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!)