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 & reevaluat
ion
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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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12

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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13

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

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
o

 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,
the

rifles, and shotgun

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 xray, 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

(FAST)

assessment with sonography for trauma

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 100mL - 500mL 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)

trauma.org

Rosens Emergency Medicine, 7th ed. 2009

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/mm 3
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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66

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

Rosens Emergency Medicine 7th e

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