Advanced Trauma Life Support (ATLS)
Case scenario:
A middle age man was brought by ambulance after an MVA to the Emergency
Department.
Please manage the patient.
1) Preparation
2) Triage
3) Primary & secondary survey
First, I would like to wash my hands.
(While putting on personal protective equipment: Gloves, mask and apron; call for help!)
Please bring the resus trolley and procedure trolley, cervical collar.
Bring the defibrillator and attach the leads to the patient.
1) Airway maintenance with cervical spine protection
• Assess airway patency protection
o Able to speak in full sentences?
o “Sir, sir. Are you okay?”
o “What is your name? Can you tell me what happened?”
• Assess for airway obstruction.
o Inspect for foreign body, secretions, blood, saliva.
o Listen for stridor ( foreign body ) , coughing/ gurgling (secretion)
o Use a Yankauer suction - Contraindication: When a foreign body is suspected
but not visible as suctioning might lodge the foreign body even deeper
o Inspect for maxillofacial injury & base of skull injury - raccoon eyes, Battle’s sign
(facial, mandibular, or tracheal/laryngeal fractures)
• Give airway support if necessary
o Approach patient with chin-lift / jaw thrust manoeuvre
o Consider airway support if GCS less than 8
o Give high-flow mask 15 LPM, and monitor SpO2 & RR. If fails, consider airway adjuncts,
followed by definitive airway
o Airway adjuncts: consider oropharyngeal airway (if no gag reflex),
nasopharyngeal airway (if no base of skull injury)
o Definitive airway: (Rapid sequence induction)
§ Preparation for PPE and resus trolley. (MEALSSS)
v Mask
v ETT
v Airway adjunct
v Laryngoscope
v Stylets
v Stethoscope
v Suction
§ Preoxygenation for 3 minutes with SpO2 > 95% (Denitrogenation)
§ Premedication given:
v Analgesia - opoid (fentanyl)
v Induction agent- Ketamine
§ Paralysis
v Suxamethonium or Rocuronium
© UMMP 14/19, STREAM 5
Last edited: October 2016
§ Proceed with placement of ETT tube.
§ Post intubation care: direct visualization of ETT, 5 point auscultation,
capnometer readings.
o If difficult airway, try video laryngoscopy, gum elastic bougie, extraglottic
device.
o Surgical airway: cricothyroidotomy (Percutaneous/Open)
• Assess for indication of cervical spine protection
o Any injury above the level of clavicles, unconscious patient with possible
history of head & neck trauma (MVA)
o Apply cervical collar. Manual in-line stabilization/immobilization. Measure distance
between mandible and clavicle using finger breadth method.
2) Breathing & ventilation
• Inspection
o Expose neck and chest adequately
o Look for any injuries, bruises, open wounds, laceration.
o Inspect for chest expansion (& symmetry) and any paradoxical chest movement (indicate
flail chest)
o Inspect for raised JVP
• Palpation
o Palpate for tracheal deviation
• Percussion
o Percuss the chest for abnormalities
• Auscultation (breath sound, air entry)
ATOM FC
Airway obstruction
Tension pneumothorax
Open pneumothorax
Flail chest
Cardiac tamponade
i) Airway obstruction
Features:
External neck deformity, haematoma, crepitus from laryngeal fracture, surgical emphysema,
hoarse voice or gurgling sound
Silent chest, paradoxical chest movement
Stridor, respiratory distress
Cyanosis
Management:
a) Yankauer suction
b) Basic airway maneuvers
c) Airway adjuncts
d) Definitive airway - ETT "7P"
e) Surgical airway
ii) Tension pneumothorax
Features:
Affected side – asymmetrical chest expansion, tracheal deviation (away), hyperresonance,
reduced breath sound
© UMMP 14/19, STREAM 5
Last edited: October 2016
Management:
a) Needle thoracocentesis
• Insert a large bore branula at the ipsilateral second intercostal space, midclavicular line
b) Chest tube
Insert chest tube at safe triangle (Borders: 4-5 intercostal space inferiorly, lateral border
th
of pectoralis major anteriorly and mid axillary line posteriorly)
Connect to underwater seal
Confirm by looking for fogging of tubing, bubbles in the water, fluctuation in water-seal
level and chest X ray ( ask patient to cough)
Be aware that tidaling—fluctuations in the water-seal chamber with respiratory effort—
is normal
iii) Open pneumothorax
Features: Bleeding, sucking/bubbling chest wound with reduced chest expansion,
hyperresonance on percussion, reduced air entry on auscultation at one side.
Management:
a) 3-sided occlusive dressing
- Use a sterile plastic patch
- Tape down 3 sides, free the lowest side
- Dressing prevent air entry during inspiration, but allow trapped air to escape during
assess BP
expiration, and allow blood to flow out
- If patient stable, do a chest X ray, then insert a chest tube. If patient unstable, suspect
tension pneumothorax and do chest tube immediately
b) Chest tube
Insert chest tube at safe triangle, the borders are 4-5 intercostal space, lateral border
th
of pectoralis major and mid axillary line
Connect to underwater seal
Confirm by looking for bubbles in the water and chest X ray
iv) Massive haemothorax
Definition: blood loss of >1500ml inside the chest cavity.
Features: Dull on percussion on one side of chest, reduced breath sound on auscultation,
hypotension
Affected side – asymmetrical chest expansion, trachea deviate away, dullness on percussion,
reduced breath sound, massive blood loss in chest tube
Management:
a) Chest tube
b) Insert 2 large bore branula
• Send blood for FBC, coagulation profile & group cross match
• Insert chest tube
• If drains large amount of blood, diagnosis is confirmed massive hemothorax
• Ask for signs of poor circulation, if poor, start fluid resuscitation, 1 L normal
saline ( warm)
• Reassess BP, if fail, start blood transfusion
• Reassess, if fail and patient still bleeding, may indicate lung laceration or pulmonary
vasculature bleeding, call cardiothoracic surgeon for emergent thoracotomy & send
the patient into OT.
