ATLS

Advanced Trauma Life

Support
Dr.Alex, MD.
Objectives
• Introduction
• Why ATLS
• Primary survey
• Secondary survey
Introduction
• Trauma management system - Is an integrated collaboration of health
care providers, agencies, and institutions dedicated to the control of
the entire spectrum of injury from effective prevention to efficient
societal reintegration of injury survivors.

• Core is coordinated and comprehensive care of the acutely injured

• Enables efficient use of available resources of health care facilities,

including disaster preparedness and response.
• The daily activity of trauma system is prevention of death
• To this end ensures expeditious access to trauma center and
appropriate triage of victims to proper care

• In exclusive trauma systems – patients are transferred to dedicated

trauma centers

• Inclusive trauma system – health facilities are evaluated, capabilities

are defined and integrated in the trauma system
Trauma system development
• In 1949 – American college of surgeons committee on trauma (ACSCOT)
was created

• In 1961 – dedicated trauma unit was opened at University of Maryland

under leadership of Dr. Cowley

• In 1966 – national academy of sciences and national research council

published Accidental Death and Disability: The Neglected Disease of
Modern Society
• In 1973, Dr. Cowley’s initiative grew to Maryland institute of
Emergency medicine
• In 1973 Emergency medical Service Systems Act become public law
which encouraged area-wide emergency medical service
• Prehospital provider curricula were standardized
• In 1976, ACS published “optimal resources for care of the seriously
injured”
• Is the 1st to establish criteria for categorizing hospitals as trauma
center
• In 1980, ACSCOT developed ATLS course
• The motivation was the experience of orthopedic surgeon after a
plane crash with his family

• Today, ATLS is accepted as a standard for the “first hour” of trauma

care by many in any kind of facility.
• There is trimodal distribution of death following injury
• 1st peak occurs seconds to minutes after injury
• Apnea from TBI or high spinal cord injury
• Rupture of heart, aorta or other large vessel

• 2nd peak minutes to several hours

• SDH and EDH
• Hemopneumothorax
 • Ruptured spleen, liver laceration, pelvic fracture or other
associated with significant blood loss

• 3rd peak occurs days to weeks

• Often sepsis or multisystem organ dysfunction

• The golden hour of care is characterized by rapid assessment and

resuscitation – fundamental principle of ATLS
Hospital management of trauma patient
• Time is crucial, so systematic approach should be applied

• Initial assessment include following components

• Preparation
• Triage
• Primary survey with immediate resuscitation for life
threatening injuries
• Adjuncts to the primary survey
• Consideration of the need for patient transfer
• Secondary survey
• Adjuncts to secondary survey
• Continued post-resuscitation monitoring and reevaluation
• Definitive care
Preparation
• Two phase – field and hospital
• Prehospital coordinated with clinicians in receiving hospital
• Prehospital providers – control airway, bleeding, shock management,
immobilize patient, triage and transport to proper facility
• Prehospital patient assessment calls for Awareness, Recognition and
Management (ARM)

• Prehospital care should aim shortening time to transfer

Hospital phase
• Preparation starts at organization level
• The American system classifies trauma centers from level 1 to level 4
• Level 1 gives the most comprehensive trauma care and level 4 the
least
• At hospital level preparation start before patient arrives
Room and equipment
• There is no official standard for amount of space needed (how big the
room should be)
• The room and equipment should be designed to enhance trauma
team performance
• You should have standard set of equipment to be used.
• Proper PPE
• Cardiac and vital sign monitor, manual BP cuff, airway equipment set,
etc.
Trauma team
• No hard recommendation in the composition of team.
• Initial assessment – identify and treat life threatening injuries and
subsequently non life threatening injuries
• Team efficiency can be divided into vertical vs horizontal resuscitation
• Horizontal is preferred – each team member carries his/her task
simultaneously
• Vertical resuscitation – each task is performed sequentially
• Team leader should be the most experienced in the room
• The leader should be at the foot of bed or at area which gives good
view
• The leader should keep the team on track
• Next steps in care are decided by the leader
• The prehospital providers should have proper hand off patient
Prehospital hand off
• MIST
• Mechanism of injury
• Injuries suspected (injury pattern)
• Signs (vital signs) and symptoms
• Treatment given
• The handover should take place before or as the patient is transferred
to hospital stretched
Primary survey
• Encompasses the ABCDE’s – identify life threatening conditions and
correct or intervene as soon as they are diagnosed

• The circulation can come before airway if there is external life

threatening bleeding

• General impression can be made quickly by simple questions

• “What is your name?” and “Can you tell me what happened?”
• Proper response indicate the patient is able to control airway, breath
and has clear mentation.
• Physical exam has limitations
• Negative predictive value is low but positive findings are significant
and should be acted on
• Primary survey should be supplemented with adjuncts
• Awareness, Recognition and Management (ARM) system helps to
immediately focus on likely problems
• Awareness – commonest cause of airway obstruction is TBI (coma)
• Recognition – look, listen and feel
• Management – e.g establish airway by simple maneuvers

