SEMINAR ON ATLS AND DAMAGE

CONTOL ORTHOPEDICS

Presenter Dr Moges
Coordinator-Dr Silamlak(orthopedic surgeon)

01/17/2023 1
 OUTLINES
• INTRODUCTION
• INITIAL ASSESSMENT AND MANAGEMENT
• DAMAGE CONTOL ORTHOPEDICS
• REFERRENCES

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 Introduction

 The Advanced Trauma Life Support (ATLS) supplies its

participants with a safe and reliable method for
 Assess a patient’s condition rapidly and accurately.
 Resuscitate and stabilize patients according to priority.
 Arrange appropriately for a patient’s interhospital or
intrahospital transfer.
 Ensure that optimal care is provided and that the level of care
does not deteriorate at any point

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 According to WHO and CDC
 >9 people die every minute from injuries
 5.8 million people of all ages and economic groups die/year
 Motor vehicle crashes (road traffic injuries )alone cause more
than 1 million deaths annually
 trauma remains the leading cause of death in 1 -44 years of age
 more than 90% of motor vehicle crashes occur in the developing
world.

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 History of ATLS
• Advanced Trauma Life Support (ATLS) was developed in 1976
following a plane crash
• They received injury care, but the resources and expertise they
needed were not available
• The care that he and his family subsequently received was
inadequate by the day’s standards,there is something wrong
with the system, and the system has to be changed.”
• A group of private-practice surgeons and doctors in Nebraska
developed prototype ATLS course

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 Trimodal Death Distribution
• Implies that death due to injury occurs in one of three periods,
or peaks.
• 50 per cent of fatally injured casualties die from non-survivable
injuries immediately, or within minutes after the accidents
• 30 percent survive the initial trauma, but die within 1–3 hours;
the remaining 20 percent die from complications at a late stage
during the 6 weeks after injury.

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 The first peak

 occurs within seconds to minutes of injury

 deaths generally result from apnea due to
severe brain or high spinal cord injury
rupture of the heart, aorta, or other large blood
vessels.
 Very few of these patients can be saved because of
the severity of their injuries.
 Only prevention can significantly reduce this peak
of trauma-related deaths

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 The second peak
 Occurs within minutes to several hours
 Deaths occurs usually due to
subdural and epidural hematomas,
Hemopneumothorax
ruptured spleen, lacerations of the liver
pelvic fractures, and/or multiple other njuries
 Most of these deaths can be avoided with an effective
emergency medical service (EMS)
 The golden hour of care after injury to prevent 30%
mortality
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 The third peak
 occurs several days to weeks
 Due to sepsis and MOF
 Care provided during each of
the preceding periods affects
outcomes

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 Initial assessment and management
 When treating injured patients, clinicians rapidly assess
injuries and institute life preserving therapy using systematic
approach termed the “initial assessment,” includes the
following elements:
Preparation
Triage
Primary survey
Adjuncts to the primary survey and resuscitation
The need for patient transfer
Secondary survey
Adjuncts to the secondary survey
Post-resuscitation monitoring and reevaluation
Definitive care
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 The primary and secondary surveys are
repeated frequently to identify change in the
patient’s status .
 The assessment sequence reflects a linear, or
longitudinal, progression of events.
 In an actual clinical situation, however, many
of these activities occur simultaneously
 Judgment is required to determine which
procedures are necessary for individual
patients, as they may not require all of them.
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 1.Preparation
Prehospital Phase Hospital Phase
• To notify the receiving  Critical aspects of hospital
hospital before transport preparation includes
the patient  A resuscitation area
• Providers emphasize on ABC  Properly functioning airway
of life, and immediate equipment
transport to the closest  Warmed intravenous
appropriate facility crystalloid solutions
• Minimize delay and give  A protocol to summon
information additional medical assistance
 Transfer agreement
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 2.Triage
• Sorting of patients based on the
 resources required for treatment and the
resources that are actually available
 severity of injury, ability to survive, and available
resources.
 also includes the sorting of patients in the field
to help determine the appropriate receiving
medical facility
 Triage situations are categorized as multiple
casualties or mass casualties
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 3.Primary Survey with Simultaneous
Resuscitation
 The primary survey encompasses the ABCDEs of trauma
care
 Airway maintenance with restriction of cervical spine
motion
 Breathing and ventilation
 Circulation with hemorrhage control
 Disability(assessment of neurologic status)
 Exposure/Environmental control
 Clinicians can quickly assess A, B, C, and D in a trauma
patient (10-second assessment)
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• During the primary survey, life-threatening
conditions are identified and treated in a
prioritized sequence based on the effects of
injuries on the patient’s physiology, because
at first it may not be possible to identify
specific anatomic injuries

