initial management of trauma patientmed.swu.ac.th/surgery/images/sar54/atls medical student .pdf ·...

Initial management of

Trauma patient

นพ.ธวชชย ตลวรรธนะ ภาควชาศลยศาสตร คณะเเพทยศาสตร มศว

ADVANCED TRAUMA LIFE SUPPORT

• (ATLS)

Advanced Trauma Life support

(ATLS)

Preparation ( Prehospital and hospital care)

Triage

Primary survey (ABCDE)

Resuscitation

Adjuncts to Primary survey and Resuscitation

Consider need for transfer patient

Secondary survey ( Head to toe evaluation and patient history)

Adjuncts to Secondary

Continued postresuscitation monitoring and reevaluation

Definite care

Prehospital phase

การประเมนผปวยและใหการรกษาในเบองตน รวมถงการเคลอนยายผปวยจากทเกดเหต

Airway maintenance

Control of external bleeding and management of

shock

Immobilization

Immediate transport

Hospital phase

Airway equipment

Intravenous crystalloid solution

Monitoring : Vital sign ,EKG , O2 sat.

Laboratory and Radiology

Universal precaution

Triage

การคดแยกผปวย เพอใหผปวยทอยในภาวะวกฤตไดรบการรกษาอยางทนทวงท

• โดยเรยงล าดบความส าคญตามหลกการ ABC ไดแก

• - Airway with cervical spine protection

• - Breathing

• - Circulation and Hemorrhage control

Measurement of vital sign and level of conciousness

GCS < 14 Systolic BP < 90 mmHg RR < 10 , > 29 /min

Assess Anatomy of Injury

Fail chest Limb paralysis

≥ 2 long bone fracture Pelvic fracture

Traumatic amputation of wrist , ankle Combination of Trauma and burn

All penetrating trauma to head , neck, Torso extremities

Evaluation for Mechanism of injury and High energy impact

High speed auto crash > 20 mile/hr Fall > 20 ft

Evaluation Age and Associated Condition

Age < 5 or > 55 years

Pregnancy

Immunosuppressed patient

Cardiac disease , Respiratory disease

DM, Cirrhosis, Morbid obesity , coagulopathy

Transport to Highest level trauma center

TRAUMA TEAM

Primary survey

• A : Airway and cervical spine protection

• B : Breathing

• C : Circulation

• D : Disability

• E : Exposure

A : Airway and cervical spine protection

• Airway problem ????????????

• Good consciousness

• No abnormal voice

• No stridor

• >> C –spine Injury ????????

• Multiple injury : blunt injury above clavicle with

loss of conscious

Airway

• Airway problem in traumatic patient can

be cause of death

• failure to recognize the need for airway intervention

• Inability to establish an airway

• Failure to recognize incorrectly airway

• Displacement of previous established airway

• Failure to recognize the need of ventilation

• Aspiration of gastric content

• “ Supplement oxygen must be administered

to all trauma patients”

Airway

• Problem Recognition

• altered level of conciousness

• maxillofacial trauma

• neck trauma

• laryngeal trauma

Sign of airway obstruction

• Agitation , Cyanosis = hypoxia

• Obtundation = hypercarbia

• Retraction / Use of accessory muscle =

Airway compromise

• Stridor / Hoarsness = Laryngeal

obstruction

• Position of trachea

airway maintenance technique

Chin-Lift Maneuver

The fingers of one hand are

placed under the mandible

with gently lifted upward the

chin anterior.

The thumb placed behind

lower incisors and depresses

lower lip to open the mouth

airway maintenance technique

Jaw-Thrust Maneuver

Grasping of the lower jaw, one hand

on each side and displacing the

mandible forward

Care must be taken to prevent neck

extension

oropharyngeal airway

INDICATION FOR DEFINITE AIRWAY

MANAGEMENT

• Presence of apnea

• Inability to maintain a patent airway

• Need for protect airway from aspiration of blood or vomitus

• Impending or potential compromise airway (Inhalation injury,Retropharyngeal hematoma,Sustained seizure

• Severe Head injury (Glasgow coma scale <8)

• Inability to maintain oxygenation by facemask oxygen supplementation

Helmet removal

1 2

3 4

Rapid sequence intubation technique

• Preparation for “ surgical airway “

• Ensure suction and positive pressure ventilatiion are ready

• Preoxygenate with 100% oxygen

• Apply pressure over cricoid cartilage

• Administer induction drug ( Etomidate 0.3 mg/kg or 20 mg )

