Advanced Trauma Life SupportSushil Paudel , MDConsultant Orthopedics
Polytrauma Prime most on nationalagenda world overInvolves diversespecialists andprocedures
PolytraumaManagement startsROADSIDEEmphasis on QUICKDIAGNOSIS AND RAPIDINTERVENTION
Management at site ofaccident : Access trapped & buried Do not Pull or TwistPriority Freeing head, neck &trunk by clea...
Transport Severely injured Move patient on stretcher Three people ideallyrequired Transfer like one piece oflog
Emergency Roommanagement : TAILORED RAPID ACTIVE URGENT METHODICAL AUTHORITATIVE
Death from trauma : trimodoldistribution The first peak of death- sec-min Cause: Aortic Rupture The second peak of death...
Establishing assessment andmanagementVital functionsRapid primary evolution ResuscitationSecondary assessmentDefiniti...
Primary SurveyA- airwayB- breathingC- circulationD-DisabilityE- exposure
Resuscitation phaseShock management,patient oxygenation andhemorrhage controlReplacement of fluidUrinary and nasogastri...
Secondary survey Head-to-toe evaluation Look, listen and feel Examine each region Neurological examination X-ray of c...
Definitive care phaseAll injuries managedComprehensivemanagement, fracturestabilization operativeintervention andtransfer
TriageSorting of patients based on need for treatmentTwo typeNo. of patients and severity of their injuries do notexcee...
Priority plan- treatment andmanagementA.Primary surveyAirway and cervical spine Assessment Management- patentairway Ch...
Airway managementAirway obstruction“Look”Agitation.Poor air movementRib retractionForeign material
“Listen” Speech Hoarseness. Noisy breathing Stridor“Feel” Airway structure in neck Tracheal deviation Hemorrhage
Abnormal Breathing• “ Look”Cyanosis Mental StateChest asymmetryTachyponeaParalysis
• “Listen” Can’t breath Stridor, wheezing Breath sound• “Feel” Surgical emphysema Chest tenderness
Treatment Clear secretion, Debris Pull jaw foreword Oral airway Nasopharangeal airway Endotracheal airway Procedure
Definitive airway“Cuffed tube in the trachea.IndicationsA- Airway- obstructed gag reflex.B- Breathing- O2 Saturation < 90%...
When to ventilate.Apnoea Hypoventilation Flail chest Spiral cord injury Glasgow come score < 9
Surgical airway Inability to intubate Neck injury Maxilo facial injury Needlecricothyroiodectomy Tracheostomy.
Assume a cervical spine injury in anypatient with Polytrauma who has- Altered level of consciousness.- Blunt or penetratin...
Protecting the cervical spine Aim to prevent damage ortransection of the spinal cord incase patient has a fracture orunst...
Protecting the cervical spine
Protecting the cervical spine
Breathing control life-threatening chestinjuries, and treatmentshould be expeditedimmediately: sucking chest wound tens...
Management of a Tension Pneumothorax Insert a large-bore intravenouscannula into secondintercostal space inmidclavicular ...
Circulation and Hemorrhage controlAssessment State of consciousness Pulse Color of skin Capillary blanch test Identit...
SHOCK“Principle problem is pooroxygen delivery.”Shock should berecognized before B.P.figure is available. Cool, pale ski...
After recognition of shock Initiate 2 I/V catheter Blood for examination Initiate ringer lactate and bloodreplacement ...
Difficult venous access If access cannot be gained within5 minutes and patient is shocked,then further measures should be...
Disability- brief neurologicalLevel of consciousnessusing AVPU methodA-alertV-Responds to vocalstimuliP-Responds topai...
GCS
Exposure Patient should be fullyexposed in the ATLS setting. Clothes should be cut off, ifnecessary. Every orifice, i.e...
Secondary Survey Head and face AssessmentInspectionRe-evaluate pupilsPalpationCranial nerve function ManagementMai...
Cervical spine/neckAssessmentInspectionAuscultationPalpationLateral, cross table cervical x-rayManagementInline imm...
ChestAssessmentInspectionPercussionAuscultationPalpationManagementPleural decompressionThoracocentesisPericardioc...
AbdomenAssessmentInspectionPercussionAuscultationPalpationManagementPeritoneal lavagePneumatic antishockgarment
Perineal and rectalEvaluate forAnal sphincter toneRectal bloodBowel well integrityProstate positionBlood on urinary m...
BackEvaluate forBony of deformityEvidence of penetrating/ blunt trauma
HePriorities Unstable StableHighest 1. Dislocations2. Vascular injuries requiring repair3. Open fracture4. Unstable pelvic...
ExtremitiesAssessment Inspection-contusion/deformity Palpation – tenderness/crepitationManagement Splinting for fract...
