Creation TO AIRWAY assessment AND control

Airway is of paramount significance in any clinical putting. It need to constantly be assessed first, and if any compromise or capacity compromise is discovered, this must be treated as a first priority.

AN AIRWAY should BE :
1.         Patent

Having a patent airway is an absolute first precedence for any patient. An obstructed airway may be real (i.e. partially or completely obstructed) or potential (eg airway burns which may also bring about revolutionary obstruction over the following few hours).

2.         protected

that is a relative priority. It does no longer take priority over the initial assessment and control of a patient's respiration and move
An airway is unprotected while the everyday protecting reflexes are absent. that is maximum typically related to a reduced recognition level. A GCS of eight or less is commonly associated with an unprotected airway.

Cervical backbone protection is a part of airway assessment and control. Any patient with a decreased stage of consciousness, who has had trauma to the pinnacle or neck, or complains of neck pain, need to be dealt with as having a capability cervical backbone harm till proved otherwise. In line immobilization of the cervical spine or protection via a tough cervical collar need to be furnished while manipulating the airway.

Evaluation OF AIRWAY

evaluation normally involves examination earlier than records as the general public of instances of airway compromise, either actual or ability, are glaring through easy remark.

1.        examination - searching out :
▪      signs and symptoms of complete obstruction
●            no air motion gift
●            grabbing at throat
●            paradoxical respiratory with excessive breathing misery ie abdomen moves inwards while chest expands for the duration of attempted concept
●            cyanosis
●            agitation
▪      symptoms of partial obstruction
●            nonetheless a few air movement present
●            stridor, cough , self posturing if patient is aware (eg sitting up and leaning forwards)
●            use of accent muscle groups of respiration
●            cyanosis at the same time as respiratory room air is a late signal of partial top airway obstruction
▪      signs of ability obstruction
●            everyday air motion
●            not one of the above capabilities
●            swollen face, swollen tongue, sore throat, outside neck trauma, circumferential neck burns, sooty sputum, burnt mouth/tongue/nasal hairs, records of fireplace or explosion in an enclosed space
▪      signs suggestive of difficult intubation
▪      signs of a non included airway
●            GCS eight or less
●            Absent gag/cough reflex

2.        history - ASK about
▪      signs of partial airway obstruction
●            voice modifications, cough, sore throat
▪      capabilities which advise capability airway obstruction
●            burns in an enclosed space
●            history of hard intubation

EINFÜHRUNG ZUR LUFTWASSERBEWERTUNG UND VERWALTUNGDie Atemwege ist in jeder klinischen Umgebung von größter Bedeutung. Es muss immer zuerst beurteilt werden, und wenn irgendwelche Kompromisse oder potenzielle Kompromisse gefunden werden, muss dies als erste Priorität behandelt werden.EIN LUFTWIRTSCHAFT IST:1. PatentMit einem Patent Atemwege ist eine absolute erste Priorität für jeden Patienten. Eine verstopfte Atemwege kann tatsächlich (d. H. Teilweise oder vollständig behindert) oder Potenzial sein (z. B. Atemwegsverbrennungen, die in den folgenden Stunden zu einer fortschreitenden Obstruktion führen können).2. GeschütztDies ist eine relative Priorität. Es hat keine Vorrang vor der anfänglichen Bewertung und dem Management der Atmung und des Umlaufs eines Patienten.33Eine Atemwege ist ungeschützt, wenn die normalen Schutzreflexe nicht vorhanden sind. Dies ist am häufigsten mit einem verminderten Bewusstseinsniveau verbunden. Ein GCS von 8 oder weniger ist in der Regel mit einem ungeschützten Atemweg verbunden.Halswirbelsäule Schutz ist Teil der Atemwege Bewertung und Management. Jeder Patient mit einem verminderten Bewusstseinsniveau, der ein Trauma auf den Kopf oder den Hals gehabt hat oder sich über Nackenschmerzen beklagt, sollte so behandelt werden, dass er eine potenzielle Halswirbelsäulenverletzung hat, bis es anders bewiesen ist. In der Linie Immobilisierung der Halswirbelsäule oder Schutz durch einen harten Halskragen muss bei der Manipulation der Atemwege zur Verfügung gestellt werden.BEURTEILUNG VON LUFTWASSERAssessment beinhaltet in der Regel eine Untersuchung vor der Geschichte, da die Mehrheit der Fälle von Atemwegs-Kompromissen, entweder tatsächliche oder potenzielle, durch einfache Beobachtung deutlich werden.1. PRÜFUNG - BETRACHTEN:▪ Zeichen der vollständigen Obstruktion● keine Luftbewegung vorhanden● in den Hals greifen● paradoxe Atmung mit extremer Atemnot, dh Abdomen bewegt sich nach innen, während sich die Brust bei versuchter Inspiration ausdehnt● ZyanoseAufregung▪ Zeichen der partiellen Obstruktion● noch etwas Luftbewegung vorhanden● Stridor, Husten, Selbst-Haltung, wenn der Patient bewusst ist (zB aufstehen und nach vorne lehnen)● Verwendung von zusätzlichen Muskeln der Atmung● Zyanose beim Atmen Raum Luft ist ein spätes Zeichen der partiellen oberen Atemwege Obstruktion▪ Anzeichen einer potenziellen Behinderung● normale Luftbewegung● keine der oben genannten Funktionen● geschwollenes Gesicht, geschwollene Zunge, Halsschmerzen, äußeres Halstrauma, umlaufende Halsbrände, rußiges Sputum, verbrannte Mund / Zunge / Nasenhaare, Brandgeschichte oder Explosion in einem geschlossenen Raum▪ Anzeichen für eine schwierige Intubation▪ Anzeichen einer nicht geschützten Atemwege● GCS 8 oder weniger● Fehlender Knebel / Hustenreflex2. GESCHICHTE - BITTE ÜBER▪ Symptome einer partiellen Atemwegsobstruktion● Stimmveränderungen, Husten, Halsschmerzen▪ Merkmale, die auf eine mögliche Obstruktion der Atemwege hindeuten● verbrennt in einem geschlossenen Raum● Geschichte der schwierigen Intubation 

