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ATLS

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الكلية كلية الطب     القسم  الجراحة     المرحلة 5
أستاذ المادة مهند عباس نوري الشلاه       15/04/2018 18:06:09
• Trauma to the Torso
The initial management of the traumatised patient must first consist of a rapid primary evaluation and resuscitation of vital functions as soon as abnormalities are detected.
Only when the patient has been stabilised and the team are content with the primary survey is a more detailed secondary assessment carried out.
The primary survey comprises the fundamental principles of the ATLS system, the ‘ABCDE’ of trauma care
ABCDE of trauma care
A, Airway with cervical spine protection
B, Breathing and ventilation
C, Circulation with haemorrhage control
D, Disability: neurological status
E, Exposure: completely undress the patient and assess for
other injuries
Airway with cervical spine protection
In every trauma situation, the patient’s airway is of paramount importance, and hence this is assessed first. If there is a vocal response from the patient, then the airway cannot be immediately compromised.
Ensuring a patent airway may require simple measures, such as clearing the mouth and suction, or manoeuvres such as a jaw thrust or chin lift. If the airway is compromised again as soon as the chin lift or jaw thrust are relaxed, then a nasopharyngeal or Guedel airway should be used, provided that the patient will tolerate it.
In the case of severe head trauma, where the patient is unconscious (a Glasgow Coma Score (GCS) of 8 or less), then a definitive airway (such as endotracheal intubation) may be required.
It is important to suspect that every patient who has had significant trauma (especially to the head) has a cervical spine injury until proven otherwise.
Therefore, throughout the initial assessment, the cervical spine must be immobilized providing that this is not impairing their safety or their airway.
This is either performed manually, with in-line immobilization techniques, or with the traditional collar, sandbags and tape.
Any efforts to maintain airway patency must also bear in mind the safety of the potentially unstable cervical spine.
Breathing and ventilation
Oxygen should be administered to all trauma patients, using a high concentration mask with a reservoir.
Ventilation requires an adequately functioning chest wall, lungs and diaphragm, and each must be systematically evaluated.
A check should be made for signs of surgical emphysema, dilatation of the neck veins, asymmetry of the chest wall, excessive respiratory effort and abnormal rate.
Tension pneumothorax, a flail chest with contusion, a massive haemothorax and an open pneumothorax are examples of life-threatening injuries that must be identified and treated in the primary survey.
Critical findings include the tracheal deviation, absence of or asymmetry of breath sounds, hyper-resonance (consistent with tension pneumothorax) or dullness to percussion (haemothorax).
Breathing
? Give 100 per cent oxygen at high flow
? Inspect/percuss and auscultate chest
? Check for tension pneumothorax and immediately decompress if suspected
? Insert chest drain for haemothorax/pneumothorax
? Major vessel bleeding within the chest needs to be controlled
Circulation and control of bleeding
Assessment here centres on three critical clinical observations:
1 Conscious level. If this is impaired or altered, in the absence
of obvious head injury, one must assume that the patient has
lost a significant amount of blood and that cerebral perfusion
has become compromised.
2 Skin colour. A patient with pink skin and warm peripheries
is rarely critically hypovolaemic, and the converse is true
for a pale, ashen, grey-looking patient with ominous signs of
hypovolaemia.
3 Pulse. A full, slow, regular peripheral pulse is usually the sign
of relative normovolaemia, whereas a rapid, thready pulse or,
worse still, one that is not peripherally palpable is a grave sign
of hypovolaemic shock, and blood volume must be rapidly
restored.
While the primary survey is being carried out, other team members should be securing two large-bore cannulae for intravenous access.
Fluid resuscitation should be titrated against the patient’s response to the initial fluid challenge and their vital signs .
Potential sites for major blood loss include the chest cavity, the abdomen, the pelvis and long bone fractures.
Each of these must be examined in turn.
Surgical intervention may ultimately be required to control hemorrhage.
Disability
The neurological status of the patient should be rapidly assessed.
The pupils are monitored for size and reactivity, and a GCS measured.
This should be repeated regularly as the test is quick
to perform and once again it is change in the score which is more important in determining how treatment is going than one isolated measurement.
Other than severe head injury, other reversible causes of an altered level of consciousness include hypovolaemia, hypoglycaemia, alcohol and drug abuse.
These must all be excluded or treated during the initial assessment.
Exposure
The patient must be fully exposed and examined front and back using a carefully controlled log roll. Spinal alignment must be maintained during this procedure with in-line traction.
Hypothermia can be rapid following trauma, and warming air blankets are vitally important in the resuscitative phase.
• Adjuncts to the primary survey
? Blood tests – full blood count, urea and electrolytes, clotting screen, glucose, toxicology, cross-match.
? ECG, pulse oximetry, arterial blood gas (ABG)
? Two wide-bore cannulae for intravenous fluids
? Urinary and gastric catheters
? Radiographs of the cervical spine, chest and pelvis
SECONDARY SURVEY
The secondary survey does not begin until after the primary survey has been completed, and all injuries have been dealt with.
In the case of a severely injuredpatient, for example, the secondary survey may not commence until the patient has returned from the operating theatre, having had life-saving surgery for primary survey ‘ABCDE’ problems.
The purpose of the secondary survey is to identify all other injuries and perform a more thorough ‘head to toe’ examination.
If possible, it is here that the patient’s history is reviewed.
The ‘AMPLE’ mnemonic from the ATLS group is helpful herepotentially life-threatening
• Review of patient’s history (AMPLE)
• Allergy
• Medication, including tetanus status
• Past medical history
• Last meal
• Events of the incident


المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .
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