ATLS review & 28 • 10 • 2020

General principles in
trauma

Reyner Valiant Tumbelaka dr., M.Ked.Klin., Sp.OT

 TODAY WE WILL LEARN
ABOUT

1
2
3
ATLS and trauma
management
principle
What’s new in 10th
edition
Case scenario
ATLS and trauma
management
principle
 Advance Trauma Life
Support

• Simultaneous diagnostic and therapeutic activities

intended to identify and treat life threatening
• This focus on urgent problems is first captured by the
‘Golden hour’
• The GOLDEN HOUR, the first hour after a traumatic
injury, when emergency treatment is most likely to
be successful.
 OUTLINES

● Triage
● Primary Survey (A,B,C,D and E)
● Adjunct to primary survey
● Secondary Survey
● Monitoring and Evaluation,
Secondary adjuncts
● Transfer to Definitive Care
 TRIAGE
The process of categorizing victims or mass casualties based on
their need for treatment and the resources available.

GOALS

1. Prevent avoidable deaths.

2. Ensure proper initial treatment within a minimal time frame.
3. Avoid misusing assets on hopeless cases
 Primary Survey

● Identifies most life-­threatening

‐ injuries

● First, most important thing when you

encounter a trauma patient is to speak to him
● A complete sentence spoken by the patient tell
us:
1. Airway is patent.
2. Breathing is intact.
3. Good cerebral circulation
Primary Survey
• Airway and Protection of Spinal Cord
• Breathing and Ventilation
• Circulation
• Disability
• Exposure and Control of the Environment
AIRWAY MANAGEMENT

Why first in the algorithm?

– Loss of airway can result in death in < 3 minutes.
– Prolonged hypoxia means Inadequate perfusion, End- organ damage.

Airway Assessment
–total or partial
PROTECTION OF SPINAL CORD
• General Principle:
• Protect the entire spinal cord until injury
has been excluded by radiography or
clinical physical exam in patients with
potential spinal cord injury.

• Rigid Cervical Spinal Collar

• Long rigid spinal board or immobilization
on flat surface such as stretcher = T/L
Spine
Clinical Pearls
• Treatment (Immobilization) before
diagnosis.
• Return head to neutral position.
• Diagnosis of spinal cord injury should not
precede resuscitation.
• Motor vehicle crashes and falls are most
commonly associated with spinal cord
injuries.
AIRWAY MANAGEMENT
• Maintenance of Airway Patency
• – Suction of Secretions.
• – Chin Lift/Jaw thrust.
• – Nasopharyngeal Airway/Oropharyngeal Airway.
Airway Support
• – Oxygen.
• – NRBM (100%)
• – Bag Valve Mask.
• Definitive Airway
– Endotracheal Intubation.
• – Surgical Crichothyroidotomy.
• – Tracheostomy.
Breathing and Ventilation
Breathing/Ventilation Assessment:

– Exposure of chest

– General Inspection (LOOK)

Tracheal Deviation
Accessory Muscle Use
Retractions
Absence of spontaneous breathing
Paradoxical chest wall movement
Breathing and Ventilation
– Auscultation to assess for gas exchange (LISTEN)
Equal Bilaterally
Diminished or Absent breath sounds

– Palpation (FEEL)
Deviated Trachea
Broken ribs
Injuries to chest wall
BREATHING AND VENTILATION
• Identify Life Threatening Injuries
–Massive hemothorax
–Rib fractures
–Open pneumothorax
–Pulmonary contusion
–Tension Pneumothorax
BREATHING AND VENTILATION
• Tension Pneumothorax
Air trapping in the pleural space between the lung and chest
wall
Sufficient pressure builds up and pressure to compress the
lungs and shift the mediastinum
Physical exam
– Absent breath sounds
– Air hunger
– Distended neck veins
– Tracheal shift
BREATHING AND VENTILATION

