Advanced Trauma Life

Support (ATLS)
dr Eko Setiawan, SpOT
 INTRODUCTION

According to the most current information from the World

Health Organization (WHO) and the Centers for Disease
Control (CDC)
• > 9 people die every minute due to injuries or violence
• The burden of injury is even more significant, 18% of the world’s
total disease
• Motor vehicle crashes alone cause more than 1 million deaths
annually and an estimated 20 million to 50 million significant
injuries; they are the leading cause of death due to injury
worldwide
 Trimodal Distribution
First described in 1982, the trimodal distribution of deaths
implies that death due to injury occurs in one of three
periods, or peaks
• The first peak occurs within seconds to minutes of injury
• Deaths generally result from apnea due to severe brain or high
spinal cord injury or rupture of the heart, aorta, or other large
blood vessels
• Very few of these patients can be saved because of the severity
of their injuries.
• Only prevention can significantly reduce this peak of trauma-
related deaths.
• The second peak occurs within minutes to several hours
following injury.
• Deaths that occur during this period are usually due to subdural
and epidural hematomas, hemopneumothorax, ruptured
spleen, lacerations of the liver, pelvic fractures, and/or
multiple other
• Injuries associated with significant blood loss.

• The golden hour of care after injury is characterized by

the need for rapid assessment and resuscitation, which
are the fundamental principles of Advanced Trauma Life
Support.
• The third peak, which occurs several days to weeks after
the initial injury
• The etiology  sepsis and multiple organ system
dysfunctions.
• Care provided during each of the preceding periods affects
outcomes during this stage.
• The first and every subsequent person to care for the injured
patient has a direct effect on long-term outcome.
 INITIAL ASSESSMENT
• Preparation
• Triage
• Primary survey (ABCDEs) with immediate resuscitation of
patients with life-threatening injuries
• Adjuncts to the primary survey and resuscitation
• Consideration of the need for patient transfer
• Secondary survey (head-to-toe evaluation and patient
history)
• Adjuncts to the secondary survey Continued
postresuscitation monitoring and reevaluation
• Definitive care
The primary and secondary surveys are repeated
frequently to identify any change in the patient’s
status that indicates the need for additional
intervention
 Primary Survey with
Simultaneous Resuscitation