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 Airway Maintenance
 The earliest priorities in managing the injured patient are
to ensure an intact airway and recognize a compromised
airway
 Rapid assessment for signs of airway obstruction includes
 Inspecting for foreign bodies;
 identifying facial, mandibular, and/or tracheal/laryngeal
fractures and other injuries that can result in airway
obstruction
 If the patient is able to communicate verbally, the airway is not
likely to be in immediate jeopardy
 A protected, unobstructed airway and adequate ventilation are
critical to prevent hypoxemia
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 Begin measures to establish a patent airway
while restricting cervical spine motion.
 Supplemental oxygen must be administered to
all severely injured trauma patients
 Although it is often related to pain or anxiety, or
both, tachypnea can be a subtle but early sign of
airway and/or ventilatory compromise

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 Objective Signs of Airway Obstruction
 Observe for
Agitatation (suggesting hypoxia)
obtunde (suggesting hypercarbia)
 Cyanosis indicates hypoxemia from inadequate oxygenation
 Listen for abnormal sounds.
 Noisy breathing is obstructed breathing.
 Snoring, gurgling,and crowing sounds (stridor) can be
associated with partial occlusion of the pharynx or larynx.
 Hoarseness (dysphonia) implies functional laryngeal
obstruction.
 Evaluate the patient’s behavior.
Abusive and belligerent patients may in fact be hypoxic; do
01/17/2023 not assume intoxication. 18
Ventilation
• A patent airway benefits a patient only when ventilation
is also adequate
• objective signs of inadequate ventilation
 Look for symmetrical rise and fall of the chest
 Listen for movement of air on both sides of the chest
 Use a pulse oximeter to measure the patient’s oxygen
saturation and gauge peripheral perfusion
 Use capnography in spontaneously breathing and
intubated patients to assess whether ventilation is
adequate

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 Breathing and Ventilation
• Examined by looking, listening and feeling.
• Adequate gas exchange is required to maximize
ventilation
• Ventilation requires adequate function of the lungs,
chest wall, and diaphragm
• Impair ventilation could be due to
 tension pneumothorax,
 massive hemothorax,
 open pneumothorax, and
 tracheal or bronchial injuries
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 INITIAL MEASURE

 The first priority of airway management is to

ensure continued oxygenation while
restricting cervical spinal motion
 the jaw-thrust or chin-lift maneuver
often suffices as an initial intervention
 suctioning to clear accumulated blood or
secretions that may lead to or be causing
airway obstruction.

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01/17/2023 22
 TEMPORARY MEASURES

 Nasopharyngeal
Airway/Oropharyngeal Airway
 Extraglottic and Supraglottic
Devices
 laryngeal mask airway
 intubating laryngeal mask
airway
 laryngeal tube airway
 intubating laryngeal tube
airway
 multilumen esophageal airway

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01/17/2023 24
 DEFINATIVE MEASURES
 A definitive airway requires a tube placed in the
trachea with the cuff inflated below the vocal cords,
the tube connected to oxygen-enriched assisted
ventilation, and the airway secured in place with an
appropriate stabilizing method.
 There are three types of definitive airways:
orotracheal tube
nasotracheal tube
surgical airway (cricothyroidotomy and
tracheostomy)

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• A surgical airway is indicated in the presence of
edema of the glottis, fracture of the larynx, severe
oropharyngeal hemorrhage that obstructs the airway,
or inability to place an endotracheal tube through the
vocal cords.
• A surgical cricothyroidotomy is preferable to a
tracheostomy because it is easier to perform,
associated with less bleeding, and requires less time
to perform than an emergency tracheostomy

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01/17/2023 27
 Difficult airway

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01/17/2023 29
 Circulation with Hemorrhage Control
 The circulation is assessed by looking for external
bleeding and the visible signs of shock
 managing shock starts with recognizing its presence and
identify the probable cause of shock
 Hemorrhage is the most common cause of shock in
trauma patients
 Any injured patient who is cool to the touch and is
tachycardic should be considered to be in shock until
proven otherwise

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• Initial determination of the cause of shock
requires an appropriate patient history and
expeditious, careful physical examination.
• Selected additional tests, such as chest and
pelvic x-rays and FAST examinations,can confirm
the cause of shock, but should not delay
appropriate resuscitation

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 Signs of shock
• Tachycardia
• hypotension
• cool extremities
• weak peripheral pulses
• prolonged capilary refill
• narrowing of pulse pressue
• increased respiratory rate
• change in skin color
• alterd mental status

