Atls

Front 1

Ch 6: Head Trauma:

Priorities for initial evaluation of patients with severe brain injuries (GCS 3-8)

Back 1

Avoid hypotension, hypoxia, hypercarbia

Reduce increased ICP

CT ASAP + Repeat if any changes

1. ABCDEs + resucitation

2. Neuro exam: GCS + pupils, record if hypotensive or not.

3. Hypotension. If SBP < 100. Priority = BP. ?Haemorrhage ?DPL ?FAST ?OT for laparotomy

4. SBP > 100 after resus. --> CT Scan if evidence head injury. Don't delay CT for DPL / FAST.

5. Borderline SBP. Try to get a CT prior to OT / laparotomy / thoracotomy

Front 2

Ch 6: Head Trauma

Focused Neurological Examination

Back 2

1. GCS - Pinch trapz, supraorbital ridge pressure, nail-bed pressure.

2. Pupils

3. Focal neurology

Confounders:

- AOD

- Other injuries

- Post-ictal

Avoid sedation until neurological examination is done. Or choose short acting agents.

Front 3

CT Head

Back 3

ASAP once stabilised.

Repeat if any changes

Routine repeat at 24 hours if evidence of contousion or haematoma on initial scan.

Midline Shift >= 5mm = Need for surgery

Front 4

CH 6: Head trauma:

Medical Therapies for brain injury

Back 4

1. Correct hypovolaemia. Don't overload. Ringer's lactate or N/S. Carefully monitor Na+ (low Na -> edema)

2. Hyperventilation. But generally normocarbia preferred. Low PaCO2 -> cerebral vasoconstriction, but may -> cerebral ischaemia if falls below 30. Use only in moderation for limited period. Generally just aim for 35mmHg.

3. Mannitol. CI in hypotension (diuresis). Strong indication = acute deterioration while being observed if euvolaemic. Gve bolus 1g/kg over 5 min. CT Head ASAP

4. Hypertonic saline. Similar indications to mannitol.

5. Barbiturates. ICP refractory to other measures. Long half life.

6. Anticonvulsants. May inhibit brain recovery. Phenytoine + fosphenytoin. 1g loading dose, rate < 50mg/min. Diazepam + lorazepam for acute seizure control.

Front 5

CH 6: Head Trauma

Brain Death Diagnosis

Back 5

Normal physiologic parameters (Hypothermai, barbiturate coma). Think hard in children - increased ability to recover.

GCS = 3

Nonreactive pupils

Basesnt bainstem reflexes (e.g. oculocephalic, corneal, doll's eyes, no gag reflex)

No spontaneous ventilatory effort on formal apnea testing

Ancillary studies

EEG - no activity at high gain

CBF - No CBF

Cerebral angiography

Front 6

CH 6: Head Trauma

Primary survey

Back 6

ABCDEs

Immobilise C-spine

Neuro exam: Pupils, GCS, Lateralizing signs

Front 7

CH 6: Head Trauma

Secondary Survey

Back 7

1. Inspection: head/face, lacerations, CSF leakage (nose / ears)

2. Palpate: ?# ?lacerations

3. Inspect lacerations: ?brain tissue, depressed #, Debris, CSF leaks

4. GCS + pupillary response

5. C-Spine: Palpate for tenderness/pain, apply collar. Cross table lateral C-spine x-ray if needed.

6. Document

7. Continuously reassess: ?frequency; ?parameters to be assessed; Serial GCS + extremity motor assessment; Reassess ABCDEs;

Front 8

CH 7: Spinal Cord Trauma

Epidemiology

Back 8

5% patients with brain injury have spinal injuyr

25% patients with spinal injury have >= mild brain injury

55% injuryies in cervical region

15% Thoracic region

15% Thoracolumbar junction

15% lumbosacral area

10% with cervical spine # have second noncontigous vertebral column #

Cervical spine injury in children - relatively rare. <1% of cases.

Front 9

CH 7: Spinal Cord Trauma

Evaluation

Back 9

Absence of pain or tenderness along spine -> excludes significant injury as long as:

- No neurological deficit, pain or tenderness along the spine, no intoxication, no distracting injury.