• Airway maintenance with restriction of cervical spine

motion
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability(assessment of neurologic status)
• Exposure/Environmental control
 Airway Maintenance with
RESTRICTION OF CERVICAL SPINE MOTION
• Rapid assessment for signs of airway obstruction
includes inspecting for foreign bodies; identifying facial,
mandibular, and/ortracheal/laryngeal fractures and other
injuries that can result in airway obstruction
• Suctioning to clear accumulated blood or secretions that
may lead to or be causing airway obstruction.
• Begin measures to establish a patent airway while
restricting cervical spine motion.
• Initially, the jaw-thrust or chin-lift maneuver often
suffices as an initial intervention. If the patient is
unconscious and has no gag reflex, the placement of an
oropharyngeal airway can be helpful temporarily
• Patients with severe head injuries who have an altered
level of consciousness or a Glasgow Coma Scale (GCS)
score of 8 or lower usually require the placement of a
definitive airway  cuffed, secured tube in the trachea
• Establish a definitive airway if there is any doubt about
the patient’s ability to maintain airway integrity.
 DEFINITIVE AIRWAYS
• There are three types of definitive airways: orotracheal tube,
nasotracheal tube, and surgical airway (cricothyroidotomy and
tracheostomy).
• The criteria for establishing a definitive airway are based on clinical
findings and include:
• A —Inability to maintain a patent airway by other means, with impending
or potential airway compromise (e.g., following inhalation injury, facial
fractures, or retropharyngeal hematoma)
• B —Inability to maintain adequate oxygenation by facemask oxygen
supplementation, or the presence of apnea
• C —Obtundation or combativeness resulting from cerebral hypoperfusion
• D —Obtundation indicating the presence of a head injury and requiring
assisted ventilation (Glasgow Coma Scale [GCS] score of 8 or less), sustained
seizure activity, and the need to protect the lower airway from aspiration of
blood or vomitus
• Assume a cervical spine injury in patients with blunt
multisystem trauma, especially those with an altered level
of consciousness or a blunt injury above the clavicle
• Patients with maxillofacial or head trauma should be
presumed to have an unstable cervical spine injury (e.g.,
fracture and/or ligament injury), and the neck should be
immobilized until all aspects of the cervical spine have been
adequately studied and an injury has been excluded.
 Several objective signs of
inadequate ventilation
• Look for symmetrical rise and fall of the chest and adequate
chest wall excursion. Asymmetry suggests splinting of the rib cage
or a flail chest. Labored breathing may indicate an imminent
threat to the patient’s ventilation
• Listen for movement of air on both sides of the chest. Decreased
or absent breath sounds over one or both hemithoraces should
alert the examiner to the presence of thoracic injury. Beware of a
rapid respiratory rate—tachypnea can indicate respiratory
distress.
• Use a pulse oximeter. This device provides information regarding
the patient’s oxygen saturation and peripheral perfusion, but does
not measure the adequacy of ventilation
 BREATHING AND VENTILATION
• The patient’s neck and chest should be exposed to adequately
assess jugular venous distention, position of the trachea, and chest
wall excursion. Auscultation should be performed to ensure gas
flow in the lungs.
• Visual inspection and palpation can detect injuries to the chest
wall that may compromise ventilation. Percussion of the thorax
can also identify abnormalities, but during a noisy resuscitation
this may be difficult or produce unreliable results.
• Injuries that severely impair ventilation in the short term include
tension pneumothorax, flail chest with pulmonary contusion,
massive hemothorax, and open pneumothorax.  CONCERN on
PRIMARY SURVEY
• Simple pneumothorax or hemothorax, fractured ribs, and
pulmonary contusion can compromise ventilation to a lesser
degree and are usually identified during the secondary survey
Tension Pneumothorax

• Develops when a “one-way valve” air leak occurs from

the lung or through the chest wall
• Air is forced into the pleural space with
no means of
escape, eventually collapsing the affected lung 
Decreasing venous return and compressing the opposite
lung.
• Shock (often classified as obstructive shock) results from
marked decrease in venous return, causing a reduction
in cardiac output..
• Tension pneumothorax is a clinical diagnosis reflecting air
under pressure in the affected pleural space. Do not delay
treatment to obtain radiologic confirmation
• Tension pneumothorax is characterized by some or all of the
following signs and symptoms:
• Chest pain
• Air hunger
• Tachypnea
• Respiratory distress
• Tachycardi
• Hypotension
• Tracheal deviation away from the side of the injury
• Unilateral absence of breath sounds
• Elevated hemithorax without respiratory movement
• Neck vein distention
• Cyanosis (late manifestation)
• Perform a breathing assessment, as described above. A
hyperresonant note on percussion, deviated
trachea, distended neck veins, and absent
breath sounds are signs of tension pneumothorax
• Arterial
saturation should be assessed using a pulse
oximeter and will be decreased when tension
pneumothorax is present
• Tension pneumothorax requires immediate
decompression and may be managed initially by
rapidly inserting a large over-the-needle catheter into
the pleural space
• Successful needle decompression converts tension
pneumothorax to a simple pneumothorax. However,
there is a possibility of subsequent pneumothorax as a
result of the maneuver, so continual reassessment of the
patient is necessary. Tube thoracostomy is mandatory
after needle or finger decompression of the chest
Open Pneumothorax

• Large injuries to the chest wall that remain open can result in
an open pneumothorax, also known as a sucking chest
wound
• Because air tends to follow the path of least resistance, when
the opening in the chest wall is approximately two-thirds the
diameter of the trachea or greater, air passes preferentially
through the chest wall defect with each inspiration. Effective
ventilation is thereby impaired, leading to hypoxia and
hypercarbia
• Open pneumothorax is commonly found and treated at
the scene by prehospital personnel. The clinical signs and
symptoms are pain, difficulty breathing, tachypnea,
decreased breath sounds on the affected side, and
noisy movement of air through the chest wall injury
• For initial management of an open pneumothorax,
promptly close the defect with a sterile dressing large
enough to overlap the wound’s edges

