ART OF LIFE ART OF LIFE SUPPORTSUPPORT

BY

Hosam Mohamad Hamza, MscASSISTANT LECTURER OF GI SURGERY

& ENDOSCOPYMinia School Of Medicine

Minia –Egypt

Trauma is the 3rd leading cause of death in people aged 1-44 years, and a leading

cause of disability .

WHO data suggest that 1 in 10 deaths worldwide is a result of trauma .

Serious multi-system injuries occur in

10-15% of PTP.

Trauma related mortality may be:

Immediate death

Early DeathLate Death

%50%30%20%

Time after injury

soon or within min.

1st few hrs (golden hrs)

days or weeks

Causes-major brain injury.

-high cord injury.

-major airway disruption.

-Airway obst.

-disruption of Breathing mech.

-Circulation failure .

-Sepsis.

-M.O.F.

PreventionCommunity education about

trauma- preventing

programs (seat belts, head

protection,…etc)

Training about ABC

resuscitation programs.

Proper patient

follow-up.

Immediate50%

Early30%

Late20%

TRAUMA CARE

Organized trauma teamOrganized trauma system

I. Trauma Team Patients with major trauma are best

treated by a well-organized trauma team.

Each team member should be assigned a specific task or tasks so each of these can be performed simultaneously.

II. Trauma System Recently, many protocols were

introduced for management of multi injured patients including :

ATLS → Advanced Trauma Life Support.

followed by:ATNC → Advanced Trauma Nursing

Course.and more recently:

PHTLS → Pre-Hospital Trauma Life Support.

LIFE SUPPORT Definition:

Several techniques used to maintain life when essential body systems are not sufficiently functioning to sustain life

unaided .

Basic Life Support (B.L.S.)

A specific level of prehospital medical care provided by trained responders, including emergency medical technicians, in the

absence of advanced medical care.

Advanced Trauma Life Support (A.T.L.S.)

In 1970s, an air crash lead to the death of the wife and serious injuries of the three children of James Styner; an American orthopedic surgeon. An event that had forced him to introduce a structured trauma management program which was soon adopted by The American Collage of Surgeons and developed the Advanced Trauma Life Support (ATLS) protocol or EMST (Early Management of Severe Trauma) as known in the UK.

Philosophy of ATLS: “ Treat the lethal injuries first, then

reassess and treat again”

Components of ATLS:

1-Primary Survey

identify what is fatal and treat it.

2-Secondary Survey

proceed to discover all other injuries.

3-Definitive Care

develop a definitive management plan.

TriageTriage SIEVE

Triage SORT

Primary survey and Resuscitation

identify and treat any life threatening condition .

- starts at the scene of accident by trained ambulance personnel.

- must be repeated any time a patient's status changes.

- Steps : (stepwise approach) history : (AMPLE )

Airway, no procedures are initiated until the airway is secured

Breathing Circulation

Disability (N. Dysfunction) Exposure / Environment

Fracture

1 -AIRWAY & SPINE CONTROL (1ry survey)Lack of an airway is one of the few situations in medicine in which

seconds count.

* assess: - esp. in : disturbed conscious level ?? ±

vomition. maxillo-facial trauma.

neck trauma . nasal or oral bleeding.

* maintain: * protect (clear):

* provide: @ endotracheal @ surgical

AIRWAY & SPINE CONTROL (continued)

AIRWAY & SPINE CONTROLAIRWAY & SPINE CONTROL (continued)(continued)

•AIRWAY & SPINE CONTROL (continued)

indications of ETE in trauma:1.Apnea (as part of CPR).

2.Respiratory insufficiency.3.Risk of aspiration (dcl w vomition)

4.Impending upper airway compromise (inhalation, maxillo- facial injuries.)

5.Closed head injuries. (hyperventilation).

Tracheostomy (tracheotomy)

Cricothyroidotomy(cricothyrotomy, mini-

tracheostomy, laryngostomy)

Types :

- needle cricothyrotomy

- surgical cricothyrotomy

? -cricothyroidotomy is more simple

and faster and nowadays is gaining popularity over tracheostomy.

- needle cricothyroidotomy is a temporary method not suitable for proper ventilation.

- surgical cricothyroidotomy can be used for ventilation for only 30-45 minutes.

- cricothyroidotomy (esp. surgical) is not suitable for children < 10 years.

? - cervical spine should be considered

unstable until provedotherwise by radiology (at least 3 views). - esp. in :*Altered level of consciousness

*Blunt injury above the clavicle. *Cervical bony abnormalities or

tenderness. *Maxillofacial trauma.- Immobilization : Backboard and rigid neck collar, sand

bags and fore head tape. If a collar is not available, manual in

line immobilization is necessary.

2 -BREATHING (1ry survey)

% Having a patent airway is not necessarily associated with normal respiration.

% Abnormal resp. after trauma may be:

§ Central (severe head trauma, RC depression)

§ Peripheral ( Suction pneumothorax, Tension

pneumothorax, Tension hameothorax, flail chest)

2 -BREATHING (1ry survey)

*assess: Inspection :- chest wall bulge or retraction.

chest expansion. wounds. respiratory rate .

tracheal shift. use of accessory muscles of

respiration. Palpation :- surgical emphysema. Tenderness.

fracture click. flail segments. Auscultation :-

air entry at different lung fields on both sides.Percussion :- (less commonly used ) for hyperresonance or dullness over different lung fields on

both sides.

