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ATLS

Primary Survey
OBJECTIVES OF ATLS
Assess the patients condition rapidly and
accurately
Resuscitate and stabilize the patient according to
priority
Determine if the patients needs exceed a facilitys
capacity
Arrange appropriately for the patients inter-
hospital transfer
Assure that optimum care is provided and that the
level of care does not deteriorate at any point
during the evaluation, resuscitation, or transfer
What are the stages of ATLS?
Preparation
Triage
Primary survey (ABCDE)
Resuscitation
Adjuncts to primary survey & resuscitation
Secondary survey (Head to toe Evaluation)
Adjuncts to secondary survey
Continued post-resuscitation monitoring and
reevaluation
Definitive care
How do you triage patients in
Trauma?
Use trauma scoring systems to triage
The Revised Trauma Score is made up of
a three categories: GCS, Systolic blood
pressure, and respiratory rate. The score
range is 0-12. A patient with an RTS
score of 12 is labeled delayed, 11 is
urgent, and 10-3 is immediate. Those
who have an RTS below 3 are declared
dead.
6

5 second Round??
Pt is conscious or not
Airway
Ventilation
Signs of massive external
hemorrhage
Any deformity
Skin color and temp and feel a pulse
What is the Golden Hour in trauma?
"There is a golden hour between life
and death. If you are critically
injured you have less than 60
minutes to survive. You might not
die right then; it may be three days
or two weeks later -- but something
has happened in your body that is
irreparable."
- R Adams Cowley
What are the 5 key components of the primary survey in
major trauma?

Airway maintenance with cervical


spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability (neurological status)
Exposure and environmental control
(completely undress the patient but
avoid hypothermia)
What is tri-modal distribution of
death in trauma?
What are the causes of immediate, early and
delayed deaths in trauma?
Immediate:
Brain laceration /Brainstem laceration /Spinal cord
laceration /Aorta rupture / Heart rupture

Early:
Epi/Subdural hematoma, Hemopneumothorax Pelvic/limb
fractures, Abdominal injuries

Late:
Sepsis / Multiple Organ Failure
Which Injuries should be identified
in the Primary survey?

1. Tension pneumothorax
2. Flail chest with pulmonary contusion
3. Massive hemothorax
4. Open pneumothorax
What does airway maintenance with cervical spine control involve in a patient with trauma?

Establish verbal contact with patient


Ensure patency and consider if airway protection
is required.
Jaw thrust and chin lift. Head tilt inappropriate with
cervical spine control. May use MILS
Use airway adjuncts oropharyngeal airway.
Nasopharyngeal airways are inappropriate in head
and facial trauma due to risk of intracranial
passage.
Suction and Magill forceps
What does assessment and management of
breathing and ventilation involve?
LOOK: Respiratory rate, depth and SpO2
Expose chest and look for external signs of
trauma, asymmetrical chest movements, Tracheal
displacement, JVP, cyanosis, sweating

FEEL: Palpation over entire chest wall may reveal


unsuspected injury e.g. crepitus / surgical
emphysema. Tracheal position, JVP, tenderness
over ribs.

LISTEN for sounds of obstruction, Auscultate for


air entry bilaterally, and added sounds
What are the Clinical Signs of airway
obstruction?

Wheezing
Sonorous sounds
Stridor
Cough
Dysphonia
Accessory muscle use
Drooling of saliva
What do you do if patient is breathing in
gasps or suddenly stops?

Insert an airway- see if he improves


Assist breathing with bag valve mask
Intubate or insert LMA
Mechanically ventilate or support
ventilation with CPAP, BIPAP
Management of breathing?
High flow oxygen 15L/min via non-
rebreather mask

Patients requiring respiratory support are


usually intubated and mechanically
ventilated

Needle thoracotomy or intercostal catheter


insertion may be required urgently
What special precaution will you
take during intubation

Consider all trauma patients as FULL STOMACH

Rapid Sequence Intubation with Sellicks


maneuvre
How will you know that ventilation is
adequate or not?

