ATLS review &

28 • 10 • 2020

General principles in
trauma

Reyner Valiant Tumbelaka dr., M.Ked.Klin., Sp.OT

 TODAY WE WILL LEARN ABOUT

1
ATLS and trauma 2
management
principle
What’s new in
3
10th edition
Case scenario
ATLS and trauma management principle
 Advance Trauma Life Support

• Simultaneous diagnostic and therapeutic

activities intended to identify and treat life
threatening
• This focus on urgent problems is first captured by
the ‘Golden hour’
• The GOLDEN HOUR, the first hour after a
traumatic injury, when emergency treatment is
most likely to be successful.
 OUTLINES

●Triage
●Primary Survey (A,B,C,D and E)
●Adjunct to primary survey
●Secondary Survey
●Monitoring and Evaluation, Secondary
adjuncts
●Transfer to Definitive Care
 TRIAGE
The process of categorizing victims or mass casualties based on
their need for treatment and the resources available.

GOALS

1. Prevent avoidable deaths.

2. Ensure proper initial treatment within a minimal time frame.
3. Avoid misusing assets on hopeless cases

 Primary Survey

● Identifies most life ‐threatening injuries

● First, most important thing when you

encounter a trauma patient is to speak to him
● A complete sentence spoken by the patient
tell us:
1. Airway is patent.
2. Breathing is intact.
3. Good cerebral circulation
-­
Primary Survey

• Airway and Protection of Spinal Cord

• Breathing and Ventilation
• Circulation
• Disability
• Exposure and Control of the Environment

AIRWAY MANAGEMENT 


Why first in the algorithm?

– Loss of airway can result in death in < 3 minutes.
– Prolonged hypoxia means Inadequate perfusion, End- organ damage.

Airway Assessment
–total or partial

PROTECTION OF SPINAL CORD

• General Principle:
• Protect the entire spinal cord until injury has
been excluded by radiography or clinical
physical exam in patients with potential
spinal cord injury.

• Rigid Cervical Spinal Collar

• Long rigid spinal board or immobilization on
flat surface such as stretcher = T/L Spine

Clinical Pearls
• Treatment (Immobilization) before
diagnosis.
• Return head to neutral position.
• Diagnosis of spinal cord injury should not
precede resuscitation.
• Motor vehicle crashes and falls are most
commonly associated with spinal cord
injuries.

AIRWAY MANAGEMENT
• Maintenance of Airway Patency
• – Suction of Secretions.
• – Chin Lift/Jaw thrust.
• – Nasopharyngeal Airway/Oropharyngeal Airway.
Airway Support
• – Oxygen.
• – NRBM (100%)
• – Bag Valve Mask.
• Definitive Airway
– Endotracheal Intubation.
• – Surgical Crichothyroidotomy.
• – Tracheostomy.

Breathing and Ventilation

Breathing/Ventilation Assessment:

– Exposure of chest

– General Inspection (LOOK)

Tracheal Deviation
Accessory Muscle Use
Retractions
Absence of spontaneous breathing
Paradoxical chest wall movement

Breathing and Ventilation

– Auscultation to assess for gas exchange (LISTEN)
Equal Bilaterally
Diminished or Absent breath sounds

– Palpation (FEEL)
Deviated Trachea
Broken ribs
Injuries to chest wall

BREATHING AND VENTILATION

• Identify Life Threatening Injuries
–Massive hemothorax
–Rib fractures
–Open pneumothorax
–Pulmonary contusion
–Tension Pneumothorax

BREATHING AND VENTILATION

• Tension Pneumothorax
Air trapping in the pleural space between the lung and chest wall
Sufficient pressure builds up and pressure to compress the lungs and shift
the mediastinum
Physical exam
– Absent breath sounds
– Air hunger
– Distended neck veins
– Tracheal shift

BREATHING AND VENTILATION

Treatment
– Needle Decompression
2nd Intercostals space, Midclavicular line
Tube Thoracostomy
5th Intercostals space, Anterior axillary line

BREATHING AND VENTILATION

BREATHING AND VENTILATION
TUBE THORACOSTOMY
Insertion site
– 5th intercostal space,
– Anterior axillary line.

