Advanced trauma life support

Dr Wrishi Raphael
The Advanced Trauma Life Support (ATLS ) program teaches a systematic, concise approach to the care of a trauma patient.
Dr James K. Styner was piloting a light aircraft in 1976 when weather conditions caused a crash that killed his wife and seriously injured
three of his four children. With his eldest son he stabilised the other children and transferred all three to a local hospital, where he was appalled that the local doctors were unprepared for treating multiple trauma cases. He famously said “When I can provide better care in the field with limited resources than my children and I received at the primary facility, there is something wrong with the system and the system has to be changed.” Following this incident he collaborated with several colleagues and in 1978 began offering an Advanced Trauma and Life Support course, now available in over 40 countries worldwide and considered the gold standard for initial management of trauma cases. He still practices today as an orthopaedic surgeon in California.

Today we will discuss mostly about ATLS related to head injuries. Quick evaluation of a patient with head injuries is essential in the Emergency Room and in General Practice settings as any delay could be potentially fatal for the patient. A very useful method known world over as the Glasgow Coma Scale (GCS) is given below.
A brief management plan:  
If the pupils are unequal, diagnose rising intracranial pressure (ICP). ICP may be raised due to accumulation of blood clots or any active bleeding between the soft tissues of the brain or meninges.
Involve neurosurgeons at an early stage, especially with comatose patients, or if raised ICP suspected.
Examine the Central Nervous System. Chart pulse, Blood Pressure, temperature, respirations and pupil size every 15min.
Assess anterograde amnesia and retrograde amnesia—its extent correlates with the severity of the injury, and it never occurs without anterograde amnesia. Anteretograde amnesia refers to loss of memory for events after an incident. Retrograde amnesia is in contrast to anterograde amnesia in which the lack of memory relates to events that occurred after a traumatic event.
Nurse semi-prone if no spinal injury; meticulous care to bladder and airway.
Who needs a CT head?
If any of the following are present, a CT is required immediately:
GCS <13 at any time, or GCS 13 or 14 at 2h following injury
Focal neurological deficits must be ruled out. Focal neurologic signs also known as focal neurological deficits or focal CNS signs are impairments of nerve, spinal cord, or brain function that affects a specific region of the body, e.g. weakness in the left arm, the right leg or paralysis of head or eye movements
Suspected open or depressed skull fracture, or signs of basal skull fracture (haemotympanum, ‘panda’ eyes, Cerebrospinal Fluid leak through nose/ears which will reveal itself as passage of clear fluid from ears or nose)
Post-traumatic seizure
Vomiting >once
Loss of consciousness and any of the following:
Age-65
‘Dangerous mechanism of injury’, eg car crash or fall from great height
Anterograde amnesia of >30min
 Artificial ventilation using endotracheal apparatus is often required in severe conditions (see photo) . When to ventilate immediately:
Coma
8 on Glasgow coma scale.
Respiratory irregularity. An Arterial Blood Gas analysis or ABG is an essential lab test in head trauma where blood is drawn from an artery to measure the amounts of essential gases like oxygen and carbondioxide. If the levels of oxygen in blood start to fall quickly, intubation is vital.  
Ventilate before neurosurgical transfer if:
Deteriorating level of consciousness
Bilateral fractured mandible
Bleeding into mouth, eg skull base fracture
Seizures
Risk of intracranial haematoma (accumulation of blood clot) in adults
If the patient is fully conscious, no skull fracture, the chances are very slim.
If the patient is disoriented
or confused but has suffered no skull fracture, haematoma risk is higher
If the patient is fully conscious but has a skull fracture the risk of skull haematoma is significant.
A confused patient with a skull fracture must be followed up very frequently or referred to nearest specialized hospital as chances of subsequent coma is highest.
The writer can be reached at: [email protected]

 

Advanced trauma life support

Dr Wrishi Raphael The Advanced Trauma Life Support (ATLS ) program teaches a systematic, concise approach to the care of a trauma patient. Dr James K. Styner was piloting a light aircraft in 1976 when weather conditions caused a crash that killed his wife and seriously injured three of his four children. With his eldest son he stabilised the other children and transferred all three to a local hospital, where he was appalled that the local doctors were unprepared for treating multiple trauma cases. He famously said When I can provide better care in the field with limited resources than my children and I received at the primary facility, there is something wrong with the system and the system has to be changed. Following this incident he collaborated with several colleagues and in 1978 began offering an Advanced Trauma and Life Support course, now available in over 40 countries worldwide and considered the gold standard for initial management of trauma cases. He still practices today as an orthopaedic surgeon in California. Today we will discuss mostly about ATLS related to head injuries. Quick evaluation of a patient with head injuries is essential in the Emergency Room and in General Practice settings as any delay could be potentially fatal for the patient. A very useful method known world over as the Glasgow Coma Scale (GCS) is given below. A brief management plan: If the pupils are unequal, diagnose rising intracranial pressure (ICP). ICP may be raised due to accumulation of blood clots or any active bleeding between the soft tissues of the brain or meninges. Involve neurosurgeons at an early stage, especially with comatose patients, or if raised ICP suspected. Examine the Central Nervous System. Chart pulse, Blood Pressure, temperature, respirations and pupil size every 15min. Assess anterograde amnesia and retrograde amnesiaits extent correlates with the severity of the injury, and it never occurs without anterograde amnesia. Anteretograde amnesia refers to loss of memory for events after an incident. Retrograde amnesia is in contrast to anterograde amnesia in which the lack of memory relates to events that occurred after a traumatic event. Nurse semi-prone if no spinal injury; meticulous care to bladder and airway. Who needs a CT head? If any of the following are present, a CT is required immediately: GCS 13 at any time, or GCS 13 or 14 at 2h following injury Focal neurological deficits must be ruled out. Focal neurologic signs also known as focal neurological deficits or focal CNS signs are impairments of nerve, spinal cord, or brain function that affects a specific region of the body, e.g. weakness in the left arm, the right leg or paralysis of head or eye movements Suspected open or depressed skull fracture, or signs of basal skull fracture (haemotympanum, panda eyes, Cerebrospinal Fluid leak through nose/ears which will reveal itself as passage of clear fluid from ears or nose) Post-traumatic seizure Vomiting once Loss of consciousness and any of the following: Age-65 Dangerous mechanism of injury, eg car crash or fall from great height Anterograde amnesia of 30min Artificial ventilation using endotracheal apparatus is often required in severe conditions (see photo) . When to ventilate immediately: Coma 8 on Glasgow coma scale. Respiratory irregularity. An Arterial Blood Gas analysis or ABG is an essential lab test in head trauma where blood is drawn from an artery to measure the amounts of essential gases like oxygen and carbondioxide. If the levels of oxygen in blood start to fall quickly, intubation is vital. Ventilate before neurosurgical transfer if: Deteriorating level of consciousness Bilateral fractured mandible Bleeding into mouth, eg skull base fracture Seizures Risk of intracranial haematoma (accumulation of blood clot) in adults If the patient is fully conscious, no skull fracture, the chances are very slim. If the patient is disoriented or confused but has suffered no skull fracture, haematoma risk is higher If the patient is fully conscious but has a skull fracture the risk of skull haematoma is significant. A confused patient with a skull fracture must be followed up very frequently or referred to nearest specialized hospital as chances of subsequent coma is highest. The writer can be reached at: [email protected]