• Tape it securely on only three sides to provide a

flutter-valve effect
Massive
Hemothorax

• The accumulation of >1500 ml of blood in one side of the

chest with a massive hemothorax can significantly
compromise respiratory efforts by compressing the lung
and preventing adequate oxygenation and ventilation
• Massive acute accumulation of blood produces
hypotension and shock and will be discussed further in
the section below.
• It is most commonly caused by a penetrating wound that
disrupts the systemic or hilar vessels, although massive
hemothorax can also result from blunt trauma.
• Inspection
• Skin for mottling, cyanosis, and pallor.
• Neck veins should be assessed for distention, although they may
not be distended in patients with concomitant hypovolemia.
Listen for the regularity and quality of the heartbeat.

• Palpation
• Assess a central pulse for quality, rate, and regularity
• In patients with hypovolemia, the distal pulses may be absent
because of volume depletion.
• Palpate the skin to assess its temperature and determine
whether it is dry or sweaty.
• Massive hemothorax is initially managed by
simultaneously restoring blood volume and
decompressing the chest cavity
• Establish large caliber intravenous lines, infuse
crystalloid, and begin transfusion of uncrossmatched or
type-specific blood as soon as possible. When appropriate,
blood from the chest tube can be collected in a device
suitable for autotransfusion
• A single chest tube (28-32 French) is inserted, usually at the
fifth intercostal space, just anterior to the midaxillary
line, and rapid restoration of volume continues as
decompression of the chest cavity is completed
 URGENT THORACOTOMY in
MASSIVE HEMATOTHORAX

• The immediate return of 1500 mL or more of blood

generally indicates.
• Patients who have an initial output of less than 1500 mL
of fluid, but continue to bleed, may also require
thoracotomy. This decision is based on the rate of
continuing blood loss (200 mL/hr for 2 to 4 hours), as
well as the patient’s physiologic status and whether the
chest is completely evacuated of blood
• The persistent need for blood transfusion
 Cardiac
Tamponade

• Cardiac tamponade is compression of the heart by an

accumulation of fluid in the pericardial sac.
• This results in decreased cardiac output due to
decreased inflow to the heart
• Cardiac tamponade most commonly results from
penetrating injuries, although blunt injury also can cause
the pericardium to fill withblood from the heart, great
vessels, or epicardial vessels
• Muffled heart tones are difficult to assess in the noisy
resuscitation room, and distended neck veins may be
absent due to hypovolemia. Kussmaul’s sign (i.e., a rise
in venous pressure with inspiration when breathing
spontaneously) is a true paradoxical venous pressure
abnormality that is associated with tamponade
• The presence of hyperresonance on percussion
indicates tension pneumothorax, whereas the presence
of bilateral breath sounds indicates cardiac tamponade
• Focused assessment with sonography for trauma (FAST)
is a rapid and accurate method of imaging the heart and
pericardium that can effectively identify cardiac
tamponade (90–95% accurate)
• When pericardial fluid or tamponade is diagnosed,
emergency thoracotomy or sternotomy should be
performed by a qualified surgeon as soon as possible.
• Administration of intravenous fluid will raise the patient’s
venous pressure and improve cardiac output transiently
while preparations are made for surgery.
• If surgical intervention is not
possible,
pericardiocentesis can be therapeutic, but it does
not constitute definitive treatment for cardiac
tamponade
CIRCULATION
“SHOCK”
 Basic Cardiac Physiology

• Cardiac output is defined as the volume of blood pumped

by the heart per minute
• Stroke volume
• is classically determined by preload, myocardial
• contractility, and afterload
BP = CO x Peripheral resitance
• Preload, the volume of venous blood return to the left
and right sides of the heart, is determined by venous
capacitance, volume status, and the difference between
mean venous systemic pressure and right atrial pressure
• Myocardial contractility is the pump that drives the
system.
• Afterload, also known as peripheral vascular resistance,
is systemic. Simply stated, afterload is resistance to the
forward flow of blood.
 SHOCK

• Shock is a life-threatening condition of circulatory failure.

