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What pathway, right? Can everyone see that? No, anyone, anyone? Great. All right. So, um, hi, everyone. So, my name's, I'm one of the ST five specialty registrars on the east of England rotation. And I'm also a, a course instructor for the ATL S courses for the Royal College. So today's gonna be a bit of a whistle stop tour um, through ATL S. Um, so I'm going to give this talk first and then Miss Chow and one of the ST four S also on the east of England rotation is also going to, er, give a little talk on um, trauma physiology. So this is not, um, gonna be, er, very extensive because essentially it is a two day, three day in person course. But this is gonna be sort of raising some of the key points you need to know. Um, if you're gonna be doing ATL S or a primary survey, um, on your job as orthopedic, er, surgeons orthopedic trainees. So this is the patient, uh patient Yankee Black. Um, so you, if you've worked in any sort of trauma centers or places where you get patients who jump off bridges, get hit by cars, et cetera. You will find that you don't necessarily know their ID and they are usually allocated a letter and a color. Um, and that's how they're identified until the point where we can actually identify them. So you're on call, you're called to a trauma call. Uh, it's a 25 year old gentleman who's jumped off a 35 ft overpass. Er, he's intoxicated but on a, on arrival into the unit, he is conscious, he is confused. As you can see, he's very tachycardic. He's got a heart rate of 100 and 32. ABP of 90/60 respirator of 40 sat at 84 on air. He's complaining of abdominal pain, pelvic pain and right knee pain. Now, just by hearing that, what sort of injuries are you concerned about? And how are you gonna go about assessing this patient? Anyone? Just, just throwing that out to the group, anyone? And I need some interaction here guys. Hello? Yeah, I can hear you. Yeah. Uh This is Aziz. Ok. Aziz. Yeah, just, just from the, from on the top. Just what are your thoughts when you hear that you're, you're the sho or the reg in, in the resource department, you being called to this trauma call once you hear that, what's going through your head. Uh So first uh my first start is that the respirate of 40 84% on room air. So there are probably some lung issues going on could have uh pneumothorax or rib fractures leading to hemothorax or something like that. Sure. Um, the BP is low. He's probably bleeding has uh reduced blood. Uh, blood volume could be pelvic fractures, could be chest. He, he uh hemo hemo hemo. Um um, he could have a brain injury. Uh, he could have, um, uh, he's confused maybe from the alcohol, might have a brain contusion. Um, he's having knee pain, he's probably got a fracture there somewhere, you know, I mean, it could be anything, couldn't it? That that's the problem with these patients. They come in, they've got something wrong with them or many things wrong with them and you have to assess it and you don't want to miss anything. So for the second question, how are you gonna assess this patient? Um So I guess the, the, the uh go through your ABC S uh you, you're gonna assess this patient with an ATL S approach. That's what this session is. So, um, yeah, no, thank you for that. That's great. So, yeah, this is the a session on how to do sort of go about the ATL S approach in a summary. So the objectives behind the session is understanding the A TL S approach. Obviously, I'm not, I can't teach you the whole thing here, but this is just understanding the principles underlying it. Um You should understand the main conditions that can be encountered in the poly traumatized patient, uh, describe some of the main interventions that can be carried out for these main conditions. But again, to highlight this is not a substitute for the ATL S course. And if you are gonna be a surgical trainee, particularly orthopedics, particularly, er, general surgery, vascular, any of the front line surgical specialties, you really should attend these ATS courses and they're really good. They're just very interesting courses. Um, so what is ATL S uh just a very brief background, it was sort of devised around sort of 78 in the US. Um Some of you've probably heard about this US, er, surge and it was sort of involved in a plane crash and then the only way he could manage multiple people was using a sort of systemic systematic approach. Um But what was found initially was that there was a massive diverse w um way people were managing poly traumas, there was nothing standardized and that was leading to very um variable levels of care essentially. So they devised this standardized um er, means of assessing and managing trauma cases throughout the US. And then subsequently, it was disseminated over the next sort of nine years, disseminate different countries. So any country that's really managing trauma should be using something er, standardized, such as the ATL S, not everyone uses it. But um it is a, a very good structured way of approaching it because it addresses conditions that will kill you in the order that they arise, er, which will kill you first. So it's the gold standard in, well, the UK and the US for how to manage trauma within the first hour of presentation. And the main focus is dealing with the greatest threats to life first rather than fixating on an overall diagnosis. It's all about dealing with those immediate problems and then once you've stabilized the patient, you can then think about definitive management. So it follows a system, a systematic ae approach and you're identifying and managing problems as they encounter, it's not just identifying problems. So who's on the trauma team? So when you get a trauma call, er, the A&E er, consultant, the red phone rings in the re in the hospital in the emergency department or a triage nurse, you get the 222 call and it means that all the members of the trauma team get there as early as possible. Um, now that is dependent on the mechanism of injury, the extent of the injuries that have been identified by the uh paramedics or first responders. And, um, does anyone know who's on the trauma team? Mhm. Just shout at some people. Anyone usually the, um, the, the team. Yeah. Absolutely. The orthopedic reg. Mhm. And then any other team, what was that last one? Sorry, the orthopedic, the general surgeon and any other team will want to come, including who want to come, there will be not many people to be honest, but you're right. No. So, um, the people who turn up are, you get the ed resource team, you get the orthopedic on call team. So the reg and the sho you get the General Surgical, uh, reg and sho you should get the itu reg and sho and if it's a pediatric trauma call, you also sort of get the pediatric team as well. So pediatric trauma calls, um, but that tends to be less common, but basically, you've got people who can deal with the bones, people who can deal with the, the Giblets and you've got people who can do the airway support and the er, any sort of vas um, any vascular support that might be needed access and airways. Um, so the at approach, um essentially, um it's ABCD E and basically, what you're doing is you're addressing each problem that will kill the patient first to last. So, starting with airway and C spine control with a massive emphasis on c spine control that goes right at the top there. Um, breathing, circulation, disability exposure slash everything else. Once you've done that, you move, that's