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Injured Infant and Child (APLS, PALS)

  Assessment and Management of the Critcally Ill and Injured Infant and Child (APLS,  PALS)

       Injured little one and toddler (APLS,  buddies)

Cardiopulmonary arrest in infants and kids is rarely a unexpected event. as a substitute, it's far regularly the result of progressive deterioration in respiration and circulatory characteristic. The epidemiology of cardiopulmonary arrest is different from that of adults. unexpected number one cardiac arrest in toddlers and youngsters is uncommon. more typically, injury or disorder reasons respiratory or circulatory failure, which progresses to cardiopulmonary failure with hypoxaemia and acidosis culminating in cardiopulmonary arrest.

Intact survival from normothermic asystolic or pulseless cardiac arrest is unusual.

In evaluation, breathing arrest on my own is related to a survival exceeding 50% when activate resuscitation is supplied.

Paediatric cardiopulmonary arrest takes place maximum normally at either quit of the age spectrum - in kids more youthful than three hundred and sixty five days and in formative years.

whilst cardiopulmonary failure is detected, preliminary priority is given to ventilation and oxygenation. If flow and perfusion fail to improve swiftly, therapy for shock is provided

Below is the path of various disease states leading to cardiopulmonary failure in infants and children (APLS).

Summary of BLS Manoeuvres in Infants and Children

MANOEUVRE	INFANT    (<1 YEAR)	CHILD ( 1 TO 8Y)
AIRWAY	Head tilt/chin lift(if trauma present, use jaw thrust)	Head tilt/chin lift(if trauma present, use jaw thrust)
BREATHING
Initial	Two breaths at 1-	Two breaths at 1-
	2secs/breath	2secs/breath
Subsequent	20 breaths/min	20 breaths/min
	(approximate)	(approximate)
CIRCULATION
Pulse check	Brachial/femoral	Carotid
Compression area	Lower half of sternum	Lower half of sternum
Compression with	2 or 3 fingers	Heel of one hand
Depth	Approximately one third to	Approximately one third to
	one half the depth of the	one half of the depth of the
	chest	chest
Rate	At least 100/min	100/min
Compression-	5:1 (pause for ventilation)	5:1 (pause for ventilation)
ventilation ratio
Foreign body	Back blows/chest thrusts	Heimlich manoeuvre
airway obstruction

(APLS)

Assessment und Management des kritisch kranken und verletzten Säuglings und Kindes (APLS, PALS)

       Verletztes Säugling und Kind (APLS, PALS)Kardiopulmonale Verhaftung bei Säuglingen und Kindern ist selten ein plötzliches Ereignis. Stattdessen ist es oft das Ergebnis einer fortschreitenden Verschlechterung der Atem- und Kreislauffunktion. Die Epidemiologie der kardiopulmonalen Verhaftung unterscheidet sich von der der Erwachsenen. Ein plötzlicher primärer Herzstillstand bei Säuglingen und Kindern ist ungewöhnlich. Häufiger verursacht eine Verletzung oder eine Erkrankung ein Atem- oder Kreislaufversagen, das mit dem Kardiopulmonalen Versagen mit Hypoxämie und Azidose fortschreitet, die in der kardiopulmonalen Verhaftung gipfelt.Intaktes Überleben von normothermen asystolischen oder pulslosen Herzstillstand ist ungewöhnlich.Im Gegensatz dazu ist die Atemstillstand allein mit einem Überleben über 50% verbunden, wenn eine sofortige Wiederbelebung vorliegt.Pädiatrische kardiopulmonale Verhaftung tritt am häufigsten am Ende des Alters-Spektrums - bei Kindern jünger als ein Jahr und in der Adoleszenz.Wenn ein kardiopulmonaler Ausfall festgestellt wird, wird die Priorität der Belüftung und Oxygenierung gegeben. Wenn sich die Zirkulation und die Perfusion nicht schnell verbessern, ist die Therapie für Schock vorgesehen.Unten ist der Weg der verschiedenen Krankheitszustände, die zum kardiopulmonalen Versagen bei Säuglingen und Kindern führen (APLS).

Zusammenfassung der BLS Manöver bei Säuglingen und KindernMANÖVERINFANT (<1 JAHR)KIND (1 BIS 8J)AIRWAYKopf Kipp / Kinn Lift (wenn Trauma vorhanden, verwenden Kiefer Schub)Kopf Kipp / Kinn Lift (wenn Trauma vorhanden, verwenden Kiefer Schub)ATMUNGInitialeZwei Atemzüge bei 1-Zwei Atemzüge bei 1-2secs / atem2secs / atemAnschließend20 Atemzüge / min20 Atemzüge / min(Ungefähre)(Ungefähre)VERKEHR
Pulsprüfung
Brachial / femoral
CarotisKompressionsbereich
Untere Hälfte des Sternums
Untere Hälfte des SternumsKompression mit
2 oder 3 finger
Ferse von einer HandTiefe
Etwa ein Drittel
Etwa ein Drittel


Eine halbe Tiefe der
Die Hälfte der Tiefe der


Brust
BrustPreis
Mindestens 100 / min
100 / minKompression-
5: 1 (Pause für die Belüftung)
5: 1 (Pause für die Belüftung)Belüftungsverhältnis




Fremder Körper
Rückenschläge / Bruststöße
Heimlich ManöverAtemwegsobstruktion




(APLS)

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DIRECTED history AND examination

Within the placing of the emergency management of a critically unwell patient, conventional records taking should be modified for you to be directed and focussed on he patient's instantaneous infection. for example, an in depth systems assessment and family records are not first of all essential when managing a affected person with acute allergies.

further, a complete neurological exam is not suitable on a patient who has epiglottitis. in the critically unwell affected person, a history and examination, that are directed keep time and will save you a loss of recognition at the patient's maximum instant wishes

1.               History
Ask about :

●            event - period and onset of signs
●            signs and symptoms -  pain, dyspnoea, cough and so forth
●            beyond records

2.                  exam
A focussed scientific examination is achieved.

