nl iii atls 9th
TRANSCRIPT
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ATLSPaleerat Jariyakanjana, MD
Emergency Physician Naresuan University
13 Dec 2015
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outlineInitial Assessment and ManagementSkill station
Cervical collars Needle thoracentesis Chest tube insertion FAST Application of pelvic binder Adult Orotracheal Intubation Principle of spine immobilization and
logrolling
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Initial Assessmentand Management
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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
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Primary survey
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Airway maintenance with cervical spine protection
Breathing and ventilationCirculation with hemorrhage controlDisabilityExposure/Environmental control
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What is a quick, simple way to assess apatient in 10 seconds?
asking the patient for his/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)
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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
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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 devicesEvaluation and diagnosis of specific
spinal injury, including imaging, should be done later.
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Breathing and ventilationneck and chest
jugular venous distention, position of the trachea, and chest wall excursion
Auscultation, visual inspection, palpation, and percussion
Injuries tension pneumothorax flail chest with pulmonary contusion massive hemothorax open pneumothorax
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Breathing and ventilation
Tension Pneumothoraxhyperresonant note on percussion,
deviated trachea, and absent breath sounds over the affected hemithorax
Open Pneumothorax (Sucking Chest Wound)≥2/3 of the diameter of the trachea
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Breathing and ventilation
Flail Chest and Pulmonary Contusion≥2 adjacent ribs fractured in ≥2
placesparadoxical motion
Massive Hemothorax>1500 mL of blood or ≥1/3 of the
patient’s blood volume 200 mL/hr for 2-4 hours
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Breathing and ventilationSimple pneumothorax or
hemothorax, fractured ribs, and pulmonary contusion can compromise ventilation to a lesser
degree usually identified during the secondary survey
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Circulation with hemorrhage control
level of consciousnessskin colorpulse
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Circulation with hemorrhage control
BleedingExternal/internalExternal hemorrhage
direct manual pressure Tourniquets
• massive exsanguination• risk of ischemic injury • only be used when direct pressure is not effective
Hemostats: damage to nerves and veins
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Circulation with hemorrhage control
Bleedingmajor areas of internal hemorrhage
chest, abdomen, retroperitoneum, pelvis, and long bones
identified by physical examination and imaging
Management: as cause
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Disability (neurologic evaluation)level of consciousnesspupillary size and reactionlateralizing signsspinal cord injury level
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Exposure and environmental control
completely undressedKeep warm
Warm blankets or an external warming device Warm intravenous fluids and a warm
environment
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Resuscitation
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AirwaySuction: rigid
suctionjaw-thrust or
chin-lift maneuver
oropharyngeal airway: unconscious and has no gag reflex
definitive airway
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Airway
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Breathing, ventilation, and oxygenation
supplemental oxygen: mask-reservoir device ≥11 L/min
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Breathing, ventilation, and oxygenation
tension pneumothorax Immediate
decompression ICD
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Breathing, ventilation, and oxygenation
Open pneumothorax occlusive dressing ICD
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Breathing, ventilation, and oxygenation
Massive hemothorax ICD
Flail Chest and Pulmonary Contusion adequate oxygenation administer fluids judiciously provide analgesia
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Circulation and hemorrhage control
2 large-caliber (minimum of 16G in an adult) IV catheters, upper-extremity peripheral IV access
Warmed crystalloids, bolus of 1-2 L of isotonic solution
unresponsive to initial crystalloid therapy: blood transfusion
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Circulation and hemorrhage control
baseline hematologic studies + G/MUPTBlood gases a/o lactate level: assess
shock
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Adjuncts to primary survey and resuscitation
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Electrocardiographic monitoringurinary and gastric cathetersother monitoring
ventilatory rate, arterial blood gas (ABG) levels, pulse oximetry, blood pressure
x-ray examinations
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URINARY AND GASTRIC CATHETERS
Urinary CathetersC/I: urethral injury
Blood at the urethral meatus Perineal ecchymosis High-riding or nonpalpable prostate pelvic fracture
Gastric CathetersC/I: cribriform plate fracture
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X-RAY EXAMINATIONS ANDDIAGNOSTIC STUDIES
AP chestAP pelvisFAST/DPL
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Consider Need for Patient Transfer
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Diagnosisconsult
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Secondary Survey
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complete history and physical examination
head-to-toe evaluation
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HistoryAllergiesMedications currently usedPast illnesses/PregnancyLast mealEvents/Environment related to the
injury
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Adjuncts to the Secondary Survey
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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 diagnostic procedures
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Reevaluation
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Continuous monitoring of vital signs and urinary output
relief of severe painTetanus toxoid, antibiotic
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Skill station
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Cervical collarsmaintains cervical immobilizationmeasures the pt for proper size
selection bottom of mandible - top of clavicle Measure the same distance on the
premarked cervical collar Select the appropriate size or adjust the
collarApply the cervical collar
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Cervical collars
http://www.rch.org.au/clinicalguide/guideline_index/Cervical_Spine_Injury/
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Needle Thoracentesis2th ICS, midclavicular lineover-the-needle catheter (minimum
16G, 2 in. [5 cm] long)Prepare for a chest tube insertion.
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Chest Tube Insertionnipple level (5th ICS), just anterior to
the midaxillary line2-3 cm transverse (horizontal)
incisionbluntly dissect through the
subcutaneous tissues, just over the top of the rib
Puncture the parietal pleura with the tip of a clamp
Digital assessment
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Chest Tube InsertionClamp the proximal end of the
thoracostomy tube (36/40 Fr) and advance it into the pleural space
directed posteriorly, medially, and superiorly
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.
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Chest Tube InsertionSuture the tube in place.Apply an occlusive dressing and tape
the tube to the chest.Obtain a chest x-ray film.
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Focused Assessment Sonography in Trauma (FAST)
Start with the subxiphoid or the parasternal view
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Focused Assessment Sonography in Trauma (FAST)
RUQ view sagittal view in the
midaxillary line, at approximately the 10th-11th rib space
hepatorenal fossa (Morrison’s pouch)
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Focused Assessment Sonography in Trauma (FAST)
LUQ view sagittal view in the
midaxillary line, at approximately the 8th-9th rib space
splenorenal fossa
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Focused Assessment Sonography in Trauma (FAST)
suprapubic view transverse view optimally obtained prior to
placement of a Foley catheter
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Focused Assessment Sonography in Trauma (FAST)
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Focused Assessment Sonography in Trauma (FAST)
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Focused Assessment Sonography in Trauma (FAST)
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Focused Assessment Sonography in Trauma (FAST)
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Focused Assessment Sonography in Trauma (FAST)
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Focused Assessment Sonography in Trauma (FAST)
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Focused Assessment Sonography in Trauma (FAST)
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Techniques to reduce blood lossfrom pelvic fractures
Internally rotate the lower legsApply a pelvic binder
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Techniques to reduce blood lossfrom pelvic fractures
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Adult Orotracheal IntubationDirect 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
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Adult Orotracheal Intubation
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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
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Principles of Spine Immobilization and Logrolling
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Principles of Spine Immobilization and Logrolling
Apply gentle, inline manual immobilization to the patient’s head and apply a semirigid cervical collar.
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
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Principles of Spine Immobilization and Logrolling
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
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Take home messagePrimary survey (ABCDEs)ResuscitationAdjuncts to primary survey and
resuscitationConsideration of the need for patient
transfer
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ReferenceATLS 9th Student ManualEMS -- A Practical Global Guidebook
by Tintinalli, Cameron, and Holliman
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Any questions?