ADVANCED

TRAUMA AND LIFE

SUPPORT (ATLS)

OBJECTIVE

Identify the correct sequence of priorities

for assessment of a multiply injured pt.
Apply the principles outlined in primary
and secondary evaluation surveys of
ATLS.
Apply guidelines and techniques in the
initial resusitative and definitive care
phases of treatment.

ATLS

PREPARATION AND TRIAGE.

PRIMARY SURVEY
RESUSITATION
ADUNCTS TO PRIMARY SURVEY
CONSIDER NEED FOR PATIENT TRANSFER
SECONDARY SURVEY
ADJUCTS TO SECONDARY SURVEY
CONTINUED POSTRESUSITATION AND
REEVALUATION OF THE PATIENT.
DEFINITIVE CARE.

PREPARATION
PREHOSPITAL PHASE
HOSPITAL PHASE
PREHOSPITAL PHASE:
Coordination with the prehospital agency and personel
can greatly fasten the treatment in the field. They inform
the receiving hospital which mobilizes the trauma team to
ED.
HOSPITAL PHASE
Advance planning for the trauma pt. beneficial. It saves
time.

TRIAGE
The process of categorizing victims or mass
casualties based on their need for treatment
and the resources available.
ITS MAIN GOALS ARE.
Prevent avoidable deaths.
Ensure proper initial treatment with a
minimal time frame.
Avoid misusing assests on hopeless cases.

Field TriageTriage- Color

Color Coding
Coding
Field

Triage- sorting of patients by injury severity and

need for transport
RED-most critically injured-immediate transfer to
hospital
YELLOW-less critically injured-delayed transfer to
hospital without endangering life
GREEN-No life/limb threatening injury- patient
ambulatory-may not need IP treatment
BLACK- Dead patient

Multiple casualties

No. of patients and the severity of their

injuries do not exceed the ability of the
facility to provide care.

MASS CASUALTIES

The no. of patients and the severity of

their injuries exceed the ability of the
facility to provide care.

Roles of
of the
the Trauma
Trauma Team
Team
Roles

Roles of
of the
the Trauma
Trauma Team
Team
Roles
Airway
Nurse

Team Member
Team Member
Boss
Attending

Nurse

PRIMARY SURVEY
What is the quick ,simple way to assess
the trauma patient in 10 seconds?
A complete sentence spoken by pt. tells
us:
1.
2.
3.

Airway is patent.
Breathing intact.
Good cerebral circulation.

AIRWAY MAINTAINENCE WITH C-SPINE

PROTECTION

Assess for obstruction, foreign bodies, facial

fractures, bleeding causing airway compromise
begin measures to establish airway.
PITFALLS

Recognize impending obstruction early before

intubation becomes too difficult.
If unable to control airway surgical airway is must.
Unknown tracheal or laryngeal disruption.

Simple maneuvers
Chin lift
Jaw thrust
Suction
Oropharyngeal and nasopharyngeal
airway
Laryngeal mask airway
Laryngeal tube airway
Gum elastic bougie.
Definitive airway
Surgical airway.

INDICATIONS OF DEFINITIVE AIRWAY

UNCONCIOUS
GCS <8
RISK OF ASPIRATION
RISK OF IMPENDING OBSTRUCTION.

BREATHING
Inspection
Auscultation
Palpation
Percussion

Identify and manage life threatening problems first

Tension pneumothorax
Cardiac temponade
Massive hemothorax
Open pneumothorax
Flail chest with pulmonary contusion

maneuvers

Bag and mask ventilation

Needle thoracocentesis
Pericardiocentesis
Chest tube intubation

water seal drainage

Definition
Indication
Purposes
Site for chest tube insertion
Type of water seal drainage
system
FUNCTION OF PLEURAL DRAINAGE
SYSTEM
PRINCIPLES OF THE CHEST TUBE

Nursing Responsibilities

water seal drainage

water seal drainage

Definition

Water seal drainage system is a closed chest

drainage system used to allow air and
fluid to escape from the plural space with
each exhalation and to prevent their
return flow with each inhalation

water seal drainage

Water seal means that the water
in the bottle seals off the
atmospheric air thus prevents
the entering of air or fluid back
into the pleural space.

water seal drainage

1.
2.
3.
4.
5.
6.
7.
8.
9.