3.                  special INVESTIGATIONS

four.                  monitoring
ECG, pulse, blood pressure and many others

 COMMENCE 

specific remedy

After the ranges of preliminary stabilisation and directed records and examination, maximum seriously ill patients would require a small number of pivotal interventions or treatments, which are often time essential. for example, the giving of antibiotics to a patient with sepsis or the commencement of rehydration and insulin in diabetic patients.

 DISPOSITION

this may be a deceptively difficult and time ingesting level of the emergency control of the critically sick affected person. however, the vital components of this stage are correct communication with body of workers who may be accountable for the continuing management of the patient, and vigilence concerning repeated assessment of the affected person

 
DIREKTTE GESCHICHTE UND PRÜFUNGBei der Einstellung des Notfallmanagements eines schwer erkrankten Patienten muss die traditionelle Geschichte unter Umständen geändert werden, um sich auf die unmittelbare Krankheit des Patienten zu konzentrieren und zu konzentrieren. Zum Beispiel ist eine umfangreiche Systemüberprüfung und Familiengeschichte zunächst nicht notwendig, wenn man einen Patienten mit akutem Asthma behandelt.Ebenso ist eine vollständige neurologische Untersuchung nicht geeignet für einen Patienten, der Epiglottitis hat. Bei den ernsthaft kranken Patienten, eine Geschichte und eine Untersuchung, die gerichtet sind, sparen Zeit und wird einen Verlust der Fokus auf die unmittelbaren Bedürfnisse des Patienten zu verhindern.
1. GESCHICHTEFragen über :● EVENT - Dauer und Beginn der Symptome● SYMPTOME - Schmerzen, Dyspnoe, Husten usw● VERGANGENE GESCHICHTE2. PRÜFUNGEs wird eine fokussierte klinische Untersuchung durchgeführt.3. SPEZIELLE UNTERSUCHUNGEN4. ÜBERWACHUNGEKG, Puls, Blutdruck usw


 KOMMENTAR SPEZIFISCHE BEHANDLUNGNach den Stadien der anfänglichen Stabilisierung und der gezielten Geschichte und der Untersuchung werden die meisten schwer erkrankten Patienten eine kleine Anzahl von entscheidenden Interventionen oder Behandlungen erfordern, die oft zeitkritisch sind. Zum Beispiel die Bereitstellung von Antibiotika für einen Patienten mit Sepsis oder der Beginn der Rehydratation und Insulin bei Diabetikern.


 ANORDNUNGDies kann eine trügerisch schwierige und zeitraubende Phase des Notfallmanagements des schwer erkrankten Patienten sein. Allerdings sind die wesentlichen Bestandteile dieser Phase eine gute Kommunikation mit den Mitarbeitern, die für die laufende Verwaltung des Patienten verantwortlich sind, und die Vigilenz über die wiederholte Beurteilung des Patienten
DIREKTTE GESCHICHTE UND PRÜFUNG

 Bei der Einstellung des Notfallmanagements ein schwer erkrankten Patienten muss die Traditionelle Geschichte unter Umständen geändert werden, um sich auf die unmittelbare Krankheit des Patienten zu konzentrieren und zu konzentrieren. Zum Beispiel ist eine umfangreiche Systemüberprüfung und Familiengeschichte nicht nicht, wenn man einen Patienten mit akutem Asthma behandelt.Ebenso ist eine komplette neurologische Untersuchung nicht geeignet für einen Patienten, der Epiglottitis Hut. Bei den ernsthaft kranken Patienten, eine Geschichte und eine Untersuchung, die gerichtet sind, sparen. GESCHICHTEFragen über: ● EVENT - Dauer und Beginn der Symptome ● SYMPTOME - Schmerzen, Dyspnoe, Husten usw ● VERGANGENE GESCHICHTE2. PRÜFUNGEs wird eine fokussierte klinische Untersuchung durchgeführt. SPEZIELLE UNTERSUCHUNGEN4. ÜBERWACHUNGEKG, Puls, Blutdruck usw


 KOMMENTAR SPEZIFISCHE BEHANDLUNGNach den Stadien der anfänglichen Stabilisierung und der gezielten Geschichte und der Untersuchung werden die meisten schwer erkrankten. Eine kleine Anzahl von entscheidenden Interventionen oder Behandlungen erfordern, die oft zeitkritisch sind. Zum Beispiel die Bereitstellung von Antibiotika für einen Patienten mit Sepsis oder der Anfang der Rehydratation und Insulin bei Diabetikern.