Front 10

CH 7: Spinal Cord Trauma

Immobilisation

Back 10

Inadequate immobilisation may --> worsening of injury

Danger of prolonged immobilisation - discomfort, decubitus ulcers

Front 11

Assessment (LITFL)

Back 11

- Preparation, triage and activation of the trauma resuscitation team.

- Transfer the patient from the ambulance stretcher to the ED resuscitation bed using spinal injury precautions if indicated.

- Obtain a handover from prehospital care providers including history, including the mechanism of injury, field treatment, and response to treatment.

- Obtain vital signs while the patient is being undressed.

- Primary survey (ABCDE) and resuscitation as needed, while obtaining large bore IV access.

- Take blood tests for group and hold/ cross-match, and baseline laboratory testing (e.g. blood gas, Hb, coagulation studies)

- Adjuncts to primary survey and resuscitation(IDC, NGT, ECG, monitoring, trauma X-ray series and bedside ultrasound)

- Consider need for patient transfer(initiate as soon as adequate information is available)

- Secondary survey

- Adjuncts to the secondary survey(further imaging and investigations)

- Continued post-resuscitation monitoring and reevaluation

- Definitive care and disposition

Front 12

Preparation (LITFL)

Back 12

People: ?trauma team; social support; ED running ok elsewhere; security; pathology / radiology / OT / ICU

Place

Equipment + Drugs: ABCDE

- universal precautions, advanced airway equipment, analgesia, RSI drugs, chest tubes, rapid transfusers, activate massive transfusion protocol, pelvic binders, femoral splints, warming equipment, emergency thoracotomy tray

Front 13

Team

Back 13

Clear roles + organisation

- Team leader

- Airway doctor

- Procedures doctor

- Assessment doctor

- Airway nurse

- Drugs/procedures nurse

- Scribe

- Runners

Communication

Front 14

Pattern of death from Trauma

Back 14

1. Immediate: unpreventable e.g. apnoea, high spinal injury, disruption great vessel

2. Early: min-hours. Usually haemorrhage related. ATLS targets.

3. Late. Days-weeks. Multi-organ failure or sepsis. Optimal early management -> may prevent these.

Front 15

Seatbelt sign significance

Back 15

Requires:

- Close observation

- Abdominal CT

Associated with intrabdominal injury e.g. small bowel, stomach, colon & vertebral injury (chance fracture)

Chance # - flexion injury of spine. Compression injury to anterior portion of vertebral body and transverse # through posterior elements. Most common = T12-L2. More common with lap belt only type.

Front 16

Preparation

1. Low GCS / Respiratory Distress

2. hypotension

3. Establish roles

Back 16

1. Prepare for airway / RSI. 2 suction catheters. RSI medications drawn up.

- e.g. 200mg suxamethonium, etomidate

2. Prepare for blood / rapid transfusion. SBP < 90 = independent predictor of poor outcome.

3. Minimum:

1) Teamleader- runs resuscitation and does primary/secondary survey, procedures

2) Nurse onone side of the patient- IVs, meds, exposure, etc

3) Tech ormedic on other side- IVs, exposure, etc.

4) Recorder(usually a nurse)

Front 17

Primary survey 15-30s

Back 17

Airway- is it patent? Any obstruction? Ask thepatient their name

Breathing-bilateral equal breath sounds (anterior chest)

Circulation-distal pulses (radial, femoral, DPs)

Disability-moves all extremities? GCS (seeother column)

- Squeeze fingers, mostly assessing following commands not power.

- QUICK way: not following commands --> call it GCS 8 and move on.

- Awake+talking+not confused = 15

- Awake+talking+confused =14

- Depressed consciousness + not following commands --> Call it GCS = 8 and consider definitive airway.

- Comatose+not moving = 3 (intubated GCS = 3T)

Exposure-start removing all patient’s clothing, expose injuries

Massivehemorraghe- apply tourniquets ASAP

Front 18

EMS Report + Secondary Survey

Back 18

EMS Report after Primary survey

Secondary Survey:

- Keep quiet

Airway person: - Airway, then HEENT exam, then ask AMPLE History

Other Doctor / Exam / Procedures doctor to do the rest i.e. clavicles down. Report findings after EMS report.