your primary survey. And after that, you move on to the secondary survey. Always stick to the order again, emphasize that always stick to the order. Do not let yourself veer off into starting airway, then you look sort of circulation and then you forget about breathing because what might happen in breathing could kill the patient before you even finish assessing circulation, um when you identify problems, address them and then reassess from the top every time you've done an intervention to make sure that what you've done has actually made an impact. That is the only takeaway message that you have to take away from this talk today. So, airway and c spine and control. What do you think that consists of anyone? So I guess you um want to assess that you've got patency of the airway. But in considering the fact that in uh high velocity or high energy injuries, um you might have a risk to the C spine. So you'd want to do in line immobilization um and manage the airway with that, that aspect often um assisted by the anesthetic team. Um But in your primary assessment, you're looking for kind of any obstructions to the airway, any swelling around the throat, any evidence of ligatures, any kind of like blood or fluid in the um in the oropharynx or nasopharynx and kind of any additional added sounds that might suggest obstruction. Yeah, very good. Absolutely. So that you've covered all the main points there really. So essentially you are stabilizing the C spine. So when you get there, um what I always been taught to and what I still do is I approach the patient out of you and then what you do is you place your hands on either side of their head before you talk to them because if you talk to someone when you're out of view, what do they do? You look at that? You look around and they've immediately moved their potentially unstable c spine. So, hands on both sides of the head and then talk to them. Introduce yourself. Hi, I am, uh, Sebastian on the orthopedic registrar. Um, I'm just going to be assessing your neck, so I need you to keep your head still. Once you've done that, then what you can do is you can assess your airway before you apply immobilization. So, what I would normally do is I would, you can look and listen for breath. Uh, you can listen for breath sounds. Does it sound normal or does it sound like there's some gurgling in there or is there snoring anything that might indicate some upper airway obstruction? You look inside the mouth. Is there anything any loose, maybe some dentures that may have come loose? Is there, uh, you know, some teeth that have been knocked loose that might be obstructing it? You can get some mcgill's Forceps and if there's anything, you can see, you can just pluck them out and you get a Yanker sucker and you clear any fluid that might be in the mouth, then you listen again and see if you can feel any breath or if they sound normal. Now, let's say you have a listen and you hear snoring, uh, or some, some heavy sort of really heavy snoring, breathing when you, er, listen for the breath sounds. What is, what are you gonna do next? Anyone I said? So I would start with, um, simple airway. Well, in the first instance is, well not getting rid of our immobilization of the C spine. Um, I would do simple maneuvers such as, um, jaw thrust. I wouldn't be doing a head tilt because they're immobilized. Um, and from there I can do some simple adjuncts. So, oropharyngeal airways, nasopharyngeal, if there's no contraindications such as a basal skull fracture, and actually, if they're snoring, the concern is, is actually are these, is this a G CS eight patient who needs to make an early airway assessment intervention for sure. So exactly that. So your what you demonstrated there was really good. It's the uh stepwise sequence of what you do for the airway. And there's um I've got a nice summary at the end of this section, but essentially you're assessing it, you've listened to it, it's snoring, you try your airway maneuver. So exactly as you said in, in normal circumstances, like, you know, a LS, you might think about doing a chin lift, but in a trauma situation where you're not sure about the c spine or you're not or you're worried there might be ac spine injury, you're gonna do a jaw thrust. So starting with the C spine immobilization. Once you've got hold of the head, do not let go of the head. If you let go of the head and they move, you've basically let them injure their neck. So you do not wanna do that if you're gonna let go because you need someone else to take over you exchange hands. So you've got hands, then someone replaces their hand over you, then they replace their hands um where your one was and then you can step away. So do not just let go before someone else gets their hands on it. Three point immobilization. So the three components, you've got the hard collar, the blocks and the tape, what you may see a lot these days, which I'm not entirely sure why I've seen it in the Royal College of Emergency Medicine Guidelines is they're starting to advocate for not having a collar on. Um And then they've only got blocks and tape except they're not blocks, they're rolled up towels and the tape is just loosely strapped on. I'm not entirely sure what that's due anymore, but that's apparently some new guidelines that are coming in, but that is not ATL S. So, and I would still insist on a hard color for the time being sizing. So a lot of people have trouble with this. They sort of measure from the edge of the mandible uh down to the trapezius like that. Um And that's not actually right because that will oversize your collar. So, what you're actually looking for is the, where the jaw line is the vertical line from the jaw to your trapezius rather than, and of the mandible, which adds an extra size up. Um And what you do when you size it on the collar, you can see in the diagram on the top right there. Z Plasticky bit and that's, it's not, you're not measuring off the bottom of the white foam. You're measuring off the blue hard plastic and where your finger lies where that you can see there's a red dot there, that's the level of the size you've sized your collar to and that needs to match up to um the size you've measured from the chin to the trapezius. What you can see in the bottom, right is proper triple immobilization. So you can see hard collar blocks and tape. Um If you are gonna remove the collar again, exchange your hands for the blocks at a time. So you're again not letting go of the neck. So airway maneuvers. Exactly as ma mentioned, chin lift, jaw thrust, do not do a chin lift. And unless you're completely happy that there's absolutely no problems with the C spine. Maintain the C spine alignment, you're gonna place your hands around the mandible angle angles and you're gonna have rest your th I usually rest my hands on the Zygomatic arches here and then you can push lift upwards and that will hopefully uh cause the snoring sounds to settle. So if it does, um exactly as Matt said, you can think about airway adjuncts. Next. Um You've got your nasopharyngeal and your oropharyngeal, um nasopharyngeal and oropharyngeal look like these here. So, oropharyngeal the way you size it, you can either do heart to heart, which is what I typically do, which is your incisors to the mandible edge, which makes sense to me because that's basically where it's gonna sit or you can do edge of the mouth to the ear, the tragus, the tragus being this part of your ear, ear. Um And then basically, when you