Atls (Advanced Trauma Life Support) Teaching Protocol

Class III
Class IV
Blood Loss (ml)	Up to 750	750-1500	1500-2000	>2000
Blood Loss (% Blood Volume)	Up to 15 %	15-30 %	30-40 %	>40 %
Pulse Rate	<100	>100	>120	>140
Blood Pressure	Normal	Normal	Decreased	Decreased
Pulse Pressure (mmHg)	Normal or increased	Decreased	Decreased	Decreased
Respiratory Rate	14-20	20-30	30-40	> 35
Urine Output (mL/hr)	>30	20-30	5-15	Negligible
CNS/Mental status	Slightly anxious	Mildly anxious	Anxious, Confused	Confused, lethargy
Fluid Repacement (3:1 rule)	Crystalloid	Crystalloid	Crystalloid and blood	Crystalloid and blood

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  Fluid Therapy:
  

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  Fluid bolus: 1-2 liters for an adult and 20mL/kg for a pediatric patient
  
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  3:1 rule
  
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  39 C ( 1 liter fluid, microwave, high power, 2 minutes )
  

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  Blood Replacement:
  

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  PRBC/Whole blood
  
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  Crossmatched/type-specific/ type O blood
  
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  FFP ( 1U FFP for every 5 U PRBC)
  

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  CVP monitoring
  

Thoracic Trauma

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  PATHOPHYSIOLOGY
  

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  1. Hypoxia: a. Hypovolemia (blood loss); b. Pulmonary ventilation / perfusion mismatch (contusion, hematoma, alveolar collapse); c. Changes in intrathoracic pressure relationships (tension pneumothorax, open pneumothorax)
  

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  2. Hypercarbia: a. Inadequate ventilation due to changes in intrathoracic pressure; b. Depressed level of consciousness
  

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  3. Metabolic acidosis: Hypoperfusion of the tissues (shock)
  

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  ASSESSMENT & MANAGEMENT:
  

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  Must consist of:
  

1. 
   Primary survey
   
2. 
   Resuscitation of vital functions
   
3. 
   Detailed secondary survey
   
4. 
   Definitive care
   

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  PRIMARY SURVEY ( Life-threatening injuries )
  

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  Airway:
  

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  Recognition of: Stridor, change of voice quality, obvious trauma
  
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  Major problems:
  

1. 
   FB obstructions,
   
2. 
   Laryngeal injury,
   
3. 
   Posterior dislocation / fracture dislocation of the sternoclavicular joint.
   

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  Management: Establishing a patent airway/ ET intubation; closed reduction.
  

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  Breathing:
  

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  Recognition of: Neck vein distention, respiratory effort and quality changes, cyanosis
  
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  Major problems:
  

1. 
   Tension pneumothorax:
   

• 
  Clinical diagnosis
  
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  Chest pain, air hunger, respiratory distress, tachycardia, hypotension, tracheal deviation, unilateral absence of breath sounds, neck vein distention, cyanosis. (V.S. cardiac tamponade)
  
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  Hyperresonant percussion.
  
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  Immediate decompression: Needle decompression/ chest tube.
  

2. 
   Open pneumothorax:
   

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  2/3 of the diameter of the trachea – impaired effective ventilation
  
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  Sterile occlusive dressing, taped securely on 3 sides.
  
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  Chest tube (remote)
  

3. 
   Flail chest:
   

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   2 ribs fractured in two or more places.
  
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  Severe disruption of normal chest wall movement.
  
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  Paradoxical movement of the chest wall.
  
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  Crepitus of ribs.
  
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  The major difficulty is underlying lung injury ( pulmonary contusion)
  
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  Pain.
  
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  Adequate ventilation, humidified oxygen, fluid resuscitation.
  
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  The injured lung is sensitive to both underresuscitation of shock and fluid overload.
  

4. 
   Massive hemothorax:
   

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  Compromise respiratory efforts by compression, prevent adequate ventilation.
  

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  Circulation:
  

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  Assessment: Pulse quality, rate and regularity. BP, pulse pressure, observing and palpating the skin for color and temperature. Neck veins.
  
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  Important notes: Neck veins may not be distented in the hypovolemic patient with cardiac tamponade, tension pneumothorax,or traumatic diaphragmatic injury.
  
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  Monitor with: Cardiac monitor/pulse oximeter.
  

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  Major problems:
  

1. 
   Massive hemothorax:
   

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  Rapid accumulation of > 1500 mL o blood in the chest cavity.
  
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  Hypoxia
  
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  Neck veins may be flat secondary to hypovolemia
  
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  Absence of breath sounds and/or dullness to percussion on one side of the chest
  
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  Management: Restoration of blood volume and decompression of the chest cavity.
  
