Trauma

 

https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534159/all/ATLS_Algorithms

 

List:

·        Bat call

·        Zero point survey

·        Primary survey

·        Primary response

·        Secondary survey

·        Special groups

 

Bat call:

Patient

·      Age

·      Special: child / pregnant / athlete / comorbid / coagulopathic

Mechanism

·      Blunt

·      Penetrating

·      Burns

·      Any hazard to staff?

Injuries

·      Brain?

·      C-spine?

·      Thorax?

·      Abdomen?

·      Limbs?

Status

·      Vital signs?

·      Conscious state?

Treatment

·      What’s been done so far?

 

Preparation

 

People:

Briefing

·      Gather team

·      Situation

·      Priorities

Role allocation

·      Team leader

·      Surgery

·      Airway

·      Vascular access

·      Blood products

·      Scribe

Heads up here

·      Specialty teams

·      Theatre

·      Blood bank

·      Radiology

Heads up there

·      Receiving hospital

·      Transfer service (i.e. ARV, PIPER)

 

Things:

Environment

·      Danger

·      Space

·      Light

·      Noise

·      Crowd control

Equipment

·      Surgery: chest drains, packs, binders, splints, tourniquets

·      A: suction, face mask, guedel, LMA, laryngoscope, ETT, trachie tie

·      B: oxygen, bag-valve-mask, ventilator

·      C: IVC kit, arterial kit, pumpset, fluid warmer

Monitoring

·      Sat probe

·      NIBP and arterial

·      ECG

·      Capno

 

Primary survey:

Goals

·      Find life-threatening problems

o  A: obstruction

o  B: tension pneumothorax

o  C: exsanguination and tamponade

Quick & dirty

·      Hx: “what is your name?”

·      Ex: end-of-bed-o-gram

Airway

·      Is the C-spine injured?

·      Is the C-spine protected?

·      Is the airway injured?

·      Is the airway patent?

·      Is there a risk of aspiration? (assume unfasted)

Breathing

·      Is it injured?

o  Look

o  Listen

·      Is oxygenation ok?

o  Colour

o  SpO2

·      Is ventilation ok?

o  Look (both sides)

o  Listen (both sides)

o  Capno

Circulation

·      Is there shock?

o  Vital signs

o  Conscious state

o  Skin colour

·      If shock, what is the cause?

o  Bleeding: on the floor plus four more

o  Pneumothorax

o  Tamponade

·      If bleeding, how much?

o  Normal response: <20%

o  Abnormal response: 20-40%

o  No response: >40%

Disability

·      Is there a head injury?

o  Look

o  GCS

o  Pupils

·      Is there a spinal cord injury?

o  Crude peripheral neuro exam

Exposure

·      Are there any injuries we have missed?

o  Head and neck?

o  Chest?

o  Abdomen?

o  Pelvis?

o  Limbs?

·      Is temperature ok?

Investigations

·      Blood tests: FBE, BGHO, biochem, coag, viscoelastic

·      Ultrasound: E-FAST

·      X rays: chest, pelvis

 

Primary response:

Goals

·      Fix life-threatening problems in order of threat

o  A: obstruction

o  B: tension pneumothorax

o  C: exsanguination and tamponade

·      Don’t make existing problems worse

o  Pneumothorax (IPPV)

o  C-spine injury

o  Head injury

Team leader

·      Co-ordinate resuscitation

·      Arrange theatre

Surgery

·      Thorax: chest tubes 30Fr Fr 5th ICS MAL (± after intubation)

·      Abdomen: exploration and packing

·      Pelvis: binder around greater trochanters

·      Limbs: tourniquets (x2 for lower limb), reduction, splints

·      REBOA

Airway & breathing

Basic:

·      Apply soft collar

·      Manual in-line stabilisation

·      Airway manoeuvres

·      Suction

·      Bag and mask

Indications for intubation:

·      A: obstructed, contaminated

·      B: respiratory failure

·      C: shock

·      D: GCS ≤8, combative

·      Logistics: theatre, CT scan, transfer

Intubation plan:

·      Monitoring: NIBP, SpO2, ECG, capno

·      Assistance: 1)airway b)C-spine c)drugs d) team lead

·      Drugs: ketamine 1mg/kg + sux 1.5mg/kg + metaraminol 0.5mg

o  If isolated head injury: use propofol

o  Sedation afterward: not sure

·      Equipment: O2 + suction + plans ABCD + ventilator

·      Plan: video laryngoscope + hyperangulated blade + styletted ETT

Circulation

1.Access:

·      2 x big PIVC

·      VBG (and send others)

·      Pumpset + fluid warmer

·      ±Arterial line

·      ±IDC

2.Haemostasis:

·      Reverse anticoagulation

·      Clotting products

·      Adjuncts (TXA, calcium)

·      Heat

3.Resuscitation:

·      Permissive hypotension: mAP 55, SBP 80

·      If TBI: aim mAP 80, SBP 110

·      Crystalloid max 1.5L

·      Blood

·      Vasoactives

Disability

↑BP:

·      Volume

·      Pressor

↓ICP:

·      Physical

·      Physiological

·      Pharmacological

·      Surgical

Exposure

·      Blanket

·      Forced air warmer

Fate

Theatre:

·      Damage control surgery:

o  Haemostasis

o  Decontamination

Transfer:

·      Patient: special demographic

·      Injury: multi-trauma, head injury, dangerous mechanism

·      Logistics: hospital unable to provide the right care

 

Secondary survey:

History

·      Questions: AMPLE

·      Source: patient + bystanders + paramedics

Examination

·      Head

·      Face

·      Neck

·      Chest

·      Abdomen

·      Pelvis

·      Limbs (& neuro)

·      Back

·      Nether regions

Investigations

·      Blood tests:

o  BGHO

o  FBE, UEC, CMP, LFT

o  Coag, viscoelastic

o  B-HCG

·      Formal imaging: consider

o  Brain

o  C-spine

o  Chest

o  Abdomen

o  Pelvis

o  Limbs

Disposition

·      Theatre

·      ICU

·      Ward

·      Transfer

 

Lethal injuries:

Chest - lethal

·      Airway obstruction

·      Tension pneumothorax

·      Open pneumothorax

·      Massive haemothorax

·      Flail chest

·      Cardiac tamponade

Chest – blunt

Rupture:

·      Aorta

·      Diaphragm

·      Oesophagus

Contusion:

·      Heart

·      Lung

Pelvis

·      Vertical shear -> iliac arteries

·      Open book -> venous plexus

 

 

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