Advanced Trauma and Life Support

(ATLS)
Epidemiology
− Road Traffic Accidents are major cause of long-term morbidity and mortality in developing nations.
− WHO predicts that Road Traffic Accidents will be second leading cause of loss of life for world’s
population.
− High Morbidity = Loss of income to society.
− Challenges in Developing Countries:
1. Technological Advances in Trauma Care
2. Lack of Infrastructure for Trauma Management
Mechanism of injury
1.Penetrating injuries
− Low velocity injuries
− High velocity injuries
2. Blunt injuries
− Direct blows
− Fall from a height
− Road traffic accidents (RTA)
o Direct injury
o Acceleration deceleration injury
o Seatbelt injury
o Associated injuries
Trimodal Distribution of Trauma
Deaths.
A. the first peak of deaths occurs within few seconds to
minutes after injury (50% of all deaths). virtually
inevitable & very little can be done.
B. the second peak occurs between a few minutes and 6
hours after injury. can be reduced by prompt initial
care in the pre-hospital phase, by early hospital
resuscitation and by prompt and competent definitive
care. This period has been labelled as “the golden
hours”. management at this time will affect the third
peak of deaths.
C. the third peak occurs several days or weeks after the
initial injury.
The second and third peaks should be regarded as potentially preventable.
Trimodal Death Of ATLS
• Within Seconds to Minutes
− Brainstem injury
− Aortic rupture
• Within Minutes to Hours
− Sub Dural Hematoma
− Rupture of Liver & Spleen
• Within Days to Weeks
− Sepsis & MODS
Golden Hours
− The first hours following a trauma during which aggressive resuscitation can improve the chances of
survival and restore the normal functions.
− Early pre-hospital care, early transport, aggressive resuscitation and interventions in ER, continued
care in ICU have a definite and significant role in preventing deaths due to trauma.
Objectives Of ATLS
• To rapidly & accurately assess trauma patients
• Early recognition & timely intervention of life-threatening conditions
• To resuscitate & stabilize trauma patients
• To understand the priorities in trauma management → Triage
• To organize quality trauma care in your hospital
Overview
1. Preparation
2. Triage
3. Primary Survey
4. Resuscitation
5. Secondary Survey
6. Continued post resuscitation monitoring and re-evaluation
7. Definitive care
1. Preparation
Pre-hospital phase
Receiving hospital is notified first.
Send to the closest, appropriate facility.
Pre-Hospital Trauma Life Support
• Primary Survey & Basic Life Support
• Spinal Protection in Long Spinal Board (LSB)
• Splinting Extremities
• Control of External Hemorrhage. Aim: To Stabilize the Patient→ Platinum 10 Minutes
2. Triage
The process of categorizing victims or mass casualties based on their need for treatment and the
resources available.
Triage-sorting of patients by injury severity and need for transport
its main goals are.
− Prevent avoidable deaths.
− Ensure proper initial treatment with a minimal time frame.
− Avoid misusing assists on hopeless cases.
A. Multiple Casualties
Number & severity of patients do not exceed the ability of the facility.
B. Mass Casualties
Number & severity of patients exceed the capability of the facility & staff.
Field Triage- Color Coding
▪ Red: most critically injured. immediate management
▪ Yellow: less critically injured. delayed transfer to hospital without endangering life
▪ Green: no life/limb threatening injury. patient ambulatory
▪ Black: dead patient
3. Primary Survey
A: Airway with cervical spine protect.
B: Breathing
C: Circulation & control external bleeding.
D: Disability or neurological status
E: Exposure (undress) & Environment (temperature control)
 − Priorities for the care of Adult, Pediatrics & Pregnant women are all the same.
− During the primary survey life threatening conditions are identified and management is
instituted simultaneously.
− What is the quick, simple way to assess the trauma patient in 10 seconds?
− A complete sentence spoken by patient tells us:
1. Airway is patent.
2. Breathing intact.
3. Good cerebral circulation.
A. Airway and Cervical Spine Control
− Clear airway (finger sweep)
− Chin lift or jaw thrust
− Oropharyngeal or nasopharyngeal airway
− Intubate with ETT
− Cricothyroidotomy
− Keep the neck immobilized
− GCS score of 8 or less require the placement of definite airway.
