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Introduction to Adv-nced Tr-um- Life Support ( ATLS )

Summ%rized by :
AHMED ALSENAFI , MD
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!ATLS is % common l%ngu%ge since itʼs %pplied %s univers%l system .

!ATLS should be performed to %ny tr%um%tized p%tient

!ATLS should be performed in % sequenced %nd f%st w%y ABCDE.....etc .

!ATLS is not needed completely to every p%tient , just essenti%l steps needed
for %ll tr%um% p%tients .
!ATLS should be repe%ted %nd p%tient reev%lu%tion is import%nt %s
somethings c%n be missed !!
!ATLS consists of prim%ry %nd second%ry surveys .

Prim-ry survey (ABCDE)

You %re c%lled to receive % tr%um%tic p%tient :
– St%rt %ctiv%ting tr%um% code
– Distribute the te%m %nd est%blish te%mwork : le%der , AIRWAY ,
BREATHING , CIRCULATION , DISABILITY , EXPOSURE , monitors , l%bs %nd
r%ds .....other %djuncts .
– once you receive the p%tient , protect yourself , we%r gown , gloves , %nd
f%ce m%sk .
– Ask the p%r%medics %bout the prehospit%l ph%se (MIST) :
Mech%nism of injury ? Injuries : wh%t %re the
reported injuries ? Signs %nd Symptoms ? Including the vit%l
signs . Tre%tment given before %rriving to hospit%l .

AIRWAY :
%sk p%tient n%me ? Are you Ok ? P%tient responds cle%rly p%tent %irw%y
ok good just put O2 m%sk
Silent p%tient then put cervic%l coll%r TO PROTECT C SPINES %fter th%t
open %irw%y by JAW THRUST MANEUVER , then %ssess if thereʼs foreign body
or blood or secretions , do suction , if thereʼs nothing , put oroph%rynge%l
%irw%y %nd O2 m%sk then see O2 s%tur%tion .
Donʼt jump to intub%te the p%tient , just move to %nother %irw%ys if O2 m%sk
f%iled :
O2 m%sk - oroph%rynge%l or n%so - LMA - intub%tion
If thereʼs M%xillof%ci%l tr%um% cricothyroidotomy
 BREATHING :
Assess by percussion , %uscult%tion , check if thereʼs distended or coll%psed
neck veins or devi%ted tr%che% %nd CXR .
Look if thereʼs :
1). Simple Pneumothor%x : decre%sed %ir entry + hyperreson%nt percussion .
If +ve chest tube

2). Tension pneumothor%x : dec %ir entry + hyperreson%nt percussion +

devi%ted tr%che% + distended neck veins .
If + ve initi%lly , inject % needle in 2nd intercost%l sp%ce of the s%me side .
Then definitely chest tube .
donʼt w%it for chest X-r%y

3). Hemothor%x : dec %ir entry + dull percussion

If +ve chest tube

4). C%rdi%c t%mpon%de : distended neck veins + muffled he%rt sounds +

hypotension (obstructed shock)
If +ve thor%cotomy or sternotomy . peric%rdiocentesis done if thereʼs no
expert surgeon .

Fin%lly observe O2 s%tur%tion , %nd ev%lu%te the chest tube dr%in%ge output :
m%ssive hemothor%x ; Immedi%te 1500 ml or more of blood thor%cotomy
200 ml/hr for 2-4 hours thor%cotomy
Unst%ble p%tient thor%cotomy
Need for blood tr%nsfusion thor%cotomy

All of points %bove %re indic%tions of thor%cotomy , %nd %nother

indic%tions :
– Penetr%ting tr%um% medi%l to nipple %nteriorly
– Or medi%l to sc%pul% posteriorly
((Thor%cotomy isnʼt performed unless thereʼs expert %nd well tr%ined surgeon
presented))

5). Lung contusion : dec %ir entry + low O2 s%t

So , no intervention is indic%ted , just O2 supply .
Remember it c%n h%ppen in pedi%trics without ribs fr%ctures !!!

6). Fl%il chest : multiple ribs fr%cture with p%r%doxic%l chest movement , so just
consider good %n%lgesi% .

CIRCULATION :
Assess by looking if thereʼs extern%l bleeding , blood pressure %nd signs of
intern%l hemorrh%ges (cut%neous ecchymosis) , CXR , pelvic X-r%y or FAST.

