ATLS [PDF]

Citation preview

A.T.L.S. Primary Secondary Survey Head Injury Spinal Injury



Primary survey A : Airway B : Breathing C : Circulation D : Disability E : Exposure Goal : recognizing life threatening condition and simultaneously do resuscitation      



Airway  Cervical Spine Control (Assume injury until proven otherwise)  Airway assessment – Obstruction? Patient can talk airway clear – Look (cyanosis/breathing pattern/uses of accessories muscle/RR/Pox ) – Listen (grunting/stridor/ total obstruction  silent) – Feel (decreased/absent airflow)  Airway management – Triple airway maneuver only if w/o possible cervical spine injury :  Slight neck extension  Jaw thrust ( elevation of mandible)  Mouth opening – Possible cervical injury : without neck extension – Adjunctive devices : oropharyngeal airway ( only if no gag reflex) / Nasopharyngeal airway ( KI: susp. Basilar skull fracture/coagulapaty) Breathing  Assesment : Look ( sign of respiratory distress/ equal chest rise /RR/P ox) /Listen ( lung sound ) /Feel ( trachea position /crepitus ,emphysema subcutis) /P  Management : Oxygen supplement / Assisted ventilation  Manual assisted ventilation – Indication : Apneic/Inadequate ventilation – Bag valve mask , RR:12 to 16 x/min, 100 % oxygen with max flow ( >10 l/min) Circulation  Assestment : pulse ( carotid/femoral/radial) / BP/HR /evaluate quickly for areas of large hemorrhaging that can easily be stopped with direct pressure  Management : – 2 Large/short IV bore : 16 or intraosseous needle – NS /RL 2-3 L/min or 20 cc/kg bolus in children – No response, blood , O negative Disability (Neuro)  AVPU ( Alert / Verbal response/Pain response/Unresponsive)  GCS ( Adult/children) Exposure  Undress patient for thorough examination  Remember hypothermia



Remember neck/spinal immobilization







Addition on primary survey  Vital sign monitor ( BP/P ox/HR or Pulse rate) / Cardiac monitor  ECG  Urinary catheter – Check for possible urethra rupture ( blood OUE/scrotal or perineal hematome/ RT : unpalpable / high prostate) – If susp. Urethra rupture, need urethra-systogram  X-ray : Cervical ( lateral ) / Thorax (AP) /Pelvic ( AP)



Secondary survey After primary survey / resuscitation and ABC stabilize Examine patient from head to toe Anamnesis : AMPLE ( Allergy / Medication/ Past medical history/ Last meal/ Event , mechanism of injury)   



HEENT  Examine face for facial fractures  Examine eyes for any gross injury, shattered glass should be irrigated then flourescein  Examine ears for hemotympanum  Examine mouth for jaw fractures/loose teeth Neck Ask patient if s/he has any neck pain Midline tenderness? Penetrating wound : which zone ? trauma to the arteries/airway?



  



Chest  Palpate entire chest for area of crepitus/tenderness  Look for Seat belt sign/bruising /asymmetric  Listen to breath sounds, symmetric ? other additional sounds?  Listen to heart sound Abdomen  Look for distension / bruising / seat belt sign  Examine for area of tenderness  Pelvic  Examine for tenderness AP/Lateral compression  Genitourinary/rectal  Examine externally for signs of bleeding  Rectal exam for blood/position of prostate( male) Back     



 



Log roll Look for bruising / tenderness on bone palpation / penetrating wound Extremities Look for deformity/laceration / bleeding site /abrasion Palpation for area of tenderness/crepitus/pulsation Neurologic GCS/Mental Status Limited sensory/motor exam



Laboratory test  Cervical spine : AP/Lateral/open mouth ( odontoid)  Hemoglobin : serial : 3x q 15 min  Urinalysis  Extremities X-ray  USG abdomen /CT



