Advance trauma life support

Andi Siswandi, MD
Surgeon
Malahayati University, Medicine Faculty
1. Preparation
2. Triage
3. Primary Survey (ABCDEs)
4. Resuscitation
5. Adjuncts to primary survey & resuscitation
6. Secondary Survey (head to toe evaluation & history)
7. Adjuncts to secondary survey
8. Continued post-resuscitation monitoring &
reevaluation
9. Definite care. 1/00 2
Preparation and TRIAGE
- The used of the following protective
devices is recommended
- Pre hospital and In Hospital
PRIMARY SURVEY
A : Airway with cervical spine protect.
B : Breathing
C : Circulation --control external bleeding.
D : Disability or neurological status (GCS)
E : Exposure (undress) & Environment
(temp control)

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RESUSCITATION
A. Airway
*definite airway if there is any doubt about the pts ability to maintain
airway integrity.

B. Breathing /Ventilation/Oxygenation
*every injured pt should received supplement oxygen

C. Circulation
*control bleeding by direct pressure or operative intervention
* minimum of two large caliber IV should be established
*pregnancy test for all female of child bearing age.
* Lactated Ringer is preferred & better if warm.

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Adjunct to Primary Survey &
Resuscitation
A. Electro-cardiographic Monitoring
B. Urinary & Gastric Catheter
C. Monitoring
D. X-Ray and Diagnostic Study

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SECONDARY SURVEY

Does not begin until the primary survey

(ABCDEs) is completed, resuscitative
effort are well established & the
patient is demonstrating normalization
of vital sign.

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SECONDARY SURVEY
- History (AMPLE), Physical Examination
Head to Toe evaluation & reassessment of
all vital signs.
- A complete neurological exam is
performed including a GCS score.
- Tube and finger in every orifice
- Special procedure is order.
Adjunct to the Secondary Survey
hemodynamic status
CT scan
Contrast x-ray studies
Extremity x-ray
Endoscopy and USG.

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Re-evaluation
reevaluation for new findings or
overlooked
continuous monitoring of vital signs ,
urinary output
0.5 ml/kg/hr
1 ml/kg/hr
ABG , EKG , pulse oximetry
effective analgesia
Definitive Care
Managing life-threatening problems
Transfer If the patients injuries
exceed the institutions treatment
capabilities
 Color Codes Triage Tag
RED : Most critical injury
YELLOW : Less critical injured
GREEN : No life or limb threatened injury
BLACK : Death or obviously fatal injury

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Priorities with multiple injuries

1. Thoracic trauma or tamponade

2. Abdominal hemorrhage
3. Pelvic Hemorrhage
4. Extremity Hemorrhage
5. Intra-cranial Injury
6. Acute Spinal Cord Injury

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ABDOMINAL TRAUMA
Outline
Objectives
Incidence
Anatomical regions of the abdomen
Types of abdominal Trauma
Hospital Care and diagnosis
Specific organs trauma
Objectives
Describe the anatomy of abdomen region
Discuss the differences of injury pattern
between blunt and penetrating abdominal
trauma
Identify the sign suggesting retroperitoneal,
intraperitoneal and pelvic injury
Outline the diagnostic and procedure
specific to abdominal trauma
The primary management of abdominal
trauma is determination that an intra
abdominal injury EXISTS and operative
intervention is required.
Incidence
Anatomy
Anterior abdomen
flank
Back
intraperitoneal contents
Retroperitoneal space contents
Pelvic cavity contents
o Anterior abdomen:
trans-nipple line, , anterior axillary lines, inguinal
ligaments and symphysis pubis.
o flank:
anterior and posterior axillary line ;sixth intercostal to
iliac crest
o Back:
posterior axillary line; tip of scapula to iliac crest
Peritoneal cavity:
upper-diaphragm, liver, spleen, stomach, and transverse
colon; lower-small bowel, sigmoid colon

Retroperitoneal space:
aorta, inferior vena cava, duodenum, pancreas, kidneys,
ureters,ascending and descending colons

Pelvic cavity:
rectum, bladder, iliac vessels and internal genitalia
Types of Abdominal Trauma
Blunt (91%) : seat belt, fall, crash injury,
sport injury
Penetrating (9%)

Blunt abdominal injuries carry a greater

risk of morbidity and mortality than
penetrating abdominal injuries.
Blunt trauma
Mechanism :
Direct blow Compression and crushing
to viceral organ deform solid and
hollow organ rupture + secondary
hemorrhage and peritonitis
Crashes also may sustain deceleration
injuries lacerations of the liver and
spleen (movable organs) at sites of
supporting ligaments (fixed structures).
Blunt Trauma

Spleen (40-55%)
Liver (35-45%)
Small bowel (5-10%)
Retroperitoneal hematoma: 15%
Penetrating trauma

Mechanism :

Stab wound
gunshot
Stab wound

Can cause laceration or cutting

Stab wounds traverse adjacent abdominal
structures and most commonly involve
the liver (40%), small bowel (30%),
diaphragm (20%), and colon (15%).
 Knives are not the sole implement used in
stabbings.

