The PPT on the Topic - Triage is based on the two topics of Bailey & Love - 26th edition.

1. TRAUMA
ATLS TRIAGE
Dr. Murali. U. M.S; M.B.A

2. Learning Outcomes
• Trauma is the commonest cause of death in the Trauma
• Describe the principles & concepts of triage in
management of injured patient based on the
mechanisms of injury
• List the types & phases of triage
• Discuss the principles of primary & secondary surveys
in the assessment & management of trauma

3. Introduction
• In all regions of the world, adults over the age of 70
years,particularly females, have significantly higher
fall-related mortality rates than younger people.
• However, children account for the largest morbidity –
almost 50% of the total number of disability adjusted
life-years (DALYs) lost globally to falls occur in children
under 15 years of age. .

4. Introduction
• With ever increasing population growth and increased life
expectancy, the injury mortality and morbidity statistics are
likely to be skewed towards the two ends of the age spectrum,
making the pediatric and the elderly very important with
respect to global health care and economics.

5. Trauma - Types
• In essence, trauma can be divided into two basic
types:
• Serious and life-threatening injury
• Significant trauma requiring treatment but not
immediately life threatening.
• While it is acknowledged that the two can and often
do overlap.

6. InTrauma - Types
* Multiple casualties - Here, the number and severity of injuries
do not exceed the ability of the facility to render care. Priority
is given to the life-threatening injuries followed by those with
polytrauma.
* Mass casualties - The number and severity of the injuries
exceed the capability and facilities available to the staff. In this
situation, those with the greatest chance of survival and the least
expenditure of time, equipment and supplies are prioritised.

7. Protocol
• The Advanced Trauma Life Support (ATLS) system was
therefore created initially in the USA and rapidly
taken up globally.
• At present, over 40 countries worldwide are actively
providing the ATLS course to their physicians.

8. Mechanism of Trauma
• Blunt Trauma – Direct or indirect blunt injury can occur. Seat belt
reduces the blunt injury in vehicles.
• Penetrating injury – severity depends on the extent of deeper injury.
• Blast injury.
• Crush injury – earthquake, industrial accidents, and train accidents –
causes crush syndrome, compartment syndrome.
• Burn injury.
• Injury in alcohol patients.

9. Concepts - Trauma Management
• Concept of “ golden hour “ to treat the trauma patient is important.
• Multidisciplinary approach
• Planning, setting up, organizing, team work.
• Assess respiratory system; circulation; breathing areas – as priority.
• Assess also whether patient is haemodynamically stable or unstable.
• Arrange fluids, blood, catheters, ventilator etc.
• Further definitive therapy depending on severity and site of injury.

10. TRIAGE

11. WHAT IS TRIAGE?
WHY DO WE DO IT?

12. PRINCIPLE GOAL OF TRIAGE IS:
TO DETERMINE , WHO SHOULD
BE SEEN FIRST!!!!

13. A second major goal
• Not just sort but also stream
• To get the right patients to the right resources
in the right place , and at the right time….

14. Definition
a Process of prioritizing patients based on the severity of
their condition.
OR
A medical classification process of priority of emergency
care of simultaneous multiple patients in function of rear
available care resources.
ORIGIN
Term comes from the
French verb
‘trier’,
Means to separate /sort / shift or select.

15. In Triage - Phases
• Triage is an important concept in modern health-care
systems & three essential phases have developed:
* pre-hospital triage – in order to despatch
ambulance and prehospital care resources
* at the scene of trauma
* on arrival at the receiving hospital

16. ADVANCETRAUMALIFESUPPORT
ADVANCE TRAUMA LIFE SUPPORT
Objective
• Identify the correct sequence of priorities for assessment of a
multiple injured pt.
• Apply the principles outlined in primary and secondary
evaluation surveys of ATLS.
• Apply guidelines and techniques in the initial resuscitative and
definitive care phases of treatment.

17. ADVANCETRAUMALIFESUPPORT
ADVANCE TRAUMA LIFE SUPPORT
Initial assessment
Primary survey
Secondary survey

18. ADVANCETRAUMALIFESUPPORT A T L S
Initial assessment
Primary survey
Secondary survey
• Initial assessment of the casualty
• Time interval
• Then proceed to the basic ATLS
procedure i.e. (in short) ABCDE

19. ADVANCETRAUMALIFESUPPORT A T L S
Initial assessment
Primary survey
Secondary survey
Breathing
AIRWAY
Circulation f
Disability
Exposure
•Confirmation
• If patient
talks normally,
airway not
compromised
• Hoarse voice
or audible
breathing,
suspicious
Assess the patient for airway obstruction (coma)
Agitation--------------- hypoxia
Cyanosis---------------- hypoxemia, secondary to inadequate oxygenation
Hoarseness,----------- suspected laryngeal fracture
s/c emphysema
& palpable
fracture

20. ADVANCETRAUMALIFESUPPORT A T L S
Initial assessment
Primary survey
Secondary survey
Breathing
AIRWAY
Circulation f
Disability
Exposure
• Established
maintenance of
airway through
either of the two
---Head tilt-chin lift
---Jaw thrust
JAW THRUST
•Rescuer fingers are placed behind the
posterior border of the ramus of the
mandible
•Displace the mandible forward,
dislocating it while tilting the head
backward
•Retract the lower lip with the thump
JAW THRUST