Head Injury Classification  Mild Head Injury : GCS : 13-15  Moderate Head Injury : GCS : 9 – 12  Severe Head Injury : GCS : 3-8 Goal  Discover all moderate/severe head injury  Discover mild head injury with intracranial injury especially needing surgery – Observation/education : patient that first appear with mild injury may worsen over several hours – Risk stratifying – Cost –effectiveness Glasgow Comatose Scale  



Adult /Children ( check in PDA : epocrates / table/ GCS ) Serial check



Mild Head Injury Clinical predictor : – GCS / Loss of consciousness  GCS 15 / LOC (+) : 10 % Intracranial injury (+) , 1% need surgery  GCS 13/ LOC (+) : 38 % Intracranial injury (+) , 8 % need surgery – Location of injury : temporo-parietal , increased risk of epidural bleeding – Significant retrograde amnesia – Older patient – Preexisting condition : on anticoagulant / hemophiliac – Difficulty to determine Level of Consciousness in intoxicated patient ( alcohol / drugs) – Sign of basilar fracture ( battles sign / raccoon eyes/ CSF leakage from nose ,ear / hemotympanum ) 



Head X-ray – Only if patient stable otherwise don’t waste time – For facial fracture CT scan Infant < 12 months , all unless :  Fall less than 1metres ( 3 feet)  Normal neuro exam  No evidence of scalp trauma ( bruising/hematoma etc) – Older children and adult  AbN neuro exam/GCS < 15  Prolonged LOC ( > 15 min)  Retrograde amnesia > 30 min  Repeated vomiting  Worsened/severe headache  Depressed skull fracture/basilar skull fracture –



Special consideration : ( anticoagulation / older patient with LOC/Intoxicated ) – Not sure / concerning mechanism of injury : CT Scan – CT scan (-) but abN neuro exam , plan for another CT in 24/48 hours or significant worsening of symptoms. 



Disposition – Mild Head Injury , No neurological deficit , GCS : 15 . low risk stratification – No Intra cranial injury on Head CT , normal neuro exam – Observation for 24 hours , including neuro checks q 2-4 hours by responsible adult ( Head Injury patient leaflet) – Follow up the next day Admission – Intra cranial injury (+) on Head CT – All abN Neuro exam / GCS < 15 Other consideration – Second Impact syndrome – Head Injury in sports , Can I return to the game? Post concussive syndrome – Headache / dizziness / poor concentration / memory problems/ emotional problems. – Most resolves after few weeks , 90 % resolves in 1 year , 10 % became chronic – If worsening , Neuro evaluation / Head CT



Moderate / Severe Head Injury      



ABC Cervical immobilization Maintain good oxygenation /perfusion ( avoid hypotension from shock) Prophylaxis anti seizures ( phenytoin) /Manitol Head CT Referral hospital / Neurosurgeon / Neurologist



Spine Injury ABCDE / Primary survey / A with cervical immobilization /Spine immobilization with long spine board/back board.  Maintain in line immobilization , i.e. hold the head with your hands/ Log roll during examination  Usage of back board : for transportation , > 2 hours can cause decubitus ulcer , if > 2 hours need to log roll q 2 hourly 



Neurological exam : – Sensory exam , check level – Motor exam , score 0 – 5 , check level – Proprioseptive / vibratory function ( posterior column) – Deep tendon reflex – Anogenital ( sacral sparing) : Bulbocavernosus /cremaster /TSA Classification – Level Lowest segment ( caudal) of the spinal cord that still have motoric ( 3/5) /normal sensoric function bilaterally Partial preservation Spinal injury level not the same with Level of bone fracture 



 



– 



–     



–    



Neurologic Deficit Complete /Incomplete Spinal Cord syndrome Anterior cord Central cord Brown Sequard Cauda Equina Spinal shock Morfology Fracture Fracture/Dislocation SCIWORA Penetration injury e.g gun shot



Cervical spine injury  Cervical collar ? If you are worried or unsure  assume there’s cervical injury until proven otherwise . Immobilize /X-ray  Ruled out C-spine injury, Low risk if following guidelines : – No midline tenderness – Alert / no neurological deficit – Not intoxicated – No other distracting injury



