Trauma

 

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

 

A few points:

-Primary survey and response happen simultaneously

-Sub-components of the paimry survey and reponse likewise happen stimulteannesly

-Secondary survey oes not start until vital signs simproved

-regularly monitor vital signs

-regularly monitor for deterioration

-repeat assessment to make sure nothing is missed

-secondary survey: section for procedures i.e. NGT or IDC

-Tension pneumothorax: if conscious and spont vent then extreme air hunger; if mech vent then CVS collapse

 

 

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 trauma

·      Penetrating trauma

·      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:

Questions

·      Threat to life?

·      Threat to limb?

·      Threat to organ?

Quick & dirty

·      Hx: “what is your name?” (A + B + C + D)

·      Ex: vital signs + take a look

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

o  Ultrasound

·      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  Pulse

o  Conscious state

o  Skin colour

·      If shock, what is the cause?

o  Bleeding?

1.    External

2.    Chest

3.    Abdomen

4.    Pelvis

5.    Retroperitoneum

6.    Thigh

o  Tension pneumothorax?

o  Tamponade?

·      If bleeding, how much?

o  Responding: <20%

o  Transiently responding: 20-40%

o  Not responding: >40%

Disability

·      Is there a head injury?

o  GCS

o  Pupils

·      Is there a spinal cord injury?

o  Crude peripheral neuro exam

Exposure

·      Are there any injuries we can’t see?

·      Is temperature ok?

Fly, you fools!

Indications for transfer:

·      Patient

o  See special categories above

·      Injury

o  Multiple injuries

o  Dangerous mechanism

o  Head injury

·      Hospital

o  Equipment

o  Expertise

 

Primary response:

Goals

·      Fix problems in order of priority

·      Don’t make existing problems worse (esp C-spine and brain)

Team leader

·      Co-ordinate resuscitation

·      Arrange theatre

Surgery

·      Thorax: chest tubes 30Fr Fr 5th ICS MAL

·      Abdomen: packing

·      Pelvis: binder

·      Limbs: reduce and splint

Airway & breathing

·      Apply collar!

·      Observe

·      Auscultate

·      Manual in-line stabilisation

·      ±Jaw support

·      ±Bag & mask

·      ±Intubate

Circulation

1.Access:

·      2 x big PIVC

·      VBG (and send others)

·      Pumpset + fluid warmer

·      ±Arterial line

·      ±IDC

2.Resuscitation:

·      Crystalloid

·      Blood

·      Vasoactives

3.Haemostasis:

·      Reverse anticoagulation

·      Give clotting products

·      Give adjuncts (TXA, calcium)

·      Keep warm (air, fluid)

Disability (neuro)

Optimise mAP: 80-90mmHg

·      Volume

·      Pressor

Minimise ICP:

·      Physical

·      Physiological

·      Pharmacological

·      Surgical

Exposure

·      Blanket

·      Forced air warmer

 

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

 

CPR in special groups

Chest trauma

·      Bilateral chest compression

·      Early thoracotomy

o  If tamponade: decompress

o  If bleeding: stop it

o  If looks normal: clamp descending aorta

Pregnant

·      Get baby out ASAP if >24/40

·      Right hip wedge

·      Defib pads anterior + posterior

·      CPR higher

·      ICCs higher

·      Anti-D if Rh-ve

Child

·      Good compensation for blood loss until the end

·      Blood volume low in absolute terms

·      Drug dosing issues

·      Equipment sizing issues

 

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