put it in, you're gonna put a tongue depressor in and you can either put it straight down, which is what some people teach or you may put it. Um So that it's facing the other way up and then you can rotate it around to pass it down through the curve. Kind of like how you suture, you're gonna pass that curve down the airway nasopharyngeal. You can measure by placing simply putting it against the nostril and hold it like a pen or a dart and you're just literally gonna pass it straight backwards. Um As Matt already mentioned, way we wouldn't use it. Um People talk about basal skull fracture, but if you actually, if that's your only option because they're not tolerating it oropher, you can still use it because if you look at how long that nasopharyngeal is, that's not gonna go too far regardless. It is an option. It's not the option you should go for unless you have no other choice to maintain, er, an airway if the Cadel is tolerated, what's that mean? Anyone? Is that a good sign or a bad sign? Uh, it's not the best, it implies that they're not that they've got a neurological injury potentially. Correct. So basically, if your G CS is reduced, it means some of your reflexes may not be working as well, which means you tolerate Gael, it means you basically have got a reduced gag reflex. It may, may imply that A G CS has dropped below eight. And that means you know, to start thinking about more definitive airway. So you've got a, you've got a gel in place you're attempting to bag and it's not giving you the best ventilation. Your next options you can think about are um more definitive. Well, they're not definitive. I sorry, they are laryngeal airways instead. So they're super glottic airways, they're not definitive airways. They sit lower down in the super glottic area and they allow for better ventilation. You can see the LMA in on the left and you can see a eye gel on the right, both if you worked in any anesthetics, these all look very familiar to you. Um The main thing before putting them in, you'll learn this on your A LS courses, but just make sure that they inflate, deflate um lubricate them and then pass them. So the, the cuff is facing away from you so that the, so the opening is facing away from you as you put it in from the top end. Um, and then you're gonna attach a cabin gray onto it to make sure that it is in the right place. If you're not getting a CO2 trace, you're not in the right place. Is it a definitive airway? Well, I've already answered that it's not. Um, and the reason why it's not is because what's a definitive airway? It needs to be a cuff that's placed in the track here. It has to be er, inflated below the vocal cords and it should allow for oxygen enriched, er, ventilation. So every time you talk about an LMA, no, it is not a definitive airway. A definitive airway needs a cuff that protects the, um, the, the trachea beneath, particularly if you've got vomiting or anything like that. Now, when are they actually indicated? Well, there's a few reasons why and, and they tend to be associated with the different section of the A to e essentially, if you're unable to maintain a patent airway and there's impending er, airway compromise. So all the other methods, you've tried your airway adjuncts your um, LA S, they're not maintaining the airway, then you need to try and get something more definitive down. If you're not getting adequate oxygenation or the patient's becoming apnic, then you need to control their breathing. And that means you need something that will allow you to ventilate through it and LMA is not gonna do that. You need an AAE T tube in there. Um If the patient becomes very combative or obtunded, you need to have, you're basically gonna need to knock them out and you're gonna need to allow them to breathe, which means you're gonna be ventilating for them again with an ET tube. And again, as mentioned, if your G CS is under eight, you need to protect the airway cos it may either collapse or they may vomit and you need to make sure nothing goes down and cause aspiration pneumonia. Um How do you check that you're in the right place? Well, you're going to try bagging it and check that there's equal lung expansion when you do. So. Um and again, you can attach capnography to make sure you're getting a CO2 trace to ensure you're in the right place. You can also auscultate the chest um to make sure you're getting breath sounds in both sides and you can check that there's no sounds of um sort of that you've intubated the esophagus blacks and which would not be great. Your rescue options, surgical airways. These are where you've got a patient who's in severe respiratory depress er, er distress and you cannot intubate them in time and you cannot ventilate them in time. So your other options are not working and you need a bit more time. So if they're a child, you can think about doing a needle cricothyroidotomy. I'm not sure why they're doing it in an adult in this picture here, but there you go. Um, and with an adult you can do a surgical rike, um, which is uh similar to a trie except you're gonna be doing it slightly, um, at a different level. The reason you can't do a, uh, does anyone know why you can't do a surgical rike in a kit? Yeah. No. So, um, basically in a kid, the cricoid cartilage is still sort of developing. It's not, um, it's not fully developed and it may collapse and cause airway um er, obstruction, er, later on if you, if you do that. So basically an adult, they're fully developed kids, they're not, which is why you try doing a needle needle rike, you can do a needle rike in an adult. Um but it's uh not the preferred method and it is only a temporizing measure. It's not gonna be your definitive airway, but it does buy you time in order to gain access with your ET tube, er intubation. So summary, I was taught it as hats, which is your hands initially to do your maneuvers, your airway adjuncts, which is your um nasopharyngeal oropharyngeal airways, er, et tubes and if those fails your surgical airways. So hats, uh once you've got something in, you're gonna try bag valving it um with the, the big uh well, the bag valve mask, um which you can take off the mask and attach it straight onto the tube. And that's gonna allow you to check that you are in the right place and you're aiming for 10 to 12 breaths per minute and checking for equal equal chest expansion, capnography, chest expansion and normal lung sounds. So Mr Yankee Black, the patient who's come in with uh having fallen off his bridge, he tolerates when you hold his head and he allows you to triple immobilize him. He's got snoring sounds. When you listen for breathing, when you look inside the mouth, you see some vomitus in there. So he's suction, it all out with the anchor. You find that he has snoring but he has normal breath sounds once you do a jaw thrust. So you drop a gel in which is not great and then you apply your high flow oxygen. So you're putting a non rebreath mask with 15 L on er while you wait for the anethe to get stuff ready for your ET tube. So breathing anyone have any ideas, what, what you'd assess when the breathing section? Um I'm happy John said, but I'll get someone else to do. Yeah. Um I think in breathing, you do your normal uh chest examination um in addition to the pulse ry, but you have to look for the life threating uh condition the chest, like the tension, pneumothorax, the massive he the flail chest. Um and I think the rupture or the disruption of the airway and you have to manage