Indication
Traumatic pneumothorax
Hemopneumothorax
Spontaneous pneumothorax
Iatrogenic pneumothorax
Broncho-pleural fistula
Emphysema
Malignancy
Pleural effusion
Thoracic or thoraco-abdominal surgeries

water seal drainage

Purposes

To permit drainage of air and fluid from the

pleural cavity
To establish normal negative pressure in the
pleural cavity for lung expansion
To equalize pressure on both sides of the
thoracic cavity
To provide continuous suction to prevent
tension pneumothorax

water seal drainage

Site for chest tube insertion

1.

Thoracic surgery.
2 chest tube are inserted

Anterior chest tube

Posterior chest tube

water seal drainage

Site for chest tube insertion

Anterior chest :
Upper/anterior chest wall
Inserted in the 2nd Intercostal space to remove the air
arising from the pleural cavity
Posterior chest tube :
Placed at the posterior chest in the 8 th or 9th Intercostal
space at the mid-Axillary line.
Indication to remove sero-sangeneous fluid at the lower
area of pleural cavity
Diameter of tube in the lower section is wider or longer
compare to the upper tube.

water seal drainage

Site for chest tube
insertion

2. Pneumothorax :
Tube placed at the 2nd
or 3rd Intercostal
space along midclavicle or anterior
Axillary line.

water seal drainage

Site for chest tube
insertion

(ATLS,2012) :

Nipple level (5th intercostal

space), anterior to mid-axillary
line) just over the top of the rib

water seal drainage

STEPS

(ATLS,2012) :

After identifying the insertion

site, sterile draping and locally
anesthetize skin until rib
periosteum
2-3 cm transverse incision
(through the rib)
Puncture parietal pleura with
the tip of clamp. With gloved
finger avoiding injury to other
organs and clearing any
adhensions, clots.

water seal drainage

STEPS

(ATLS,2012) :

Advance the tube entering into

pleural space with clamp
(directed posteriorly)
Connect the end of the tube to
underwater-seal apparatus
Suture the tube (can be
performed earlier before
entering tube)
Evaluate (see aftertreatment)

water seal drainage

Chest Drainage
System
1
bottle

2 bottles

3 bottles

Pleurovac

water seal drainage

TYPES OF SYSTEM - 1 BOTTLE
DRAINAGE

water seal drainage

TYPES OF SYSTEM - 2 BOTTLE
DRAINAGE

water seal drainage

TYPES OF SYSTEM - 3 BOTTLE
DRAINAGE

water seal drainage

FUNCTION OF PLEURAL DRAINAGE
SYSTEM
Inspiration
Intrapleural pressure
Lungs
reexpand

Air and fluid

move into bottle
Pleural space
becomes
negative

water seal drainage

PRINCIPLES OF THE CHEST TUBE
1.

Gravity

2.

Under water seal

3.

Suction

water seal drainage

PRINCIPLES OF THE
CHEST TUBE
1.
Gravity
Enhances flow from
high to low
Chest drain is placed
below clients bed

water seal drainage

PRINCIPLES OF THE CHEST TUBE
2.

Under Water Seal

Is a barrier to prevents backflow into pleural

space.
Rod depth determines the negative
pressure
Air bubbles is released through the rod
Air vent to allow drained air to escape to
prevent pressure build up

water seal drainage

PRINCIPLES OF THE CHEST TUBE
3.
Suction

Is

a pull force
MUST be in another bottle
Purpose for the suction is, when :
i.
- gravity drainage is not enough.
ii. - patients respiration and cough are too weak
iii. - air leak is fast into the pleural space
iv. - need to speed up removal from pleural space

water seal drainage

Factors affecting water seal drainage
1.
2.
3.
4.
5.
6.
7.
8.

Proper placement of chest catheter

Proper placement of chest drainage apparatus
Length of drainage tubing
Patency of chest tubing
Maintenance of air tight drainage system
Position of the client
Application of mechanical suction
Activity of the client

water seal drainage

Factors affecting water seal drainage
1.
.
.
.