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  Indication of thoracotomy: a. Immediately 1500 mLof blood evacuated. b. 200mL/hr for 2-4 hrs. c. Patient’s physiology status. d. Persistent blood transfusion requirements.
  

2. 
   Cardiac tamponade:
   

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  Beck’s triad: venous pressure elevation, decline in arterial pressure, muffled heart tones.
  
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  Pulsus paradoxicus.
  
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  Kussmaul’s sign.
  
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  PEA
  
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  Echocardiogram.
  
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  Management: Pericardiocentesis.
  

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  RESUSCITATIVE THORACOTOMY
  

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  Left anterior thoracotomy
  
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  The therapeutic maneuvers that can be effectively accomplished with a resuscitative thoracotomy are:
  

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  Evacuation of pericardial blood causing tamponade.
  
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  Direct control of exsanguinating intrathoracic hemorrhage
  
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  Open cardiac massage
  
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  Cross cramping of the descending aorta to slow blood loss below the diaphragm and increase perfusion to the brain and heart.
  

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  SECONDARY SURVEY:
  

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  Further in-depth PE, Chest x-rays (PA), ABG, Monitoring.
  
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  Eight lethal injuries are considered:
  

1. 
   Simple pneumothorax
   
2. 
   Hemothorax
   
3. 
   Pulmonary contusion
   
4. 
   Tracheobronchial three injuries
   
5. 
   Blunt cardiac injuries
   
6. 
   Traumatic aortic disruption
   
7. 
   Traumatic diaphragmatic injury
   
8. 
   Mediastinal traversing wounds.
   

Simple Pneumothorax

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  Breath sounds are decreased on the affected side. Percussion demonstrates hyperresonance.
  
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  CXR
  
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  Chest tube insertion  F/U CXR..
  
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  Never use general anesthesia or positive pressure ventilation to patient who sustains traumatic pneumothorax until a chest tube is inserted.
  

Hemothorax

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  Lung laceration/ intercostal vessel laceration/ Int.mammary a. Laceration.
  
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  Chest tube
  
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  Guide line of surgical exploration.
  

Pulmonary Contusion

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  Respiratory failure.
  
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  Patients with significant hypoxia should be intubated.
  
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  Monitoring.
  

Tracheobronchial Tree Injury

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  Hemoptysis, subcutaneous emphysema, tension pneumothorax with a mediastinal shift.
  
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  Pneumothorax associated with a persistent large air leak after tube thoracostomy.
  
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  Bronchoscopy
  
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  Opposite main stem bronchial intubation.
  
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  Intubation may be difficult  operative intervention
  

Blunt Cardiac Injury

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  Result in: Myocardial muscle contusion, cardiac chamber rupture, valvular disruption.
  
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  Hypotension, ECG abnormalities, wall-motion abnormality
  
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  ECG: VPC, sinus tachycardia, Af, RBBB, ST seg. changes.
  
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  Elevated CVP.
  
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  Monitor.
  

Traumatic Aortic Disruption

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  High index of suspicion
  
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  Adjunctive radiological signs:
  

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  Widened mediastinum
  
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  Obliteration of the aortic knob
  
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  Deviation of the trachea to the right
  
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  Obliteration of the space between the pulmonary artery and the aorta
  
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  Depression of the left main bronchus
  
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  Deviation of the esophagus to the right
  
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  Widened paratracheal stripe
  
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  Widened paraspinal interfaces
  
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  Presence of a pleural or apical cap
  
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  Left hemothorax
  
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  Fractures of the first or second rib or scapula.
  

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  Angiography is the gold standard.
  
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  On critical.
  

Traumatic Diaphragmatic Injury

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  More commonly diagnosed on the left side
  
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  NG tube
  
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  UGI series.
  
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  Direct repair.
  

Mediastinal Traversing Wounds

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  Surgical consultation is mandatory.
  
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  Hemodynamic abnormal : thoracic hemorrhage, tension pneumothorax, pericardial tamponade.
  
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  Mediastinal emphysema: esophageal or tracheobronchial injury.
  
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  Mediastinal hematoma: great vessel injury.
  
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  Spinal cord.
  
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  For stable patient.
  

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  Angiography
  
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  Water-soluble contrast esophagography
  
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  Bronchoscopy
  
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  CT
  
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  Ultrasonography.
  

Others

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  Subcutaneous emphysema
  
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  Traumatic Asphyxia
  

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  Compression of the SVC.
  
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  Upper torso, facial and arm plethora.
  

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  Rib, Sternum, and Scapular fractures.
  
