5What is ATLS?Structured algorithm designed to prioritize management issuesDesigned as a team-based approachApplicable to both Academic and Rural SettingsIt’s useful – take it.
6What ATLS isn’t?A substitute for clinical acumen – trust your instinctMost up-to-date, most evidence based approach (revised q4yrs, most recently 2004)
7Why is the ATLS protocol so nice? Overall, the tenets areGreatest threats to life are identified and treated 1stLack of definitive Tx should never impede the application of an indicated TxDetailed Hx was not essential to begin the evaluation of the acutely injured patient
8ATLS overview Preparation Triage Primary Survey (ABCDE’s) ResuscitationAdjuncts to primary survey and ResusSecondary SurveyAdjuncts to Secondary surveyContinued post-resus monitoring and R/ADefinitive Care
9ATLS Overview Primary Survey Adjuncts Secondary Survey CANNOT MOVE ON UNTIL YOU ADDRESSTHE PROBLEM!!!Primary SurveyReassessAdjunctsReassessSecondary Survey
11Case 1 60ishM Coming in by STARS, ETA 10 mins MVC – no more details Facial fractures, unable to intubateSignificant Chest trauma, hypotenseGreat...I’ll just go see this LBP patient and wait till I hear the call to the Trauma Bay
12ATLS overview Preparation Triage Primary Survey (ABCDE’s) ResuscitationAdjuncts to primary survey and ResusSecondary SurveyAdjuncts to Secondary surveyContinued post-resus monitoring and R/ADefinitive Care
13Organizing the Trauma Bay What do you want?Who do you want?
14What do you want prepare before he arrives? 1° SURVEYAirway: Intubation equipment incl difficult airway cart, drugs, +/- anasthesiaBreathing: RT, bilateral CT set-upCirculation: fluids hung, blood ready, level 1 infuser primed, +/- central accessAdjunctsX-ray, FAST, B.W., U/S
15What’s the best way to mobilize the right people… Soil your scrubs and hope someone notices and calls for helpCall Trauma CodeConsult Hospitalist
16Who do you want? RT, RN’s – 3 ideal, DI techs, U.C. ER res/doc +/- Level 1 Call-out (trauma, gen surg, ICU)FAST provider – ER IP or RadiologyOthers: Ortho, NA, SW,Trauma Team Activation6. ER doc discretion
19Organizing the Trauma Bay ONE leader:only leader should be talking and giving ordersFMC ER doc 1o survey and stabilization THEN trauma junior/ortho/plastics 2o surveySmall rural centers you’re itBe decisiveShort window of opportunity for sick patientsRapid decision making importantErr on the side of being aggressiveThanks Trevor
20Learn names and use them Be directive Minimize noise/people in room Close the LoopVerbalize your findings and thought process.i.e. I think he has a tension PTX – I’m gonna fix it
22Important Historical Features MVCWgt/size vehicleSpeedLocation of pt in veh?ejectedMech’m of accidentAmt of damage (esp windshield, steering wheel)?seatbelt (type)Airbag?Other deaths
23Motorcycle Pedestrian vs MVC Assault GSW’s Same + ?helmet Type of gun SpeedDamage to windshieldAssaultWeapon used?trajectory?sexual assaultGSW’sType of gunHandgun: low velocityRifles: high velocityType of AmmunitionDistance shot fromRoute of Entry
24Injury Patterns Frontal/Side Impact Side Impact Rear Impact MVC versus pedestrianAdultPeds
26EjectionNo specific pattern, but significant risk of severe injury to all systemsMVC versus PedestrianAdults triad ofTib/fib/femurTruncal injuryCraniofacial injuryPeds: tend to be run over