Neurological EvaluationAssessmentSensorimotorevaluationParalysisParesisManagementImmobilization ofentire patient
Definitive careInter hospital triagecriteria help determinethe level, pace andintensity of initialmanagementOutline rati...
Re-evaluate the patientRe-evaluatecontinuously – newsign/symptomsMonitor vitals sign andurinary output
Records and legal considerationRecordsRecord keepingReportingchronologicallyConsent for treatmentConsentIn life-thre...
Thank you
Polytrauma sushil
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Polytrauma sushil

Published on: Mar 4, 2016
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Transcripts - Polytrauma sushil

  • 1. Advanced Trauma Life SupportSushil Paudel , MDConsultant Orthopedics
  • 2. Polytrauma Prime most on nationalagenda world overInvolves diversespecialists andprocedures
  • 3. PolytraumaManagement startsROADSIDEEmphasis on QUICKDIAGNOSIS AND RAPIDINTERVENTION
  • 4. Management at site ofaccident : Access trapped & buried Do not Pull or TwistPriority Freeing head, neck &trunk by clearingdepressGently move out patient
  • 5. Transport Severely injured Move patient on stretcher Three people ideallyrequired Transfer like one piece oflog
  • 6. Emergency Roommanagement : TAILORED RAPID ACTIVE URGENT METHODICAL AUTHORITATIVE
  • 7. Death from trauma : trimodoldistribution The first peak of death- sec-min Cause: Aortic Rupture The second peak of death –min-hr This is the Goldenhour on which ATLS focuses The third peak of death –days-wks Causes: Sepsis,SIRS
  • 8. Establishing assessment andmanagementVital functionsRapid primary evolution ResuscitationSecondary assessmentDefinitive care
  • 9. Primary SurveyA- airwayB- breathingC- circulationD-DisabilityE- exposure
  • 10. Resuscitation phaseShock management,patient oxygenation andhemorrhage controlReplacement of fluidUrinary and nasogastriccatheter inserted
  • 11. Secondary survey Head-to-toe evaluation Look, listen and feel Examine each region Neurological examination X-ray of chest and cervicalspine Tubes and fingers in everyorifice
  • 12. Definitive care phaseAll injuries managedComprehensivemanagement, fracturestabilization operativeintervention andtransfer
  • 13. TriageSorting of patients based on need for treatmentTwo typeNo. of patients and severity of their injuries do notexceed ability of the facility. Here patient with lifethreatening problems and there sustaining multiplesystem are treated firstNo. of patients and severity of their injuries exceedcapability of the facility and staff. Here patients withthe greatest chance of survival with the leastexpenditure of time, equipment supplies andpersonnel are managed first
  • 14. Priority plan- treatment andmanagementA.Primary surveyAirway and cervical spine Assessment Management- patentairway Chin lift or jaw thrust Clear foreign bodies Oropharyngeal airway Orotracheal/ nasotrachealintubation Cricothyroidotomy Cervical spine in a neutralposition
  • 15. Airway managementAirway obstruction“Look”Agitation.Poor air movementRib retractionForeign material
  • 16. “Listen” Speech Hoarseness. Noisy breathing Stridor“Feel” Airway structure in neck Tracheal deviation Hemorrhage
  • 17. Abnormal Breathing• “ Look”Cyanosis Mental StateChest asymmetryTachyponeaParalysis
  • 18. • “Listen” Can’t breath Stridor, wheezing Breath sound• “Feel” Surgical emphysema Chest tenderness
  • 19. Treatment Clear secretion, Debris Pull jaw foreword Oral airway Nasopharangeal airway Endotracheal airway Procedure
  • 20. Definitive airway“Cuffed tube in the trachea.IndicationsA- Airway- obstructed gag reflex.B- Breathing- O2 Saturation < 90%.C- Circulation systolic BP <75mm.D- DisabilityGlasgow coma scale score < 8E- Environmenthypothermia (core temp <330C)
  • 21. When to ventilate.Apnoea Hypoventilation Flail chest Spiral cord injury Glasgow come score < 9
  • 22. Surgical airway Inability to intubate Neck injury Maxilo facial injury Needlecricothyroiodectomy Tracheostomy.
  • 23. Assume a cervical spine injury in anypatient with Polytrauma who has- Altered level of consciousness.- Blunt or penetrating injury above thelevel of clavicles.
