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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 bones → 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
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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
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