– First thing stop the ext. bleeding by direct compression over the wound
using g%uze for 10 min , %nd repe%t th%t for 2nd time . If bleeding doesnʼt
stop %pply tourniquet %nd write time %nd d%te over it .
– Two l%rge IV c%nnul% must be pl%ced in bil%ter%l cubit%l foss% veins for
bolus cryst%lloid solution infusion (1 L of norm%l s%line 0.9% or Ringerʼs
l%ct%te) then observe blood pressure %nd urine output .
– Ask for blood grouping , %nd if the p%tient doesnʼt respond to fluid
resuscit%tions do cross m%tching of w%rm unit of blood (donʼt forget the
univers%l donor O-) . If thereʼs no response even %fter blood tr%nsfusion ,
surgic%l intervention mostly indic%ted .
– If the p%tient responds to fluid resuscit%tion , then keep the infusion of
m%inten%nce fluids .
– In c%ses of pelvic fr%ctures , do pelvic binders
– In c%ses of pregn%nt women %bdomin%l tr%um% , move the p%tient to left
side for IVC decompression . And ev%lu%te the b%by .
– In c%ses of %bdomin%l tr%um% , chest tr%um% or pelvic fr%ctures %nd the
p%tient is hemodyn%mic%lly unst%ble despite resuscit%tion Oper%tion
Room.
– Be c%reful %bout femur fr%cture since itʼs %ssoci%ted with 2-3 L loss of
blood , so consider gentle tr%ction of the femur with inline splint tr%ction .
– In c%ses of he%d tr%um% , the blood pressure will be high , so donʼt try to
reduce the blood pressure .
– In pedi%trics , you might need intr%osseous infusion .
– Tr%nxemic %cid

DISABILITY :
Assess by Gl%sgow Com% Sc%le (GCS) , pupils re%ctivity %nd neurologic%l
l%ter%liz%tion .

– Protect the spin%l cord by pl%cing the p%tient over h%rd spine bo%rd with
cervic%l coll%r . And donʼt move the vertebr%l column %t %ny level .
– Do log rolling with 4 te%m members %nd ex%mine the b%ck + per rect%l
ex%min%tion .
– norm%l GCS is 15
0
– GCS of 8 is indic%tion for intub%tion unless itʼs contr%indic%ted .
– Pupils re%ctivity is indic%tor of br%in vi%bility .
– Look for %ny sign of neurologic%l l%ter%liz%tion indic%ting br%in or spin%l
cord tr%um% .
– Put in mind the neurogenic shock : there will be sudden p%r%lysis of
effected %re%s below the level of S.Cord injury + low blood pressure due to
loss of v%scul%r tone .
 EXPOSE %nd ENVIRONMENT :
The whole body of p%tient must be exposed with quick ev%lu%tion %nd
ex%min%tion , then cover the p%tient with w%rm bl%nket to %void hypothermi% .

%djuncts to prim%ry survey :

continuous vit%l signs monitoring .

continuous ECG monitoring .
L%bs : CBC , U/E , VBG , co%gul%tion profile %nd blood grouping .
R%ds : CXR , pelvic X-r%y , FAST %nd c.spine X-r%y .
urine c%theter .
g%stric c%theter .
Drugs : %n%lgesi% , cef%zolin , metronid%zole %nd tet%nus toxoid
v%ccine .
E%rly consult%tion for others speci%lities is import%nt : thor%cic surgery ,
GS , ortho , v%scul%r...etc
consider p%tient tr%nsfer if your center doesnʼt h%ve the c%p%bility to tre%t
the p%tient (e.g. he%d tr%um% with no neurosurgeon) , so tr%nsfer the p%tient
with QUALIFIED CLINICIAN %fter :
– completing the prim%ry survey
– Discussing the c%se with the recipient doctor in %nother center +
ACCEPTANCE
– writing the p%tientʼs report
You c%n proceed to second%ry survey if you c%n %nd without del%ying
p%tient tr%nsfer (e.g. br%in CT) .

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Second-ry survey
Includes history , physic%l ex%min%tion %nd other investig%tions or tre%tment :

1). History
use the pneumonic AMPLE :
Allergy : is the p%tient %llergic to % drug or %nything ?
Medic%tions : does the p%tient t%ke %ny medic%tions ?
P%st medic%l history Or Pregn%ncy ?
L%st me%l ?
Event : wh%t h%ppened ? RTA ? F%ll ? Fight ?