Ice picks, pens, coat hangers, screwdrivers, and broken

bottles.

most commonly in the upper quadrants, the left

more commonly than the right.
Gunshot Wounds

handguns, rifles, and shotgun

the degree of injury depends .

amount of kinetic energy imparted by the bullet to the victim
mass of the bullet and the square of its velocity
distance .
 type I wounds: long range (>7 yards) , a penetration
of subcutaneous tissue and deep fascia only.

Type II wounds: distance of 3 to 7 yards and may

create a large number of perforated structures.

Type III wounds occur at point-blank range (<3

yards) and involve a massive destruction of tissue
multiple organ injuries are sustained, notably
perforations to bowel .

greatest for small bowel, followed by the

colon and then the liver.
Missiles effects
Extensive tissue damage
external contaminants tend to be dragged into the
wound.
the closure of the tract immediately after the
bullet's passage may lead to an underestimation of
tissue damage.
high-velocity bullets can fragment internally
Hospital Care and Diagnosis
In hypotensive patients, the doctors goal
rapidly determine if an abdominal injury
is present (whether it is the cause of
hypotension).
Hemodynamically normal patients
without signs of peritonitis a more
detailed evaluation
History
Mechanism of Injury (detailed about the
accident)
History from prehospital care team or
transferring hospital : the vital signs,
physical assessment, prehospital course,
and response to therapy
In penetrating trauma:
shots or stabs
Type of weapon
Distance b/w firearm and victim
Physical examination
Inspection : undressed, contusio, abrasion,
laceration, penetrating wound, evisceration
of omentum, pregnant
Auscultation : ileus?
Percussion : tympanic sound? Dullness?
Palpation : rebound tenderness?
Evaluation of penetrating wound
laparotomy
Assessing pelvic stability : manual
compression of anterosuperior iliac crests
(very careful!!)
Physical examinatioin
Penile, perineal and rectal examination :
blood, ecchimosis?
Vaginal examination : laceration?
Gluteal examination
Adjuct
NGT
Decompression of stomach
Careful with facial fracture or suspicious to basis cranii
fracture
Urinary Catheter
relieve retention, decompress bladder before performing a
DPL, monitoring urinary output
Hematuria sign of Genitourinary tract trauma
Caution:
Inability to void
Unstable pelvic fracture
Blood at the meatus, a scrotal hematoma or perineal
ecchymoses, high-riding prostate a retrograde
urethrogram urethra intact?
Blood and urine sampling
Cross match
Complete blood count (CBC), potassium,
glucose, amylase (for blunt trauma), and
blood alcohol levels.
Urinalysis and a urine drug screen if
indicated.
A blood test or urine pregnancy
X- Ray
Screening for blunt trauma
lateral cervical spine x-ray,(AP) chest x-ray,
and a pelvic x-ray
Abdominal x-rays (supine, upright, or lateral
decubitus) in hemodynamically stable patients
Screening for penetrating trauma
Do not require
Apply clipped for gun shot
Special circumstances (uretrography,
cystography, CT/IVP, angiography)
X-Ray
Plain films:
fractures nearby visceral damage
free intraperitoneal air
Foreign bodies and missiles

Rosens Emergency Medicine, 7th ed. 2009

 CT
Accurate for solid visceral lesions and intraperitoneal hemorrhage
guide nonoperative management of solid organ damage
IV not oral contrast
Disadvantages : insensitive for injury of the pancreas, diaphragm,
small bowel, and mesentery

Rosens Emergency Medicine, 7th ed. 2009

Imaging
Angiography
To embolize bleeding vessels or solid visceral
hemorrhage from blunt trauma in an unstable pt
Rarely for diagnosing intraperitoneal and
retroperitoneal hemorrhage after penetrating
abdominal trauma