The effects of shock are initially reversible, but rapidly
become irreversible, resulting in multiorgan failure (MOF)
and death
• Shock is defined as a state of cellular and tissue hypoxia
due to reduced oxygen delivery and/or increased oxygen
consumption or inadequate oxygen utilization
Four types of shock are recognized:
• Distributive  Septic shock, Neurogenic shock, anaphylactic
shock
• Cardiogenic  Pump Failure (Cardiomyopathies,
Arrhythmias)
• Hypovolemic  Hemorrhagic and non hemorrhagic
• Obstructive  pulmonary embolism, severe pulmonary
hypertension
• Hemorrhage is the most common cause of shock after
injury, and virtually all patients with multiple injuries have
some degree of hypovolemia
• The primary treatent of hemorrhagic shock focus is to
promptly identify and stop hemorrhage. Sources of
potential blood loss—chest, abdomen, pelvis,
retroperitoneum, extremities, and external bleeding—
must be quickly assessed by physical examination and
appropriate adjunctive studies.
 SHOCK on ATLS Protocols

• Non Hemorrhagic
The category of non-hemorrhagic shock includes
cardiogenic shock, cardiac tamponade, tension
pneumothorax, neurogenic shock, and septic shock. Even
without blood loss, most non-hemorrhagic shock states
transiently improve with volume resuscitation

• Hemorrhagic
The physiologic effects of hemorrhage are divided into four
classes, based on clinical signs, which are useful for
estimating the percentage of acute blood loss.
• Class I hemorrhage is exemplified by the condition of an
individual who has donated 1 unit of blood
• Class II hemorrhage is uncomplicated hemorrhage for
which crystalloid fluid resuscitation is required
• Class III hemorrhage is a complicated hemorrhagic state in
which at least crystalloid infusion is required and perhaps
also blood replacement.
• Class IV hemorrhage is considered a preterminal event;
unless aggressive measures are taken, the patient will die
within minutes. Blood transfusion is required.
 Initial management
Fluid Changes Secondary to Soft-Tissue Injury
Major soft-tissue injuries and fractures compromise the hemodynamic
status of injured patients in two ways
• First, blood is lost into the site of injury, particularly in major fractures.
For example, a fractured tibia or humerus can result in the loss of up to
750 mL of blood. Twice that amount, 1500 mL, is commonly associated
with femur fractures, and several liters of blood can accumulate in a
retroperitoneal hematoma associated with a pelvic fracture
• Second, edema that occurs in injured soft tissues constitutes another
source of fluid loss  related to the magnitude of the soft-tissue injury
 activation of a systemic inflammatory response and production and
release of multiple cytokines  result of shifts in fluid primarily from
the plasma into the extravascular, or extracellular space as a result of
alterations in
• endothelial permeability
• Airway and Breathing
Establishing a patent airway with adequate ventilation and
oxygenation is the first priority. Provide supplementary
oxygen to maintain oxygen saturation at greater than 95%.
• Circulation: Hemorrhage Control
Bleeding from external wounds in the extremities usually
can be controlled by direct pressure to the bleeding site,
although massive blood loss from an extremity may
require a tourniquet.
A sheet or pelvic binder may be used to control bleeding
from pelvic fractures. Surgical or angioembolization may
be required to control internal
• hemorrhage.
• Disability: Neurological Examination
A brief neurological examination will determine the
patient’s level of consciousness, which is useful in assessing
cerebral perfusion, Alterations in CNS function in patients
who have hypovolemic shock do not necessarily imply
direct intracranial injury and may reflect inadequate
perfusion
• Exposure: Complete Examination
When exposing a patient, it is essential to prevent
hypothermia, a condition that can exacerbate blood loss by
contributing to coagulopathy and worsening acidosis.
To Prevent hypothermia, always use fluid warmers and
external passive and active warming techniques
• Gastric Dilation: Decompression
Gastric dilation often occurs in trauma patients, especially
in children. This condition can cause unexplained
hypotension or cardiac dysrhythmia, usually bradycardia
from excessive vagal stimulation
In unconscious patients, gastric distention increases the
risk of aspiration of gastric contents, a potentially fatal
complication
Consider decompressing the stomach by inserting a nasal
or oral tube and attaching it to suction
• Urinary Catheterization
Bladder catheterization allows clinicians to assess the urine for
hematuria, which can identify the genitourinary system as a source of
blood loss
Monitoring urine output also allows for continuous evaluation of renal
perfusion
Blood at the urethral meatus or perineal hematoma/bruising may indicate
urethral injury and contraindicates the insertion of a transurethral
catheter before radiographic confirmation of an intact urethra
Vascular Access