2). Physic%l ex%min%tion :

He%d to toe physic%l ex%min%tion with full exposure

3). Further investig%tions :

He%d tr%um% br%in CT without contr%st
Abdomin%l tr%um% %bdomin%l CT with contr%st
Skelet%l Tr%um% : c%lled tr%um% survey X-r%y
Others , %ngiogr%phy , ECHO .... etc

4). Tre%tment (Definitive c%re) :

Any ther%peutic medic%tion or oper%tion .

Miscell-neous Notes

Chest tr%um% :
– ABCDE
– discussed before !
– In c%ses of open simple pneumothor%x due to gun bullet , %pply 3 sided
wound covering initi%lly then perform chest tube .

Abdomin%l tr%um% :
– ABCDE
– note the signs of %bdomin%l tr%um% e.g. se%t belt sign , peritonism ,
Collenʼs sign , or Grey turner sign .

. Io
– If you resuscit%te the p%tient %nd still hemodyn%mic%lly unst%ble

– Gunshot %bdomin%l injury usu%lly requires explor%tion l%p%rotomy . But

OR

2
st%b wounds do not .
– Air fluid levels or di%phr%gm%tic rupture OR .
– Eviscer%tion OR . 5
– Bleeding in stom%ch or per rectum or genitourin%ry system following
penetr%tion tr%um% OR .
– Liver tr%um% usu%lly tre%ted conserv%tively , just %pply p%cking to the
liver .
– Splenic tr%um% depends on the gr%des , so if you h%ve splenic l%cer%tion
or sh%ttered spleen splenectomy .
– If thereʼs %bdomin%l tr%um% %nd the p%tient developed signs of peritonitis
OR .
– The best initi%l test is FAST .
– The best di%gnostic test is %bd CT with contr%st .
– Scrot%l swelling , peri%n%l ecchymosis , bleeding per me%tus retrogr%de
urethrogr%m . Donʼt insert Foleyʼs c%theter .

Musculoskelet%l tr%um% :
– ABCDE
– put in mind neurov%scul%r structures . So , %lw%ys %ssess the pulse %nd
sens%tion dist%l to %ny fr%cture . Therefore , c%lcul%te ABI to ev%lu%te the
effic%cy of %rteri%l blood flow .
– Be %w%re %bout comp%rtment syndrome due to muscul%r engorgement
 –

– o
%round the fr%cture . Rx : f%ciotomy .
Femur fr%cture %nd pelvic fr%ctures %re %ssoci%ted with sever
hemorrh%ge , then e%rly m%n%gement is m%nd%tory .
–

–
out by im%ging . II
Donʼt move the spines %t %ny level unless the tr%um% is completely ruled

F%lls tr%um% %re %ssoci%ted with pelvic fr%ctures (open book or vertic%l
she%r)
– F%lls tr%um% %re %ssoci%ted with c%lc%neus bone fr%cture , then donʼt
forget to %ssess the vertebr%l column %lso .
– In c%ses of open fr%ctures , initi%lly give IV %ntibiotics . Then , surgic%l
debridement is the most import%nt step .

Therm%l tr%um% (burns) :

– This includes ; fires , chemic%l injury , frostbites !, Electric%l
shock tr%um% %nd inh%l%tion injury .
– First remove the p%tient from the injurious %re% .
– ABCDE
– Keep the burned %re% sterile , %nd donʼt touch unless you h%ve sterile
gloves %nd g%uze .
– Minimize the number of c%regivers to keep the infection %w%y from the
p%tient .
– In chemic-l burns , st%rt w%shing the p%tient with w%rm s%line %t le%st
for 20 min .
– In c%ses of t-r tr%um% , donʼt c%use further tr%um% by removing the t%r
m%nu%lly , you c%n do cooling then use miner%l oil to remove the t%r .
– E%rly %irw%y m%n%gement with intub%tion is better .
– Consider p%tient tr%nsfer if thereʼs %irw%y injury .
– Donʼt c%use further h%rm to %irw%ys in c%ses of inh%l%tion injury . So ,
cricothyroidotomy in such c%se could be better .
g
– Resuscit%te the p%tient with peripher%l lines , if c%n not be done , consider
centr%l lines or intr%osseous fluids infusion .
– Resuscit%ting the p%tient is very import%nt %s in c%ses of burns the p%tient
lose lots of fluids continuously .
– The go%l of fluid resuscit%tion is to m%ke % b%l%nce , no over resuscit%tion
( edem% comp%rtment syndrome) %nd no under resuscit%tion
(shock) . So , c%lcul%ting the needed %mount of fluids infusion %nd urine
o
output is cruci%l .
– Just if the p%tient is hypotensive , give bolus of fluid infusion .
– P%rkl%nd formul% in ONLY used for ELECTRICAL INJURY resuscit%tion for
%ll %ges . = 4 ml LR * TBSA % * body weight (kg)
– In electric%l shock tr%um% , the clenched h%nd is ch%r%cteristic , so
%pply the prim%ry survey , %nd f%sciotomy m%ybe needed .
– Frostbites tr%um% !requires w%rm fluids resuscit%tion , covering the
tr%um%tic side with w%rm bl%nket , then rew%rming the injured limb with %
running w%rm w%ter 40^C , %nd consider good %n%lgesi% %s the process is
p%inful . Be c%rful %bout reperfusion injury . So , c%rdi%c monitoring is

