Advanced Trauma Life Support An Introduction to management of the trauma patient Rob Simpson Acute Block Teaching

The Pre-hospital phase n Good Trauma Care starts at the road side n Moving towards hub and spoke model in the UK

Trauma Resuscitation n Preparation (call for senior help!!) n Primary Survey (cA&cBCDE) n Resuscitation / Adjuncts to primary survey n Secondary Survey (head-to-toe) n Continued monitoring and re-evaluation n Definitive Care

Preparation n Assemble team n Prepare equipment n Delegate tasks n MIST handover

“The trauma team” n Airway n Primary survey n Lines and bloods n Radiographer / radiology n Scribe n Specialty opinions

Arrival of the patient n MIST handover –MMechanism of injury –I Injuries Identified –S Vital signs –T Treatment & timings

Control of massive haemmorhage n Stepwise process –Direct pressure –Elevation –Tourniquet

Airway n Assessment –Look & listen

Airway with cervical spine control n Manual in-line immobilization n Collar, blocks & tape n Airway manouvers –Jaw thrust –Simple adjuncts –Advanced airway techniques n High-flow oxygen

Breathing n Rapid assessment –Inspection –Auscultation –Percussion –Palpation »Trachea »crepitus

Immediately life “B” problems n TOM FC

n Tension Pneumothorax n Open pneumothorax n Massive haemothorax n Flail segment n Cardiac tamponade

n Do you have a confident management plan for each of these ?

Tension pneumothorax n What is it ? n How does it present ? n What is the immediate action ? n What should be done next ?

Open Pneumothorax n What is it ? n Why does it cause a problem ? n What is the immediate management ? n What should be done next ?

Massive haemothorax n What is the definition of a massive haemothorax ? n What is the management ? n Theatre ?

Flail chest n What is the definition ? n What is the management? n What is the principal concern ?

Cardiac tamponade n Suspect if resistant hypotension in the absence of bleeding n What is the definitive investigation? n What is the treatment ?

Circulation n Assessment n Where has it all gone ? Rule of 5 n Basics of trauma resuscitation – not just sea water! n Massive Transfusion protocol

Assessment n Same as any other “c” assessment n but – n control life threatening haemorrhage

Where has it all gone n 1.Chest n 2.Abdomen n 3.Retroperitoneum /pelvis n 4.Limbs n 5.On the floor »Remember losses at scene

Assessung sites of potential blood loss n Chest xray n Pelvic xray n FAST scan n CT scan

Resuscitation n IV lines n Concept of balanced resuscitation –Radial pulse –Mentation –BP n Use blood as first line fluid – or nothing! n MTP –Military model 1:1:1 –CRASH 2 trial

STOP the bleeding! n Compression of active bleeding sites n Early imaging n Early surgical involvement n Splinting of femoral fractures

Disability n Optimisation of ABCs –Careful BP management n Early CT scan n Early involvement of neurosurgeons n Consider head up if isolated head injury

Exposure/environmental control n Fully expose the patient n Assess for other potentially life/limb threating injuries n Cover the patient

Monitoring n Cardiac monitor n pulse oximeter n automated blood pressure n serial blood gases n urine output n Nurses should institute this during the primary survey / resuscitation phase

Analgesia n Makes assessment easier n patient easier to manage n less stressful for staff n intravenous opiate n titrate to effect n remember anti-emetic

Secondary survey n Head to toe examination for as yet undiscovered injuries n X-ray relevant areas if patient stable enough

DEFINITIVE CARE n essential investigations n necessary specialists n stabilization/protection/safe transfer n further investigation/intervention

Questions?

Summary n Robust pre-hospital care n Experienced and effective team leadership n Rapid identification and treatment of life- threatening injuries n Stabilisation and definitive care