atls for nl
TRANSCRIPT
ATLS
Paleerat Jariyakanjana, MD
Emergency Physician, Naresuan University
outline
Initial Assessmentand Management Skill station
Adult Orotracheal Intubation Cervical collars Application of pelvic binder Needle thoracentesis Chest tube insertion FAST Principle of spine immobilization and logrolling
INITIAL ASSESSMENTAND MANAGEMENT
Initial assessment
Preparation Triage Primary survey (ABCDEs) Resuscitation Adjuncts to primary survey and resuscitation Consideration of the need for patient transfer Secondary survey (head-to-toe evaluation and patient
history) Adjuncts to the secondary survey Continued postresuscitation monitoring and reevaluation Definitive care
PRIMARY SURVEY
Airway maintenance with cervical spine protection Breathing and ventilation Circulation with hemorrhage control Disability Exposure/Environmental control
What is a quick, simple way to assess apatient in 10 seconds?
asking the patient for his or her name, and asking what happened no major airway compromise (ability to speak clearly) breathing is not severely compromised (ability to generate
air movement to permit speech) no major decrease in level of consciousness (alert enough
to describe what happened)
Airway maintenance with cervical spine protection
able to communicate verbally patent signs of airway obstruction
Secretion or blood per mouth/nose Stridor inspection for foreign bodies facial, mandibular, or tracheal/laryngeal fractures severe head injuries definitive airway
Airway maintenance with cervical spine protection
traumatic incident loss of stability of the cervical spine should be assumed protection of the patient’s spinal cord with appropriate
immobilization devices Evaluation and diagnosis of specific spinal injury,
including imaging, should be done later.
Breathing and ventilation
neck and chest assess jugular venous distention, position of the trachea,
and chest wall excursion Auscultation, Visual inspection and palpation,
Percussion Injuries
tension pneumothorax, flail chest with pulmonary contusion, massive hemothorax, and open pneumothorax
Simple pneumothorax or hemothorax, fractured ribs, and pulmonary contusion can compromise ventilation to a lesser degree and are usually identified during the secondary survey.
Circulation with hemorrhage control
The elements of clinical observation that yield important information within seconds are level of consciousness, skin color, and pulse.
Circulation with hemorrhage control
Bleeding external or internal External hemorrhage
direct manual pressure on the wound Tourniquets are
• effective in massive exsanguination• risk of ischemic injury • only be used when direct pressure is not effective
Hemostats: damage to nerves and veins
Circulation with hemorrhage control
Bleeding major areas of internal hemorrhage
chest, abdomen, retroperitoneum, pelvis, and long bones The source of the bleeding is usually identified by
physical examination and imaging (e.g., chest x-ray, pelvic x-ray, or focused assessment sonography in trauma [FAST]).
Management may include chest decompression, pelvic binders, splint application, and surgical intervention.
Disability (neurologic evaluation)
level of consciousness pupillary size and reaction lateralizing signs spinal cord injury level
Exposure and environmental control
completely undressed Keep warm
Warm blankets or an external warming device Warm Intravenous fluids and a warm environment (i.e.,
room temperature)
RESUSCITATION
Airway
Suction: rigid suctionjaw-thrust or chin-lift
maneuveroropharyngeal airway:
unconscious and has no gag reflex
definitive airwayprotection of the
cervical spine
Breathing, ventilation, and oxygenation
supplemental oxygen: mask-reservoir device with a flow rate of at least 11 L/min
tension pneumothorax chest decompression ICD
Open pneumothorax occlusive dressing ICD
Massive hemothorax: ICD
Circulation and hemorrhage control
2 large-caliber IV catheters, upper-extremity peripheral IV access
Warmed crystalloids, bolus of 1-2 L of isotonic solution If the patient is unresponsive to initial crystalloid therapy,
blood transfusion should be given.
baseline hematologic studies + G/M UPT Blood gases and/or lactate level: assess shock
ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION
Electrocardiographic monitoring urinary and gastric catheters other monitoring
ventilatory rate, arterial blood gas (ABG) levels, pulse oximetry, blood pressure
x-ray examinations
URINARY AND GASTRIC CATHETERS
Urinary Catheters C/I in urethral injury
Blood at the urethral meatus Perineal ecchymosis High-riding or nonpalpable prostate
Gastric Catheters C/I: cribriform plate fracture
X-RAY EXAMINATIONS ANDDIAGNOSTIC STUDIES
AP chest AP pelvis FAST/DPL
CONSIDER NEED FOR PATIENT TRANSFER
During the primary survey and resuscitation phase, the evaluating physician frequently obtains enough information to indicate the need to transfer the patient to another facility.
