1. Advanced Trauma Life Support
    1. Rapid assessment
    2. Rususcitation
    3. ATLS concept:
      1. 1. Treat greatest threat to life first
      2. 2. Lack of diagnosis should not stop treatment
      3. 3. Detailed history not essential in acutely injured
      4. Primary Survey
        1. A - Airway with cervical spine protection
          1. Assess airway patency
          2. Can you hear me?
          3. Facial fractures?
          4. Foreign bodies in moth?
          5. Chin lift, jaw thrust.
          6. Assume C-spine injury
          7. Manual in-line immobilisation
          8. Immobilisation devices
          9. Oxygenation
        2. B- Breathing
          1. Assess Ventilation (lungs, chest wall and diaphragm)
          2. Look
          3. is chest wall rising and falling equally
          4. bruises/cuts?
          5. Feel
          6. trachea
          7. Percuss
          8. chest wall sound?
          9. Listen
          10. air entry in nose/mouth?
          11. Oxygenation
        3. C - Circulation - control external bleeding
          1. Assess blood volume and CO
          2. level of consciousness
          3. skin colour
          4. pale
          5. pink
          6. pulse rate
          7. within parameter for age
          8. Stop external bleeding
          9. direct pressure
          10. limb elevation
          11. bleeding in pelvis?
          12. Get intravenous access
          13. into cubital fossa/ neck
          14. for fluid replacement
          15. Adequate perfusion
        4. D - Disability or neurological status
          1. Assess neurological status (Glasgow Coma Scale)
          2. A - Alert
          3. V - Vocalising
          4. P - Painful stimuli
          5. U- Unresponsive
          6. Assess pupils
          7. size, equality, reactivity
        5. E- Exposure (undress) and Envrionment (control temperature)
          1. Remove all clothing
          2. Prevent hypothermia
          3. blankets
          4. warm IV fluids
          5. warm room
      5. Secondary Survey
        1. AMPLE history
          1. A - Allergies
          2. allergic to any medicines?
          3. M - Medications
          4. on medications like Warfarin?
          5. P- Past history
          6. cancer? heart attacks?
          7. L- Last meal
          8. anaesthetics
          9. E - Events
          10. trip? RTA?
        2. Head to toe examination
        3. 'Tubes and fingers in every orifice'
      6. Adjuncts to surveys in ATLS
        1. ECG
        2. Urinary and gastric catheter
        3. Pulse oximetry
        4. Arterial blood gases
        5. Blood test
        6. Blood pressure, pulse rate, respiratory rate
        7. Xrays: trauma series
          1. Chest/ pelvis
    4. Definition: protocol for the management of trauma victims
    5. designed to maximise management in the first "golden hour" following trauma, and thus ensure an optimal long term outcome
    6. Trimodal Distribution of Death
      1. 1st peak: Minutes.
        1. 50% - immediate death
          1. catastrophic head, neck, major vessel injury
      2. 2nd peak: hours (the 'golden hour')
        1. 40% - late
        2. golden hour =time during which there is the highest likelihood that prompt medical treatment will prevent death
      3. 3rd peak: days
        1. 10% - first day
  2. Shock
    1. Definition: 'A clinical state in which there is inadequate tissue oxygenation due to decreased organ perfusion'
    2. Recognise its presence, identify probable cause, treat
    3. Basic Cardiac Physiology
      1. CO = SV x HR
        1. = volume of blood pumped by heart per minute
      2. SV
        1. Volume of blood pumped with each heart beat
        2. preload - venous return
        3. afterload-resistance to forward flow
        4. contractility - myocardial muscle stretch (Starling's law)
    4. Symtpoms
      1. Shaky
      2. Sweaty
      3. Anxious
      4. Dizzy
      5. Tachycardia
      6. Vision
      7. Weak
      8. Headaches
    5. Remember compensatory signs
      1. 1. Tachycardia = pulse rate > 100bpm
      2. 2. Progressive vasoconstriction = cool peripheries
      3. 3. Increase in diastolic BP = pulse pressure decreases
      4. Injured patient + tachycardia + cool = shock until proven otherwise
    6. Haemorrhagic shock
      1. hypovolaemic
        1. = acute loss of circulating blood volume
      2. Four classes of haemorrhagic shock (numbers like tennis)
        1. Class I - 15% blood volume loss
          1. 0-750ml
          2. pulse - normal/slight elevation
          3. peripheries - warm
          4. pulse pressure - normal
        2. Class Ii - 15-30% blood volume loss
          1. 1500ml
          2. pulse > 100
          3. peripheries - warm... anxious
          4. pulse pressure - decreases (diastolic BP increases)
        3. Class III - 30-40% blood volume loss
          1. 1500-2000ml
          2. pulse > 120
          3. peripheries - cool
          4. pulse pressure - decreases (systolic BP decreases)
          5. compensatory mechanisms now falling...
        4. Class IV - 40% blood volume loss
          1. >2000ml
          2. pulse > 140
          3. peripheries - cold and pale
          4. pulse pressure - very narrow (diastolic BP unrecordable)
      3. but volume replacement guided by clinical response, not by classification of shock
    7. Non- Haemorrhagic shock
      1. cardiogenic
      2. neurogenic
        1. spinal injury
      3. septic
      4. anaphylactic
  3. Life Threatening injuries after trauma
    1. Tension pneumothorax
      1. decompress/relieve pressure in chest
      2. small hole in chest that goes through chest wall
      3. pressure outside increases relative to intrathorax pressure and collapse lung
      4. air flow continues into thoracic cavity
      5. trachea displacement away from cavity
    2. Open pnemothorax
      1. flap valve
      2. decompress less than for tension pneumothorax
    3. Massive haemothorax
      1. blood in pleural space
    4. Cardiac Tamponade
  4. Fractures