 CIRCULATION
Shock
• Impaired tissue perfusion Pale skin color
• Prolonged shock state leads to multi- Cool clammy skin
organ system failure and cell death
Delayed cap refill (> 3 seconds)
• Clinical Signs of Shock
Altered LOC
– Altered mental status
– Tachycardia (HR > 100) = Most common Decreased Urine Output (UOP <
sign 0.5 ml/kg/hr)
– Arterial Hypotension (SBP < 120)
– Inadequate Tissue Perfusion

CIRCULATION
Types of Shock in Trauma Sources of Bleeding
– Hemorrhagic – Chest
Assume hemorrhagic shock in all trauma patients
until proven otherwise
– Abdomen
Results from Internal or External Bleeding – Pelvis
– Obstructive – Bilateral Femur Fractures
Cardiac Tamponade
Tension Pneumothorax
– Neurogenic n Spinal Cord injury

CIRCULATION
General Treatment Principles
• Stop the bleeding
Apply direct pressure
– Close open-book pelvic fractures
Abdominal pelvic binder/bed sheet
– Restore circulating volume
Crystalloid Resuscitation (1L)
Administer Blood Products
– Immobilize fractures

▪(almost always seen with a

penetrating wound)
▪Beck’s triad:
Hypotension
distended neck veins
Muffled heart sounds
Pulsus paradoxus

CIRCULATION
 DISABILITY
Baseline Neurological Exam
–Pupillary Exam
• Dilated pupil
– suggests transtentorial herniation on ipsilateral side

AVPU Scale
• Alert
• Responds to verbal stimulation
• Responds to pain n
• Unresponsive
– Gross Neurological Exam – Extremity Movement
Equal and symmetric
Normal gross sensation
– Glasgow Coma Scale: 3-15
– Rectal Exam

DISABILITY
• Key Principles
– Prevention of further injury and identification of neurological injury is
the goal.
– Maintenance of adequate cerebral perfusion is key to prevention of
further brain injury.
Adequate oxygenation
Avoid hypotension

EXPOSURE
• Remove all clothing
– Examine for other signs of injury
– Injuries cannot be diagnosed until seen by provider
Logroll the patient to examine patient’s back
– Maintain cervical spinal immobilization
– Palpate along thoracic and lumbar spine
– Minimum of 3 people, often more providers required
Avoid hypothermia
– Apply warm blankets after removing clothes
– Hypothermia = Coagulopathy
Increases risk of hemorrhage

Adjuncts to Primary Survey

• Vital Signs/ECG monitoring
• ABGs
• Pulse oximetry
• Urinary/gastric catheters
• Urinary output
• ECG
• CXR, C-spine, Pelvis,
DPL ,Ultrasound

 Secondary Survey

Secondary Survey is started

after primary survey is
completed and patient has been
adequately resuscitated.
 SECONDARY SURVEY
• AMPLE History
–Allergies
–Medications
–Past Medical History, Pregnancy
–Last Meal
–Events surrounding injury, Environment
 

 SECONDARY SURVEY
Physical Exam
1. Head
2. Neck
3. Chest
4. Abdomen
5. Pelvis
6. Genitourinary
7. Extremities
8. Neurological
 

 DEFINITIVE CARE
Secondary Survey followed by radiographic evaluation
–further investigation
– Consultation n
Neurosurgery
Orthopedic Surgery
Vascular Surgery

Transfer to Definitive Care

– Operating Room
– ICU
– Higher level facility

Dying from trauma

What’s new in 10th edition
 10th Edition
Update

ATLS®
Advanced Trauma Life Support

Initial
Assessment
 Initial Assessment
• 1 litre of fluid, judicious approach
• Focus on massive transfusion
protocols
• Tranexamic acid
• Coagulopathy
• Canadian C Spine Rule
• Trauma team

 INITIAL A S S E S S M E N T

TXA
Peds Adult

1 L of crystalloid Blood Early (1:1:1 ratio)

20 cc/kg < 40 kg 10-20 mL/kg of RBC/FFP/Plt

 CERVICAL SPINE T R A U M A

Dangerous Mechanisms
• Fall from > 1 meter/5
Canadian C-Spine Rule (CCR)
stairs
1.Age > 65 years • Axial load of head
2.Dangerous mechanism • MVC with ejection,
rollover, > 60 mph
3.Paresthesias in extremities
• Motorized recreational
4.Rotate neck 45 degrees left and right vehicle collision
• Bicycle collision