27ATLS overview Preparation Triage Primary Survey (ABCDE’s) ResuscitationAdjuncts to primary survey and ResusSecondary SurveyAdjuncts to Secondary surveyContinued post-resus monitoring and R/ADefinitive Care
28Airway LOOK LISTEN FEEL MANAGE A I R W Y Thanks Trevor/Rob LOC Facial traumaUAW burnStridorGurglingHoarsenessCrepitusTendernessEdemaTrachea midlineCervical CollarTemporize:SuctionJaw ThrustOP/NP airwaysRemove FBPrepare and perform ETT: draw meds, start iv, get BP/ toolsThanks Trevor/Rob
29Breathing LOOK LISTEN FEEL MANAGE B R E A T H I N G Thanks Trevor/Rob Resp effortResp rateCyanosisChest wallmovementsFlail segmentAE =CrepitusTendernessChest mvmt100% oxygenBVMPulse oxDecompress chestSeal open chest woundsThanks Trevor/Rob
30Circulation LOOK LISTEN FEEL MANAGE Thanks Trevor/Rob C I R U L A T O PaleSweatyLOCExternalBleedingJVDHeartSoundsMurmurPulse rate,QualityQuick feel of abdomen,pelvis,femursObtain HR, BPCardiac and BP monitorsTwo large iv.sPressure to external bleedingBolus crystalloidBloodConsider SOURCE OF BLEEDINGThanks Trevor/Rob
33*NABISH II (ED Enrollment) 3. w/i 2 hrs of injuryGoal is moderate hypothermia (32-33°) for 48 hr
34ATLS overview Preparation Triage Primary Survey (ABCDE’s) ResuscitationAdjuncts to primary survey and ResusSecondary SurveyAdjuncts to Secondary surveyContinued post-resus monitoring and R/ADefinitive Care
35Adjuncts X-rays: which ones do you want Blood Work: which ones do we get routinelyFoley, NG: do we need the NG?FAST/dpl: Who can do it? More to come in the future.
36X-rays CXR C-spine(we’ll come back to this) Pelvis Do we need to this in every trauma patient?Order others you deem necessary (but if unstable prioritize them until after secondary survey)
37Routine pelvic radiography in severe blunt trauma: is it necessary? ALL STUDIES ARE LEVEL II or III, so interpret w/caution…Civil ID, Ross SE, Botehlo G and Schwab CW. Ann Emerg Med 17(5): (1988)All patients were classified as unconscious; impaired; awake, alert, and symptomatic; or alert, oriented, and asymptomatic for pelvic fracture on admission. All underwent a plain anterior- posterior radiograph of the pelvis.N=265, 26 pelvic #. 7/26 were unconscious,11/26 were impaired, 8/36 Sx.No fractures were identified in 110 awake, alert, oriented, and asymptomatic patients (P less than .0001).They conclude that pelvic radiographs are required in unconscious or impaired victims of severe blunt trauma and those with signs or symptoms of pelvic fractures but are not required in the awake, alert, and asymptomatic patient.CONCLUSION: Err on the Side of Caution
38Preserve clot - minimal movement, gentle handling, minimum of rolling Preserve clot - minimal movement, gentle handling, minimum of rolling. Punch anyone who tries to 'spring' the pelvis. Fit pelvic belt (elasticated version of the old 'many-tailed-bandage' with velcro fastening) on basis of mechanism of injury. Minimal iv fluid to preserve systolic of 70 (90 mmHg if associated head injury). Take to a hospital that understands the condition!Timothy J Coats MD FRCS FFAEM Senior Lecturer in Accident and Emergency/Pre-Hospital Care Royal London Hospital, UK.
39Trauma/B.W. What blood work do we get when this is ordered? If you had only one blood test what would it be Sultana or Heather?