• At each stage ABC is completed, reevaluate for improvement or

deterioration
Airway with C-spine immobilization #1
• Look – facial trauma, mandibular fracture, secretions, foreign bodies,
injuries to teeth or tongue, signs of difficulty breathing
• Listen – snorting or stridor
• Feel – crepitus on neck, laceration on the neck, hematoma and in case
necessary landmarks for cricothyroidotomy
• Look for sings of tracheal or laryngeal injury

• If patient can speak fluently in his/her normal voice, then airway is

surely patent
Airway with C-spine immobilization #2
• Commonest cause of airway compromize is TBI
• GCS ≤ 8 is indication for definitive airway placement
• Any doubt on airway patency - definitive airway control
• Initially open airway by simple maneuvers, chin lift and jaw thrust
• If unconscious and no gag reflex – oropharyngeal airway

• Do not use head tilt till C-spine is cleared to be stable

Airway with C-spine immobilization #3
• Use in-line C-spine stabilization when collar is removed for airway
management
Airway with C-spine immobilization #4
• Protect the entire spinal cord until injury ruled out
• Use long rigid spinal board or flat surface such as stretcher
• Before intubating a patient perform quick but thorough neurologic
exam
• Intubation is RSI and be prepared for potential difficult airway
Breathing
• Patent airway does not mean patient is breathing adequately
• Expose patient neck and chest
• Rapid auscultation of each hemithorax – ensure presence or absence
of gas flow
• Presence of gas flow does not rule out pathology
• Absence of gas flow indicates hemo- or pneumothorax requiring
urgent treatment
• Check symmetry of chest excursion, bruising, open wound,
tachypnea, bony crepitus, tracheal position, oxygen saturation

• Injuries that impair ventilation – tension pneumothorax, massive

hemothorax, open pneumothorax, tracheal or bronchial injuries

• Tension pneumothorax is clinical diagnosis

• If suspected – needle decompression in the 2nd intercostal space
midclavicular or the 5th intercostal space anterior to midaxillary
• Chest wall thickness affects the likelihood of success
• If this fails finger thoracotomy should be done
• These should be followed by tube thoracotomy
• Open pneumothorax (sucking wound) – use any occlusive dressing
large enough and tape it on 3 sides
Circulation with bleeding control #1
• Hemorrhage is the second to TBI as the commonest cause of death in
trauma
• Consider blood loss as cause of hypotension/shock until it is ruled out

• Perform initial assessment by checking the central pulses

• If carotid and femoral pulses are felt and no exsanguinating injury, the
circulation can be momentarily assumed to be intact
Circulation with bleeding control #2
Palpable Minimal threshold Systolic BP
pulse
Carotid 60 – 70mmHg
Femoral 70 – 80mmHg
Radial 90 – 100
Pedal >100mmHg
• Any injured patient who is cool and tachycardic should be assumed to
be in shock until proven otherwise
• Narrow pulse pressure → significant blood loss
• Take BP manually, since automated BP measurements are erroneous
in shock
• Nursing staff should insert large bore iv catheter (16G or larger
preferably)
• Take sample for basic lab tests
• If iv access is not available, consider intraosseous
• In patients with injury below diaphragm, have at least one iv line in
the tributaries of SVC
• Control external bleeding preferably by direct pressure
• Use torniquet for massive bleeding from extremities
• Torniquet should be released periodically (e.g every 45 min)

• Blind clamping of bleeding vessel should not be performed

• Clamping under direct vision of bleeding vessel can be accepted if
necessary
• Bleeding from scalp can be stopped by running heavy suture
• Bleeding at other sites can be stopped by packing, whip-stitching or
wound exploration
• Apply pelvic binder for unstable pelvic fracture
• The most important part of hemorrhagic shock management is
control of bleeding
• Tranexamic acid reduces bleeding after traumatic injury and
demonstrated to decrease mortality when administered early

• Administration after 3 hours of injury is less effective and potentially

harmful

• Dose – 1g over 10min, then 1g over 8 hours

• REBOA – resuscitative balloon occlusion of the aorta

• May be indicated for life threatening hemorrhage below the

diaphragm with unresponsive shock

• What degree of hypotension makes a patient candidate for REBOA

remains unknown
• Sources of blood loss that can result in shock
• External
• Thoracic cavity
• Abdominal cavity
• Retroperitoneal space
• Pelvic fracture
• Long bone (femoral shaft fracture)
• Shock should be assumed hypovolemic and iv crystalloid initiated
• Fluid should be warmed storing in a warm environment (37 to 40°C)
or use fluid warmer
• Do not administer fluid liberally – increases mortality
• Bolus of 1 liter crystalloid in an adult and 20ml/kg for pedi <40kg, if
unresponsive then blood transfusion should be considered
• Management of trauma shock is damage control – centered on
control of bleeding
• Hemorrhagic shock is classified into 4 classes based on physical exam
• Significant drop in BP occurs when at least 30% blood volume is lost
• Younger patients can compensate for large volume loss then
decompensate rapidly
• The elderly on other hand has limited reserve and thus have lower
threshold for resuscitation