weight
 –
d
import%nt .
– The new %pplic%ble formul% for burns (fl%me or sc%ld) resuscit%tion for
%dults is : = 2 ml of LR * TBSA % * body weight (kg)
= tot%l ml/24hrs . Then one h%lf is given over first 8 hrs , %nd the second
h%lf is given over beyond.
– For children : 3ml LR * TBSA % * body weight (kg)
– TBSA is c%lcul%ted depending on rule of nines .
– T%rgeted %dult urine output is 0.5ml/kg/hr.
– T%rgeted pedi%trics urine output is 1ml/kg/hr.

He%t rel%ted tr%um% :

– ABCDE
– In hypothermi% , body temper%ture less th%n 35^C , w%rm the p%tient %nd
remove him/her from the cold environment , use w%rm IV fluids , %nd w%rm
bl%nkets . Also put in your mind coldness might le%d to low RR %nd HR ,
then CPR m%ybe needed to some p%tient depending on the severity of
hypothermi% .
– In he%t exh%ustion (temp<39^C) or he%t stroke (temp>=40^C) , cool the
p%tient by pl%cing ice p%cks ! over the groins , neck %nd %xill%e . Also be
c%reful %bout seizures , he%rt %rrhythmi%s %nd electrolytes %bnorm%lities .

Ocul%r tr%um% :
– ABCDE
– In chemic%l injures , irrig%te the p%tientʼs eye with %t le%st 1 L of norm%l
s%line .
– In retroorbit%l hemorrh%ge , c%nthitomy m%ybe required but with well
tr%ined doctor .
– Ask the p%tient to minimize eye movement .
– Ophth%lmologist consult%tion is m%nd%tory .

Pedi%tric tr%um% :
– ABCDE
– Intub%tion is the best to m%int%in %irw%ys .
– Excellent outcome in gener%l .
– Child %buse c%n be detected with multiple body bruises or old fr%ctures
seen in X-r%y , so tre%t , report wh%t you find then c%ll child protection
workers .

Geri%tric tr%um% :
– ABCDE
– As pedi%tric tr%um% , %buse or ignor%nce c%n be detected , so tre%t ,
report %nd c%ll soci%l workers .
– Neck of Femur fr%cture is common due to f%lls .
– Tr%um%tic br%in injury is common .
Pregn%ncy tr%um% :
– ABCDE
– In this c%se , you %re de%ling with two p%tients , but remember the
motherʼs life is superior to the fetusʼs life .
– Assess %nd st%bilize the mother first . Then %ssess the fetus , %nd consider
e%rly obstetric%l consult%tion or tr%nsfer .
– Do r%diologic%l studies including X-r%ys if urgently indic%ted .
– Moving the mother to left side m%ybe indic%ted to decompress IVC for
st%bilizing motherʼs circul%tion .
– If thereʼs %bdomin%l tr%um% ne%r to the fetus , %nd the mother is Rh (-) ,
give IV Rh immunoglobulin to the mother .
– P%rtner violence c%n be detected , so tre%t , document %nd c%ll soci%l
workers .

C%tu%lity m%ss
??

Rescue the ones who %re more likely to live .

Multiple c%su%lties ??
Rescue the most sick p%tient .

Consent :
– in life s%ving procedures or oper%tions , donʼt w%it to get the consent .