40Trauma/B.W. What blood work do we get when this is ordered? If you had only one blood test what would it be Sultana or Heather?T&S, T&CWhat’s the diff?Unmatched – immediate (F: 0-, M: 0-/+)T&S – approx 10 min (screens for ABO &Rh)T&C- approx 30min-1 hr (screens for ABO, Rh, other antibodies)
42Utility of CBC Coags Hgb – helpful if low, not helpful if N Initial hgb fxns more as baselineWBC- who caresPlts-helpful if lowCoagsProbably useful, some good evidence for HI, ?elderly
43Lytes913 Trauma pts bw – 54 had clinically significant abN, only 6 changed Tx (all hypokalemia)authors concluded that a history of hypertension, age older than 50, and a Glasgow Coma Scale (GCS) score less than or equal to 10 appeared to be useful criteriaTortella B, Lavery R, Rekant M. Utility of routine admission serum chemistry panels in adult trauma patients. Acad Emerg Med 1995;2:Cr/BUNNo evidence but likely worthwhile, esp if potential for CT and contrastEtOHAllows you to correlate clinical picture with EtOH
44Amylase LFT’s Lactate/Base Deficit Trop No role Mure A, Josloff R, Rothberg J, et al. Serum amylase determination and blunt abdominal trauma. Am Surg 1991;57:LFT’sNo Role in detecting liver injuriesLactate/Base DeficitMultiple studies showing that the higher/more –ve these values are the sicker the patients are and more aggr mngmt is needed – DUHH!TropNo helpful, unless you think it’s the cause of accidentFor cardiac contusion – may be a role, but not likely in the ED
53ATLS overview Preparation Triage Primary Survey (ABCDE’s) ResuscitationAdjuncts to primary survey and ResusSecondary SurveyAdjuncts to Secondary surveyContinued post-resus monitoring and R/ADefinitive Care
54Secondary Survey Look, listen and feel when possible Finger (only one)/tubes in every orificeAMPLE Hx:Systematic: head to toeHEENTAbdomen + GUMaxillofacialPelvisNeuro (incl CNS/PNS, CN, M/S/R)Vertebral Column (C/T/L)ChestBackCVSExtremeties
55Back to the CaseThe trauma jr asks the nurse to put a foley in and she notesScrotal hematomaBlood at meatusPerineal EcchymosisRectal N (and I’ve got short fingers)What do you want to do?
56Retrograde Urethrogram What is it?Retrograde injection of contrast urethral integrity and x-rayHow do you do it?Plain KUB 1stSterile, insert foley 1-2cm, inflate baloon w/2-4cc H20ORInsert 60cc syringe with x-mas tree adaptorSlowly inject 60cc of radio-opaque dye (avoid forceful inj)Ensure not to spill any (spurious results)Two x-rays, one AP, one lateral/oblique when 10cc left to inject
60Partial tear Complete tear +/- talk to urology, attempt to pass 12-14F foleyIf resistance/difficulties, speak to urology – may need suprapubic catheterComplete tearTalk to urology (actually, page them, wait 6 hours and then talk to them) and they’ll likely need a suprapubic catheter
61Retrograde Cystogram KUB Foley Gravity fill bladder with 400cc of contrast (age + 2) x 30 for pedsAP and Oblique/Lateral x-raysThen AP post-evacuation X-ray
63Case #18M, Story from EMSBrought in from Coventry Hills by STARS who “Scooped and Ran” with himHx: MVC (car vs cement abutment), prolonged extrication (>1hr), hwy speeds, couldn’t intubateP/E: hypotense, pale, concerned about chest/abdo, bilateral femur #, L humerus
64What do you want to do? Airway: Breathing: Do you want to do anything? How, ?RxBreathing:Post-intubation - LDDx:InterventionWhat if the CXR is N, can they still have a PTX
65103 PTX, 57 (55%) were not seen on AP CXR Likely of little significance in the non-ventilated ptBut for those who are intubated or going to OR- thought that they may progressOne small study, RCT of CT or nothing for oPTX (ventilated and non-ventilated) – NO differenceJ Trauma Jun;46(6):987-90
66Primary SurveyWhat are six(seven) life-threatening injuries you need to identify and Tx in the primary survey?
