Advanced trauma life support [advanced]

Colour triage coding

• RED = most critical injury
• YELLOW = less critical injury
• GREEN = no life or limb threatening injury
• BLACK = death or fatal injury

Background

• Team members and their roles
  • Emergency medicine consultant/registrar – lead
  • Emergency medicine doctor – primary survey
  • Anaesthetist – airway
  • Orthopaedic doctor – manage pelvis and other bone injuries
  • General surgery doctor – manage spleen/gut/chest
  • Intensive care doctor – decide upon ICU admission
  • Emergency medicine nurses x 2 – one for patient care (observations etc) and one for code red
  • Health care assistant – help with getting things etc
  • Operating department practitioner – organise theatre if required
• Trauma handover – ATMIST
  • Age
  • Time everything happens
  • Mechanism
  • Injuries
  • Signs – observations, capillary refill
  • Treatment so far – e.g. triple immobilised, pelvic binder, oxygen, tranexamic acid
• Prioritising injuries in polytrauma
  • Life-threatening bleeding wounds e.g. splenic rupture, pelvic/thoracic injury
  • Limb threatening injuries e.g. vascular injury, extensive limb bleeding requiring tourniquet to control blood loss
  • Fractures, dislocations and wounds at risk of complications (e.g. infection, neurovascular damage, bleeding)
  • Stable fractures and other non-urgent injuries are managed later and may even be best left until swelling has resolved

Preparation and triage

• Advance planning
• Gather equipment e.g. goggles, gloves, gowns, shoe covers, masks
• Call trauma team

Primary survey – C-ABCDE

Catastrophic haemorrhage

• Sources: external (usually from neck) or pericardial
• Management
  • Emergency thoracotomy for penetrating chest trauma causing cardiac arrest
  • Pressure over bleeding points
  • Warmed blood transfusion

Airway maintenance with C-spine protection

• Look for causes of airway compromise: maxilla fracture (bleeds +++, ask to bite down to assess), laryngeal fracture (hanging), burns/inhalation, neck haematoma, GCS less than or equal to 8, neuromuscular paralysis, vomiting, stridor
• Management
  • Airway manoeuvres e.g. jaw thrust
  • Artificial airway e.g. nasopharyngeal/oropharyngeal, intubation, surgical cricothyroidotomy (see artificial airways notes)
  • Remove foreign bodies
  • Suction  
  • Triple immobilisation for C-spine until cleared by cervical spine X-rays and/or CT scan
    • Hard collar
    • Blocks or sandbags
    • Tape over chin and forehead

Breathing

• Assessment
  • Saturations, respiratory rate
  • Look (cyanosis, respiratory effort, neck vein distention, bruises)
  • Feel (surgical emphysema, tenderness over ribs)
  • Expansion (haemothorax, pneumothorax, flail segment)
  • Percuss (haemothorax, pneumothorax)
  • Listen (haemothorax, pneumothorax)
• Management
  • Chest drain for haemothorax/pneumothorax
  • High flow oxygen

Circulation

• Assessment
  • Heart rate, blood pressure
  • Peripheral pulse (requires systolic pressure of 80mmHg)
  • Heart sounds
  • Lactate (>5 significant)
  • Look for bleeding – “blood on floor (external) and 4 more”, working down:
    • Chest → FAST scan, examination, CXR
    • Abdomen → FAST scan, examination (e.g. bruising)
    • Pelvis → Pelvic X-ray or CT scan
    • Long bone → X-rays, examination
• Management
  • Place 2 wide-bore IV cannulae and take blood (including G&S, FBC, clotting screen, fibrinogen)
  • Aim for permissive hypotension
  • Shock: Hartmanns 1-2L bolus (or 20ml/kg for child). Subsequent fluids depend on response
    • No response: give O negative blood
    • Transient response: give more fluids (crystalloid or gelofusine) and type-specific blood
  • Massive haemorrhage (ie. SBP<90, poor response to fluid resus, suspected haemorrhage): activate ‘code red’ transfusion protocol, give tranexamic acid, keep patient warm
  • Ensure all transfused blood/fluids are warmed and patient is kept warm
  • Leave pelvic binder on until pelvis cleared
  • Traction for long bone fractures
  • Combat application tourniquet only if compression fails to control limb blood loss

Types of shock

• Haemorrhagic
• Cardiogenic: blunt cardiac trauma, tamponade, air embolus, MI
• Tension pneumothorax
• Neurogenic (↓BP + ↓HR)
• Septic

Classes of shock

• Class 1: 15% blood loss; normal observations
• Class 2: 15-30% blood loss; HR >100, normal BP, RR 20-30
• Class 3: 30-40% blood loss; HR >120, decreased BP, RR 30-40
• Class 4: >40% blood loss; HR  >140, decreased BP, RR >35

Code red protocol

• Give pack 1 first, then pack 2 if needed, then alternate until haemorrhage controlled
• Pack 1 = 6U blood, 4U FFP
• Pack 2 = 6U blood, 4U FFP, 1U platelets, 2U cryoprecipitate

Disability

• Assessment
  • Glasgow coma score
  • Limb movements
  • Pupils reactivity
• Management
  • CT head if indicated (done after resuscitation)

Everything else

• Try not to expose (need to conserve heat) unless absolutely necessary e.g. stab check, can’t get CT scan

Resuscitation

• Oxygenation and ventilation
• Management of shock and bleeding
• Management of life threatening injuries

Adjuncts to primary survey and resuscitation

• Trauma CT (head, spine, chest, abdo, pelvis), or:
  • X-rays:
    • Broken bones
    • C-spine
    • Chest, pelvis
  • FAST scan
  • CT head if indicated
• Urinary catheter
• Monitoring: ABG, end-tidal CO₂, ECG, observations

Secondary survey

Takes place only after primary survey and resuscitation is established and there is demonstration of normalisation of vital functions.

• History – AMPLE
  • Allergies
  • Medication
  • Past medical history/Pregnancy
  • Last meal
  • Events/Environment related to injury
• Top-to-toe exam – plot all injuries on a drawing

Adjuncts to secondary survey

• Trauma CT scan (head, chest, abdomen, spine)
• Further X-rays e.g. extremities, spine
• Ultrasound
• Other procedures required e.g. endoscopy/bronchoscopy, angiography, contrast urography

Post resuscitation monitoring and re-evaluation

• Regular observations
• Bloods
• Urine output monitoring (aim >0.5ml/kg/h)
• Others: ABG, cardiac monitoring
• Analgesia

Definitive care

• Treat/transfer