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 Cause of shock in trauma

types cause clinical features mgt

hypovolumic Hemorrhage bleeding stop bleeding ,fluid, blood,

shock stabilization of bony injuries, and
appropriate treatment of soft tissue
injuries

obstractive tension shock wz Needle decompression

pneumothorax ipsilateral chest
finding

p.tamponade Beck’s triad Pericardiocentesis

cardiogenic myocardial dysrhythmia cardiac monitor and ECHO

contusion

distributive sptic shock septic features fluid,antibiotics,inotrops,debrideme

nt of nonviable tissue

01/17/2023 neurogenic shock body wkness controled fluid mgt33

 Hemorrhagic Shock
• Hemorrhage is an acute loss of circulating blood volume.
• normal adult blood volume is 7% of body weight
• the systolic blood pressure may not drop significantly
until 30 percent of the patient’s blood volume has been
lost
• The primary focus in Hemorrhagic Shock is to promptly
identify and stop hemorrhage.
• Sources of potential blood loss—chest, abdomen, pelvis,
retroperitoneum, extremities, and external bleeding

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 Physiologic Classification of shock

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Initial Management of Hemorrhagic Shock
• The basic management principle is to stop the bleeding and
replace the volume loss,obtaining adequate intravenous
access, and assessing tissue perfusion.
• Bleeding from external wounds in the extremities usually can
be controlled by direct pressure to the bleeding site, although
massive blood loss from an extremity may require a
tourniquet.
• A sheet or pelvic binder may be used to control bleeding from
pelvic fractures
• Surgical or angioembolization may be required to control
internal hemorrhage

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 Vascular Access and Initial Fluid Therapy
 Inserting two large caliber peripheral intravenous
catheters
 The rate of flow is proportional to the fourth power of
the radius of the cannula and inversely related to its
length
 The amount of fluid and blood required for resuscitation
is difficult to predict on initial evaluation of a patient.
 Administer an initial, warmed fluid bolus of isotonic fluid.
 The usual dose is 1 liter for adults and 20 mL/kg for
pediatric patients weighing less than 40 kilograms.
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• Absolute volumes of resuscitation fluid should be
based on patient response to fluid administration,
ncludes any fluid given in the prehospital setting
• The goal of resuscitation is to restore organ perfusion
and tissue oxygenation
• Surgical consultation and evaluation are necessary
during initial assessment and treatment of rapid
responders, as operative intervention could still be
necessary

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 Response to Fluid Therapy

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• The easily obtainable
parameters of arterial blood
pressure, heart rate, urine
output, central venous pressure,
and pulmonary artery occlusion
pressure are poor indicators of
the adequacy of tissue
perfusion.
• Therefore, surrogate parameters
have been sought to estimate
the O2 debt
 serum lactate and base deficit
have been shown to correlate
with O2debt.

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• Base deficit measurement is
critical; a base deficit of >8
mmol/L implies ongoing cellular
shock
• Serum lactate also is used to
monitor the patient’s physiologic
response to resuscitation
• Evaluation of the CVP or IVC may
assist in distinguishing between
cardiogenic and hypovolemic
shock

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 Blood Replacement
• The decision to initiate blood transfusion is based on
the patient’s response
• Patients who are transient responders or
nonresponders require pRBCs, plasma and platelets
as an early part of their resuscitation.

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 Massive Transfusion
• A small subset of patients with shock will require
massive transfusion, most ofte defined as > 10 units of
pRBCs within the first 24 hours of admission or more
than 4 units in 1 hour
• Early administration of pRBCs, plasma, and platelets in
a balanced ratio to minimize excessive crystalloid
administration may improve patient survival.
• This approach has been termed “balanced,”
“hemostatic,” or “damage control” resuscitation.

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 Disability (Neurologic Evaluation)
• A rapid neurologic evaluation establishes the
patient’s level of consciousness and pupillary size and
reaction; identifies the presence of lateralizing signs;
and determines spinal cord injury level, if present
• Until proven otherwise, always presume that
changes in level of consciousness are a result of
central nervous system injury

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 Exposure and Environmental Control
• During the primary survey, completely undress the patient,
usually by cutting off his or her garments
• After completing the assessment, cover the patient with warm
blankets or an external warming device
• The use of a high-flow fluid warmer to heat crystalloid fluids to
39°C (102.2°F) is recommended.
• When fluid warmers are not available, a microwave can be used
to warm crystalloid fluids, but it should never be used to warm
blood products

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 Adjuncts to the Primary Survey
 continuous electrocardiography, pulse oximetry,carbon dioxide
(CO2) monitoring, and assessment of ventilatory rate, and arterial
blood gas (ABG) measurement.
 urinary catheters can be placed to monitor urine output and assess
for hematuria
 Gastric catheters decompress distention and assess for evidence of
blood.
 Other helpful tests include blood lactate, x-ray examinations (e.g.,
chest and pelvis), FAST, extended focused assessment with
sonography for trauma (eFAST), and DPL.
 Physiologic parameters such as pulse rate, blood pressure, pulse
pressure, ventilatory rate, ABG levels, body temperature, and
urinary output are assessable measures that reflect the adequacy
of resuscitation.
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 Patient Transfer
• During the primary survey the evaluating doctor frequently
obtains sufficient information to determine the need to transfer
the patient to another facility for definitive care.
• It is important not to delay transfer to perform an in depth
diagnostic evaluation.
• Only undertake testing that enhances the ability to resuscitate,
stabilize, and ensure the patient’s safe transfer.
• Once the decision to transfer made, communication between
the referring and receiving doctors is essential.
• When? Where? Who? What way?With?