Treatment
– Needle Decompression
2nd Intercostals space, Midclavicular line
Tube Thoracostomy
5th Intercostals space, Anterior axillary line
BREATHING AND VENTILATION
BREATHING AND VENTILATION
TUBE THORACOSTOMY
Insertion site
– 5th intercostal space,
– Anterior axillary line.
CIRCULATION
Shock
• Impaired tissue perfusion Pale skin color
• Prolonged shock state leads to multi- Cool clammy skin
organ system failure and cell death
Delayed cap refill (> 3 seconds)
• Clinical Signs of Shock
Altered LOC
– Altered mental status
Decreased Urine Output (UOP <
– Tachycardia (HR > 100) = Most
common sign 0.5 ml/kg/hr)
– Arterial Hypotension (SBP < 120)
– Inadequate Tissue Perfusion
CIRCULATION
Types of Shock in Trauma Sources of Bleeding
– Hemorrhagic – Chest
Assume hemorrhagic shock in all trauma
patients until proven otherwise
– Abdomen
Results from Internal or External Bleeding – Pelvis
– Obstructive – Bilateral Femur Fractures
Cardiac Tamponade
Tension Pneumothorax
– Neurogenic  Spinal Cord injury
CIRCULATION
General Treatment Principles
• Stop the bleeding
Apply direct pressure
– Close open-book pelvic fractures
Abdominal pelvic binder/bed sheet
– Restore circulating volume
Crystalloid Resuscitation (1L)
Administer Blood Products
– Immobilize fractures
 (almost always seen with a
penetrating wound)
 Beck’s triad:
Hypotension
distended neck veins
Muffled heart
sounds Pulsus
paradoxus
CIRCULATION
DISABILITY
Baseline Neurological Exam
–Pupillary Exam
•Dilated pupil
– suggests transtentorial herniation on ipsilateral side

AVPU Scale
•Alert
• Responds to verbal stimulation
•Responds to pain 
•Unresponsive
– Gross Neurological Exam – Extremity Movement
Equal and symmetric
Normal gross sensation
– Glasgow Coma Scale: 3-15
– Rectal Exam
DISABILITY
• Key Principles
– Prevention of further injury and identification of neurological injury is
the goal.
– Maintenance of adequate cerebral perfusion is key to prevention of
further brain injury.
Adequate oxygenation
Avoid hypotension
EXPOSURE
• Remove all clothing
– Examine for other signs of injury
– Injuries cannot be diagnosed until seen by provider
Logroll the patient to examine patient’s back
– Maintain cervical spinal immobilization
– Palpate along thoracic and lumbar spine
– Minimum of 3 people, often more providers required
Avoid hypothermia
– Apply warm blankets after removing clothes
– Hypothermia = Coagulopathy
Increases risk of hemorrhage
Adjuncts to Primary Survey
• Vital Signs/ECG monitoring
• ABGs
• Pulse oximetry
• Urinary/gastric catheters
• Urinary output
• ECG
• CXR, C-spine, Pelvis,
DPL ,Ultrasound
 Secondary Survey

Secondary Survey is started after

primary survey is completed and
patient has been adequately
resuscitated.
 SECONDARY SURVEY
• AMPLE History
–Allergies
–Medications
–Past Medical History, Pregnancy
–Last Meal
–Events surrounding injury, Environment
  SECONDARY SURVEY
Physical Exam
1. Head
2. Neck
3. Chest
4. Abdomen
5. Pelvis
6. Genitourinary
7. Extremities
8. Neurological
DEFINITIVE CARE
Secondary Survey followed by radiographic evaluation
–further investigation
– Consultation 
Neurosurgery
Orthopedic Surgery
Vascular Surgery

Transfer to Definitive Care

– Operating Room
– ICU
– Higher level facility
Dying from trauma
What’s new in 10 th

edition
 10th Edition
Update

ATLS ®
Advanced Trauma Life Support
Initial
Assessment
Initial Assessment
• 1 litre of fluid, judicious approach
• Focus on massive transfusion
protocols
• Tranexamic acid
• Coagulopathy
• Canadian C Spine Rule
• Trauma team
 INITIAL A S S E S S M E N T

TXA
Peds Adult

1 L of crystalloid Blood Early (1:1:1 ratio)

20 cc/kg < 40 kg 10-20 mL/kg of RBC/FFP/Plt

CERVICAL SPINE T R A U M A

Dangerous Mechanisms
• Fall from > 1 meter/5
Canadian C-Spine Rule (CCR)
stairs
1.Age > 65 years • Axial load of head
• MVC with ejection,
2.Dangerous mechanism
rollover, > 60 mph
3.Paresthesias in extremities • Motorized recreational
4.Rotate neck 45 degrees left and right vehicle collision
• Bicycle collision

Imaging indicated if
any present
Low risk factors (prior to assessing ROM)
Simple rear-end MVC Sitting
position in ED Ambulatory at any
time Delayed onset of neck pain
No midline cervical tenderness

Stiell,
2003
Airway
and
Ventilatio
n
Airway and Ventilation
• RSI changed to Drug
Assisted Intubation
• Video-laryngoscopy
• Trauma team
SHOCK
Shock
• Class of haemorrhage table
amended: Base excess
• Early use of blood and blood
products
• Management of
coagulopathy
• Tranexamic acid
• Trauma team
ATLS classification of hypovolemic shock