accordingly to whatever you find? Ok. So how would you, do you ever sort of, what sort of things would you actually? So, so there is obviously the conditions exactly what we're gonna go into at the moment conditions you're gonna look for. But how are you actually gonna assess the patient? You've got this uh guy Yankee Black in front of you. What are you gonna, what steps, physical steps are you gonna do? So you do the um an inspection, you look for the chest expansion. Um See if there's any um like abnormality in the chest expansion, for example, uh side is more expanding or less expanding than the other one. And if you, so uh if the sitting is a little bit quiet, you can do the percussion to look for hyperresonance in terms of like tension, he or dullness uh for hemo and of course, the cult uh again for de entry or crackles um that might indicate some fluid. Um And then you check the pulse oximetry. Um You check the, the optimum situation uh And you don't forget the respiratory rate. Um Yeah, that's it. If you have um a bedside chest X ray, you can do that. But I don't think UK practice actually do that because in four ct scan, very clear. Sure, fine, so good. No, absolutely. So those are the uh you've hit all the big topics that, that all all the big sections that need to be done. So uh absolutely get your monitoring on as soon as possible. So the moment and in reality, all these things happen simultaneously, people will get monitoring on the moment. Someone will be doing the primary survey but someone else will be getting all the stuff on which is exactly right. You are going to put the pulse ox on and that will give you your, your sats and it will also give you a heart rate monitor and go on BP as well. That'll give you a BP to see if anything is going on there. You're gonna look, you're gonna listen, you're gonna feel and you're gonna um the percuss. So all the standard things you do in a chest examination and uh yeah, exactly what you said. So when I do this, I try and work in a sort of systematic order. So I've already started the ahead. I've dealt with the airway up here. I work my way down from airway down to the track here. So I'm gonna have a feel for the track here, feel that whether it's central and I can also check the JVP at the same time. So as the JV VP raise cos there might be something obstructive in the chest. Is it collapsed because the patient might be hemorrhaging out and then I move down to the chest. So I have a look, look for chest expansion. Is it equal or is it asymmetric? I have a feel so I can check is chest expansion the same or different on either side. Um And then I percuss, percuss, percuss, percuss work your way down and then you're gonna repeat the same section with breath sounds. And I would also listen to the heart sounds in the same setting. Um As mentioned, the saturations and respirate will be part of the observations that start taking place the moment the patient lands in the resource department. So in terms of what you also mentioned, X rays, CTS, remember it's all about sticking to the order. So you're gonna deal with life threating things immediately. Now we'll come onto the conditions that so we'll go go to that. So first big condition that you encountered. What you exactly as Mohammed you mentioned is a tension pneumothorax, this is life threating emotion, this will kill a patient if you don't address it as soon as possible. So the main findings as all of you know, from medical school and everything since then ipsilateral on the affected side, no breath sounds when you look at it, it's not gonna be moving but it would be expanded. Why cos it's full of air er in the pleural space, compressing the lung. When you p when you percuss over it, you're gonna find a a very raised hyperresonant sound on that affected side and the other side will be normal. So, hyre normal, hyper resident normal and you probably will not see track or deviation because that is a late sign. But often in assessments, they usually just to help you, they'll say the track is deviated away from the affected side because the lung is the, the uh hemithorax is filling with air and it's pushing the tracker off to one side. These patients are hemode unstable. And the reason for that is because there's no venous return because the er, thorax is full of air. And so you get obstructive shock, we're gonna go into shock. What that is? Um on the left here, I've put image not found because you shouldn't have a chest X ray that shows attention in the thorax. Because if you're waiting too long long enough to get a chest X ray, you might have already let the patient die already. But some people have obviously done a check X ray and found 10 the thorax as you can see here on the left hand side. So how are you gonna treat? So you've identified this patient Yankee White, uh Yankee Black. In this case, he has a hyperresonance, left hand side with no breath sounds and he's got um expanded chest with no movement on the left, the right side is moving normal, his BP is low. His heart rate is fast. What are you gonna do now? Well, that's true. It just says decompression there, doesn't it? I guess you gonna decompress with them. How, how are you gonna do that? Someone anyone um with a needle decompression in the er triangle of safety? OK. Very good. Yeah, absolutely. So where is the triangle of safety matt? So it is in the mid auxiliary line where the anterior border is the lateral border of pe major, the posterior border is the lateral border of terrors major, last side and the fifth rib. And then exactly. So, I mean, you know, the, in, in the, in reality, you're not gonna start working out which muscles, which muscles where you're literally gonna go. Look at the side on view, look at where the mid axillary line is and you're literally gonna go anterior to it. Um If you go straight through it, you might risk the nerve that supplies that dorsi and then cause problems later on. So the old way when I first learnt ATL S when I was an F two, I think back in 20 F-16, um the way they taught it was still um second intercostal space, midclavicular line, but that has now changed to er fifth intercostal space, anterior anterior to mid axillary line. Um I think that was due to people hitting it, putting it in the wrong place. I think I can't remember why they changed it, but that is the new way of doing it. So, exactly, as you said, you're gonna get a large bore cannula, so an orange cannula, you're gonna mount it on a syringe. Um Some people put a bit of saline in. So they can see when it bubbles, when the air comes out and you're literally gonna clean the area or don't even clean the area. It doesn't really matter. And you're just gonna pass that needle above the rib to avoid the neurovascular bundle under it. Go straight in and look for that. Either hiss if you've got no syringe or with saline attached to it or the bubbling of, uh, of the air coming out. And that, and what you should see is that the patient has quite quick reaction where the SATS start improving the respirate, it starts improving. Heart rate improves BP. Should, if that's the only thing going on, start climbing back up again and then what you should need to do if you have done a needle decompression, it's successful. What should your next step be? Restart your uh ATS primary survey from the top? But then, well, when you get back down to the bottom, you're going to stick in a chest stra correct. So if you do not proceed to a chest drain for someone who's