Rosens Emergency Medicine, 7th ed. 2009

Diagnostic
FAST
DPL
CT
 FAST
Focused assessment with sonography for trauma (FAST)
To diagnose free intraperitoneal blood after blunt trauma
4 areas:
Perihepatic & hepato-renal space (Morrisons pouch)
Perisplenic
Pelvis (Pouch of Douglas/rectovesical pouch)
Pericardium (subxiphoid)
sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid
Extended FAST (E-FAST):
Add thoracic windows to look for pneumothorax.
Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%)
Rosens Emergency Medicine, 7th ed. 2009 Trauma.org
 Morrisons pouch (hepato-renal space)

trauma.org

Rosens Emergency Medicine, 7th ed. 2009

 Perisplenic view

trauma.org Rosens Emergency Medicine, 7th ed. 2009

 Retrovesicle (Pouch of Douglas)

Pericardium (subxiphoid)

Rosens Emergency Medicine, 7th ed. 2009

trauma.org
Diagnostic Peritoneal Lavage
Largely replaced by FAST and CT
In blunt trauma, used to triage pt who is
Hemodynamic unstable and has multiple injuries
with an equivocal FAST examination
In stab wounds, for : dx of hemoperitoneum,
determination of intraperitoneal organ injury,
and detection of isolated diaphragm injury
not used much

Rosens Emergency Medicine, 7th ed. 2009

Diagnostic Peritoneal Lavage
1. attempt to aspirate free peritoneal blood
>10 mL positive for intraperitoneal injury
2. insert lavage catheter by seldinger, semiopen, or
open
3. lavage peritoneal cavity with saline
Positive test:
In blunt trauma, or stab wound to anterior, flank, or
back: RBC count > 100,000/mm3
In lower chest stab wounds or GSW: RBC count >
5,000-10,000/mm3

Rosens Emergency Medicine, 7th ed. 2009

CT scan
Use in stable patient
There is no indication for emergency
celiotomy
Indication for celiotomy
1. Blunt abdominal trauma with hypotension
and clinical evidence of intraperitoneal
bleeding
2. Blunt abdominal trauma with positive DPL
or FAST
3. Hypotension with penetrating abdominal
wound
4. Gunshot wounds traversing the peritoneal
cavity or visceral/vascular retroperitoneum
5. Evisceration
Indication for celiotomy
6. Bleeding from the stomach, rectum, or
genitourinary tract from penetrating trauma
7. Presenting or subsequent peritonitis
8. Free air, retroperitoneal air, or rupture of
the hemidiaphragm after blunt trauma
9. Contrast-enhanced CT demonstrates
ruptured gastrointestinal tract,
intraperitoneal bladder injury, renal pedicle
injury, or severe visceral parenchymal injury
after blunt or penetrating trauma.
Specific organ trauma
Diaphragm : blurring hemidiaphragm, NGT at
the chest
Duodenum : bicycle handlebar.
Retroperitoneal air
Pancreas : amylase serum, CT, ERCP
Genitourinary : IVP
Small bowel : seatbelt sign or chance
fracture, FAST, CT or DPL
Solid organ injury : liver, spleen and kidney
unstable hemodynamicceliotomy
forsurenot.com
Management
1. Preparation
2. Triage
3. Primary Survey (ABCDEs)
4. Resuscitation
5. Adjuncts to primary survey & resuscitation
6. Secondary Survey (head to toe evaluation & history)
7. Adjuncts to secondary survey
8. Continued post-resuscitation monitoring & reevaluation
9. Definite care.

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Management
Management of blunt and penetrating
trauma to the abdomen includes:

1. Reestablishing vital functions and

optimizing oxygenation and tissue
perfusion
2. Delineating the injury mechanism
3. Meticulous initial physical examination,
repeated at regular intervals
Management
4. Selecting special diagnostic maneuvers as
needed, performed with a minimal loss of
time
5. Maintaining a high index of suspicion
related to occult vascular and
retroperitoneal injuries
6. Early recognition for surgical intervention
and prompt celiotomy
Thoracoabdomen

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Rosens Emergency Medicine 7th ed
Rosens Emergency Medicine, 7th ed. 2009
Pelvic Trauma
Patients with hemorrhagic shock and
unstable pelvic fractures have 4 potential
sources of blood loss:
Fractured bone surfaces
Pelvic venous plexus,
Pelvic arterial injury, or
Extrapelvic source.
Mechanism of Injury
Anteroposterior compression
Lateral compression
Vertical Shear
Complex or combination pattern
Assessment
Inspection : flank, scrotum and perineal
area, inspected blood at the urethral
meatus; swelling or bruising; or a
laceration in the perineum, vagina, rectum,
or buttocks
Palpation : high riding prostate
Mechanical instability leg-length
discrepancy or rotational deformity
without a fracture of that extremity.
AP X-Ray
Management
Thank you