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  Blunt esophageal Rupture
  

Abdominal Trauma

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  Mechanism of Injury:
  

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  Blunt Trauma:
  

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  Spleen, liver, retroperitoneal hematoma
  

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  Penetrating Trauma:
  

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  Stab: Liver, small bowel, diaphragm, colon
  

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  Gunshot: small bowel, colon, liver, abdominal vascular structures.
  

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  Assessment:
  

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  Hitory.
  
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  PE:
  

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  Inspection
  
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  Auscultation:
  

1. Bowel sounds

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  Percussion
  

1. 
   signs of peritonitis
   
2. 
   Tympanic/ diffuse dullness
   

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  Palpation
  

1. 
   Involuntary muscle guarding
   

• 
  Evaluation of penetrating wounds:
  

Determine the depth

• 
  Assessing pelvic stability:
  

Manual compression

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  Penile, perineal and rectal examination:
  

1. 
   Presence of urethral tear.
   
2. 
   Rectal exam: Blunt (sphincter tone, position of the prostate, pelvic bone fractures), Penetration (sphincter tone, gross blood from a perforation)
   

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  Vaginal examination
  
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  Gluteal examination
  

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  Intubation:
  

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  Gastric tube:
  

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  Relieve acute gastric dilatation.
  
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  Presence of blood
  

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  Urinary catheter:
  

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  Relieve urine retention
  
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  Monitoring urine output.
  
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  Caution: The inability to void, unstable pelvic fracture,blood in the meatus, a scrotal hematoma, perineal ecchymoses, high-riding prostate.
  

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  X-rays studies:
  

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  Blunt Trauma:
  

• 
  Hemodynamically stable:
  

Supine/upright abdominal x-rays

Left lateral decubitus film

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  Penetrating Trauma:
  

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  Hemodynamically stable:
  

Upright CXR.

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  Contrast Studies:
  

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  Urethrography
  
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  Cystogaphy
  
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  IVP
  
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  GI series
  

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  Special diagnostic studies in blunt trauma:
  

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  DPL
  
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  Ultrsonography
  
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  Computed tomography
  

• 
  Special diagnostic studies in penetrating trauma:
  

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  Lower chest wounds
  
• 
  Anterior abdominal
  
• 
  Flank/back
  

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  Indications For Celiotomy
  

• 
  Based on abdominal evaluation
  

• 
  Blunt: Positive DPL/ ultrasound
  
• 
  Blunt: Recurrent hypotension despite adequate resuscitation
  
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  Peritonitis
  
• 
  Penetrating: Hypotension
  
• 
  Penetrating: Bleeding from the stomach, rectum, GU tract.
  
• 
  Gunshot wounds: Traversing the peritoneal cavity
  
• 
  Evisceration
  

• 
  Based on x-rays studies:
  

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  Free air, retroperitoneal free air, rupture of the hemidiaphragm
  
• 
  CT demonstrates ruptured organ/ GI tract.
  

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  Special Problems
  

• 
  Blunt Trauma:
  

• 
  Diaphragm
  
• 
  Duodemun
  
• 
  Pancrease
  
• 
  Genitourinary
  
• 
  Small bowel
  

• 
  Pelvic Fractures:
  

• 
  Assessment:
  

• 
  The flank, scrotum and perianl area should be inspected
  
• 
  Blood at the urethral meatus, swelling/bruishing/laceration in the peritoneum, vagina, rectum, or buttock  open pelvic facture
  
• 
  Palpation of a high-riding prostate gland.
  
• 
  Manual manipulation of the pelvis should be performed only once.
  

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  Management:
  

Exsanguination with/without open pelvic fracture (BP<70mmHg)	Blood pressure stabilizees with difficulty and closed/unstable fracture (BP 90-110mmHg)	Blood Pressure normal and closed/unstable or stable fracture (BP 120 mmHg)
Initiate ABCDEs If transfer neccessary, apply PASG If open go to OR for possible perineal exploration and celiotomy ; if closed, supraumbilical DPL or Ultrasound to exclude intraperitoneal hemorrhage. Positive Negative After operation Red uce & reduce & apply apply fixation device fixation device as appropriate as appropriate Hemodynamically Abnomal Angiography	Initiate ABCDEs If transfer neccessary, apply PASG supraumbilical DPL or Ultrasound to exclude intraperitoneal hemorrhage. Positive Negative After celiotomy Reduce reduce & apply & apply fixation device fixation as appropriate device as appropriate Hemodynamically Abnomal Angiography	Initiate ABCDEs If transfer neccessary, apply PASG Evaluate for other injuries Apply fixation device if needed for patient mobility