Professional Documents
Culture Documents
ATLS:
Based on primary survey that means:
• simultaneous diagnostic and therapeutic activities intended to
identify and treat life and limb-threatening injuries, beginning with
the most immediate.
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• continue
• If establishment of a secure airway and adequate
ventilation require a surgical procedure such as a
tracheostomy, tube thoracostomy, or open thoracotomy,
this procedure must be precede.
• 20
Indication of endotracheal intubation:
• Cardiac or respiratory arrest
• Respiratory insufficiency
• Airway protection
• The need for deep sedation or analgesia, general anesthesia
• Transient hyperventilation of patients with space occupying
intracranial lesions and evidence of increased intracranial
pressure (ICP)·
• Delivery of %100 FIO2 patients with carbon monoxide
poisoning ·
• Facilitation of the diagnostic workup in uncooperative or
intoxicated patients.
Approach to Endotracheal Intubation:
• Appropriate equipment:
oxygen source,
bag-valve-mask ventilating system,
mechanical ventilator,
suction, selection of laryngoscope blades,
endotracheal tubes,
devices for managing difficult intubations
• Neuromuscular usage???
• Although concern may exist that the use of
neuromuscular blocking drugs and potent induction
anesthetics outside the OR will be associated with a
higher complication rate, the opposite is in fact more
likely correct.
• Indirect larengoscope
Personel:
• Three providers are required to ventilate the patient,
hold Cricoid pressure, and provide in-line cervical
stabilization; a fourth provider to administer anesthetic
medications
• Additional assistance may be required to restrain a
patient who is combative as a result of intoxication or
TBl.
• The immediate presence of a surgeon or other physician
Who can perform a cricothyroidotomy is desirable.
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• Trans tracheal jet ventilation:
• through a Percutaneous catheter attached to a high-pressure
fresh gas source
• After initial successful placement the catheter may kink or pull out
of the trachea with motion of the patient's head or neck.
• reserved for only the most urgent situations and should be closely
followed by open cricothyroidotomy
Oral versus nasal intubation:
oral intubation is preferred over nasal intubation in the emergency
setting because of the risk of direct brain trauma from nasal
instrumentation in a patient with a basal skull or cribriform plate
fracture
• 50
• continue
• These compounds cause direct damage to the cell, as well as form
the bulk of the toxic load that will be washed back to the central
circulation when flow is reestablished.
• Shock in the elderly may therefore be rapidly progressive and may not
respond predictably to fluid administration.
Continue
• Accumulation of immune complex and cellular factors in
pulmonary capillaries leads to neutrophils and platelet
aggregation, increased capillary permeability, destruction
of lung architecture, and respiratory distress syndrome.
• Intestinal cell death causes a breakdown the barrier function of the gut that
results in increased translocation of bacteria to the liver and lung, thereby
potentiate ARDS.
• The liver has a complex microcirculation and has been demonstrated to suffer
reperfusion injury during recovery from shock.
• 61
• Early resuscitation:
• This vicious cycle has been recognized since the First World War and remains
a complication of resuscitation therapy today.
Deliberate hypotensive
• Application of this technique to the initial management of
a hemorrhaging trauma victims highly controversial and
has been the focus of numerous laboratory and clinical
research efforts.
• A large body of laboratory data have shown the benefits of
limiting fluid administration to actively hemorrhaging animals
• HS will draw fluid into the vascular space from the interstitium,
HS a popular choice for fluid resuscitation
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Continuous
• Recognition of dilutional effects of fluid administration and
continued improvement in the safety of donated blood have led to
•
• Eleven variables were significantly different: aortic clamping for
control of BP, use of inotropic drugs, time with systolic BP less
than 90 mm Hg, time in the OR, temperature lower than 34°C, urine
output, pH less than 7.0, Pao2/Flo2 ratio less than 150, Paco2
higher than 50 mm Hg, potassium greater than 6 mM/L, and
calcium less than 2 mM/L
Continuous
Of these variables, the presence of the first three in the face of
transfusion of more than 30 U of PRBCs was invariably fatal.
Total blood loss and the amount of transfused blood were less
critical than the depth and duration of shock.
A unit of RBCs :
• will predictably restore oxygen-carrying capacity
• expand intravascular volume as well as any colloid solution will.
• cross matching is desirable when time allows
• Type O blood the "universal donor“ can be given to patients of
any blood type with little risk of a major reaction
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• Continuous:
• the subclavian vein is the most common site for early and ongoing
central access in trauma patients because the subclavian region is
easily visible and seldom difficulty traumatized.
• Risk of Pneumothorax
• Arterial line
• Hypothermia:
• traditional vital sign markers such as BP, heart rate, and urine
output have been shown to be insensitive to the adequacy of
resuscitation.
Occult hypoperfusion syndrome
• is common in postoperative trauma patients, particularly young ones
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• Invasive monitoring change to noninvasive approaches that assess
of adequate metabolism,respiration, and oxygen transport in
peripheral tissue beds.