67Primary SurveyWhat are six(seven) life-threatening injuries you need to identify and Tx in the primary survey?Airway: ObstructionBreathing:Tension PTXOpen PTxMassive Hemothorax+/-FlailCirculationCardiac Tamponade (?Beck’s)Life-Threatening Bleeds
68Where’s he bleeding from? CirculationBP - unable to measureBut palpable radials – what’s his BP?, Only Femorals, Only Carotid?Where’s he bleeding from?What are the three big areas you can bleed into?How about kids?
69Fluid Resus Crystalloids 2 L then blood Level 1 infuser Goal is sBP 90ishWhat do you want to do know?RA
70Summarizing What next? Intubated, needle thoracostomy, no CT yet L humerus, bilateral femurs, VS pelvic #FAST –veGross blood from FoleyBP still very tenuousWhat next?Let the TTL decide - OR
71What about the kidneys?When do you worry enough about renal injuries to image the kidneys?
72Nicholaisen G, McAninch J, Marshall G, et al Nicholaisen G, McAninch J, Marshall G, et al. Renal trauma: Re-evaluation of the indications for radiographic assessment. J Urol 1985;133:
73What Grade of Renal Injury? CT RenalWhat Grade of Renal Injury?
74Renal Injury Classification Grade 1: subcapsular hematoma – non-operativeGrade 2: superficial renal laceration with perirenal hemorrhage – non-operativeGrade 3: deep laceration w/o extension into the collecting system of the kidney – serial exams, usu non-opGrade 4: parenchymal injury: deep laceration that extends into collecting system, – serial exams, usu non-op, +/- embolization/ORGrade 5: parenchymal injury: multiple deep lacerations that result in a shattered kidney OR Renal Artery Avulsion - ORHarris A., Zwirewich C CT Findings in Blunt Renal Trauma, Radiographics, 2001
76Case #3 27M Transferred from 8th and 8th – Single stab wound to the right chest.Chest had been needle decompressedIntubated in ED for hypotensionChest Tube on R side.
77Move onto your secondary survey? CT scanner? After chest tube (which is not draining any blood) and intubation, his vitals are…BP80/40, HR 120, Sats 100% on ventWhat do you want to do?Move onto your secondary survey?CT scanner?
78CANNOT MOVE ONTO THE NEXT STEP UNTIL YOU’VE DEALT WITH ALL THE ISSUES. WHAT ABOUT LOG ROLLING?
81Case # 423F, 28wks pregnantBrought into trauma bay pt begins to c/o of severe crampingVS – 70/30,HR-100, RR-12, sats 94%, c/s-NWhat do you want to do?
82Supine Hypotension Syndrome IVC compressionMay have vasovagal bradycardia90% of term pregnant women have COMPLETE obstruction of IVC when supineMx: tilt spine board, towel roll under on hip, manually displace uterusThanks Rob
83PEARLPregnant patient may lose up to 40% of blood volume before manifesting typical signs of shock. The fetus is compromised before signs of shock.
84So you put her into the LLD position and she goes into asystolic arrest. What do you do?
85Perimortem C-section Indications Gestation must be at least wks- progress if fundal hgt 25wks?Less if doing for momCPR w/no response to other Tx modalities (LLD, fluids, needle chest, ACLS Tx, ) w/i four minutesIdeal, start by four minutes/finish 5 minutesMother hemodynamics improve considerably
86Procedure Do not stop CPR Don’t prep/drape Vertical incision from epigastrium to pubis right through peritoneumScapel to upper uterus, extend with scissorsDeliver babyNRP for baby
87Perimortem C-Section Results Katz VL. Obstet Gynecol61 cases b/w that survivedTIME NUMBER NORMAL NEUROSQL<>
88Case #5 69F MVC, restrained driver, hwy speeds PMHx – o Stable, A & O x 3, ++ agitated
90When to order CT abdo? Stable: CT abdomen +/- FAST Abnormal vitalsAbdominal pain/tenderUnreliable physical examination (EtOH, Rx, HI, SCI, sedated).Inability to do serial examinationsDangerous mechanism of injuryGross HematuriaStable: CT abdomen +/- FASTUnstable: FAST or DPL
91What Injuries does CT abdo miss? DiaphragmaticPancreaticBowelShould we add Telebrex then?
