advanced trauma life support

1. Advanced Trauma Life
Support
Presented by -
Dr. Sheetal Kapse
Moderator -
Dr. Rajasekhar G.

2. Contents
1. Introduction
2. Initial Assessment and Management
3. Airway and Ventilatory Management
4. Shock
5. Head Trauma
6. Spine and Spinal Cord Trauma
7. Thoracic Trauma
8. Abdominal and Pelvic Trauma
9. Musculoskeletal Trauma
10. Thermal Injuries
11. Paediatric Trauma
12. Geriatric Trauma
13. Transfer to Definitive Care
14. Conclusion
15. References

3. Introduction
• The treatment of seriously injured
patients requires the rapid
assessment of injuries and institution
of life-preserving therapy.
• Because timing is crucial, a
systematic approach that can be
rapidly and accurately applied is
essential. This approach is termed
the “initial assessment” and includes
the following elements:
I. Preparation
II. Triage
III. Primary survey (ABCDEs)
IV. Resuscitation
V. Adjuncts to primary survey and
resuscitation
VI. Consideration of the need for
patient transfer
VII. Secondary survey (head-to-toe
evaluation and patient history)
VIII. Adjuncts to the secondary survey
IX. Continued postresuscitation
monitoring and re-evaluation
X. Definitive care

4. Initial Assessment and Management
A. Preparation
B. Triage
C. Primary Survey
D. Resuscitation
E. Adjuncts to Primary Survey and Resuscitation
F. Consider Need for Patient Transfer
G. Secondary Survey
H. Adjuncts to the Secondary Survey
I. Reevaluation
J. Definitive Care
K. Disaster Records and Legal Considerations

5. Airway and Ventilatory Management
Failure to recognize the need for an airway intervention
Inability to establish an airway
Inability to recognize the need for an alternative airway plan in the setting of
repeated failed intubation attempts
Failure to recognize an incorrectly placed airway
Displacement of a previously established airway
Failure to recognize the need for ventilation
Aspiration of gastric contents

6. Helmet Removal

8. laryngeal mask airway
laryngeal tube airway

10. Intubation through an “Intubating
Laryngeal Mask.” Once the laryngeal mask is
introduced,
a dedicated endotracheal tube is inserted into it,
allowing therefore a “blind” intubation
technique.

11. Insertion of the GEB designed to aid
in difficult intubations.
(A) The GEB is lubricated and directed
posterior to the epiglottis with the tip angled
anteriorly.
(B) It slides under the epiglottis and is
maneuvered in a semiblind or blind fashion
anteriorly into the trachea.
(C) Placement of the GEB into the
trachea may be detected by the palpable
“clicks” as the tip passes over the cartilaginous
rings of the trachea.

12. Needle Cricothyroidotomy. This
procedure is performed by placing a large-
caliber plastic cannula through the
cricothyroid membrane into the trachea
below the level of the obstruction.

13. Needle Cricothyroidotomy
Puncture the skin in the midline
with a12- or 14-gauge needle
attached to a syringe, directly
over the cricothyroid
membrane.
Remove the syringe and withdraw the
stylet, while gently advancing the
catheter downward into position,
taking care not to perforate the
posterior wall of the trachea.

14. Surgical Cricothyroidotomy
(A) Palpate the thyroid notch,
cricothyroid interval, and the
sternal notch for orientation.
(B) Make a transverse skin
incision over the cricothyroid
membrane and carefully incise
through the membrane
transversely.
(C) Insert hemostat or tracheal
spreader into the incision and
rotate it 90 degrees to
open the airway.
(D) Insert a proper-size, cuffed
endotracheal tube or
tracheostomy tube into the
cricothyroid membrane
incision, directing the tube
distally into the
trachea.

16. Shock
• Hemorrhage is the most common cause of shock in the
injured patient.

17. MASSIVE TRANSFUSION
A small subset of patients with shock will
require massive transfusion, most often
defined as >10 units of pRBCs within the first
24 hours of admission.

