Advanced Trauma Life

Support

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S
 INTRODUCTION

S The treatment of seriously injured patients requires

the rapid assesment of injuries and intitution of life-
preserving therapy. Because timing is crucial, a
systematic approach that can be rapidly and
accurately applied is essential. This approach is
termed the initial assesment and includes the
following elements

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 INTRODUCTION
INITIAL ASSESMENT
1. Preparation

2. Triage

3. Primary survey (ABCDEs)

4. Resuscitation

5. Adjuncts to primary survey and resuscitation

6. Consideration of the need for patient transfer

7. Secondary survey (head to toe evaluation and patient history)

8. Adjuncts to the secondary survey

9. Continued post resuscitation monitoring and re evaluation

10. Definitive care 3

 1. PREPARATION

S Pre-hospital phase
Coordination with prehospital agencies and personnel can greatly
expedite treatment in the field and should be set up to notify the receiving
hospital before transport the patient frome the scene.
S In Hospital Phase
S Advanced planning for the trauma patient arrival is essensial. A resuscitation
area should be available. Properly functioningairway equipment (e.q.
laryngoscopes and tubes) should be organized.

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 2. TRIAGE
Triage involves the sorting of patients based on their needs for
treatment and the resources available to provide that treatment.

Triage situations are categorized as multiple

casualties or mass casualties
S A Multiple Casualties
Although there is more than one patient, the number of patients
and the severity of their injuries do not exceed the capability of the
facility to render care.
S Mass Casualties
The number of patients and the severity of their injuries exceed
the capability of the facility and staff.
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Color Codes Triage Tag
RED : Most critical injury
YELLOW : Less critical injured
GREEN : No life or limb threatened injury
BLACK : Death or obviously fatal injury

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 3. PRIMARY SURVEY

S A : Airway with cervical spine protect.

S B : Breathing

S C : Circulation --control external bleeding.

S D : Disability or neurological status

S E : Exposure (undress) & Environment (temp control)

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 3. PRIMARY SURVEY

S Priorities for the care of Adult , Pediatrics & Pregnancy women are all
the same.
S During the primary survey life threatening conditions are identified and
management is instituted SIMULTANEOUSLY.

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 Airway Maintenance with
Cervical Spine Protection.

S GCS score of 8 or less require the placement of definite airway.

S Protection of the spine & spinal cord is the important
management principle.
S Neurological exam alone does not exclude a cervical spine injury.
S Always assume a cervical spine injury in any pt with multi-
system trauma, especially with an altered level of consciousness
or blunt injury above the clavicle.

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 Breathing & Ventilation

S * Airway patency does not assure adequate ventilation.

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Circulation with Hemorrhage Control

S Blood Volume & Cardiac Output

S level of consciousness.
S skin color
S Pulse.
S Bleeding
S external bleeding is identified & controlled in the
S primary survey.
S Tourniquets should not be use.

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 Disability ( Neurological
Evaluation)

S Simple Mnemonic to describe level of consciousness ( AVPU )

S A : Alert
S V : Responds to Vocal stimuli
S P : Responds to Painful stimuli
S U : Unresponsive to all stimuli

S Not forget to use also Glascow Coma Scale.

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 Exposure / Environmental
Control

S It is the pts body temp that is most important, not he comfort of the
health care provider.
S Intravenous fluid should be warm.

S Warm environment (room tem) should be maintained.

S early control of hemorrhage.

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 4. RESUSCITATION

S Airway
S definite airway if there is any doubt about the pts ability to maintain airway integrity.

S Breathing /Ventilation/Oxygenation
S every injured pt should received supplement oxygen

S Circulation
S control bleeding by direct pressure or operative intervention
S minimum of two large caliber IV should be established
S pregnancy test for all female of child bearing age.
S Lactated Ringer is preferred & better if warm.

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 5. ADJUNCT TO PRIMARY SURVEY &
RESUSCITATION

S Electro-cardiographic Monitoring
S Urinary & Gastric Catheter
S Urinary catheter.
S Urethral injury should be suspected if
S Blood at the penile meatus
S Perineal ecchymosis
S Blood in the scrotum
S High riding or nonpalpable prostate
S Pelvic fracture

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 Monitoring
Ventilatory rate & ABG
Pulse oximetry
does not measure ventilation or partial O2 pressure
Blood pressure
poor measure of actual tissue perfusion.
X-Ray & Diagnostic Studies
C-spine, CXR, Pelvic film
Essential x-ray should not be avoid in pregnant pt.