C2 C3 C4 C5 C6 C7 C8



Physical exam Sensory exam Top of head Ear Neck Shoulder Thumb Middle finger Little finger



Motor exam C3/4/5 diaphragm Shoulder shrug Biceps ( elbow flexion) Triceps ( elbow extension) Finger muscle



Posterior column sensation proprioception ( finger up/down) Imaging Studies  X-ray : Lateral / Open Mouth Odontoid (OMO) /AP ( check proc. spinosus)  CT –Scan : – To illustrate detail of fracture – If fracture is suspected but no adequate X-ray  MRI : – Ligament /spinal cord Management : Methyl prednisolone, initial dose : 30 mg / kg IV over 1 hour followed by 5.4mg /kg/hour for the next 23 hours ( total 24 hours) Exclusion criteria :  To be given within 8 hours  > 13 years old  No serious injury  Not pregnant  Not already taking other steroids  Not given naloxone recently Neurogenic Shock :



Not common . Cause by spinal cord injury . Decreased vascular tone and relative bradycardia. ( symphatic enervation of the heart) Spinal shock  After spinal cord injury . Flacid / loss of reflexes. Temporary . 



THORACIC TRAUMA Life threatening condition that need to be identified and treated immediately on Primary Survey Airway Laryngeal Injury • Sign of upper airway obstruction ( stridor) • Hoarseness/emphysema subcutaneous emphysema/palpable fracture of the larynx • Humidified Oxygen/IV access/Prepare for early intubation or surgical airway/ ENT consult • If edema larynx : Dexamethasone, adult 4 mg IV, ped: 0.25 mg – 0.5 mg/kg IV Fracture /Dislocation of Sternoclavicular joint • Obvious sign of trauma on the base of the neck with palpable defect on the sternoclav. Joint • Closed reduction of the sternoclavicular joint in supine position Breathing Tension Pneumothorax • Clinical diagnosis : Chest pain / respiratory distress/tachycardia/ hypotension/ tracheal deviation/unilateral absence of breath/JVD/cyanosis • Needle thoracocentesis ( large bore needle , 14-16 G, 2 nd intercostal space, midclav) followed by insertion of chest tube Open Pneumothorax • Large defects of chest wall which remain open or sucking chest wound • Close the defect with sterile occlusive dressing, large enough to overlap the wound, tapes securely on 3 sides Flail chest • Multiple ribs fractures ie, two or more ribs fractured in two or more places • Paradoxical movement of the chest wall ( inspiration/expiration) • Main problem is the underlying lung disease : Pulmonary contusion • Humidified oxygen/fluid resuscitation/analgesic • Asses adequate ventilation for the need for assisted ventilation /intubation Circulation Massive Hemothorax • > 1500 ml blood in the chest cavity or blood loss > 200 ml/hour for 2 to 4 hours • shock associated with the absence of breath sound and or dullness on percussion on one side of the chest • Management : Fluid resuscitation/blood transfusion simultaneously with decompression of chest cavity ( chest tube)



Cardiac Tamponade • Commonly associated with penetrating injury • Beck’s triad : JVD/hypotension/muffled heart sounds, not always present • PEA in the absence of hypovolemia/tension pneumothorax • Pericardiocentesis Secondary Survey • Further physical examination • CXR • P ox /Blood Gas Analysis • ECG Simple Pneumothorax • Decreased breath sounds / hyperresonance /CXR • If pneumothorax < 15 %, no cardiovascular or respiratory compromise : observe for 4 to 6 hours and repeat CXR , if no change : discharge otherwise chest tube insertion Hemothorax • Shown in CXR , needed to be evacuated with chest tube Pulmonary contusion • Cause respiratory failure • Intubation Blunt Cardiac Injury Traumatic Aortic Disruption • Persistent hypotension • CXR: widened mediastinum Subcutaneous emphysema • Not require treatment • Underlying injury • If needed to assist ventilation with positive pressure, anticipate possible pneumothorax Rib fractures • Upper ribs : 1-3 : severe injury , associated with other serious injury ( major blood vessels) • Lower ribs : 10 -12 : considered hepatosplenic injury • Common associated injury : pneumohemato thorax • Treatment : adequate pain management to improve ventilation. Risk of infection esp. in elderly Traumatic Diaphragmatic injury • More common in the left side Sternum/scapular fractures • Generally results of direct pressure • Sternum fracture can accompanied by lung contusion/blunt cardiac injury