− Protection of the spine & spinal cord is the important management principle.
− Neurological exam alone does not exclude a cervical spine injury.
− Always assume a cervical spine injury in any patient with multi-system trauma, especially with an
altered level of consciousness, maxillofacial trauma or blunt injury above the clavicle.
Indication For Definite Airway
• Unconscious
• Severe maxillo-facial fracture
• Risk for aspiration: Bleeding/ vomiting
• Risk for obstruction: neck hematoma, laryngeal/tracheal injury, stridor
• Apnea: Neuromuscular paralysis/unconscious
• Inadequate respiratory effort: tachypnea/hypoxia/hypercapnia/cyanosis
• Severe closed head injury needs for hyperventilation
Airway Obstruction
▪ Snoring and gurgling sound implies → partial Pharyngeal occlusion.
▪ Hoarseness implies → laryngeal obstruction.
• Nasotracheal intubation→ safer for patients with cervical spine injuries
• Orotracheal intubation→ provided manual in-line cervical immobilization is maintained.
− Radiological evaluation is done later after trolley side of head stabilization of vital systems. At least
three views of the cervical spine (lateral, AP, and odontoid) are done.
B. Breathing with Supplemental Oxygen
− Inspect: Equal chest rise, paradoxical chest movements, contusion, sucking chest wound, distended
neck veins, RR and use of accessory muscle.
− Auscultate: equal breath sounds, absence of breath sounds.
− Palpate: Trachea, chest wall tenderness, subcutaneous emphysema, sternal and rib fracture.
− Percuss: dullness, hyperresonance.
o If you think about giving oxygen, give it!
Identify and manage life threatening problems first
• Tension pneumothorax
• Massive hemothorax
• Open pneumothorax
• Flail chest with pulmonary contusion
• Cardiac tamponade
Management
− Commence 100% oxygen; Patients with inadequate ventilation may require assisted ventilation.
− Suction secretions
Tension pneumothorax
 − respiratory distress
− hyperinflated chest
− deviated trachea
− decreased movement
− decreased breath sound
− tachycardia
− hypotension
needle thoracostomy via 2nd ICS in mid clavicular line (MCL) followed by definitive chest tube (4th- 5th
ICS just anterior to MAL connected to water under seal drain)
Massive hemothorax
− signs similar to tension pneumothorax except dullness on percussion
− shock
− ICT/ tube thoracostomy
− thoracotomy in
>1500ml/hr.→ drain immediately
>200 ml/hr.→ for 4 hours
Open Pneumothorax
− Chest tube at site separate to defect
− Cover wound with 3 sides gauze
− Definitive debridement in Operating Theater (OT)
Flail Chest
− > 2 rib fractures in 2 or more places
− paradoxical chest wall movement
− inadequate ventilation
− re-expand lungs: intubation, Intermittent positive-pressure ventilation (IPPV), Cardiothoracic and
Vascular Surgery (CTVS) consultation
Cardiac Tamponade
− penetrating injury
− Beck's triad →
− echo/ fast Hypotension
− emergency room thoracotomy/ urgent thoracotomy
C. Circulation & control of hemorrhage
Assess:
− Pulse rate and character Muffled
− Skin colour and temperature
Distended
heart
neck veins
− Conscious level (GCS) sound
− Capillary refill time
− Decreased urine output
− Hypotension: a late sign when ≥ 30% blood volume lost.
Stopping the bleeding: most important priority
Be aware of possible sources of internal bleeding both from blunt and penetrating trauma
– Chest
– Abdomen
– Pelvic Fractures
– Long Bone Fractures
Shock
1. Hemorrhagic. Commonest. Tension pneumothorax reduces venous return and worsens this shock.
2. Cardiogenic. Tamponade and myocardial trauma.
3. Neurogenic. Spinal cord injury
Management:
− Control external hemorrhage by direct pressure; No tourniquets/hemostats.
− Insert 2 large intravenous catheters
 − Draw blood for CBC, blood typing, cross matching, chemistries; arterial blood for blood gases.