had a needle decompression, there is a high chance that uh pneumo will redevelop because it's not addressed the underlying problems. So a chest drain has to be prepared once that's been done. Um And you're gonna place it in the same site. Basically, you're gonna go for the same fifth intercostal space in the mid axillary anterior to the mid axillary line. Um Good and a, exactly as you said, once you've got all that done, you're gonna reassess, you're gonna start at the airway, make sure your, the airway is still patent, make sure you've still secured the airway and then you're gonna carry on back down to the breathing and reassess that. What you've done has improved the respirate, the saturations and everything else outstanding. Very good. So this is just a diagram here. You can see someone doing a needle decompression into that er, triangle of safety. Um You know that the er, nipple is around sort of the fifth um er, sort of around the fourth rib area and you're gonna drop beneath that. So that's your, if you're in a rush, that's sort of what the levels you're looking for, but obviously be careful with it. You've, we've seen people put chest strains into the livers and that doesn't do it patients any favors. Um So across to me with a chest drain exactly as Matt said, and that's, you can see someone fingering inside the er chest cavity to make, break down any adhesions and make sure they're in the cavity before you pass your, um, your chest drain in. You can see they prepped the air with Betadine. But what you can't see is that they have not put any uh sterile drapes up there, but I'm guessing they're in quite a hurry. So there you go, hemothorax. Another condition that you'll uh potentially come across this will be present slightly differently in that they'll have collapsed neck veins because the patient is very, um, hypovolemic cos they're bleeding out. Um, the chest movements will move but not as much. The breath sounds will be there, but they'll be dull. And when you palpate, uh, when you percussor you'll get a dull resonance because it's not full of air, it's full of blood. So, the whole thing is more rocky and, er, stony and it's not gonna give you as much sounds. Now, when it becomes a massive hemothorax is when either the moment you put a chest straight in which you'll need to do to decompress the chest, you get a liter and a half come out straight away or if you don't get a liter and a half straight out, um straight away, you're gonna see how much comes out over the next few hours. And if you get sort of 200 mils an hour, then again, that counts as massive hemothorax. The other, the third criteria which I forgot to put on here is if you are continuing to need to give blood transfusions and even that is not maintaining the patient's BP, um and heart rate, then again, that's a massive hemothorax. All of these patients need a consult with cardiothoracic. So usually these patients need to either go to a center like that or they should have been there in the first place. Cos that should have been identified by the, um, er, by the prehospital, er, doctors and paramedics. So, the other condition that you probably don't come across as much as a tracheal bronchial fistula, which is basically a tearing of either the trachea, um, or one of the main bronchi, er, at the level of usually around the carina, um, sort of about an inch away from the carina. Um, most of these patients die on the scene which is probably why you don't see them that much. But the patients who do come in, they've got hemoptysis, they've got subcutaneous emphysema and sometimes they'll have a tension pneumothorax. The reason being that area is just leaking out into the surrounding area. So that's what gives them the emphysema. It may cause that pneumothorax. Um and you may get some crept and er surgical emphysema everywhere else in the abdomen and the neck everywhere else. Um and that can lead to um comp er, respiratory and ventil ventilation, er compromise because it starts compressing the space around the airway. Um The classic thing they talk about is when you place a chest drain, there's still persisting air leaks, there's still um more surgical emphysema developing, there's still the lung doesn't re expand and you need to place a second drain and get an urgent cardiothoracic opinion cos they'll probably need to go in and repair that. Um But rare because most patients die on the scene. So this patient Yankee, black R 40 sats, 84% on 15 L, he's got tracheal deviation to the right. He's got reduced breathing movements on the left. Um Although the l hemithorax on the left is expanded, he has increased residence of the left hemithorax and no breath sounds. So what happens? He has a chest drain. He has a needle decompression, then he has a chest drain because he's got a tension pneumothorax. So that does improve things but not completely. When a hiss, you get a hiss on needle decompression. So see circulation, what comes in under this section? One. So this is where you kind of think about your one on the floor and four more, which is like the areas that you can lose blood. So one on the floor could be essentially blood around the patient on the sheets, blood that has been seen and when the patient has been transferred and your four more is the four cavities that you expect to lose blood, um which is kind of thoracic abdomen, pelvis and then long bones which are kind of like both of your femurs good. And what sort of things are, how are you actually going to assess this patient? What sort of things can you look at and what sort of things can you intervene with? Um So I guess chest you've kind of already covered. So you might get your attention. Um sorry, um hemothorax, er abdomen, you're you're looking at because they have, they got a rigid abdomen is there any kind of signs of a retroperitoneum bruising seatbelt, strap marks, um, pelvis, you again, they got any kind of blood coming out of the meatus as the pelvis sprung open. Um And then kind of in that situation, you kind of look at your pelvic binders, um, long bones, you're looking at significant deformities to the, to the femurs. Um And then you're kind of thinking about traction in nose to try and reduce the fracture and kind of stems on that bleeding. Um And then that's, then you're on to looking at your blood products. Um So you're kind of picking out your major hemorrhage if you need it for your package that and then reversing any, if you've got kind of facilities reversing any bleeding issues essentially. Yeah. Absolutely. Yeah. I mean, a lot of people talk about, I don't think they have it at s actually kind of think that I think some of the places down in London, like George's and Kings might have it. But yeah, we don't really use roam. But no, that's really, that's really good knowledge because um, we don't talk about that much these days. So you're gonna look at the patient from the end. I like start peripheral, have a feel of the hands, the legs. Are they cool and clammy or are they very warm? And you know, things are too warm. They shouldn't um, warmer than they should be your check, the cap refill, check people to try and do peripheral cap refill, but really you should be checking essentially. So press on the sternum and see what the cap refill is like. Check the BP, check the heart rate. You should already have those from having the monitoring on. For the first instance, you've already listened to the chest as part of your chest examination, but listen to the