Diagnosis & consult
SECONDARY SURVEY
complete history and physical examination head-to-toe evaluation
History
Allergies Medications currently used Past illnesses/Pregnancy Last meal Events/Environment related to the injury
ADJUNCTS TO THE SECONDARY SURVEY
Specialized diagnostic tests Additional x-ray examinations of the spine and extremities CT scans of the head, chest, abdomen, and spine Contrast urography and angiography transesophageal ultrasound Bronchoscopy Esophagoscopy other diagnosticprocedures
REEVALUATION
Continuous monitoring of vital signs and urinary output relief of severe pain TT, antibiotic
SKILL STATION
Adult Orotracheal Intubation
Direct an assistant to manually immobilize the head and neck.
The patient’s neck must not be hyperextended or hyperflexed during the procedure.
Take off the collar
Cervical collars
maintains cervical immobilization measures the pt for proper size selection
Measure the distance from the bottom of the pt’s mandible to the top of the pt’s clavicle
Measure the same distance on the premarked cervical collar
Select the appropriate size or adjust the collar Apply the cervical collar Ensure that the collar is properly sized and firmly in
position
TECHNIQUES TO REDUCE BLOOD LOSSFROM PELVIC FRACTURES
Internally rotate the lower legs to close an open-book type fracture reduce a displaced symphysis, decrease the pelvic
volume, and serve as a temporary measure until definitive treatment can be provided
Apply a pelvic binder.
Needle Thoracentesis
2th ICS, midclavicular line
over-the-needle catheter (minimum 16 gauge, 2 in. [5 cm] long)
Prepare for a chest tube insertion.
Chest Tube Insertion
nipple level (5th ICS), just anterior to the midaxillary line 2- to 3-cm transverse (horizontal) incision bluntly dissect through the subcutaneous tissues, just
over the top of the rib Puncture the parietal pleura with the tip of a clamp Finger exploration Clamp the proximal end of the thoracostomy tube and
advance it into the pleural space to the desired length. directed posteriorly, medially, and superiorly
Chest Tube Insertion
Look for “fogging” of the chest tube with expiration or listen for air movement.
Connect the end of the thoracostomy tube to an underwater-seal apparatus.
Suture the tube in place. Apply an occlusive dressing and tape the tube to the
chest. Obtain a chest x-ray film.
Focused Assessment Sonography in Trauma (FAST)
Start with the subxiphoid or the parasternal view
Focused Assessment Sonography in Trauma (FAST)
RUQ view sagittal view in the
midaxillary line, at approximately the 10th or 11th rib space
hepatorenal fossa (Morrison’s pouch)
Focused Assessment Sonography in Trauma (FAST)
LUQ view sagittal view in the
midaxillary line, at approximately the 8th or 9th rib space
splenorenal fossa
Focused Assessment Sonography in Trauma (FAST)
suprapubic view transverse view optimally obtained prior to placement of a
Foley catheter
Subxiphoid view
RUQ view
RUQ view
LUQ view
LUQ view
Suprapubic view
Suprapubic view
Principles of Spine Immobilization and Logrolling
4 people 1 person to maintain manual, inline immobilization of the
patient’s head and neck 1 for the torso (including the pelvis and hips) 1 for the pelvis and legs 1 to direct the procedure and move the spine board
Apply gentle, inline manual immobilization to the patient’s head and apply a semirigid cervical collar.
Principles of Spine Immobilization and Logrolling
Principles of Spine Immobilization and Logrolling
cautiously logroll the patient as a unit toward the two assistants at the patient’s side, but only to the least degree necessary to position the board under the patient.
Place the spine board beneath the patient Padding and tape the patient’s head and neck straps
across the patient’s thorax just above the iliac crests across the thighs just above the ankles
used only for transferring the patient
Take home message
Primary survey (ABCDEs) Resuscitation Adjuncts to primary survey and resuscitation Consideration of the need for patient transfer
Reference
ATLS 9th Student Manual EMS -- A Practical Global Guidebook by Tintinalli,
Cameron, and Holliman
ANY QUESTIONS?