Imaging indicated if
any present
Low risk factors (prior to assessing ROM)
Simple rear-end MVC Sitting
position in ED Ambulatory at any
time Delayed onset of neck pain
No midline cervical tenderness

Stiell, 2003

Airway
and
Ventilation
 Airway and Ventilation
• RSI changed to Drug Assisted
Intubation
• Video-laryngoscopy
• Trauma team

SHOCK
 Shock
• Class of haemorrhage table
amended: Base excess
• Early use of blood and blood
products
• Management of coagulopathy
• Tranexamic acid
• Trauma team

ATLS classification of hypovolemic shock

*
Early use of blood and blood
products
• Early resuscitation with blood and blood
products must be considered in patients
with evidence of class III and IV
hemorrhage.
• Early administration of blood products at a
low ratio of packed red blood cells to
plasma and platelets can prevent the
development of coagulopathy and
thrombocytopenia.

 Thoracic Trauma
• Life Threatening Injuries
• Flail chest out
• Tracheobronchial injury now in
• Tension pneumothorax
• Needle thoracocentesis
- 5th ICS MAL for adult
- UNCHANGED 2nd ICS for child
• 28-32 Fr chest drain for hemothorax (not 36-40 Fr)
• Algorithm for circulatory arrest approach
• Aortic rupture management with Beta Blocker
• Trauma team

Abdominal
and Pelvic
Trauma
 Abdominal and
Pelvic Trauma
• Palpation of prostate gland no
longer recommended for urethral
injury
• Flow chart for pelvic fracture with
hemorrhage amended
• Trauma team

Pelvic fractures and hemorrhagic shock management

algorithm
Head
Trauma
 Head Trauma
• Detailed guidance on SBP
management
• Classification – ‘mild’ head
trauma
• Anticoagulation reversal guidance
• Seizure prophylaxis
• Trauma team

 Detailed guidance on
SBP management

Maintain SBP at ≥ 100 mmHg for patients

50-69 years or at ≥ 110 mmHg for
patients 15-49 years or older than 70
years; this may decrease mortality and
improve outcomes (III).
 Goals of treatment of brain injury
Clinical Parameters Laboratory Parameters
• Systolic BP ≥ 100 mmHg • Glucose 80–180 mg/dL
• Temperature 36–38°C • Hemoglobin ≥ 7 g/dl
• INR ≤ 1.4
Monitoring Parameters • Na 135–145 meq/dL
• CPP ≥ 60 mm Hg* • PaO2 ≥ 100 mmHg
• ICP 5–15 mm Hg* • PaCO2 35–45 mmHg
• PbtO2 ≥ 15 mm Hg* • pH 7.35–7.45
• Pulse oximetry ≥ 95% • Platelets ≥ 75 X103/mm3
*Unlikely to be available in the ED or in low-resource settings
Data from ACS TQIP Best Practices in the Management of Traumatic Brain Injury.
ACS Committee on Trauma, January 2015.

Spine and
Spinal Cord
Trauma
Spine and
Spinal Cord Trauma
• C-spine protection changed to
‘Restriction of spinal motion’
• New myotome diagram
• Canadian C-Spine Rule (CCR) and
NEXUS Criteria
• Trauma team

Musculo-
Skeletal
Trauma

 Musculoskeletal Trauma

• Weight based IV antibiotic regime

• Highlighting risk factor of bilateral
femur fractures
• Trauma team

Transfer to
Definitive Care
 Transfer to Definitive Care

• Specific mention of avoiding CT in

primary hospital
• SBAR template for communication
• Trauma Team

 Avoiding CT in primary hospital

Do not perform diagnostic procedures (e.g.,

DPL or CT) that do not change the plan of
care.
However, procedures that treat or stabilize an
immediately life-threatening condition should
be rapidly performed.