© UMMP 14/19, STREAM 5
Last edited: October 2016
c) Indications of emergency thoracotomy:
1. Initial blood drainage >1500ml
2. Ongoing drainage of >500ml/hr for the first hour OR >300ml/hr for 2 consecutive hours
OR >200ml/hr for 3 consecutive hours.
3. persistent blood transfusion requirements.
4. large retained pneumothorax especially if associated with continual bleeding
5. continued haemodynamic instability.
6. suspicion of oesophageal, cardiac, great vessels or major bronchial injuries.
v) Flail chest
Definition - fracture of two or more ribs, in two or more location, producing a free floating,
unstable chest wall
Features: Paradoxical movement of flail segment, reduced air entry on auscultation, chest
pain.
Management:
a) Analgesia
- If patient can breathe normally after analgesia, then fine
- IV morphine 1 mg, then PCA
b) Ventilation
• Close monitoring of SpO2, respiratory effort, ABG.
• Give HFM 15L O2/min.
• Intubation and mechanical ventilation indicated if ABG shows pCO2 high and patient
become more tired or increasing SOB
c) Chest tube
- Indicated only if patient have evidence of pneumothorax
- Not indicated if patient alert, respond well to analgesia
- Dangerous if patient having concurrent pneumothorax, as positive ventilation from the
mechanical ventilator will worsen it, causing tension pneumothorax
vi) Cardiac tamponade
Features:
Suspect in chest trauma and persistent hypotension, signs of shock
Beck’s triad – muffled heart sounds, distended neck veins, hypotension ( if hypotension, start
normal saline 2 pint over 2 hours)
Ultrasound – accumulation of fluid in the pericardium
Kussmaul’s sign (increased neck distension during inspiration and pulsus paradoxus)
Management:
Pericardiocentesis
- 1-2 cm below xiphoid process, 45 degrees, direct towards left shoulder, aspirate the fluid
out
- Ensure cardiac monitoring in case injure myocardium and ECG changes (arrhythmias)
- 2 methods: blind technique / ultrasound guided (preferable if available)
- refer cardiothoracic surgeon for open thoracotomy if failed pericardiocentesis.
- reassess BP.
© UMMP 14/19, STREAM 5
Last edited: October 2016
Approach to ATOM FC
- Recognize features by clinical examination (IPPA)
- Establish diagnosis "I think the patient is having ..."
- Manage the patient
- Reassess patient’s response to treatment
- Ask for all vital signs
- Manage accordingly if any of the vital signs is not stable
3) Circulation
• Capillary refill time, temperature of peripheries. Acting like you are touching patient's hand!!
• Pulse volume (feeble or normal)
• Blood pressure
• Inspect for open wound with bleeding ( External haemorrhage)
- Direct manual compression
- Elevation
- Compression of pressure point
• Examine abdomen
- Check for internal bleeding
- Inspection: scars, wound
- Palpation: tenderness, guarding, distention, board like rigidity
- Percussion
- Auscultation
- If suggestive of intra-abdominal bleeding, do fast scan, refer surgeon later.
• Examine pelvis
- Check for pelvic fracture / open book fracture. (Inspect for bruises or
haematoma. If none, proceed with palpation)
- Open outwards & inwards
- Press on symphysis pubis
- If suspect fracture, bind the pelvic with a pelvic binder
• Examine long bones
- Expose adequately
- Ask the patient to move all 4 limbs
- Assess for Open or closed fracture
- Open fracture - send to OT
- Closed fracture- traction and immobilization
• Approach ( if patient had circulation problem)
- 2 large bore IV access
- Send blood for cross match
- IV warm 1L of isotonic solution in bolus
- FAST scan
4) Disability
• GCS
- Check level of consciousness
- Eye: E4 spontaneous, E3 to speech, E2 to pain, E1 none
- Speech: V5 orientated, V4 confused, V3 incoherent words, V2 incomprehensible
sounds, V1 none
- Motor: M6 obeys command, M5 localize pain, M4 withdraws from pain, M3
decorticate, M2 decerebrate, M1 none
Consider ETT if GCS <8
© UMMP 14/19, STREAM 5
Last edited: October 2016
• Pupillary size and reaction
- If dilated probably there is increase in ICP due to intracranial haemorrhage. Start
cerebral protection and give mannitol. KIV refer to neurosurgeon.
5) Exposure
• Undress & change into hospital attire
• Put on blanket to keep warm to prevent hypothermia
Dispose the patient accordingly.
Extra Notes:
*anion gap = [ Na + K ]– [ Cl + HCO3 ] 1. Respiratory acidosis
1. Metabolic acidosis ↑ anion gap VQ mismatch,
2. Metabolic acidosis normal anion gap
Methanol Depression of respiratory centre d/t
Diarrhea
Uremia disease/damage,
Renal tubular acidosis
DKA Airway Obstruction (AEBA/AECOPD),
Spironolactone
PCM Lung disease
Addison disease
Intoxication/infx Pancreatic fistula 2. Respiratory alkalosis
Lactate acidosis - shock, sepsis, hypoxia NH4 ingestion Hyperventilation
Ethanol Drug - acetazolamide ↑ altitude
Salicylate acid/ASA Salicylate poisoning
3. Metabolic acidosis ↓ anion gap
Hypoalbuminemia
© UMMP 14/19, STREAM 5
Last edited: October 2016