*test :

1 -Pulse oximetry? (unreliable)

2-ABG sampling 3 -Diagnostic Thoracocentesis

(Diagnostic Aspiration = in respiratory distress)

-site : -result :

4-Imaging

Flail chest

Hypoxia

1- Rib fracture pain may cause the patient to hold the chest still.

2- Pulmonary contusion (if present) causes extravasation of fluid and blood into the alveoli.

3- Paradoxical respiration .

Tension pneumothorax is a clinical diagnosis.

do not wait for radiographs if suspecting Classic signs :

- respiratory distress .- cyanosis .- chest pain .

- refractory shock. - decreased breath sounds .

- tympany of the affected lung .- jugular venous distension .

- tracheal deviation to the opposite side

Tension (Massive) hemothorax is defined as 1500 mL of blood in the chest cavity.

Patient who continues to bleed (a flow of 200 mL / h for 2-4 hours) may require thoracotomy to control bleeding.

3 -CIRCULATION (1ry survey)

Failure of peripheral circulation is known as SHOCK.

causes of SHOCK with trauma: 1 - hypovolaemic (hgic) :

commonest. 2 -neurogenic : severe pain.

3 -cardiogenic : haemopericarcardium or

cardiac trauma. 4 -septic : late and rare.

*assess: -fatigue . - altered mentality . - cold pale

clammy skin with slow capillary

refill and collapsed veins.

- vital signs :

weak rapid pulse. hypotension. hypothermia.

hunger to air (tachypnea).

-oliguria: ↓ urine output < 0.5 ml/kg/hour in adults.

* estimate : (amount of blood loss) -clinically:

- external blood loss : (WTa –WTb x 1.5 -2)

- internal blood loss:

¤type of injury: hematoma in closed fracture tibia → 500 –

1500 ml.

hematoma in closed fracture femur →500 –2000 ml.hematoma in closed fracture pelvis →2000 –3000 ml.

¤abdominal US or CT scan.

Class IClass IIClass IIIClass IV

Blood lossUp to 15%15 – 30%30 – 40%> 40%

Mental stateNormal to Anxious

Anx. to Restless

Aggressive or Drowsy

Drowsy to

unconscious

Pulse / min< 100100 - 120100 – 140 140

Systolic BPNormalNormal )supine(

↓↓

Diastolic BPNormal↑↓↓

Pulse P.Normal↓↓↓

Cap. refillNormal> 2 sec> 2 sec> 2 sec

R.R.14 - 2020 - 3030 - 35>35

SkinNormalPale & coldPale &colder

P &very cold

Urine )ml/h(0 - 1010 - 2020 - 30> 30

* treat:

-define & treat the cause.

- 4 tubes:

*Resuscitate with:

two large-bore (14- to 16-gauge) I.V. catheters

warmed fluids.

packed RBCs if necessary.

*Control hemorrhage .

*Use the left lateral position for all pregnant patients at more than 20 weeks of gestation .

4 -DISABLITY (1ry survey) *causes :

head injury, shock , hypoxia and intoxication.

*assess:

AVPU method Alert and responsive .

Vocal stimulus elicits response.

Painful stimulus is needed to elicit a response.

Unresponsive.

Response SCORE

Eye opening response

Spontaneous4

To voice3

To pain2

None1

Best verbal response

Oriented5

Confused 4

Inappropriate speech3

Incomprehensible speech2

None1

Best motor response

Obeys commands6

Localizes pain5

Withdraws to pain4

Flexes to pain3

Extends to pain2

None1

TOTAL3 - 15

5 -EXPOSURE / ENVIRONMENT (1ry

survey)

All clothes are removed using large sharp scissors.

Keep the emergency room

warm and use blankets to prevent hypothermia.

Some cases may require transfer to another hospital with higher facilities or to another department in the same hospital. The level of care MUST not be allowed to DROP during the transfer .

Summary of the primary survey

Airway - Airway opened, airway obstruction treated, possible definitive airway placed

Breathing - Breathing assessed, treat threats . Circulation - Blood circulation and tissue

perfusion assessed, intravascular volume loss replaced with fluids and blood, external hemorrhage controlled .

Disability - Neurologic status assessed Exposure/environment - Patient fully

undressed and environment controlled to protect from hypo or hyperthermia

Consider transfer - For higher level of care if necessary.Adjuncts - Trauma radiographs, laboratory studies, urinary or gastric catheters, temperature monitoring, consider blood transfusion

Secondary Survey -starts once resuscitation efforts are

underwent and preliminary X rays have been evaluated.

-steps : * examine the patient from head to

toe and from front to back. * complete and integrate all data

(clinical, laboratory and radiological) .

* Formulate a management plan .

Definitive Care * after identification of the cause &

region of injury . * Patients with multiple injuries require

the attention of a number of specialists. * The most appropriate person to take

the primary responsibility in such cases is usually the general surgeon.

* Patients require repeated evaluation as some injuries may present late e.g. delayed splenic injuries, retroperitoneal duodenal injuries and subdural hematomas.