• “Permissive hypotension” – minimize crystalloid and administer blood

products to maintain MAP of 55 to 65mmHg until hemorrhage is
controlled
• Transfusion of crossmatched blood, takes time
• Odds of death may increase by 5% for every minute spent waiting for
blood product

• Give O, Rh –ve blood for women of childbearing age and O Rh +ve for
males can be given
• Or give unmatched group specific blood
• Warm blood by infusing through iv fluid warmers to 39 °C to prevent
hypothermia
• Trauma lethal triads – hypothermia, coagulopathy and acidosis
• 1 in 4 trauma patient has clinical laboratory coagulopathy at ED
• Massive transfusion protocol is developed to combat trauma induce
coagulopathy

• Traditional definition of massive transfusion – transfusion of 10 units

of PRBC in 24 hours

• Other new definition – 3 units of PRBC in any one hour period within
1st 24 hours of admission
• Profound shock – immediate blood replacement alongside FFP and
platelet

Major hemorrhage pack

• Assessment of blood consumption (ABC) score
 Penetrating mechanism (1)
 +ve FAST (1)
 SBP ≤ 90mmHg (1)
 Heart rate of ≥ 120/min (1)
• A score of ≥ 2 predicts the need for MTP with sensitivity of 75% and
specificity of 86%
• Damage control resuscitation principles
 Permissive hypotension
 Restriction of crystalloid resuscitation
 Earlier initiation of blood transfusion with balanced FFP,
platelet and PRBC
 Goal directed correction of coagulopathy
• As you manage shock, search for source of shock
• Any investigation not directly contributing to finding source of shock
should not be done
Disability
• Rapidly determine level of consciousness, pupil size and reactivity,
lateralizing sign, level of SCI and RBS.

• Consider other causes of altered mentation but always assume

altered mentation as result of TBI until proved otherwise

• The GCS is widely used for mental status assessment

• The motor component is most important

• Motor score of <6 is almost as good as total score in predicting
outcome
• Hypoxia and hypoperfusion affect mental status, so reevaluate patient
• Based on GCS patients can be classified as
 Mild TBI (GCS 13 to 15)
 Moderate TBI (GCS 9 to 12)
 Severe TBI (GCS 3 to 8)
• Pupillary exam is other important exam
• Brain injury is dynamic – primary injury and secondary injury
• Common secondary insults are
 Hypotension
 Hypoxia
 Hyperpyrexia
 Anemia
Interventions
• Prehospital setting – most important are addressing hypoxia and
hypotension
• Prehospital intubation is controversial

• Putting patient on face mask oxygen can be better than BMV or

attempting intubation
• Intubate patients with GCS <9, inability to maintain SpO2 >90, or signs
of herniation
• Perform GCS and pupillary exam before sedation and paralysis
• Ventilate patient with 100% O2 till blood gas measurements are
obtained

• Target SpO2 of >98%

• Set ventilation parameters to maintain PaCO2 of approximately

35mmHg
• Prophylactic hyperventilation for ICP is not recommended
• Single episode of hypotension doubles mortality
• Remember – neurologic exam in hypotensive patients is unreliable

• Maintain SBP ≥ 100mmHg for age 50 to 69 years and ≥110mmHg for

15 to 49mmHg and >70 years

• Use normal saline to maintain euvolemia

• Balanced solutions like RL are relatively hypotonic and may worsen
cerebral edema.
• Don’t use glucose containing solutions
• Tranexamic acid may be given to patients with moderate TBI within 3
hours of injury
• 1g over 10 min followed by 1g infused over 8 hours

• Avoid fever (maintain temp ≤ 37.5◦C)

• Evaluate and start management for increased ICP
 Elevate head of bed to 30 degree
 Optimize venous drainage – neck in neutral position, loosen
tight neck braces
 Intubation and mechanical ventilation
 Analgesia and sedation
 Osmotic therapy
 Maintain MAP of 80 to 100mmHg
• For patients with surgical lesion do not delay neurosurgical treatment
for sake of medical therapy of ICP

• Trying to treat an emergent surgical problem with medical therapy

can be very harmful for the patient

• Osmotic therapy for increased ICP – mannitol 0.25 to 1g/kg q 4 to 8

hour
• Hypertonic saline – 30 to 60ml of 23.4% via central line over 10 to
15min (effect lasts longer than mannitol)
• 3% hypertonic saline may be given peripherally – target serum Na
level of 145 to 155mEq/l
Exposure and environmental control
• Completely undress the patient by cutting of clothes
• After completing the exam cover with warm blankets or use eternal
warmer
• The resuscitation area should be warm
Adjuncts to the primary survey
• Cardiac (ECG) monitor, eFAST, pulse oximeter, CO2 monitor
(capnography), ABG, X-ray (pelvic and chest), urine catheter, NG tube

• Do not delay patient resuscitation or transfer for definitive care for

detailed examination
Secondary survey
• SAMPLE history
 Signs and symptoms
 Allergies
 Medications
 Past medical illness/pregnancy
 Last meal
 Events
• Perform detailed physical exam
Adjuncts to the secondary survey
• Additional x rays as needed, CT of head, chest, abdomen and spine;
contrast urography, angiography; bronchoscopy, esophagoscopy ect.