ABDOMINAL TRAUMA • • • • • • • • •



Primary survey : ABCDE , Hypotension? Obvious sign of trauma on the abdomen : blunt/penetrating injury Internal organ injury : Liver/spleen/pancreas/hollow viscus/kidney Sign of peritonitis ( distension /tenderness/muscle guarding/ rebound) Serial Hb/urinalysis/pregnancy test Abdominal series /USG Pelvic Injury , associated with major blood vessel Genito-urinary trauma : blood OUE/scrotal-perineal hematoma/high riding prostate or blood on the rectal exam , precaution for urinary catheter. Penetrating injury : closed wound with gauze soaked with NS



MUSCULOSKELETAL TRAUMA • • • • • • • • • • • • •



AB C DE IV/O2 /Monitor Hipovolemic shock  Femur fr. Pain management . Narcotic pain relief ( Pethidine/Morphine) Asses N V D ( Neurovascular distal) . Always check colour/pulsation/capillary refill / sensation, compare bilaterally, and documented prior and after every manipulation /splint Open wound  Open fractures ? , cover with sterile dressing Splint , immobilized one joint above and one joint below the injury site Mal-aligned/ compromise NVD : attempt to realign by gentle traction. If after traction NVD compromise worsened  back to position before and splint in that position Do not forced re-alignment  if difficult splint in that position Tetanus prophylaxis : vaccine/Ig Antibiotic : Cefazolin ( gr I ) , + gentamycine ( gr II / III ) , dose check on 5MEC Orthopedic consult Compartment syndrome o Pain is the earliest symptoms esp. with passive stretching of the involved groups of muscle o Other ischemic sign: 5 P :pain /pressure/paresis/paresthesia/pulse o Unconscious patient is at increased risk



NEAR DROWNING Near Drowning : survival at least a day after submersion Secondary drowning : Complication of near drowning after initially successful resuscitation ( may be delayed by up to 12 hours in otherwise normal appearing patient) In near drowning, aspiration as little as 2 cc/kg may cause lung damage/hypoxia :



• Surfactant loss/alveolar dysfunction • Direct tissue toxicity , pulmonary edema • V/Q mismatch , vasoconstriction Even without aspiration, life threatening pulmonary edema may occur due to cerebral hypoxia or cardiac failure ( dry drowning) Management Prehospital • ABCDE with neck/spinal injury and hypothermia ( especially in children) precaution • Begin CPR immediately with max Oxygen • IV/ Monitor • No role for trying to evacuate water by Heimlich or other maneuvers • Asymptomatic patient still need to be observe for possible secondary drowning Patient with Cardio pulmonary arrest /.P ox < 90 % with max Oxygen, should be transported to hospital with facility of Intubation Emergency Department Consider other associated injuries ( spine/head/other trauma) and medical condition ( AMI/Disrythmia/ stroke) Patient who arrived awake but with respiratory distress or hypoxia • IV /O2 max with NRB/Monitor • CXR PA/Lat and other X-ray if needed • ECG / ABG / electrolyte/BUN /Creatinin/CBC/ Glucose • If unable to maintain P ox > 90 % with max O2, need to intubate • Antibiotic : Levofloxacine 500 mg QD • Observation for 12-24 hours • Repeat CXR/lab test every 6 to 12 hours Patient who arrived without any symptoms • If physical exam/CXR and Pox normal , patient may be discharged after 6 hours of observation ( repeat CXR/lab test) High risk patient • Loss of consciousness • Cardiopulmonary arrest • Cyanotic /tachypnoe / respiratory distress • Seizures • Prolonged time under water /water ingestion • Preexisting medical condition /elderly/young children