 ABC-SBAR template for transfer of

trauma patients
• Airway, Breathing, and Circulation problems identified and
interventions performed
• Situation: patient name, age, referring facility, referring physician
name, reporting nurse name, indication for transfer, IV access site,
IV fluid and rate, other interventions completed
• Background: event history, AMPLE assessment, blood
products, medications given (date and time), imaging performed,
splinting
• Assessment: vital signs, pertinent physical exam findings,
patient response to treatment
• Recommendation: transport mode, level of transport care,
medication intervention during transport, needed assessments and
interventions

CASES
SCENARIO 1


Male 35 yo, 70 kilograms, earthquake victim. Found under the rubble of

building with his right lower leg stuck for almost 6 hours.
Primary Survey
• Airway : Clear
• Breathing : No Traumatic sign, RR 24 / minutes, Similar both hemi
thorax
• Circulation : HR 100 / minutes, BP 100 / 60
• Disability : GCS 15, No neurologic abnormality

How do you manage this patient?

• Primary survey indicate shock hypovolemic class 2 with estimation
blood loss 15 % - 30% of body weight. Resuscitation should be done
using 2 lineCrystalloid 2000 cc initially and observe patient response.
Urine catheter is essential to monitor fluid intake and patient
response. Patient response could be :
• Good response
• Transient response
• No response

SCENARIO 2
A 18 years old male (70 kgs), fell from truck and hit from behind. He was
referred from a rural area hospital, already given 500cc of Saline and
already done pelvic x-ray.
Primary Survey Assesment:
• Airway : Clear with cervical support
• Breathing : No traumatic sign, RR 24x/min. SaO2 95%
• Circulation : Cold extremity, HR 124x/min. BP 80/50 mmHg. Pelvic
unstable
• Disability : GCS 356. Isochoric pupil. No neurologic abnormality
• Exposure : Open wound on perineum, traumatic mark on pelvis

How do you manage this patient?

 Response after
resuscitation
The patient have rapid response after
application of pelvic sheet and fluid
resuscitation (given 1-2L saline)
• BP : 100/60
mmHg
• HR : 98 x/min
• RR : 18 x/min
• Temp : 36.8
• GCS : 456
• Urine output: 60 cc/h
(N = (50-100
cc/h)

PARAMETER VALUE NORMAL PARAMETER VALUE NORMAL

Hb 7.6 g/dL
WBC 18. x 103 pH 7.29 7.35-7.45
Plt 145 x 103
HCT 30% pCO2 39 mmHg 35-45
Ureum 25 8-20 pO2 88.6 mmHg 80-100
Creatine 1.3 0.7-1.3
Na 128 mmol/L 135-145 HCO3 19 mEq/L 22-26
Lactate 15 mmol/L 0.5-2.0
K 5.5 mmol/L 3.5-5.0
Cl 101 mmol/L 98-106

Ca 9 mmol/L 9-10.5
• A (Airway and C-spine control) : identify and manage the airway
problem and identify C-spine problem and secure C-spine
• B (Breathing) : identify and manage breathing problem. Patient give O2
rebreathing mask 10 lpm.
• C (Circulation) : identify and manage circulation problem, this patient
present with the classic signs of inadequate perfusion, including marked
tachycardia and tachypnea, cold extremity, significant changes in mental
status, and a measurable fall in systolic blood pressure, in accordance
with the class III haemorrhagic shock.
• Priorities for managing circulation include controlling obvious

• hemorrhage, obtaining adequate intravenous access, and assessing tissue

perfusion. Put on large bore IV needle and give 1-2L saline while preparing
blood samplefor transfusion. Bleeding from external wounds in the extremities
usually can be controlled by direct pressure to the bleeding site. A pelvicsheet
or pelvic binder must be used to control bleeding from pelvic fractures.
• Monitoring urine output via catheterization also allows for continuous
evaluation of renal perfusion. Important to remember, blood at the urethral
meatus or perineal hematoma/bruising may indicate urethral injury and
contraindicates the insertion of a transurethral catheter before radiographic
confirmation of an intact urethra. In this patient, no bloody discharge on
urethral meatus. For wound at perineum, control bleeding by packing with
gauze

• D (Disability) : Identify problem with brain. Patient with GCS 356,

slight mental change due to haemorrhagic shock
• E (Exposure): expose all body surface and identify the potential
problem. Open wound at right perineal region extend to anal canal.

• Adjunct to primary survey:

• X-ray thorax: normal
• FAST ultrasound: normal
• X-ray Pelvic: on screen

@chirurgien.bss
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