 ANORDNUNGDIEN kann eine trügerisch schwierige und zeitraubende Phase des Notfallmanagements des schwer erkrankten Patienten. Allerdings sind die besten Bestandteile dieser Phase eine gute Kommunikation mit den Mitarbeitern, die für die laufende Verwaltung des Patienten verantwortlich sind und die Vigilenz über die wiederholte Beurteilung der Patienten

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Assessment and control of the severely Ill

Grownup patient   (  e.g. Acute bronchial asthma, Pneumonia, repute Epilepticus and so forth)

intense trauma (ATLS) and cardiac sufferers (ACLS) make up handiest a part of the entire quantity of patients seen in the emergency putting. To address a huge range of scientific emergencies eg, acute allergies, extreme pneumonia, pulmonary embolism, pulmonary oedema, exacerbation of COPD, poisoning, reputation epilepticus and so on, we will now outline an approach to the control of sufferers presenting with these troubles. there's obviously a positive quantity of overlap with the ACLS and ATLS procedures, but it's far however beneficial to give an technique to those conditions one at a time as they represent a huge percentage of emergencies seen.

 initial STABILISATION
- evaluation OF crucial features AND instant remedy OF identified lifestyles THREATENING ABNORMALITIES

1.                  function affected person correctly
a)        The unconscious affected person
To keep away from obstruction of the airway, position the affected person head down and within the left lateral role, with neck flexed and head prolonged (if trauma and cervical spine damage is suspected, do not pass the neck). This prevents the tongue from falling returned over the airway. additionally, if the patient vomits, it's miles more likely to run out of the mouth as opposed to down the airway.
b)        The dyspnoeic patient
The patient who is dyspnoeic will often choose to take a seat upright. There are precise physiological motives for this. It enables finest use of accessory muscular tissues of respiration and inside the case of pulmonary oedema, helps reduce shunting.
dealing with those sufferers within the upright position will no longer best reduce hypoxia, however additionally get maximal co-operation.
c)        the child with partial higher airway obstruction
unless the kid is in extremis, the high-quality place is sitting up in the discern's lap. The sitting role allows the child to keep the pinnacle and neck in a manner that keeps patency of the airway. Being seated on the lap has a chilled impact on children in an environment, which is quite frightening to them. this can decrease the risk of changing a partial airway obstruction right into a whole one.
d)        The greatly surprised patient
The supine position is excellent for sufferers in shock. It lets in for the most efficient use of the cardiovascular compensatory mechanism and for this reason, the exceptional perfusion of the important organs. the usage of Trendelenburg (ft extended above the top) is controversial and has not been shown to make any distinction to affected person final results or improve physiological parameters.
e)        the head injured affected person
except shock or spinal harm is present, patients need to be located with head expanded at 30 degrees to the horizontal. this can lessen intracranial stress.
f)         The patient with facial trauma or partial top airway obstruction from any cause
If the patient is aware and does not have a sizable cervical spine damage, encourage self posturing to hold airway patency. inside the putting of facial
trauma this helps to save you any facial fractures from falling backwards and occluding the airway, and will also prevent blood from jogging down the airway.
g)        The pregnant affected person
in the 1/3 trimester of pregnancy care has to be taken if the patient is lying flat to prevent supine hypotension from vena caval compression. this will require a wedge below the proper flank or positioning of the affected person inside the left lateral function.

2.                  AIRWAY
hold patent. this can require a combination of preferred airway commencing manoeuvres or extra complicated manoeuvres. guard cervical backbone with a tough collar or in line immobilisation if there is a suspicion of trauma.

three.                  respiration

measure the respiratory fee. If insufficient, assist ventilation with a bag valve bag (Ambu Bag) connected to oxygen.
measure SaO2. If < 95% and not requiring assisted air flow, administer oxygen through the ideal face mask at a price in step with the clinical condition.

four.                  circulation

▪       If in cardiac arrest, commence CPR, in any other case:
▪       degree pulse rate, blood strain and capillary replenish
▪       attach to a cardiac screen and assess the rhythm. accurate any lifestyles threatening rhythm disturbances.
▪       Insert an IV cannula
▪       Take blood from the cannula for suitable blood assessments
▪       If in shock, provide fluids and inotropes as appropriate

5.                  disability
record a Glasgow Coma Scale (GCS) and scholar reaction. If GCS eight or much less, do not forget intubation to defend the airway.

6.                  measure
Temperature and finger prick sugar

7.                  reveal
ECG, SaO2, Blood strain

Assessment und Management der Ernsthaftigkeit
Erwachsene Patient (z. B. Akutes Asthma, Pneumonie, Status Epilepticus usw.)Starke Trauma (ATLS) und Herzpatienten (ACLS) machen nur einen Teil der Gesamtzahl der Patienten aus, die in der Notfallstellung gesehen wurden. Um mit einer breiten Palette von medizinischen Notfällen umzugehen, zB akutes Asthma, schwere Lungenentzündung, Lungenembolie, Lungenödem, Verschlimmerung von COPD, Vergiftung, Status epilepticus usw., werden wir nun einen Ansatz für die Behandlung von Patienten mit diesen Problemen skizzieren. Es gibt offensichtlich eine gewisse Überschneidung mit den ACLS- und ATLS-Ansätzen, aber es ist jedoch sinnvoll, diesen Bedingungen eine Herangehensweise zu präsentieren, da sie einen großen Teil der Notfälle darstellen.