Level of consciousness improves


Vital signs
Skin color
Lung sounds
Pulse oximetry
ABG
What are the elements that provide the
information about the hemodynamic status of
the injured patients?

Level of consciousness
Skin color
Pulse ( quality, rate, regularity )
Capillary refill
Neck veins
If you can feel the carotids, what is
the likely SBP?

carotid pulse SBP 60 mmHg

femoral pulse SBP 70 mmHg

radial pulse SBP 80 mmHg


What are the causes of hypotension in
trauma?
What are the 6 key areas you
look for bleeding ?
The 6 key areas are:

Chest, abdomen, retroperitoneum,


pelvis, long bones and externally.
How will you manage circulation? What lab
reports would you send first?

Insert 2 large bore (at least 16 gauge)


intravenous cannulae,
Send off trauma bloods emergently, most
importantly cross match blood
Venous BG for rapid determination of lactate
and initial hemoglobin.
Others tests include full blood count, urea and
electrolytes, creatinine, glucose, coagulation
profile and lipase.
IV fluids usually Normal Saline or
Hartmans Solution 1-2 L STAT. Change
to blood if remains hemodynamically
unstable after 2 L of crystalloid, or earlier if
obvious signs of major bleeding..

How do you do Hemorrhage control?


Most external bleeding can be temporarily
controlled with direct pressure, tourniquets
or by tying off vessels.
If cannot control, damage control surgery
may be needed.
A patient with trauma has altered mentation. What
are the possibilities?

Severe blood loss- 30-40 % of blood volume


Was under influence of alcohol
TBI

What are the dangers of giving too much IV fluid?

Hypothermia
Dilution Coagulopathies
Dislodgement of thrombus
What does disability (neurological
evaluation) involve?

AVPU
Assess GCS and document its components (e.g. E4,
V5, M6 = GCS 15)
Assess pupillary size and responsiveness (if you can
open the eyelids due to swelling, consider using
ocular ultrasound)
Assess gross motor and sensory function in all 4
limbs
How do you check for spinal injury?
LOG ROLL
Absence of limb movements. Check for priapism, loss
of anal sphincter tone.
What does exposure and environmental
control involve?
While maintaining thermostasis, completely
expose the patient
If not yet done, consider log-rolling the patient now
Areas where potentially life threating injuries can
be missed are:
Back of head
Back
Buttocks
Perineum
Axillae
Skin folds
Which investigations can be done as
adjuncts to primary survey?

Standard Trauma X-rays: AP chest, AP pelvis


FAST Exam
CT brain is ordered if there is suspicion of
head trauma
X-ray of extremities if fracture is suspected.
ADJUNCTS TO PRIMARY SURVEY AND
RESUSCITATION?

Electrocardiographic Monitoring.
Urinary Catheter
Gastric Catheter
Monitoring
ABG
Pulse oximeter
Blood pressure
X-rays
AP CXR
AP pelvis
C-spine
Diagnostic peritoneal lavage
Abdominal ultrasonography (FAST)
The well practiced
trauma team
should aim to
complete the
primary survey in
less than 10
minutes

Illinois EMSC 30
Hemorrhage classification
Class % blood Heart rate Blood Pulse Resp rate Capillary Urine Other Mortality
loss pressure pressure refill output
I 10 19 Normal
(750 cc)
II 20 29 >100 Slightly Delayed
(1250)

III 30 39 >120 (>30) Very Oliguria Acidosis 25%


(2000) Delayed

IV >40 >140 Anuria 60%


What is the lethal triad in
trauma?
A combination of acidosis,
hypothermia, and coagulopathy
ADJUNCTS TO THE SECONDARY
SURVEY
These specialized tests should not be
performed until the patients hemodynamic
status has been normalized and the patient
has been carefully examined.
Additional x-rays of the spine and
extremities
CT of the head, chest, abdomen, and spine
Contrast urography
Angiography
Bronchoscopy
Esophagoscopy
Others
SECONDARY SURVEY