  • 24. Protecting the cervical spine Aim to prevent damage ortransection of the spinal cord incase patient has a fracture orunstable dislocation of cervicalspine One member of team holds headin the line of the body Another member applies a well-fitting hard collar and immobilisesthe head by placing sandbags oneither side of the head Sticky-tape is passed from oneside of the bed across theforehead to the opposite side ofbed to further reduce movementof the head and neck
  • 25. Protecting the cervical spine
  • 26. Protecting the cervical spine
  • 27. Breathing control life-threatening chestinjuries, and treatmentshould be expeditedimmediately: sucking chest wound tensionpneumothorax/Hemothorax large flail segment cardiac tamponade Management High conc. of oxygen Alleviate tensionpneumothorax Seal open pneumothorax
  • 28. Management of a Tension Pneumothorax Insert a large-bore intravenouscannula into secondintercostal space inmidclavicular line on affectedside If there is a sudden release ofair, the diagnosis is confirmedand should be followedimmediately by an intercostalchest drain in the fifthintercostal space in themidaxillary line If the diagnosis is in doubt,order a chest x-ray andproceed with the chest drain ifconfirmatory
  • 29. Circulation and Hemorrhage controlAssessment State of consciousness Pulse Color of skin Capillary blanch test Identity exsanguinatinghemorrhage
  • 30. SHOCK“Principle problem is pooroxygen delivery.”Shock should berecognized before B.P.figure is available. Cool, pale skin, sweatingperipheries (Poor bloodflow in skin) Anxiety, confusion &restlessness (Poor bloodflow in brain) Oliguria aftercatheterization( Poor blood flow in kidneys)
  • 31. After recognition of shock Initiate 2 I/V catheter Blood for examination Initiate ringer lactate and bloodreplacement Pneumatic antishock garment E.C.G. monitor Urinary and nasogastric catheter Restore oxygen delivery Immediate intervention Stop external bleeding by localpressure For extremity bleeding compressionbandage Elevate with traction
  • 32. Difficult venous access If access cannot be gained within5 minutes and patient is shocked,then further measures should betaken until access is gained Sites for cannulation include: Cut-down in the antecubital fossa -safest, most effective site Cut-down to the long saphenousvein in the groin, rather than at theankle, as intense vasospasm mayprevent infusion Percutaneous cannulation of thefemoral vein - using the Seldingertechnique Percutaneous cannulation of neckveins using Seldinger technique Intra-osseous infusion in a severelyill child
  • 33. Disability- brief neurologicalLevel of consciousnessusing AVPU methodA-alertV-Responds to vocalstimuliP-Responds topainful stimuliU-UnresponsiveThe pupils for size,equality and reactionGlasgow coma scale
  • 34. GCS
  • 35. Exposure Patient should be fullyexposed in the ATLS setting. Clothes should be cut off, ifnecessary. Every orifice, i.e. ear, eye,nostril, mouth, etc. should belooked at All limbs palpated for fracturesso that nothing is missed Also, one should not forget toperform a log roll and look atthe back
  • 36. Secondary Survey Head and face AssessmentInspectionRe-evaluate pupilsPalpationCranial nerve function ManagementMaintain airwayHemorrhage control
  • 37. Cervical spine/neckAssessmentInspectionAuscultationPalpationLateral, cross table cervical x-rayManagementInline immobilization of the cervicalspine
  • 38. ChestAssessmentInspectionPercussionAuscultationPalpationManagementPleural decompressionThoracocentesisPericardiocentesisChest X-ray
  • 39. AbdomenAssessmentInspectionPercussionAuscultationPalpationManagementPeritoneal lavagePneumatic antishockgarment
  • 40. Perineal and rectalEvaluate forAnal sphincter toneRectal bloodBowel well integrityProstate positionBlood on urinary meat usScrotol hemotoma
  • 41. BackEvaluate forBony of deformityEvidence of penetrating/ blunt trauma
  • 42. HePriorities Unstable StableHighest 1. Dislocations2. Vascular injuries requiring repair3. Open fracture4. Unstable pelvic ring fracture5. Femur fracture6. Unstable spinal fracture7. Other wounds .8. Unstable spinal fracturesLowest 9. Intraarticular fractures10. Other long bone injuries11.Deep hand injuriesMusculoskeletal Injury
  • 43. ExtremitiesAssessment Inspection-contusion/deformity Palpation – tenderness/crepitationManagement Splinting for fractures Pneumatic antishockgarment Relief of pain Tetanus injection
  • 44. Neurological EvaluationAssessmentSensorimotorevaluationParalysisParesisManagementImmobilization ofentire patient
  • 45. Definitive careInter hospital triagecriteria help determinethe level, pace andintensity of initialmanagementOutline rationale forpatient transfer
  • 46. Re-evaluate the patientRe-evaluatecontinuously – newsign/symptomsMonitor vitals sign andurinary output
  • 47. Records and legal considerationRecordsRecord keepingReportingchronologicallyConsent for treatmentConsentIn life-threateningemergencies- treatmentfirstForensic evidenceOvercoming poverty is not a task of charity, it is an act of justice
  • 48. Thank you

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