 ERSTE STABILISIERUNG- BEURTEILUNG VON VITALFUNKTIONEN UND SOFORTIGE BEHANDLUNG VON IDENTIFIZIERTEN LEBENSDREHENDEN ABNORMALITÄTEN1. POSITION PATIENTEN GENEHMIGA) Der unbewusste PatientUm eine Verstopfung der Atemwege zu vermeiden, positioniere den Patientenkopf nach unten und in die linke seitliche Position, mit Hals gebeugt und Kopf verlängert (wenn Trauma und Halswirbelsäule Verletzung vermutet wird, nicht den Hals bewegen). Dadurch wird verhindert, dass die Zunge über die Atemwege zurückfällt. Auch, wenn der Patient erbricht, ist es wahrscheinlicher, aus dem Mund zu laufen, anstatt hinunter die Atemwege.B) Der dyspnoeische PatientDer Patient, der dyspnoeisch ist, wird oft lieber aufrecht sitzen. Dafür gibt es gute physiologische Gründe. Es ermöglicht eine optimale Nutzung der zusätzlichen Muskeln der Atmung und im Falle von Lungenödem, hilft, Rangieren zu reduzieren.Die Verwaltung dieser Patienten in der aufrechten Position wird nicht nur die Hypoxie reduzieren, sondern auch eine maximale Kooperation erhalten.C) Das Kind mit teilweiser Obstruktion der oberen AtemwegeWenn das Kind nicht in Extrem ist, sitzt der beste Platz im Schoß des Elternteils. Die Sitzposition erlaubt dem Kind, den Kopf und den Hals in einer Weise zu halten, die die Durchgängigkeit der Atemwege aufrechterhält. Sitzen auf dem Schoß ist eine beruhigende Wirkung auf Kinder in einer Umgebung, die für sie ziemlich erschreckend ist. Dies kann das Risiko der Umwandlung einer partiellen Atemwegsobstruktion in ein vollständiges verringern.D) Der schockierte PatientDie Rückenlage ist am besten für Patienten im Schock. Es ermöglicht die effizienteste Nutzung des Herz-Kreislauf-Kompensationsmechanismus und damit die beste Perfusion der lebenswichtigen Organe. Die Verwendung von Trendelenburg (Füße über dem Kopf) ist umstritten und hat sich nicht gezeigt, dass sie einen Unterschied zum Patientenergebnis haben oder die physiologischen Parameter verbessern.E) Der verletzte PatientWenn keine Schock- oder Wirbelsäulenverletzung vorliegt, sollten die Patienten mit einem Kopf von 30 Grad zur Horizontalen positioniert werden. Dies kann den intrakraniellen Druck verringern.F) Der Patient mit Gesichts-Trauma oder partielle obere Atemwege Obstruktion aus irgendeiner UrsacheWenn der Patient bewusst ist und keine signifikante Halswirbelsäule-Verletzung hat, ermutige die Selbst-Haltung, um die Durchgängigkeit der Atemwege zu bewahren. In der Einstellung der Gesichtsbehandlung
Trauma dies hilft, um zu verhindern, dass Gesichtsfrakturen rückwärts fallen und die Atemwege verschließen, und wird auch aufhören, Blut aus der Luftweg laufen.G) Der schwangere PatientIm dritten Trimester der Schwangerschaft ist Vorsicht geboten, wenn der Patient flach liegt, um eine Rückenlage aus der Vena-Kavalkompression zu verhindern. Dies erfordert einen Keil unter der rechten Flanke oder Positionierung des Patienten in der linken Seitenlage.2. AIRWAYHalten Sie das Patent. Dies kann eine Kombination von Standard-Atemwegsöffnungsmanövern oder komplexeren Manövern erfordern. Schützen Sie die Halswirbelsäule mit einem harten Kragen oder in der Linie Immobilisierung, wenn es einen Verdacht auf Trauma.3. ATMUNGMessen Sie die Atemfrequenz. Wenn unzureichend, unterstützen Sie die Belüftung mit einem Beutelventilbeutel (Ambu-Beutel), der an Sauerstoff befestigt ist.Messen Sie SaO2. Wenn <95% und nicht die unterstützte Belüftung erforderlich sind, verabreichen Sie Sauerstoff über eine geeignete Gesichtsmaske mit einer Rate nach dem klinischen Umstand.4. ZIRKULATION▪ Wenn bei Herzstillstand CPR anfangen, sonst:▪ Pulsfrequenz, Blutdruck und Kapillaren nachfüllen▪ An einen Herzmonitor anschließen und den Rhythmus beurteilen. Korrigieren Sie alle lebensbedrohlichen Rhythmusstörungen.▪ Eine IV-Kanüle einsetzen▪ Nehmen Sie Blut aus der Kanüle für entsprechende Blutuntersuchungen▪ Bei Schock ggf. Flüssigkeiten und Inotropen geben5. BEHINDERUNGNehmen Sie eine Glasgow Coma Scale (GCS) und Pupillenreaktion auf. Wenn GCS 8 oder weniger, betrachten Intubation zum Schutz der Atemwege.6. MESSUNGTemperatur und Finger-Stachel Zucker7. MONITOREKG, SaO2, Blutdruck 

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Assessment and Management of the Seriously Injured Patient

 ACUTE TRAUMA LIFE SUPPORT  (ATLS)

A regulated and planned approach to the seriously injured trauma patient is presented, using the ATLS guidelines.

PRIMARY SURVEY AND RESUSCITATION

A.       Airway and Cervical Spine

The airway may be:

●            patent, partially obstructed, or completely obstructed (this may result from physical obstruction or loss of muscle tone)

●            adequately protected or at risk

Check for responsiveness

Is the patient alert and responsive to questions? A verbal reply confirms that there is:

¤       a maintained and protected airway

¤       temporary adequate breathing and circulation

¤       cerebral functioning

Look listen and feel for breathing

The absence of breath sounds indicates the need to attempt airway opening manoeuvres, and if unsuccessful to consider the possibility of airway obstruction.

Look for signs of partial upper airway obstruction

¤       Snoring - the familiarsound of obstruction caused by the soft tissuesof the mouth and pharynx. It often accompanies the reduced muscle tone of a lowered level of consciousness.

¤       Rattling or gurgling - the soundof fluids in the upperairway.

¤       Stridor - a harsh crowing sound best heard on inspiration. Stridor suggests obstruction at the levelof the larynx and uppertrachea.

¤       Drooling - the inabilityto swallow saliva.It suggests blockageat the back of the throat.

¤       Hoarseness - gross voice change. This also suggestsobstruction at the level of the larynx.