*** Consider the need for patient transfer.

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 6. SECONDARY SURVEY

S Does not begin until the primary survey (ABCDEs) is

completed
S Head to Toe evaluation of the trauma patient that is a complete
history and physical examination,including reassesment of all vital
sign.
S During the secondary survey, a complete neurologic examination is
performed, including a repeat GCS score determination. X-Ray are
also obtained, as indicated by the examination.

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 6. SECONDARY SURVEY
Anamnesis
History
A : Allergies.
M : Medication currently used.
P : Past illness/ Pregnancy.
L : Last Meal
E : Events/Environment related to the injury.
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 6. SECONDARY SURVEY

ANAMNESIS

The patients condition is greatly influenced

by the mechanism of injury. Injury usually is
classified into two broad categories
-Blunt trauma
-Penetrating trauma

Other types of injuries:

-Thermal injury
-Hazardous Environment
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 PHYSICAL EXAMINATION
Follow the sequence of:
1. Head
2. Maxillofacial structures
3. Cervical spine and Neck
4. Chest
5. Abdomen
6. Perineum/Rectum/Vagina
7. Musculoskeletal system
8. Neurologic System

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 PHYSICAL EXAMINATION
1. HEAD
The entire scalp and head should be examined for lacerations, contusion, and evidence
of fractures.
Because edema around the eyes can later preclude an in-depth examination,the eyes
should be reevaluated for:
S Visual acuity
S Pupillary size
S Hemorrhage of conjunctiva and fundus
S Penetrating injury
S Contact lenses(remove before edema occurs)
S Dislocation of lens
S Ocular movement 21
2. MAXILLOFACIAL STRUCTURES
If not associated with airway obstruction or major
bleeding should be treated only after patient is stabilized
completely.
3. CERVICAL SPINE & NECK
Patient with maxillofacial or head trauma should be
presumed to have an unstable cervical spine injury and the
neck should be immobilized until all aspect of the cervical
spine have been adequately studied and an injury has been
excluded.

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 4. CHEST

Elderly patients may not

tolerate even relatively minor
chest injuries.
Children often sustain
significant injury to the
intrathoracic structures
without evidence of thoracic
skeletal

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5. ABDOMEN
Normal physical examination do net get rid of diagnostic
abnormalities intraabdomen because sign maybe arise
slowly

6. PERINEUM/RECTUM/VAGINA

contusio, hematom, laceration, and bleeding from

urethra or vagina

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 7. MUSCULOSKELETAL SYSTEM
deformity, fracture or dislocation
8. NEUROLOGICAL SYSTEM
examination for consciousness, size of pupils, motoric
and sensoric examination

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7. ADJUNCT TO THE SECONDARY SURVEY
include additional x-ray and all other special procedure.

8. RE-EVALUATION
Adult urine output 0.5ml/kg/hr
Pediatric urine output 1mg/kg/hr
*Pain relief

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 10. DEFINITE CARE

S Indication For Definite Airway

S Unconscious
S Severe maxillo-facial fracture
S Risk for aspiration : Bleeding/ vomiting
S Risk for obstruction : neck hematoma/laryngeal,tracheal injury/ stridor
S Apnea : Neuromuscular paralysis/unconscious
S Inadequate respiratory effort: tachypnea/hypoxia/hypercapnia/cyanosis
S Severe closed head injury need for hyperventilation

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 Normal Blood Amount:
Normal adult blood volume : 7% of body weight
Normal blood volume for child : 8-9% of body weight

Hemorrhage Classification :
Class I Hemorrhage : up to 15% loss
Class II Hemorrhage : 15-30% loss
Class III Hemorrhage : 30-40% loss
Class IV Hemorrhage : >40% loss

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 3 for 1 Rule

a rough guideline for the total amount of crystalloid

volume acutely is to replace each ML of blood loss
with 3 ML of crystalloid fluid, thus allowing for
restitution of plasma volume lost into the interstitial
& intracellular space

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 Initial Fluid Therapy

Lactated Ringer is preferred

* For adult 1-2 liters bolus

* For child 20ml/kg bolus

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Head Injury Classification:

Mild : GCS 14-15

Moderate : GCS 9-13
Severe : GCS 3-8

Coma = GCS score of 8 or less

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 Fluid Therapy in
2nd or 3rd Degree Burn

Total amount of first 24 hours:

4 ml of Ringer lactate x BW(kg) x BSA
* give 1/2 in first 8 hrs
* 1/2 in remaining 16 hrs

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Priorities with multiple injuries

1. Thoracic trauma or tamponade

2. Abdominal hemorrhage
3. Pelvic Hemorrhage
4. Extremity Hemorrhage
5. Intra-cranial Injury
6. Acute Spinal Cord Injury

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 THANK YOU

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