18. Shock Management
• Peripheral Venous Access
• Femoral Venipuncture: Seldinger Technique
• Subclavian Venipuncture: Infraclavicular Approach
• Internal Jugular Venipuncture: Middle or Central Route
• Intraosseous Puncture/Infusion: Proximal Tibial Route
• Identification and Management of Pelvic Fractures: Application of Pelvic
Binder
• Venous Cutdown

19. Head Trauma

23. CT Scans of Intracranial Hematomas.
(A) Epidural hematoma. (B) Subdural hematoma.
(C) Bilateral contusions with hemorrhage. (D) Right
intraparenchymal hemorrhage with right to left midline
shift. Associated biventricular hemorrhages.

24. Patientisawakeandmaybe
oriented.(GCS13–15)
Algorithm for
Management
of
Minor Brain Injury

25. Algorithm for
Management
of
Moderate
Brain Injury

26. Algorithm
for Initial Management of Severe Brain
Injury

27. Spine and Spinal Cord Trauma
X-Ray Evaluation
• Cervical Spine
• Thoracic and Lumbar Spine
General Management
• Immobilization
• Intravenous Fluids
• Medications
• Transfer

29. Spinal Dermatomes. (A)
Key sensory points by
spinal dermatomes. (B)
Assessing
sensory response–nipple,
T4.
Adapted from the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2002. Chicago,
IL: American Spinal Injury Association; 2002.

30. Key Myotomes.

31. Immobilization. Cervical spine injury requires continuous
immobilization of the entire patient with a semi-rigid cervical
collar, head immobilization, backboard, tape, and straps before
and after transfer to a definitive-care facility.

32. Secondary Survey History
• A Allergies
• M Medications
• P Past illnesses
• L Last meal
• E Events related to injury
1.Blunt
2.Penetrating
3.Burns
4.Hazardous Environment

33. Secondary Survey Head
• Scalp
• Eyes
• Nose
• Mouth
• Bite occlusion
PITFALLS
• Hyphema
• Optic nerve injury
• Lens dislocation
• Head injury
• Posterior scalp laceration

34. Secondary Survey Maxillofacial
• Midline facial fractures
• Bite occlusion
• Bleeding
• Fracture repair can wait

35. Midface Fractures Lefort
• I: Maxilla only transversely above the alveolar ridge
Most common isolated
• II (pyramidal): Through nasal bone or nasal bone disarticulation with frontal
bone
Most common when associated with other fractures
• III (dislocated face): Through nasal bone, across floor of orbit, through
lateral wall of orbit, zygomatic arch Rare

37. Secondary Survey Maxillofacial
PITFALLS
• Pending airway obstruction
• Changes in airway status
• Cervical spine injury
• Exsanguinating midface fracture
• Lacrimal duct lacerations
• Facial nerve injuries

38. Thoracic Trauma
1 Identify and initiate treatment of
the following injuries
during the primary survey:
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Flail chest and pulmonary contusion
• Massive hemothorax
• Cardiac tamponade
2 Identify and initiate treatment of
the following potentially
life-threatening injuries during the
secondary
survey:
• Simple pneumothorax
• Hemothorax
• Pulmonary contusion
• Tracheobronchial tree injury
• Blunt cardiac injury
• Traumatic aovrtic disruption
• Traumatic diaphragmatic injury
• Blunt esophageal rupture
3 Describe the
significance and
treatment of the
following
injuries:
• Subcutaneous
emphysema
• Thoracic crush injuries
• Sternal, rib, and
clavicular fractures

39. Tension Pneumothorax.

40. Needle Decompression.
Tension pneumothorax may be
managed initially by rapidly
inserting a large-caliber needle
into the second intercostal
space in the midclavicular line
of the affected hemithorax.

44. Cardiac Tamponade. (A) Normal heart.
(B) Pericardial tamponade can result from penetrating
or blunt injuries that cause the pericardium to fill with
blood from the heart, great vessels, or pericardial
vessels. (C) Ultrasound image showing cardiac
tamponade.
Aortic Rupture. Traumatic aortic rupture
is a common cause of sudden death after an
automobile collision or fall from a great height.