93Case #6 57M, working in the Foothills Industrial Area Working inside a metal structure welding, when a explosion occurredPt was found unresponsive insideEMS has intubated the patient (for GCS of 3)
94Blast Injuries What injury patterns are seen in Blasts? What bodily structures would you expect to be involved?What do you want to know about accident scene?
95IncidenceIn NA tend to be industry related, accidental (fireworks), bombings/Sept.11
961° blast injury is caused solely by the direct effect of blast overpressure on tissue. Air is easily compressible, unlike water. As a result, a primary blast injury almost always affects air-filled structures2° blast injury is caused by flying objects that strike people.
973° blast injuries occurs when people fly through the air and strike other objects. Miscellaneous blast-related injuries encompass all other injuries caused by explosions, i.e. fires
98Location is importantAn explosion that occurs in an enclosed space tends to cause more serious injury.Intensity of an explosion pressure wave declines increasing distance from the explosion.Blast waves are reflected by solid surfaces; thus, a person standing next to a wall may suffer increased primary blast injury.
99Complications Injuries from projectile objects, BarotraumaTM’s: perforation, hemotympanum, ossicle #Lungs: PTX, contusion, ARDSGI: pneumoperitoneum, hemotoma, solid organ damageAcute Gas embolism - ?TxDICInjuries from projectile objects,Injuries from being thrown (MSK, CNS)Inhalational, Burns, Toxins (CN, CO)
100Work-Up Look at their TM’s B.w. – CO/CN if explosion/fire and entrapped, lytes,CXR (PA and Lat) preferred)UrineSerial Abdo Exams orAXR/CT abdo if abdo painOther tests PRN – CT head as PRN CT head rule
101Management TM’s – avoid putting stuff in their ears, Lung – manage PTX as per NIf PTX, probably worth monitoring to ensure no contusion developsBelly: high index of suspicion for bowel hematoma – may need to be Admitted for serial examsAGE – LL decubitus, 100% O2, hyperbaric 02, ASA
102PEA/Asystole 75M MVC, prolonged extrication Lost vitals en route EMS Unable to intubateWhat do you want to do?What’s you Ddx for PEA/Asystole?What can we reverse?
109Why is she hypotense Neurologic shock – but she’s moving here legs Belly – her abdo FAST is –ve, where else could the blood beHeart – Autopsy study: 33/61 had cardiac injuries and in 16/33, the heart was felt to be cause of death – pericardial /transmural tears, epicardial tearsSO, WE SHOULD AT THE HEART w/FASTBlunt Cardiac Trauma Caused by Fatal Falls From Height: An Autopsy-Based Assessment of the Injury Pattern. Journal of Trauma-Injury Infection & Critical Care. 57(2): , August Turk, E E. MD; Tsokos, M MD
111Important because… Missed cuz… Long-term disability (i.e. scaphoids) LitigationOvershadow our heroic measures, “sure they saved my life, but they missed my sprained ankle”Missed cuz…Tx life-threatening stuff 1stAltered sensoriumDistracting injuriesInadequate p/eMisinterpretation of investigations
112MI defined as injury detected >24hrs after A or missed by 3° survey Intervention: 3° form required to be filled out for ever patient admitted to the TICU or trauma serviceResults: significant decrease in MI’s post intervention
114Missed Injuries Unavoidable to some extent To prevent… Think of MOI 3° Exam – no studies in ED, but makes senseD/c instructionsInterpret your x-raysIf they’re not going to trauma – ENSURE NOTHING ELSE IS GOING ON