21. ADVANCETRAUMALIFESUPPORT A T L S
Initial assessment
Primary survey
Secondary survey
Breathing
AIRWAY
Circulation f
Disability
Exposure
• If debris ( broken
tooth, dentures) is
present, remove it
by—Finger sweep
technique or
--Yankauer suction or
-- Magill’s forceps (for
large object)
• If ---no foreign body is visible, endotracheal tube should be used to secure the
established airway
--- If the foreign body cannot be removed quickly or the vocal cords cannot be
adequately visualized or endotracheal intubation is not possible, then
cricothyroidotomy is indicated
•

22. ADVANCETRAUMALIFESUPPORT
Yankauer
suction
Magill’s
forcepsCRICOTHYROIDOTOMY
A T L S

23. ADVANCETRAUMALIFESUPPORT A T L S
Initial assessment
Primary survey
Secondary survey
Breathing
AIRWAY
Circulation f
Disability
Exposure
• In patient
sustaining
significant blunt
injury, should be
assume to have
cervical spine injury,
until prove other-
wise
•--- such pt. should
have cervical spine
immobilized with semi rigid cervical
collar and bilateral sand bags or block
joined with tapes or straps across the
forehead

24. ADVANCETRAUMALIFESUPPORT A T L S
semi rigid cervical collar
block joined with tapes or straps across the forehead

25. BREATHING
Airway
Circulation f
Disability
Exposure
ADVANCETRAUMALIFESUPPORT A T L S
Initial assessment
Primary survey
Secondary survey
•Conditions that
acutely compromised
breathing are--
• Tension
pneumothorax
• Massive
hemothorax
• Flail thorax
accompanied by
pulmonary contusion
• open pneumothorax compromise breathing
•Such condition can be diagnosed with physical examination & should be treated
immediately
•It can be treated with endotracheal intubation, mechanical ventilation, needle
thoracocentesis, or tube thoracostomy.

26. ADVANCETRAUMALIFESUPPORT
NEEDLE THORACOCENTESIS TUBE THORACOSTOMY
A T L S

27. Breathing
Airway
CIRCULATION
Disability
Environment &
exposure
ADVANCETRAUMALIFESUPPORT A T L S
Initial assessment
Primary survey
Secondary survey
•Circulatory problems
in trauma patients are
usually caused by
hemorrhage
•First action is to stop
bleeding
•For ---
Intra oral bleeding-----------------bite a cotton swap
Tongue laceration------------------deep suture across the laceration
Bleeding from fracture-----------manually reducing and brittle wiring of the fracture fragments
mandible end
Mobile maxilla---------------------rubber mouth gags
Soft tissues of head & neck----direct pressure on the bleeding site
Torrential bleeding from--------epistat tube with anterior and posterior balloons
the nasopharynx region

28. Breathing
Airway
Circulation f
DISABILITY
Environment &
exposure
ADVANCETRAUMALIFESUPPORT A T L S
Initial assessment
Primary survey
Secondary survey
• Assessment of the
neurological status.
The Glasgow coma
score (GCS)
• worst score is 3 points
• GCS can be caused by a focal brain injury
• Optimal oxygenation and circulation are important to prevent secondary injury to
the brain
• Impaired consciousness can be caused by hypoxia or hypotension for which ABC
stabilization is essential
•Patients who open
their eyes
spontaneously, obey
commands, and are
normally oriented score
a total of 15 points

29. Breathing
Airway
CIRCULATION f
Disability
EXPOSURE
ADVANCETRAUMALIFESUPPORT A T L S
Initial assessment
Primary survey
Secondary survey
• Represent
Hypothermia
Burns, and
Possible exposure
to chemical and
radioactive
substance
 Should be
evaluated and
treated

30. ADVANCETRAUMALIFESUPPORT A T L S
Initial assessment
Primary survey
Secondary survey
• Under this the pt. is examined from head to toe
• Appropriate additional radiographs of the
thoracic and lumbar spine and the extremities
are performed when indicated.
• CT scans, when indicate
•Secondary survey mnemonics
•Head/skull Has
•Maxillofacial My
•Cervical Spine Critical
•Chest Care
•Abdomen Assessed
•Pelvis Patient's
•Perineum Priorities
•Orifices Or
•Neurological Next
•Musculoskeletal Management
•Diagnostic tests/ Decision?
Definitive care

31. ADVANCETRAUMALIFESUPPORT
RE-EVALUATION
IF, DURING THE SECONDARY SURVEY, THE PATIENT'S CONDITION
DETERIORATES, THE PRIMARY SURVEY SHOULD BE REPEATED
BEGINNING WITH “A”.

32. ADVANCETRAUMALIFESUPPORT
ADVANCE TRAUMA LIFE SUPPORT
Analgesia
Documentation & Legal
Definitive care

33. Triage at an accident scene
is performed by a paramedic
or an emergency physician,
using the four-level scale of
Cannot wait
Has to wait
Can wait
Lost
No chance of survival

34. category meaning consequences examples
T1 (I) acute danger for life
immediate treatment, transport as soon as
possible
arterial lesions, internal haemorrhage, major
amputations
T2 (II) severe injury
constant observation and rapid treatment,
transport as soon as practical
minor amputations, flesh wounds, fractures
and dislocations
T3 (III) minor injury or no injury
treatment when practical, transport and/or
discharge when possible
minor lacerations, sprains, abrasions
T4 (IV) no or small chance of survival
observation and if possible administration of
analgesics
severe injuries, uncompensated blood loss,
negative neurological assessment
T5 (V) deceased
collection and guarding of bodies,
identification when possible
dead on arrival, downgraded from T1-4, no
spontaneous breathing after clearing of airway

35. References
• Bailey & Love’s - Short Practice of Surgery
26th edition.
• Internet websites.