ATLS / EMST
Outline
- reception
- primary survey
- secondary survey
- radiology
- procedures
- limb injuries
- spinal injuries
Reception
- Prehospital Information
- Nature of Incident
- Number, age & sex of casualties
- ABCD
- Management & Effect
- ETA
Airway & Cervical Spine control
- Assess: Ask name, facial/neck injuries, vomit
- Clear Airway: with sucker or Magill forceps
- Chin Lift - one hand on chin, thumb in mouth, pull forward
- Jaw Thrust
- Orotracheal intubation with in-line neck stabilisation: absent gag & poor ventilation, head injury
- 100% oxygen at flow rate 15 l/min
- Full cervical spine immobilisation - hard collar & lateral supports with straps across forehead & chin
Breathing
- Inspect neck & thorax - NB trachea, neck veins
- Respiratory Rate
- Auscultate
Life Threatening thoracic conditions:
- Trauma Clinicians Often Miss Fractures
- Tension pneumothorax
- Cardiac tamponade
- Open chest wound
- Massive haemothorax
- Flail chest
Circulation
- Shock assessment: skin colour, capillary refill, mental state, pulse, blood pressure
- control haemorrhage
- 2 large(14g) cannulas peripherally
- Withdraw 20ml blood for FBC, U&E, Gluc., X-match
- warmed crystalloids
-
Blood:
- full x-match
- type specific
- O Neg
Dysfunction
pupils - size, equal, response to light.
conscious level
- Alert
- Verbal stimuli
- Pain stimuli
- Unresponsive
Exposure
clothing - remove all
cold - be aware of Hypothermia, keep warm (warmed blankets)
Secondary survey
- head-to-toe
- log-roll
- PR (& PV)
- tubes - 2 large peripheral IV; urinary catheter, NGT, (chest drain, DPL, central line, arterial line)
- analgesia, anti-tetanus, antibiotics
X-Rays: (done after Primary Survey)
- lateral cervical spine (followed by AP & peg view in X-Ray dept. when patient stable- do not remove collar until all 3 films cleared)
- chest
- pelvis
ATLS- C-spine, pelvis, chest AP
- A- adequacy & alignment
- B- bones - margins & architecture - follow bone margins & comment on general density & architecture
- C- cartilage/joints - joint spaces, surfaces
- S- soft tissues - swelling, air in tissues (open wound/ open fracture)
history (AMPLE)
- Allergies
- Medications
- Past medical history
- Last meal
- Events of injury
cricothyroidotomy
- •last resort for airway control
- •Y connector with O2at 15 l/min
- •Intermittent jet insufflation- sedate & paralyze, only for 30-45min., caution for FB
intercostal drain
- 4th or 5th intercostal space, mid-axillary line
- local anaesthetic down to pleura
- ‘above the rib below’
- blunt dissection. finger exploration
- pass large drain on forceps superior & posterior
- underwater drain
- pursestring suture
pericardiocentesis
- Beck’s Triad- shock,distended neck veins, muffled heart souns
- ECG monitor
- wide bore long sheathed needle
- enter 2cm below left xiphochondral junction, aiming 45° posterior towards tip of left scapula
- positive -> urgent thoracotomy
Limb injuries
Primary survey
Secondary survey
Immobilisation & reduction
Pain control
Wound Care
- Antibiotic prophylaxis
- Tetanus cover
- Photograph
- Betadine dressing
- Culture swab
- Debridement (generous)
- Irrigation
- Fracture stabilisation
- LEAVE WOUND OPEN
spinal injuries
primary suvey
- A: cervical spine control, intubation(blind tracheal, fibre-optic laryngoscope, naso-tracheal), nasogastric tube (ileus)
- B: intercostal paralysis
immobilisation - scoop, spinal board
secondary survey
- Log Roll -swelling, tenderness, steps, gaps
- Neurological exam. - NB. bulbocavernosus reflex
Neurogenic shock: - hypotension, bradycardia [be aware of Patient.s on B-blockers], warm periphery
Spinal Shock: flaccid limbs, reduced reflexes, reduced sensation, Urinary retention, paralytic ileus. [return of bulbocavernosus reflex indicates end of Spinal Shock]