous cannulation had failed on two attempt.

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Head Injury Classification:

Mild Severe : GCS 14-15 : GCS 3-8

Moderate : GCS 9-13

Coma = GCS score of 8 or less

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Diagnostic Peritoneal Lavage Indication

A. Change in sensorium--Head injury/alcohol/drug. B. Change in sensation--Spinal cord injury. C. Injury to adjacent structure(indicating abd injury)--lower ribs/pelvic/lumbar spine.

D. Equivocal physical examination.

E. Prolong loss of contact with patient anticipated. *** Positive Test: >100,000 RBC/mm3, >500 WBC/mm3 or Gram Stain with bacteria
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Determining the level of quadriplegia

a. Raise elbow to level of shoulder -- Deltoid C5 b. Flexes the forearm -- Biceps C6

c. Extend the forearm -- Triceps C7

d. Flexes wrist & finger -- C8

e. Spread finger -- T1

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Determine the level of paraplegia

a. Flexes the hip -- Iliopsoas L2 b. Extend knee -- Quadriceps L3 c. Dorsiflexes ankle -- Tibialis anterior L4 d. Plantar flexes ankle -- Gastrocnemius S1

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Thoracic Trauma
8 lethal Injury 1. Simple pneumothorax

2. Hemothorax
3. Pulmonary contusion 4. Tracheo-bronchial tree injury 5. Blunt cardiac injury 6. Traumatic aortic disruption

7. Traumatic diaphragmatic injury

8. Mediastinal traversing wounds.
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Fluid Therapy in 2nd or 3rd Degree Burn

Total amount of first 24 hours:

4 ml of Ringer lactate x BW(kg) x BSA

* give 1/2 in first 8 hrs * 1/2 in remaining 16 hrs

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Referral to Burn Center

* 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y/o

* 2nd or 3rd degree burn > 20% BSA in other age group
* 2nd or 3rd degree burn of face/eye/ear/hands/feet/ genitalia/perineum or major joints

* 3rd degree burn >5% in any age group

* Significant electrical/lightning injury * Significant chemical burn

* Inhalation injury
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Color Codes Triage Tag

RED : Most critical injury YELLOW : Less critical injured

GREEN : No life or limb threatened injury

BLACK : Death or obviously fatal injury

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Priorities with multiple injuries

1. Thoracic trauma or tamponade

2.
3.

Abdominal hemorrhage
Pelvic Hemorrhage

4.
5. 6.

Extremity Hemorrhage
Intra-cranial Injury Acute Spinal Cord Injury
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