Front 19

Secondary Survey:

HEENT

Back 19

Scalp + lacerations - apply pressure with gauze. Leave dressed wounds until primary + secondary survey is done.

Palpation:

- Face: abrasions, press on foreface, midface, jaw

Mouth: Look with light, careful, bleeding, lacerations, broken teeth

Nose: nasal septum for haematoma, rhinorrhoea

Ears: Haemotympanum

Midface stability: Press on maxillary sinuses, press on anterior teeth, ?do their teeth line up

Neck: Palpate with stabilisation, trachea + any obvious injuries

Front 20

Secondary Survey:

Chest

Abdomen

Pelvis

Back 20

1. Chest: Rpt auscultation, palpate for tenderness / injuries

2. Abdomen: Bruising, abrasions, palpation, tenderness, peritonism

3. Pelvis: Compress AP, compress inwards

Front 21

Secondary Survey:

1. Lower extremities

2. Upper extremities

Back 21

Methodically work up each arm/leg, recheck pulses, check axilla, check groin

Front 22

Secondary Survey:

1. Roll the patient

Back 22

Log roll

Avoid rolling towards any injuries

Tell patient to answer yes / no (Don't shake head)

Tenderness, deformities

PR

Perineum

Get an x-ray plate under the patient before putting them back.

Front 23

Rectal examination

Perineum

Back 23

?Necessary

ATLS suggests PR for all patients

- Decreased tone

- Blood on finger

- High riding prostate, difficult to identify

If deemed not necessary, ask pt to squeeze but cheeks together = good

Perineum:

- Wounds

- Inspection

Front 24

FAST

Back 24

RUQ - Liver + Right Kidney

LUQ - L kidney + spleen

Bladder View

Cardiac view

eFAST --> add pneumothorax check

Abdominal views - looking for a black stripe

Bladder - free fluid around bladder

Cardiac - black stripe around heart

Positive fast + haem normal --> CT Scan

Positive FAST + abnormal vitals -> OT

Front 25

Airway in Trauma

Back 25

Hypoxia = BAD

Desaturation or altered mental status --> definitive airway

Beware PTx / tension PTx

Front 26

RSI

Back 26

Suxamethonium 1.5mg / kg

Etomidate 0.3mg / kg

70kg patient = 100mg sux + 20mg etomidate

Ketamine ?raises ICP - Dose =1-2mg / kg. Same dose for procedural sedation in the trauma bay.

RSI:

- Prepare the team

- Everyone quiet and focused on the task

- Clear about when to give the medication

Tube depth ~3x tube size

Front 27

Breathing:

- ?PTx / Tension

Back 27

Tension PTx / PTx

ATLS --> long 14g IVC, 2nd intercostal space, mid-clavicular line, insert until hear decompression.

- Often unsuccessful, needle not long enough e.g. 8cm or specialised decompression catheter

Need a chest tube - consider just cutting through the chest wall until you get the rush of air.

Tension PTx - speed important, act quick, can go without LA / sedation.

Front 28

Procedural Sedation

Back 28

Ketamine 1-2mg / kg, lasts ~20min

Ketamine 2-4mg / kg, IM

?increased ICP

Front 29

Circulation Priorities

IO line - procedure

Back 29

IV access

- Failed / more than 60s to get access --> IO line

- Large bore

Medial tibia, 1 finger breadth below tibial tuberosity, move finger medially and feel for flat area.

- Check with 5mL saline flush

Front 30

Spinal Shock

Back 30

Rare

Noradrenaline

3 lumen central line

Don't miss life threatening bleeding

Front 31

Resucitation Fluid

Back 31

ATLS - 2L warmed saline

Current trauma practice - Blood products

Front 32

Blood products

Back 32

Packed RBCs

Plasma

Platelets

1:1:1 - Plasma + platelets important for clotting factors and clotting.

Front 33

BP Aim / Permissive Hypotension

Back 33

Theory: BP too high, might impair clotting / blow off a clot

e.g. SBP 90, if mentating OK at that level

Another lecture - Permissive