− Initial Fluid Therapy: Rapid crystalloid infusion with warmed Ringer’s Lactate solution. is preferred:
• For adult 1-2 liters bolus
• For child 20ml/kg bolus
3 for 1 Rule
a rough guideline for the total amount of crystalloid volume acutely is to replace each ml of blood loss
with 3 ml of crystalloid fluid, thus allowing for restitution of plasma volume lost into the interstitial &
intracellular space.
Blood replacement
O-, group specific or fully cross matched packed cells
Remember other blood product requirements: Fresh Frozen Plasma (FFP), Cryoprecipitate (cryoppt),
platelets.
D. Disability (Neurological Evaluation)
Simple Mnemonic to describe level of consciousness
• A: Alert
• V: Responds to Vocal stimuli
• P: Responds to Painful stimuli
• U: Unresponsive to all stimuli
Not forget to use also Glasgow Coma Scale.
Common causes of neurological deficits related to trauma are
− Head injury.
− Hypoxia.
− Shock.
− Alcohol or drugs abuse.
Check Pupils
size; evidence of inequality
reaction
response to light
Sensory: can feel in all parts of body?
Motor: can move all limbs?
E. Exposure
Undress the patient completely but prevent hypothermia.
Logrolling and looking for back of the patient is very important.
4. Resuscitation
A. Electro-cardio graphic monitoring
B. Urinary & gastric catheter
Urethral injury should be suspected if
− Blood at the penile meatus
− Perineal ecchymosis
− Blood in the scrotum
− Pelvic fracture
C. Monitoring
− Ventilatory rate & ABG
− Pulse oximetry: does not measure ventilation or partial O2 pressure
− Blood pressure: poor measure of actual tissue perfusion.
Diagnostic tools
− CXR, C-spine, Pelvis
− DPL
− Ultrasound→ FAST
History
− A: Allergies.
− M: Medication currently used.
 − P: Past illness/ Pregnancy.
− L: Last Meal
− E: Events/Environment related to the injury:
blunt trauma/penetrating trauma/injuries due to cold & burn/hazardous environment?
5. Secondary Survey
• Secondary Survey does not begin until the primary Survey (ABCDEs) is completed, resuscitative
efforts are well established, and patient is demonstrating normalization of vital functions
Physical Examination
1. Head
Visual acuity
Pupillary size
Hemorrhage of conjunctiva and fundi
Penetrating injury
Contact lenses (remove before edema occurs)
Dislocation of lens
Ocular movement
2. Maxillofacial Injury
No Nasogastric Tube (NGT) tube, definite airway?
3. Cervical Spine & Neck
Patient with maxillofacial or head trauma should be presumed to have and unstable cervical spine.
4. Chest
− Elderly patients are not tolerant of even relatively minor chest injury.
− Children often sustain significant injury to the intrathoracic structure without evidence of thoracic
skeletal trauma.
5. Abdomen
Excessive manipulation of the pelvic should be avoided.
6. Perineum/rectum/vagina
7. Musculoskeletal
8. Neurologic
Protection of spinal cord is required at all times until a spine injury excluded, especially when the patient
is transfer.

Glasgow Coma
Verbal Response Motor response Eye Opening
Oriented 5 Obeys 6 Spontaneous 4
Confused 4 Localizes 5 To speech 3
Inappropriate words 3 Withdraws 4 To pain 2
Incomprehensible sounds 2 Decortication 3 None 1
None 1 Decerebration 2
None 1
Adjunct to The Secondary Survey
Include additional x-ray and all other special procedure.
6. Re-Evaluation
Adult urine output 0.5ml/kg/hr.
Pain relief -- IM should be avoid.
Diagnostic Peritoneal Lavage Indication
− Change in sensorium → Head injury/ alcohol/ drug.
− Change in sensation → Spinal cord injury.
− Injury to adjacent structure → lower ribs/ pelvic/ lumbar spine.
− Equivocal physical examination.
 − Prolong loss of contact with patient anticipated.
Positive Test: >100,000 RBC/mm3, >500 WBC/mm3 or Gram Stain with bacteria
7. Definitive Care
− After identifying the patient's injury.
− Managing life threatening problems
− Obtaining special studies.
− If the patient's injuries exceed the capabilities of the institution.