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 Secondary survey
• The head-to-toe evaluation of the trauma patient—that is, a
complete history and physical examination, including
reassessment of all vital signs.
• The secondary survey does not begin until the primary survey
(ABCDE) is completed.
• When additional personnel are available, part of the secondary
survey may be conducted while the other personnel attend to
the primary survey
• To identify minor injuries can be missed during the primary
survey and resuscitation, but cause long term morbidity if
overlooked

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 Reevaluation and Definitive Care
• Trauma patients must be reevaluated constantly to
ensure that new findings are not overlooked and to
discover any deterioration in previously noted
findings
• Definitive Care requires a detailed assessment of the
patient’s injuries and knowledge of the capabilities of
the institution, including equipment, resources, and
personnel.

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01/17/2023 51
 Damage Control Orthopaedics 1990s
 An approach that contains and
stabilizes orthopaedic injuries,
so that the patient's overall
physiology can improve.
 Its purpose is to avoid worsening
of the patient's condition by the
"second hit" of a major
orthopaedic procedures
 principles of damage control
surgery is used in all trauma care
and had following phases

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 Phase 0-rapid transport and triage for treatment
 Phase 1
arest bleeding,limit contamination,maitain
obtimal blood flow to vital organs
limit operative time(minimize deady triads)
 Phase 2---resuscitation in ICU
 Phase 3-definative repair ,could be staged
 Phase 4 ---soft tissue closure

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 Historical perspective

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Before 1950--
 the surgical stabilization of fractures of the long bones was not
routinely performed.
 The multiply- injured patient was not considered to be stable
enough to withstand a prolonged surgical procedure
 Cast and skeletal traction treatment preferred
1970s-
 studies showed that early stabilization of femoral fractures of
reduced dramatically incidence of Fat Emb,Syndrome of
pulmonary failure(ARDS) and postoperative complications
Damage control surgery ---1983

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 Early Total Care-Late 1980s
• There is a beneficial effect of early stabilization of fractures on
both mortality and morbidity and length of hospital stay
• This new philosophy in the management of the patient with
multiple injuries was named Early Total Care ( ETC )
• “The patient is too sick not to be treated surgically”
• Patients were able to mobilize early and were discharged
from hospital sooner, avoiding the complications associated
with prolonged bed rest.
• Best operation for a patient is one, early and definitive
procedure

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 DCO--Early 1990s

 Outcome after ETC – increased incidence of adult

respiratory distress syndrome ARDS and multiple
organ failure (MOF) multiple organ failure (M.O.F)
 These complications mainly developed in patients
with severe chest injuries,severe hemodynamic
shock and in cases post reamed intramedullary
nailing without thoracic trauma.

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 Indications
 Severe degree of physiologic insult
hypothermia <34℃
evidence of coagulopathy
intra op evidence of shock/PH,base deficit,lactate
 Inablity to control bleeding using conventional methods
 Large volume resuscitation required
 pelvic fracture with shock
 polytrauma in gediatrics
 Need for staged reconstruction
01/17/2023
long bone fracture with chest/head injury 58
01/17/2023 59
 Optimal time of surgery

 patient are at increased risk of ARDS and multisystem failure

during acute inflammatory window (period from 2 to 5 days
characterized by a surge in inflammatory markers)
 only potentially life-threatening injuries should be treated in
this period including
 compartment syndrome
 fractures with vascular injurie
 unreduced dislocations
 long bone fracture
 unstable spine fractures
 open fractures

01/17/2023 60
 pathophysiology
 Invasive fracture fixation surgery Stimulates a
secondary inflammatory reaction (SIRS)“
 The second hit” detectable by an elevation of pro
inflammatory cytokines
 This inflammatory reaction may lead to ARDS and
MOF
 After trauma, there is a balance between the systemic
inflammatory response (SIRS) and the
contraregulatory anti inflammatory response (CARS)
 External fixation is a safe, viable procedure to achieve
temporary rigid stabilization
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 REFERRENCES
• Advanced Trauma Life Support®,Tenth Edition
• UPTODATE 2022
• Apley’s System of Orthopaedics and Fractures
Ninth Edition
• ORTHO BULLETS 2017
• Schwartz’s Principles of Surgery 11th Edition

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 THANK YOU

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