heart sounds. Are they muffled? Maybe a cardiac camp? Um and obviously you're listening to, you know, the breathing it, the breath sounds er, muffle er, dull because they've got hemothorax exactly as you mentioned, floor and four more. So the floor is just checking. Are they bleeding externally somewhere? You don't know where, but the four count is exactly as you mentioned really nicely. The thorax, the abdomen and the pelvis and you're gonna check the long bones and that's not just the femurs, it can be the tibias, it can be the humerus, they can be bleeding out from anywhere and you can lose a lot of blood from those sections as well. You're gonna gain IV access, you're gonna get um get some men with IV access so you can give products and take blood out. Um, you're gonna get a catheter in um to make sure you can monitor their urine output because that's a really sensitive way of measuring organ hypoperfusion and TX A. We're gonna go on to that in a moment. So shock anyone can any, can anyone give me a definition of shock. Anyone. It's easy. All right. Fine. So a lot of people say shock, oh, it's, it's hypotension. It's um it, it's not, it's all about being, having inadequate end organ perfusion. So it can be any cause of, it doesn't have to be hemorrhagic. It can be any reason why your circulation is not keeping up with the perfusion for an end organs. Um, to function, kidneys are very sensitive, which is why we use urine output. So, um so much um it can be hemorrhagic. It can be obstructive like a pneumothorax or a tamponade. It can be cardiogenic. It could as in the heart's not pumping enough if there's a blunt cardiac trauma, if they've had a myocardial infarction, a pea et cetera or it can be distributive. So that's your where the circulation has collapsed. So your vaso your peripheral vascular system has collapsed. It's vasodilated, leading to neurogenic shock, er such as neurogenic shock or septic shock and the type of shock will determine what you do for it because the same thing cannot be applied to every type of shock. Basically. So, hemorrhagic shock, there's four different types of hemorrhagic shock. I've got another slide, uh exactly what those are and there are things that can confound these results. Um such as a young athletic person or an old person, like a young person may actually compensate for a massive amount of blood loss before they suddenly fall off a cliff because they can no longer maintain their BP from vasoconstriction and cardiac output. Um So you have to be really wary and suspicious in these sorts of patients and just, um, start treatment for what you think is going on. Essentially the floor and floor more exactly is uh mentioned. Um And you wanna turn off the tap, so stop the bleeding, find out why and where it's bleeding from and replace what's missing and determine some definitive management. So in terms of hemorrhagic shock, um a lot of you have probably seen this er, back in medical school and sometime during your surgical training, but essentially you think about it like tennis, you're 15% 15 to 3030 to 4040 plus er percent and that's how much blood loss has um occurred. What you see first is when you only have less than 15% and most people can compensate for this. Um, usually they might get a bit a bit tachy, but usually they're ok. Most people can bounce back from this without too much problems. Now, when you go to the next section, so you're 750 to sort of a liter and a half, you get a bit tachycardic, you get a bit tachy and patients just start feeling a bit off. Um, you may find that the base exit, the base deficit starts changing. Um, when you do your uh your gas and then after that, you get more tachycardia, you become, start getting hypertensive, some people also become hypertensive sooner such as elderly patients, your urine output starts dropping off as well and patients start becoming disorientated, confused, et cetera. You wanna turn off the tap. So crash two is all about TX A. So TX, it was um, a big er study that was carried out in 2013 and they had about 20,000 trauma patients and they, some were given TX a, a gram of ticks over 10 minutes on first presentation, um, with a subsequent 1 g infusion over the next eight hours. And what it found in those 20,000 patients was that there was a very significant reduction in mortality in the next sort of four weeks following, um, er, following, er, these patients who were given, er, TX A, um, as particularly it was given either within the first hour or the first hour to three hours beyond three hours didn't make so much of a difference. Those patients died anyway. Um, but TX a massive game changer. Um, so if you go for your, um, ST three interviews, you have to know the crash two trial cos it was a big, um, a big paper that was produced, er, in the, I can't remember what it was published anyway. Er, very useful. So you are turning off the tap so you need to stop the bleeding, whether that's, um, splinting a limb, you know, if you've got a long bone injury, you need to splint it. You got a pelvic fracture, you're gonna close the book. Um, if you've got a, you know, any sort of internal bleeding, then obviously that might need, that will need surgical intervention, but you need to find the tap. So what can you do for that? You've got a variety of imaging. You can either do sort of fast scanning. Uh, you can do trauma CT s but you need to stabilize the patient first. So do the things you can do first before you move on to, um having to go digging around cos the patient might not live long enough for that. Now, the definitive management may be surgery you may need to, that's the only way you can stabilize someone who's bleeding out. But a lot of things can be stabilized in the recess department and that can be compression, torque, splinting fractures, putting pelvic binders on. So pelvic binders, the level of application you can tell me uh, great tr correct. So a lot of people um, put the tr the binders on at sort of the level of the acis cos, that's where they think the er, the hips are. But really what you do is you're placing them at the greater tranter. So that allows that will allow you to internally rotate the pelvis to close it down. Because what is the main purpose of a pelvic binder? Why do we put them on, uh, try to reduce the space uh inside the pelvis. Yeah. So, you know, people often worry about um oh if I take the binder off, I'm gonna make the pelvis unstable. It's not really that what you're doing, it's a hemostatic agent. You are a lot of the bleeding comes from the in uh particularly these, you know, your A PC um your open but pelvic fractures, a lot of the bleeding comes from those poster plexus and what you do by closing the pelvis down, what you do is one you compress over those venous plexus and two, you create a, a limited space for the uh bleeding to tamponade inside the pelvis. And then who knows when you can remove them? When, when can you take a pelvic binder off? I guess after um rolling out um pelvic injuries and the patient is dynamically stable. So the patient is. So let's say, you know, there's a, you, you do find there's a pelvic fracture. When can you take it off? Then in the chin, in that instance, then you do actually take it off. It can lead to pressure. So um I think we all think that we just leave them on forever. Um But there should be a level of HD U recess counts as well uh with ideally invasive monitoring, but certainly close monitoring and you'd have an AP film before