Management

The possibility of an injury of the cervical spine should be suspected in all patients with a significant history of trauma. In these cases no airway manoeuvres should involve movement of the neck. Immediate manual cervical spine immobilisation should be done by a designated team member until the primary survey has been completed and an immobilizing device can be applied.

A rigid cervical collar can be applied to assist with spinal immobilisation but it should not delay the management of the airway. The cervical collar alone does not provide complete stabilisation of the cervical spine.

The stepped airway protocol is followed if any signs of a compromised airway are present. The aim is to open and improve, and then to establish and secure.

¤       The mouth is opened and the oral cavity inspected (chin lift / jaw thrust manoeuvre). Any visible foreign objects must be removed (finger sweep, Magill's forceps). If any secretions or blood are present, rapid controlled suctioning with a rigid suctioning tip is performed under direct vision.

¤       This is followed by placement of an oropharyngeal tube, if a gag reflex is absent. This is a temporary measure, while the intubation equipment is prepared.

¤       Endotracheal intubation :

This is the gold standard for definitive airway management.

An assistant should apply in line cervical spine immobilisation, preferably from the caudal position.

Pre-oxygenation with 100% oxygen is performed for 2-3 minutes. Cricoid pressure is applied during manual ventilation.

A pulse oximeter is used to monitor the patient.

The time of intubation should not be longer than 30 seconds, the time of an average breath hold.

It is important to replace the oropharyngeal tube in the mouth after endotracheal intubation to prevent the patient from biting the tube.

The position of the tube should always be checked personally, by auscultation, first over the epigastrium, then over the axillae.

¤       A surgicalairway may be necessary if endotracheal intubation fails.

Oxygen.

All trauma patients must receive the highest possible oxygen concentration.

Risk of aspiration

All trauma patients should be presumed to have a full stomach. This, together with alcohol intoxication, increases the risk of vomiting and subsequent aspiration. It takes only one breath after vomiting to aspirate.

A rigid suctioning catheter should be at hand and the patient turned to the left lateral position if signs of vomiting appear. If this cannot be done safely and immediately, the head of the bed should be dropped 20 degrees and the vomit is suctioned from the mouth.

A.       Breathing

This part of the examination should be done in a careful and systematic way, otherwise important information will be missed.

Inspection

¤       Rate, rhythm, depth, symmetry of breathing

¤       Loss of consciousness

¤       Colour                               - cyanosis

¤       Trachea                            - displaced

¤	Neck veins	- distension in tension pneumothorax/cardiac tamponade
¤	Swelling around the neck	- haematoma, surgical emphysema
¤	Accessory muscles	- platysma, scaleni, intercostal, abdominal
¤	Chest wall	- wounds, recession, airway obstruction, paradoxical movement, flail chest
¤	Abdomen	- abdominal breathing, spinal injury between level C5 and T12, gastric distension splinting diaphragmatic movement.
Palpation ¤       Symmetry of movement		- unequal, flail chest, pneumo/haemothorax
¤	Tenderness	- rib fracture, flail chest
¤	Crepitus	- displaced fractures
¤	Surgical emphysema	- chest and neck
Percussion
¤	Dull	- haemothorax
¤	Resonant	- normal or pneumothorax
¤	Hyper-resonant	- tension pneumothorax
Auscultation
¤	Air entry	- always compare left with right (axillae more accurate than anterior chest because of less muscle and fewer transmitted sounds from large airways)
¤	Breath sounds	- crepitations, rhonchi, wheezes, transmitted upper airway sounds

¤              Re-confirm placement of endotrachealtube 

Factors which compromise breathing

¤       Central depression

¤       Airway obstruction

¤       Tension pneumothorax (diagnosis must be made clinically!): respiratory distress, tachycardia, distended neck veins, hyper- resonance and absent ipsilateral breath sounds, contralateral tracheal deviation, hypotension, pulsus paradoxus.

¤       Open chestwound - suckingwound especially if > 2/3 of trachealdiameter, preferential flow throughwound

¤       Flail chest - two or more ribs fracturedat two or more places

¤       Massive haemothorax - hypotension, decreased breath sounds, dullness to percussion

¤       Cardiac tamponade- hypotension, muffledheart sounds, tachycardia, pulsus paradoxus, distended neck veins (not visible if hypovolaemic)

A pulse oximeter is a useful guide during the assessment of breathing but it does not give a direct reflection of the partial pressure of oxygen in the blood : 100% oxygen saturation = PaO2 > 90 mm Hg, 95% = 70 mm Hg, 90% = 60 mm Hg.

Management

Detailed discussion of management will be discussed later in the module, only a brief outline will be presented here.

1.         Airway obstruction - reassess airway

2.         Apnoea or bradypnoea - rescue breathingshould be instituted and definitive airway established.

3.         Tension pneumothorax - treatment should not be delayed in order to confirm with chest x-ray. Immediately decompress with a 14 gauge cannula in the second intercostal space, midclavicular line.

4.         Sucking chest wounds - should be immediately sealed off with an occlusive dressing on three sides, allowing air to escape from the pleural cavity (one way valve) in order to prevent a tension pneumothorax caused by air leakingfrom the underlying injured lung.

5.         Flail chest - may be associated with significant underlying lung contusion and progressive hypoxia. The treatment is aimed at correcting the abnormality in chest movement and optimally ventilating the damaged lung tissue through intubation and positive pressure ventilation.

6.         Cardiac tamponade - immediate needle pericardiocentesis can be attempted. Beware of false negativeaspiration due to clotted blood. Urgent thoracotomy if required. Fluid resuscitation provides only temporaryimprovement.