46. Management

47. Treatment
• Needle Thoracentesis
• Chest Tube Insertion

48. Abdominal and Pelvic Trauma
This procedure should be performed only once
during the physical examination, as testing for pelvic
instability can result in further hemorrhage. It
should not be performed in patients with shock and
an obvious pelvic fracture.
Evaluation of
Pelvic
Stability. Gentle
pressure over the
iliac wings in a
downward and
medial fashion
may reveal laxity or
instability.
Add -
Radiographs
USG
Pelvic Stabilization

49. Musculoskeletal Trauma
THE FOLLOWING PROCEDURES ARE INCLUDED –
1. Physical Examination
2. Principles of Extremity Immobilization
3. Realigning a Deformed Extremity
4. Application of a Traction Splint
5. Compartment Syndrome: Assessment and Management
6. Identification of Arterial Injury

50. Thermal
Injuries
Rule of Nines. This practical guide
is used to evaluate the severity of
burns and determine fluid
management. The adult body is
generally divided into surface areas
of 9% each and/or fractions or
multiples of 9%.

51. Depth of Burns. (A) S hallow partialthickness burn
injury. (B) Partial-thickness burn. (C) Deep partial, full-
thickness burn injury. (D) Full-thickness burn injury on a
patient’s upper arm and back.

52. PrimarySurveyandResuscitationof
PatientswithBurns
• Airway
• Breathing
• Circulation—Burn Shock
Resuscitation
• Physical Examination
• Documentation
• Baseline Determinations for
Patients with Major Burns
• Peripheral Circulation in
Circumferential Extremity Burns
• Gastric Tube Insertion
• Narcotics, Analgesics, and
Sedatives
• Wound Care
• Antibiotics
• Tetanus
SecondarySurveyandRelated
Adjuncts

53. Paediatric Trauma

56. Geriatric Trauma

57. Transfer to Definitive Care

59. TREATMENT PRIOR TO TRANSFER
1. Airway
a. Insert an airway or endotracheal tube, if needed.
b. Provide suction.
c. Insert a gastric tube to reduce the risk of aspiration.
2. Breathing
a. Determine rate and administer supplementary oxygen.
b. Provide mechanical ventilation when needed.
c. Insert a chest tube if needed.
3. Circulation
a. Control external bleeding.
b. Establish two large-caliber intravenous lines
and begin crystalloid solution infusion.
c. Restore blood volume losses with crystalloid fluids or blood and
continue replacement during transfer.
d. Insert an indwelling catheter to monitor urinary output.
e. Monitor the patient’s cardiac rhythm and rate.
4. Central nervous system
a. Assist respiration in unconscious patients.
b. Administer mannitol, if needed.
c. Immobilize any head, neck, thoracic, and lumbar
spine injuries.
5. Diagnostic studies (When indicated; obtaining these
studies should not delay transfer.)
a. Obtain x-rays of chest, pelvis, and extremities.
b. Sophisticated diagnostic studies, such as CT and aortography,
are usually not indicated.
c. Order hemoglobin or hematocrit, type and crossmatch, and
arterial blood gas determinations for all patients; also order
pregnancy tests for females of childbearing age.
d. Determine cardiac rhythm and hemoglobin saturation
(electrocardiograph [ECG] and pulse oximetry).
6. Wounds (Performing these procedures should not delay
transfer.)
a. Clean and dress wounds after controlling external
hemorrhage.
b. Administer tetanus prophylaxis.
c. Administer antibiotics, when indicated.
7. Fractures
a. Apply appropriate splinting and traction.

60. TREATMENT DURING TRANSPORT
• Monitoring vital signs and pulse oximetry
• Continued support of cardiorespiratory system
• Continued blood-volume replacement
• Use of appropriate medications as ordered by a doctor or as
allowed by written protocol
• Maintenance of communication with a doctor or institution
during transfer
• Maintenance of accurate records during transfer

61. Conclusion
Initial management of trauma patients requires a team approach in which each member
is allocated a specific task, the overall aim being to identify and treat life-threatening
conditions collectively. The ABC approach provides the doctor with one acceptable
method for safe immediate management in which life-threatening injuries are identified
and treated in the order in which they would otherwise kill the patient. Once the patient
has been stabilized, a full assessment is carried out, during which an AMPLE history is
taken and the patient is examined from top to toe, front to back, and side to side.
Throughout this process, the emphasis is on continuous assessment and reevaluation, so
that the response to any therapy can be monitored.

62. References