as well to compare it to take it off, immediately repeat the BP um and immediately repeat the BP and, um, if it's starting to go down, put it back on again, hopefully. Well, first clock, best clock. So you might be in trouble. Um, if that's the case, it's an immediate packing in theater. Really? Yeah. Good. So, you've been paying attention to? No. So that's good. So, um, absolutely. So, basically, uh, like I mentioned, it's a hemostatic agent. So you place the binder on and you leave it on until the patient is hemodia stable because exactly as you're saying, you know, the, the first clot is the best clot. You want hemostasis in that pelvic area. If that's where the bleeding's coming from. Now, once the patient is stable, um if they're not stable, that becomes an entirely different thing. And that's a talk on pelvic fracture, which is very interesting and I'd love to talk about it on another day, but we'll focus on this today. Um You, once they're stable, then you need to take it off in a monitored bay. So, recess is fine. HD U is fine. Itu is fine. A ward is not fine. You need somewhere where they can monitor the BP, the heart rate very closely because what you're gonna do is once their hemo doy is stable, you're gonna ease the binder off, but you're not gonna remove it, you're just gonna ease it off until it's not technically compressing anything. And for the next 30 minutes, you're gonna be watching that BP and that heart rate like a hawk. Now, if it stays fine, you're great. That's fine. You can leave it there. You don't even have to remove it, just leave it on the bed. But if it starts dropping again, you need to get that pelvic binder back on cos evidently it was providing some manner of tampon art and it will help pelvic packing. That is when you've got someone who is completely unstable, they are not, um, they are not responding to blood products, et cetera. I'm gonna go on to that in a moment, but those patients are not gonna do well. And you have to get, the only way you're gonna get hemostasis is getting in there and stuff. A ton of those, uh, big swab, those massive pelvic packs and just pack all the vessels around the back and the sides to stop it bleeding. But that's something entirely different. Those you keep the pelvic binder on as well, cos you pack against the binder level GTs hemostasis. And this is what I just mentioned. That's what a pelvic binder looks like. You can achieve the same with a bed sheet, you can achieve the same. Um, with all these diff, there are loads of different ones you can use and what you, if you don't have anything, you can literally just get the legs, bring them internally, rotate them and just lash the legs together. And that can also serve to try and close down the pelvis to some degree. This is what a pelvic fracture may look like before. You can see it's almost like a vertical shear because you can see on the left hand side, the hemipelvis have moved entirely superiorly. There's no connection at that sacral alar at the back. Um And you can also see there's massive gapping of the um pubic symphysis diastasis. It's just completely separated, extremely unstable injury. Once you have a pelvic binder, you can close down the space and it will look more like this sort of pattern. I don't think it's the same patient, but you can achieve that sort of pattern. It's not fully aligned, but you can close down that volume significantly. Um massive major hemorrhage protocol, learn your find out what your region protocol is for the major hemorrhage protocol. This is the east of England trauma network. So this is what we use here. You get pack one pack two, which gives you different things, red blood cells, f FP platelets and you should be aiming 1 to 1. Um You start with warm crystalloids, but if you've got a patient who is bleeding, you replace blood with blood, there's no point diluting what blood they do have with crystalloid. Um coagulopathy is a major worry which is why we give F FP and platelets because if you just give red cells, they'll become coagulopathic and bleed out. And that's what the whole Rotem er concept is about hypothermia. Again. All the fluids are warmed, um, through a, uh, oh, I can't know what it's called. Now, there's, um, a device that basically warms blood and Bel Bel one. Thank you. Exactly. That, um, that allows you to pass the, uh, the blood through quickly and warms it up very good. So, responders, non responders, transient responders. So these are the three classes of people. They can be when you give fluids, um, rapid responders, you put a bolus of fluid in BP improves heart rate improves and they stay at that point. Those people are good, usually corresponds to a sort of a class one type hemorrhagic shock. So um only about 750 mils, only about 15% of their blood volume is lost. And those people usually you can stabilize them and you hopefully won't need to do too much in the way of intervention. But you should have all the circle teams on standby. Transient responders usually means they do improve, but then they might either drop off or you have to. Um which means you've either inadequately resuscitated them or they're still leakage going somewhere, they're still leaking from somewhere and you need to turn the tap off. Now, your minimal or non responder patients are the ones you've put blood in, you've put uh crystal, you put blood in, no changes are happening. Those patients need to go somewhere to have that tap turned off. Usually the operating theater, open them up, find the source and just plug it one way or the other. It may be. You need the help from the interventional radiologist to plug a big artery. Uh But typically these patients end up in surgery access, gonna go over this quickly large ball access to the ACF S. You give it a go, you can't get it. What are you gonna do? You're gonna get intraosseous access, which looks like this. This is the easy IO kit, which is what most hospitals use. So you can literally, it's a drill mounted on these things. You can pass it into the main bony points, proximal humerus. You have to internally rotate the shoulder, don't stick it here. That's your uh your coracoid and a chromium. You want to drop down just below it. Feel if you're not sure give the shoulder a slight movement and it needs to move. That was where, you know, you're in the proximal humerus and you're gonna fire it into the graded cancer. I like to go more into the proximal tibia on the sort of medial face. Um Just cos I find it's a nice flat surface where I know it's definitely gonna go in. Um If they've got an associated associated fracture there, don't go into that area, cos they'll leak fluid through that area. So don't bother with that. That's not gonna work. You can deliver everything right. You can deliver blood, you can deliver fluid via the IO. So those. It's a very reliable way of delivering things. If you're struggling to get normal access. Usually if you fail twice, you should go for the grab the IO. Don't even worry about it. Fast scanning. I'm not gonna go into this because this is more of a, a domain of the emergency guys. Um but basically gives you a full view access. Look for bl uh bleeding inside the pericardium, look for blood in the gutters and down into the pelvis. Uh just gives you a quick idea. If anything is bleeding or any intraabdominal fluid, then you, if you've got a patient who's stable enough to go to the CT, you should put them through a top to toe um CT scan and that's um not most people just get