7.         Massive haemothorax - this is confirmed (during the secondary survey) by placementof an intercostal drainage tube and drainageof

>1500 ml blood initially or >200 ml/hour. The placement of an intercostal tube does not resolve the emergency, but should be followed by an emergency thoracotomy. These patients are ideal candidates for autotransfusion. A massive haemothorax may not be obvious on a supine chest x-ray owing to blood spreading posterior to the lung.

B.       Circulation and Haemorrhage Control

The presence of a carotid pulse should be checked for 5-10 seconds. The rate, rhythm and symmetry must be noted. The presence of tachycardia is one of the most sensitive indicators of early circulatory shock.

The location of the most peripheral pulse is a useful guide to the systolic blood pressure.

¤       radial pulse: systolic bloodpressure (SPB) at least 80 mm Hg

¤       femoral pulse : SBP at least 70 mm Hg

¤       carotid pulse : SBP at least 60 mm Hg The presence of external bleeding is determined Signs of circulatory shock to be lookedfor:

¤       loss of consciousness

¤       respiratory rate : tachypnoea

¤       neck veins: distended - cardiac tamponade, tension pneumothorax

The following 4 signs are all indicative of peripheral vasoconstriction, one of the first compensatory mechanisms during circulatory shock.

Colour : central or peripheral pallor or cyanosis

Moisture : diaphoresis Temperature : cool Capillary refill : > 2 seconds

An ECG monitor and blood pressure recordings assist in the assessment of the above signs. Always treat the patient and not the monitor!

Blood loss can be expressed as a percentage of blood volume according to the following :

< 15 %

15-30%

30-40%

>40%

For possible sources of blood loss (one on the floor and four more)

¤	On the floor	- history from paramedics
¤	In the chest	-  heart, great vessels or lung laceration: > 2 litres blood; -  ribs: 100 to 200 ml each
¤	In the abdomen	- aorta, inferior vena cava, liver or splenic injury : 2 litres
¤	In the pelvis	- pelvic fracture: 1 - 3 litres.
¤	In the thigh	- femur fracture: 1 - 2 litres

- other long bones: 0.5 - 1 litres

Management

●            Control external haemorrhage:

¤       Direct pressure

¤       Elevation

¤       Pressure points (radial, brachial, femoral etc)

¤       Mast suit of limitedvalue in terminating arterial haemorrhage (inflated pressure 30-40 mm Hg)

●            Establish 2 large bore IV lines

14/16 cannula with high capacity administration set

Compare: 14G - 125ml/min = 1 litre over 10 minutes 18G - 35 ml/min = 1 litre over 30 minutes

Peripheral lines are the first option with the least complications. Limbs with proximal long bone fractures must be excluded.

In adults there are 3 alternatives if a peripheral site is not available or attempted unsuccessfully. Venous cut-down requires the correct equip- ment and can be time consuming if the practitioner is not experienced. Central venous pressure lines carry an increased risk of complications and require more experience. The addition of a pneumo or haemothorax

may further compromise the already traumatised patient. A large short bore cannula, which will allow faster infusion rates, should be used.

Femoral lines are of limited value for the purpose of drug administration during severe hypovolaemia or active resuscitation where there is minimal blood flow below the diaphragm. Femoral lines should also be used with caution when the inferior vena cava and iliac vessels may be compromised as a result of abdominal or pelvic injuries.

In children less than 6 years of age there is one alternative if a peripheral site is not available or unsuccessful, namely an intra-osseus line. The maximum flow rate is 40-50 ml/min through an intra-osseus needle.

Proximal long bone fractures must be excluded.

Obtain blood samples for biochemistry, full blood count/haematocrit and cross match. Pregnancy testing must also be considered in a female patient of childbearing age.

●            How much fluid?

The traditional concept of "as much as possible as soon as possible" has fallen into disfavour. Hypotensive resuscitation (SBP - 90-100 mmHg) is becoming more popular owing to the fact that it decreases the gradient for blood loss and reduces the "blowing off" of clots from damaged blood vessels. Massive infusion of clear fluids will increase bleeding, cause haemodilution and disseminated intravascular coagulation (DIC). It can also cause hypothermia if not warmed to 40 degrees C.

Fluid resuscitation has only limited value and should not delay surgical consultation and subsequent operative management to locate and terminate haemorrhage.

If the patient is hypotensive, 1 litre crystalloid (Ringers, 0.9% saline) may be infused and the patient's response evaluated. If there is no response, another litre is infused while ordering O type blood. If there is no response after the second litre, colloids (starches, gelatines) may be considered until the blood arrives. If there is a transient response to the fluid therapy, there may be time to order type specific blood.

Dextrose containing solutions have no place during fluid resuscitation. Less than 100 ml of each litre remains intravascular! Increased serum glucose concentrations may actually cause osmotic diuresis.

Hyperglycaemia may aggravate head injuries.

Adrenaline and other resuscitation drugs have very little place in hypovolaemic shock.

C.       Disability and Neurological Evaluation

A brief neurological evaluation is performed and any evidence of neurological deficit or lateralising signs should be noted.

AVPU or Glasgow Coma Scale Score

The above are used in the assessment of level of consciousness. A patient with spinal injuries might not respond to pain stimuli owing to the absence of sensation at that level.

A	=	Alert
V	=	Responds to verbal stimuli
P	=	Responds to painful stimuli
U	=	Unresponsive

Pupillary size, equality and reaction

A unilateral dilated pupil indicates a focal intracranial mass lesion and necessitates urgent referral to a neurosurgeon.

D.      Exposure and Environmental Control

The patient's clothes should be cut to provide exposure to enable further clinical examination to take place. Prevention of hypothermia is very important.