• Administer 1-2 mg/kg of Succinylcholine IV

• Intubation after patient relaxes then inflate the cuff and confirm tube

placement

• Release cricoid pressure and ventilate patient

Surgical airway

emergency cricothyroidotomy

B :BREATHING AND VENTILATION

• EMERGENCY LIFE THREATENING CAUSING INADEQUATE VENTILATION

• TENSION PNEUMOTHORAX

• OPEN PNEUMOTHORAX

• FAILED CHEST AND PULMONARY CONTUSION

• MASSIVE HEMOTHORAX

Tension pneumothorax

one way valve air leak

from lung through

thoracic cavity

Respiratory distress and

hypotension

Trachea deviation

Decrease breath sound

Needle Thoracocentesis

Angiocatheter needle No.16-18

second Intercostal space , Midclavicular line

Intercostal chest drainage (ICD)

Open pneumothorax

• “ Sucking chest

wound”

• Full thickness loss of

chest wall --> free

communication

between pleural

space and

atmosphere

• Prevent lung inflation

and alveolar

ventilation

Management of open pneumothorax

Failed chest and pulmonary contusion

• 3 or more contiguous ribs are fractured in at least 2 locations.

• paradoxical movement of free floating segment and pain --> compromise ventilation

• Pulmonary contusion --> decrease lung compliance and increase shunt (often progress during first 12 hours)

Management

• Adequate pain control (

epidural anesthesia )

• Oxygenation

• Optimal hydration

• Intercostal chest drainage

• Respiratory support

• Chest physical therapy

Chest Physical therapy

• Respiratory

training

• Breathing

exercise

• Clear airway

secretion

Massive hemothorax

- Compromised respiration by compressing lung and prevent adequate

ventilation

- Bleeding > 1500 cc

- Continuous bleeding > 200 cc/hr for 2-3 hr

C : Circulation and Hemorrhage

control

• Hemorrhagic shock : Most common

cause of shock in traumatic patient

• Evaluated by level of consciousness,

pulse, skin color

ADVANCED TRAUMA LIFE SUPPORT CLASSIFICATION OF HEMORRHAGIC SHOCK

RESPONSE TO INITIAL FLUID

RESUSCITATION

• Rapid response ผปวยกลมนจะมการเสยเลอดนอยกวา 20% ของ blood

volume เเละจะม vital sign เปนปกตดภายหลงไดรบ initial fluid

resuscitation ท าใหมเวลาพอทจะตรวจสบคนเพมเตมส าหรบหาสาเหตของ Shock ตอไป

• Transient response ผปวยกลมนจะมการเสยเลอดประมาณ 20-40%

ของ blood volume โดยจะมการตอบสนองตอการให initial fluid

resuscitation ดในชวงเเรก เเลวกลบม Unstable vital sign อกครงมกมสาเหตมาจาก Inadequate resuscitation หรอ ม Ongoing blood loss

ผปวยกลมนมความจ าเปนตองไดรบการท า surgical intervention เพอหามเลอดอยางทนทวงท

• Minimal or No response ผปวยกลมนจะไมมการตอบสนองตอ Initial

fluid resuscitation เเละมความจ าเปนตองไดรบ Blood transfusion

group O, Rh-negative ทนท เพอใหม adequate circulation เเละน าผปวยเขาหองผาตดเพอท าการผาตดหามเลอดโดยรบดวน

Hemorrhage control

• Direct manual compression

• Ballon tamponade

• Immobilization : Long bone fracture

• Pelvic splint : Pelvic fracture

Cardiogenic shock

• Blunt/ penetrating injury to Heart or Great vessel --> Blood in pericardial sac

• Decrease cardiac output

• Clinical : Muffle heart sound,engorged neck vein,Hypotension ( Beck's triad),Kussmaul 's sign (increase venous pressure during spontaneous inspiration)

• Diagnosis : FAST

• Managenent : Pericadiocentesis

NEUROGENIC SHOCK

• Occur in spinal cord injury patient --> Loss of sympathetic tone

• Clinical : Hypotension without tachycardia ,cutaneous vasoconstriction or narrowed pulse pressure as in Hemorrhagic shock patient

• CVP Monitoring

• Management : Intravenous fiuid resuscitation + vasopressive drug

Pulse oximetry

TO BE CONTINUE ....