a head to pelvis and then you, you can think about getting uh radiographs afterwards. The problem is if you've got a patient who's not particularly stable and they get rushed straight from the CT scanner or rather than passing back through X ray, they end up being rushed to theater and then itu then they might be sitting on the ITU unit for a long time and you have no idea if their limbs are fractured or if their, what's actually going on if you need to do anything about them. So a top to toe is an ideal in a patient who is um you know, major polytrauma, but typically you won't get it. Unfortunately, you get the result report quickly. They also do it as an A to e um as an urgent and then they'll do a subsequent more detailed report. Um and it can determine management, basically help guide management and determine who you need neurogenic shock. So this is just something very quickly. Can someone tell me what's the difference between neurogenic shock and spinal shock? Anyone give it a bash? Ok. Yeah. Yeah. Anyone. Oh fine, never mind. So, neurogenic shock is shock, it's shock in the way that we describe it as, as physicians. So, neurogenic shock is tends to be a spinal injury where you get an injury above the level of T six and ba the reason for that is it interferes with the sympathetic um nervous supply that allows for vasoconstriction. Now, if you get that you get a circulatory collapse, you get a distributive shock. So all your peripheral vessels vasodilate suddenly and all the blood drains away from all the important areas. So that leads to end organ um im impaired in er perfusion. And that's why you get shock. The management. Obviously, if you dump a ton of fluid in there, a ton, ton of blood in there and they're not bleeding, you're not really achieving much. Co all you're doing is you're filling up the dilated um vascular system. So instead you need to be thinking about presses, so you're thinking about sort of noradrenaline. Um and that needs to obviously be delivered in an hu environment, spinal shock is an entirely different thing. Spinal shock is not shock in the sense that we talk about it in um, sort of as, as positions. Um, it's more a, it's a temporary depolarized state of the spinal um uh of the, of the spine. Um when you have some manner of trauma that leads to sort of fluidity and er, a reflex and all sorts of things and it's associated with spinal cord injuries. So it's not shock the way we talk about it. So someone in a trauma situation who is hypertensive, that's not spinal shock, they are either bleeding out or it's neurogenic shock. But hemorrhagic shock tends to be the commonest thing you encounter. So it's usually that to deal with that first or rule it out first. Uh fine. So Yankee black circulation, he's tachycardic is hypertensive, he's cool clammy. His cat refills raised, there's no blood on the floor. Uh But when you do give him some blood, it does improve his heart rate and it does improve his blood blood pressure. You do notice some bleeding around the urethral meatus, the bleeding's internally somewhere. He has a fast scan, he's got some free fluid inside his abdomen. He's got what feels like an unstable pelvis or a pelvic bone was whacked on there. And uh he's also got a um but there's no obvious long bone injuries that you can notice. At first disability, I'm gonna go over this too quickly. Cos I'm running into MS Chow and's time now G CS pupils temperature blood sugars as always, never forget the blood sugars cos that can always affect things that you, you know, you cannot miss any of these sorts of things out. The Glasgow coma score has been revised um back when I learned it, it was the one on the left the or the original scale, but this has changed a bit. Now you've now got the non testable um criteria um that uh that you can mark it as, um, and they slightly changed some of the wording. So, rather than causing pain, you're causing pressure. Um And then you're rather than sort of talking about decorticate, dece, decerebrate uh reactions. So you're now talking about abnormal er flexion or existent what that looks like is this? So, in the people who have got a very low mo they can either decorticate post strength or they sort of flex tense up like that. Um And the other one is where they extend outwards abnormally. So that's your to cerebrate uh posturing in response. And that's again a very poor sign of their G CS and motor function. Uh This gentleman, people's fine. He opens his eyes when you trap squeeze, he moans when you ask questions and he withdraws. So you're looking at um, well, they reduced G CS, you can calculate it for yourself. Um That's an exercise for another time. You'll be quizzed. On that a lot. If you go on your atl s course exposure, have a look at the patient, you fully expose them, don't expose to a patient the entire body at one time. What you're gonna do is you're gonna expose sections um and then you're gonna cover other sections as you go along. So stop the patient freezing. Basically cos you're gonna be in a cold Reuss department. And the last thing you want is for the patient to become hypothermic because that can also have an impact on other things. Their bleeding, their coag coagulopathy, et cetera. Uh keep the patient warm otherwise and identify injuries that you haven't identified and reassess and you're gonna go all the way back to the beginning after you've done your exposure, so fully exposed to this gentleman's body, he's got right upper quadrant tenderness with guarding. He's got deformity of his right knee, but it is noted to be a closed injury. He's got free fluid noticed on his far scan again, located to the right upper quadrant and secondary survey is gonna come afterwards. But that is after you've done your primary survey. And by this point, you've got all your people, all your team there. You don't need to worry about it. So I'm not gonna go into this too much detail. Take a quick history, do a head to toe exam log, well, check the spine, do other diagnostic tests. So coming back to Yankee Black in some rock, a trauma called 25 year old gentleman jumped off over past in top, scared, conscious, confused, tachycardic, hypertensive, high respirate, low SATS. So we found he's got a reduced G CS and he's needed likely less than eight cos he tolerated Cadell and he's gonna need et tubing. He's got ac spine, immobilizer, triple immobilization. He was identified to have a tension pneumothorax which decompressed with a needle decompression followed by a chest strain. He was bleeding quite heavily. He had a pelvic binder applied and this helped slow down some of his bleeding. He's also noticed to have tenderness in his abdomen in the right upper quadrant area with fluid on the free on the fast scan. He has also got um deformities to his right knee implying some man or a fracture. So that's him. So in summary, just to go over everything that we've sort of talked about. Stick to the order, identify and manage problems as they're identified. Uh In reality, multiple things happen at the same time because you've got multiple people there. There's no point, everyone's staring at one person doing the assessment. Um But it's important if you are the person doing the primary survey to stay on track and not get distracted by other things. And uh that's my whole presentation. So, there you go. Um Does anyone have any questions about that? Anyone at all? Great job. Seb Love the presentation. Thanks man. All right. I will pause recording there.