Proper placement of chest catheter

2 & 3rd intercostal space and 8 &9 th

intercostal space
These catheter should be connected to the
separate bottle
When there is single tube it is usually
placed in lower intercostal space

water seal drainage

Factors affecting water seal drainage
2.Proper placement of drainage apparatus
Drainage apparatus should be placed at
lower level then the chest
It helps in gravity and also prevent the back
flow of air and fluid into pleural cavity
While transferring patient apparatus should
be placed over the bed or trolley after
clamping the tubing at two places

water seal drainage

Factors affecting water seal drainage
3. Length of drainage tubing

Drainage tubing neither too short nor too long

It should fall in straight line to the drainage
system
There should not be any loop of drainage tubing
Too short drainage tubing may restrict the
movement of patient on bed or it may get
disconnected from the catheter

water seal drainage

Factors affecting water seal drainage
4. Patency of chest tubing

Patency of chest tube should be checked frequently

Any kink or pressure over chest tubing may obstruct
the flow from pleural space
Ensure that patient is not lying over the tubing
Any clot or mucus plug in pleural space may also
obstruct the flow
Milking the tube helps to dislodge the plug
Never clamp the tubing until it is necessary.

water seal drainage

Factors affecting water seal drainage

5. Maintenance of air tight drainage system

Drainage system should be air tight with
stoppers and all the tubing should be taped
well

water seal drainage

Factors affecting water seal drainage
6. Position of the client

Fowlers position
So that fluid can be localized in lower pleural
space and can be drained out easily

water seal drainage

Factors affecting water seal drainage
Application of mechanical suction
Continuous and gentle suction is used when :
i.
- gravity drainage is not enough.
ii.
- patients respiration and cough are too
weak
iii.
- air leak is fast into the pleural space
iv.
- need to speed up removal from pleural
space
7.

water seal drainage

Factors affecting water seal drainage
Activity of the client
Movement of the patient on bed helps the fluid
to drain from chest.
Patient should be encouraged to cough and
deep breath
Which helps in rising the intra-pleural and
intra-pulmonary pressure
8.

water seal drainage

AFTER TREATMENT :
Observe for the fluctuating movement of
fluid inside the tubing
Observe the chest drainage
Watch for bubbling in water seal bottle
Obtain chest x-ray, SaO2, BGA (if
necessary)

CIRCULATION AND HEMORRHAGE CONTROL

Assess for:
Shock
External bleeding
Occult bleeding
Estimate the blood loss on initial
presentation of patient and the signs and
symptoms
Replace fluid accordingly, 2 litres of
warm crystalloid solution.

DISABILITY
Glasgow Coma Scale (Eye, Verbal,
Motoric)
Pupillary reaction and size
EXPOSURE
Undress the patient completely, but
prevent hypothermia (ex: warm infusion)
Log-rolling and looking for back of the
pt. is very important.

LOG-ROLLING

ADJUNCTS TO PRIMARY SURVEY

AND RESUSSITATION

ECG
PULSE OXIMETRY
Xray chest AP view
Xray pelvis AP view
URINARY CATHETER
GASTRIC CATHETER
BLOOD PRESSURE
Blood Gas Analysis
FAST
DPL

NEED TO TRANSFER or
REFER?

SECONDARY SURVEY
Secondary survey does not begin until the primary survey
is completed,resuscitative efforts are established and
patient is demonstrating normalization of vital functions.
It includes:
Head to toe evaluation
AMPLE history
Allergy
Medications currently taking
Past illness
Last meal
Event/environment related to injury.

physical examination
Reassessment of all vital organs (IMPORTANT ReEvaluate Patient General Condition)

Adjucts to secondary
survey

CT SCAN (brain CT-scan)

CONTRAST STUDIES (ex:
arteriography)
EXTREMITY X-RAY
ENDOSCOPY
ULTRASONOGRAPHY (FAST)

POSTRESUSITATION MONITORING AND

REEVALUATION

Reevaluation for new finding or

overlooked IMPORTANT
Continous monitoring of vital signs.
Effective analgesia.

DEFINITIVE CARE

AFTER identifying the patients injury.

Managing life threatening problems
Obtaining special studies.
If the patients injuries exceed the
capabilities of the institution refer

Take home message

1.
2.
3.
4.
5.

ABCDE APPROACH.
TREAT GREATEST THREAT TO LIFE.
DEFINITIVE DIAGNOSIS IS NOT
IMMEDIATELY IMPORTANT.
TIME IS THE ESSENCE.
DO NO FURTHER HARM THE
PATIENT

THANK YOU