What is Surgery – ATLS Courses
Advanced trauma life support (ATLS) INDICATIONS
Early management of trauma with emphasis on treating the greatest threat to life first.
Pre-hospital phase: Rapid assessment of the trauma patient. Treatment of hypoxaemia,shock and prompt evacuation to an appropriate hospital.
Hospital phase: Primary survey is carried out by a trauma team comprising of a team leader, and usually at least a general surgeon, an orthopaedic surgeon, an anaesthetist and nursing support. The team leader should ensure a systematic approach to the primary and secondary surveys and each member of the team should have a pre-specified function.
Airway management with c-spine control: Suction and check mouth for foreign body. Check for capacity to maintain own airway (conscious/unconscious patient). Chin lift/jaw push, oral or nasopharyngeal (not in head injuries) airway as necessary, intubation or cricothyroidotomy as required.
Breathing: Give oxygen, 100 percent via non-rebreather mask. Check for tracheal deviation and symmetrical chest expansion, bilateral breath sounds and respiratory rate. Pulse oximetry. If tension pneumothorax, needle decompression on side of pneumothorax. Check for subcutaneous emphysema. Open sucking pneumothorax requires dressing with closure on three sides and chest drain. Look for flail chest.
Circulation: Assess pulse, blood pressure, pulse pressure, capillary return, combined with intravenous access (two large-bore peripheral cannulae) and blood collection for FBC, U&E, G&S ± crossmatch blood. Assessment of shock/haemodynamic instability, treatment of external haemorrhage, assessment for internal bleeding: evaluate main body cavities, abdomen, pelvis for evidence of pelvic fractures, chest for haemothorax. Fluid resuscitation (crystalloid/colloid/blood); however, if intracavity bleeding is not yet controlled, ‘permissive hypotension’ of systolic BP may be appropriate (not in severe head injury where cerebral perfusion pressure should be adjusted).
FAST (focused abdominal sonogram for trauma) scan or CT if stable.
Disability: Assessment of neurologic damage grossly utilising an AVPU (Alert, Voice elicits response, Pain elicits response, Unresponsive) score or the Glasgow Coma Score (GCS) (GCS). Check blood glucose.
Exposure: Check for other injuries, totally strip patient, prevent hypothermia, logroll patient, checking for posterior or spinal injuries.
Avoid and treat hypothermia: warming blankets, warm IV fluids, etc. Frequent reassessment is crucial. Any worsening needs quick reevaluation of the ABC. When a team is completing the assessment and resuscitation, most of the ABC may be carried out in simultaneously.
Secondary survey: Does not begin until the primary survey is completed and resuscitation is started. Head-to-toe evaluation. AMPLE history (Allergies, Medications, Past illness/ Pregnancy, Last meal, Events linked to the injury).
Frequent reassessment vital! Full neurological examination. Radiology, and other indicated tests, e.g. FAST scan, ABG, radiographic imaging of any fractures. Urinary catheter/gastric tube. Further definitive management is dependent on injuries.
Transfer to tertiary trauma or neurosurgical centre is sometimes essential.
INVESTIGATIONS Blood: FBC, U&E, LFTs, clotting, blood group and crossmatch as appropriate. Urinalysis: Urine dipstick for haematuria, β-HCG if danger of pregnancy.
Imaging: Cervical spine, chest and pelvic radiographs as part of primary survey. Penetrating abdominal injuries may be evaluated using erect chest X-ray.
FAST scanning: Taking over as a non invasive quick assessment for haemoperitoneum in trauma.
CT scanning: As appropriate in the stable patient. Suspicion of intra-abdominal bleed (e.g. hypotension, enlarged abdomen) demands rapid laparotomy. Radiographs: If shattered bone is suspected.
MORTALITY Trimodal distribution of death. Early (within minutes) caused by large-vessel/brain/spinal cord damage. Second peak (within hours) owing to haemorrhage, the golden hour refers to the period in which there is the highest possibility that prompt medical treatment may avoid mortality. Third peak (within days to weeks) owing to sepsis.
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