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13.02.06 ATLS

Primary survery
  • Vitals
  • ABG
  • Pulse Ox
  • ETCO2
  • Catheters
    • Urine
    • Gastric
  • Urine o/p
  • ECG


AMPLE

  • Allergies
  • Medications
  • PMH
  • Last meal
  • Event / Environment


Guedel airway

  • Hard-to-hard
    • Incisors to angle of jaw
  • Soft-to-soft
    • Side of mouth to tragus
  • Put it in upside down + turn


Nasopharyngel airway

  • Size of their little finger
  • Length = Tip of nose to tragus
  • Put in the right side


Shock

  • Blood loss is like tennis:
    • 15%
      • 750 ml
      • Unlikely even to notice
    • 30%
      • 1.5 litres
      • Tachy but normotensive
        • This is the dangerous one!
    • 40%
      • 2 litres (e.g. femur/pelvis fracture)
      • Start to become hypotensive
    • Game (>40%)
      • Bradycardia
      • Catastrophic hypotension


Danger areas in assessing shock

  • The 30%-ers
    • Still normotensive
  • Athletes
    • 80 bpm may be very tachy.
  • Beta blockers


Rib fractures

  • 1-3
    • Need SEVERE force
    • Check for associated injuries
      • Brachial plexus
      • C. spine
      • Vessels
  • 4-9
    • Risk of pulmonary contusion + pneumothorax
  • 10-12
    • Look for abdo injury (spleen etc)


6 killers in thoracic trauma

  • Laryngeotracheal injury
    • Rare
    • Horseness
    • Subcut emphysaema
      • Walking on snow
  • Tension pneumothorax
    • Resp. distress
    • Shock (from VENOUS compression)
    • Distended neck veins (may be hidden by c. spine collar)
    • Cyanosis is a LATE sign
  • Open pneumothorax
    • Seal 3 sides => Valve to let air out
  • Flail chest / Pulmonary contusion
    • Multiple ribs broken in multiple places
    • => Sections sucked in on inspiration
    • => Contusion underneath => Blood in lung
    • Big ventilation problems appear in a few hours
  • Massive haemothorax
    • Requires a BIG vessel
    • Stage 3 shock
    • No breath sounds
    • Dull percussion
    • Fluid level on CXR but only if upright
  • Cardiac tamponade
    • PEA
    • Muffled heart sounds
    • Hypotension
    • Distended neck veins


Other serious thoracic traumas

  • Tracheobronchial tree injury
    • Causes a persistent pneumothorax (still bubbling after an hour)
  • Blunt cardiac injury
    • Bruising => Dysrhythmia
  • Oesophageal rupture
    • Pain + shock out of proportion to injury
    • Patriculate matter comes out of chest tube
    • Check with contrast swallow
  • Simple pneumothorax
    • Beware pressure changes (ventilation, air transfer)
  • Pulmonary contusion
    • May look like a haemothorax on CXR
  • Traumatic aortic disruption


Notes

  • SBP >80 to feel peripheral pulse
  • Careful with fluid resuscitation - Can dislodge clot
  • FAST scan for free fluid
    • Focused Assessment with Sonography for Trauma
  • Diagnostic peritoneal lavage - Only in resource-poor settings these days
  • Seesaw respiration => Obstructed airway
  • Women tend to be chest-breathers (to prepare for pregnancy?)
  • Pelvis = Polo mint => Look for secondary break
  • Abdo injury = Nipples to groin (trauma can be very high up!)
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