E.       Resuscitation

Re evaluate :

a)         Airway

b)         Breathing/Ventilation/Oxygenation

c)         Circulation

d)         Urinary and Naso-gastric catheter

e)         Monitoring:

¤       Ventilatory rate, arterial blood gases and end tidal CO2

¤       Pulse oximetry

¤       Blood pressure

¤       ECG

f)          Xrays - chest, cervical spine and pelvis

g)         Consider need for transfer

SECONDARY SURVEY

The secondary survey only commences after the primary survey has been completed and the resuscitation is well under way. It is a rapid but thorough physical examination for the purpose of identifying as many injuries as possible. However, it is important to note that if the patient's condition deteriorates, one must revert to the primary survey (ABC). The secondary survey should not delay definitive care.

Objectives of the secondary survey

●            Reassessment of vital signs

●            Detailed head to toe examination

●            Complete medical examination

●            Special investigations

●            Assimilation of all the clinical, laboratory and radiological information

●            Formulation of a management plan for the patient

●            Clinical records for medicolegal purposes

a)        History : (AMPLE)

●            Allergies

●            Medications

●            Past History

●            Last meal

●            Events

●            Blunt trauma

¤       Penetrating injury

¤       Burns or cold injury

¤       Hazardous environment

b)        Physical examination

●            Head

●            Maxillofacial

●            Cervical spine and neck

●            Chest

●            Abdomen

●            Perineum/Rectum/Vagina

●            Musculoskeletal

●            Neurological

c)        Re-evaluation

d)        Definitive Care

e)        Three important Xrays

1.)   Chest Radiography

Good radiographic technique is essential for producing good diagnostic chest Xrays.

¤       Exposure factors

Looking through the heart on a PA film one should just be able to make out the architecture of the thoracic vertebrae. If these are seen too clearly, the film is over-penetrated, if not seen at all the film is under-penetrated, making it difficult to comment on the lungfields.

¤       Size and shape of the chest- exposures will vary according to the size and shape of the chest.

¤       Good inspiration - one should be able to visualize at least 11 ribs posteriorly above the diaphragm. Poor inspiration will result in difficulties in measuring heart size and assessing the lungs.

¤       Patient positioning - PA position is best. AP films will result in difficulties in assessing cardiac size and pulmonary vasculature. Check that patient is not rotated by checking that the medial edges of the clavicles and the spine are equidistant.

How to read a chest radiograph

1.         Soft tissues : compare both sides. In females check for both breast shadows. Look for signs of surgical emphysema.

2.         Skeleton: count all ribs and check for fractures. Check clavicles, scapulae, shoulders, thoracicand cervical spines.

3.         Pleura. Check costophrenic angles for haemothorax. Check for pnemothorax.

4.         Diaphragm : the righthemidiaphragm is 2cm superior to the left. Compare the shape and position. Look for free air under the diaphragm.

5.         Mediastinum: check the position of the heart with two thirds of the transverse diameter of the heart to the left of the spine and one third to the right. In the superior mediastinum the trachea should be central. Check for widening of the superior mediastinum at the level of the aortic arch.

Heart size is <50% off transthoracic diameter.

6.         Hilar region : the left is 2cm superior to the right. Check position, contour and density.

7.         Lungs : compare both sides. Divide the lungs into three zones: upper, middle and lower and compare both sides.

A few important points:

On a supine AP chest Xray a haemothorax may be difficult to detect as there may only be a white haze present on the affected side. When in doubt request a lateral decubitus xray. Similarly a pneumothorax may also be difficult to detect, this is best seen in erect films taken in expiration.

A subpulmonic haemothorax may appear as a raised diaphragm on the affected side, if in doubt request a lateral decubitus CXR.

2)        Cervical Spine Xrays

The lateral cervical spine radiograph taken after spinal trauma is the single most useful projection. All seven cervical vertebrae should be included.

Special projections such as the swimmer's view should be performed if the C7/T 1 junction cannot be visualized.

The 5 spinal lines to be assessed are as follows : 

Line 1 : Pre-vertebral soft tissue line.

Anterior to the upper four cervical vertebrae, the maximum pre- vertebral soft tissue width is 5mm, while in the lower cervical spine

the soft tissue width should not exceed the AP diameter of the adjacent vertebral body.

Line 2 : Anterior spinal line

This line links the anterior cortices of the cervical vertebral bodies, and should form a gently curving line.

Line 3 : Posterior spinal line

This links the posterior cortices of the cervical vertebral bodies, and should form a gently curving line.

Line 4 : Spinolaminar line

The line links the junctions between the laminae and base of the spinous processes of the cervical vertebrae. It should form a gently curving line.

Line 5 : The spinous processes should be examined for the presence of fractures.

3)        Pelvic Fractures

These can be broadly classified into stable and unstable fractures.

1.        Stable fractures :

a)         do not involve the pelvic ring e.g. avulsion fractures, isolated fractures of the iliac wing

b)         involve the ring but result in little bone displacement, leaving the soft tissues intact.

2.        Unstable fractures :

Generally involve the pelvic ring in two or more sites. Look carefully at the posterior sacroiliac joints for possible displacement, indicating instability. These fractures are often associated with severe visceral and major vessel damage.

SUMMARY

The ABC system of managing the resuscitation of the severelyinjured patient during the first few minutes to one hour of arrival offers a safe, efficient initial approach to the trauma patient. The flow of the process identifies the potentially lethal injuries first and takes steps to reverse them as they are discovered. Management of a condition is possible without a firm diagnosis, it may not be known what the cause of the problem is, but there must be clarity about what to do about it.

The first priority is to evaluate the patient rapidly and to detect and treat all immediately life threatening conditions.

Following this, a detailedhead to toe assessment can be completed. The team leaders can then list the patient's injuries and establish priorities for both further investigation and definitive treatment.

An adequate history of the patient and the incident is as essential as the clinical examination in evaluating and managing the trauma patient.

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