• Is best accomplished by inserting two largecaliber (minimum

of 18-gauge in an adult) peripheral intravenous catheters
• The most desirable sites for peripheral, percutaneous
intravenous lines in adults are the forearms and antecubital
veins
• If peripheral access cannot be obtained, consider placement of
an intraosseous needle for temporary access. If circumstances
prevent the use of peripheral veins, clinicians may initiate
large-caliber, central venous (i.e., femoral, jugular, or
subclavian vein) access
Initial Fluid Therapy
• Administer an initial, warmed fluid bolus of isotonic fluid.
The usual dose is 1 liter for adults and 20 mL/kg for
pediatric patients weighing less than 40 kilograms
• The goal of resuscitation is to restore organ perfusion
and tissue oxygenation, which is accomplished with
administering crystalloid solution and blood products to
replace lost intravascular volume.
• If the patient’s blood pressure increases rapidly before the
hemorrhage has been definitively controlled, more
bleeding can occur. For this reason, administering
excessive crystalloid solution can be harmful.
 Controlled Resuscitation
Fluid resuscitation and avoidance of hypotension are important
principles in the initial management of patients with blunt trauma,
particularly those with traumatic brain injury. In penetrating trauma
with hemorrhage, delaying aggressive fluid resuscitation until
definitive control of hemorrhage is achieved may prevent additional
bleeding; a careful, balanced approach with frequent reevaluation is
required. Balancing the goal of organ perfusion and tissue
oxygenation with the avoidance of rebleeding by accepting a lower-
than-normal blood pressure has been termed “controlled
resuscitation,” “balanced resuscitation,” “hypotensive resuscitation,”
and “permissive hypotension.” Such a resuscitation strategy may be a
bridge to, but is not a substitute for, definitive surgical control of
bleeding.
 Controlled Resuscitation

Early resuscitation with blood and blood products must be

considered in patients with evidence of class III and IV
hemorrhage. Early administration of blood products at a
low ratio of packed red blood cells to plasma and platelets
can prevent the development of coagulopathy and
thrombocytopenia.
Response to Initial Fluid Resuscitation
 BLOOD REPLACEMENT
• The main purpose of blood transfusion is to restore the
oxygen-carrying capacity of the intravascular volume
• If crossmatched blood is unavailable, type O pRBCs are
indicated for patients with exsanguinating hemorrhage
• Hypothermia must be prevented and reversed if a patient is
hypothermic on arrival to the hospital. The use of blood
warmers in the ED is critical, even if cumbersome
• The most efficient way to prevent hypothermia in any
patient receiving massive resuscitation of crystalloid and
blood is to heat the fluid to 39°C (102.2°F) before infusing
it. This can be accomplished by storing crystalloids in a
warmer or infusing them through intravenous fluid warmers
 MASSIVE TRANSFUSION

• Most often defined as > 10 units of pRBCs within the first

24 hours of admission or more than 4 units in 1 hour