*
Early use of blood and blood products

• 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.
Thoracic Trauma
• Life Threatening Injuries
• Flail chest out
• Tracheobronchial injury now in
• Tension pneumothorax
• Needle thoracocentesis
- 5th ICS MAL for adult
- UNCHANGED 2nd ICS for child
• 28-32 Fr chest drain for hemothorax (not 36-40 Fr)
• Algorithm for circulatory arrest approach
• Aortic rupture management with Beta Blocker
• Trauma team
Abdominal
and
Pelvic
Trauma
Abdominal and
Pelvic Trauma
• Palpation of prostate gland no
longer recommended for urethral
injury
• Flow chart for pelvic fracture with
hemorrhage amended
• Trauma team
Pelvic fractures and hemorrhagic shock management
algorithm
Head
Traum
a
Head Trauma
• Detailed guidance on SBP
management
• Classification – ‘mild’
head trauma
• Anticoagulation reversal
guidance
• Seizure prophylaxis
• Trauma team
 Detailed guidance on SBP
management

Maintain SBP at ≥ 100 mmHg for patients

50-69 years or at ≥ 110 mmHg for
patients 15-49 years or older than 70
years; this may decrease mortality and
improve outcomes (III).
 Goals of treatment of brain injury
Clinical Parameters Laboratory Parameters
• Systolic BP ≥ 100 mmHg • Glucose 80–180 mg/dL
• Temperature 36–38°C • Hemoglobin ≥ 7 g/dl
• INR ≤ 1.4
Monitoring Parameters • Na 135–145 meq/dL
• CPP ≥ 60 mm Hg* • PaO2 ≥ 100 mmHg
• ICP 5–15 mm Hg*
• PaCO2 35–45 mmHg
• PbtO2 ≥ 15 mm Hg*
• pH 7.35–7.45
• Pulse oximetry ≥ 95% • Platelets ≥ 75 X103/mm3
*Unlikely to be available in the ED or in low-resource settings
Data from ACS TQIP Best Practices in the Management of Traumatic Brain Injury.
ACS Committee on Trauma, January 2015.
Spine and
Spinal
Cord
Trauma
Spine and
Spinal Cord Trauma
• C-spine protection changed to
‘Restriction of spinal motion’
• New myotome diagram
• Canadian C-Spine Rule (CCR) and
NEXUS Criteria
• Trauma team
Musculo-
Skeleta
l
Trauma
 Musculoskeletal Trauma

• Weight based IV antibiotic regime

• Highlighting risk factor of bilateral
femur fractures
• Trauma team
Transfer to
Definitive Care
 Transfer to Definitive Care

• Specific mention of avoiding CT in

primary hospital
• SBAR template for
communication
• Trauma Team
Avoiding CT in primary hospital

Do not perform diagnostic procedures (e.g.,

DPL or CT) that do not change the plan of
care.
However, procedures that treat or stabilize an
immediately life-threatening condition should
be rapidly performed.
 ABC-SBAR template for transfer of
trauma patients
• Airway, Breathing, and Circulation problems identified
and interventions performed
• Situation: patient name, age, referring facility, referring physician
name, reporting nurse name, indication for transfer, IV access site,
IV fluid and rate, other interventions completed
• Background: event history, AMPLE assessment, blood
products, medications given (date and time), imaging performed,
splinting
• Assessment: vital signs, pertinent physical exam findings,
patient response to treatment
• Recommendation: transport mode, level of transport care,
medication intervention during transport, needed assessments and
interventions
CASES
SCENARIO 1

Male 35 yo, 70 kilograms, earthquake victim. Found under the rubble of

building with his right lower leg stuck for almost 6 hours.
 Primary Survey
• Airway : Clear
• Breathing : No Traumatic sign, RR 24 / minutes, Similar both hemi
thorax
• Circulation : HR 100 / minutes, BP 100 / 60
• Disability : GCS 15, No neurologic abnormality
How do you
manage this
patient?
• Primary survey indicate shock hypovolemic class 2 with estimation
blood loss 15 % - 30% of body weight. Resuscitation should be done
using 2 lineCrystalloid 2000 cc initially and observe patient response.
Urine catheter is essential to monitor fluid intake and patient
response. Patient response could be :
• Good response
• Transient response
• No response
SCENARIO 2
A 18 years old male (70 kgs), fell from truck and hit from behind. He was
referred from a rural area hospital, already given 500cc of Saline and already
done pelvic x-ray.
Primary Survey Assesment:
• Airway : Clear with cervical support
• Breathing : No traumatic sign, RR 24x/min. SaO2 95%
• Circulation : Cold extremity, HR 124x/min. BP 80/50 mmHg. Pelvic unstable
• Disability : GCS 356. Isochoric pupil. No neurologic abnormality
• Exposure : Open wound on perineum, traumatic mark on pelvis
How do you
manage this
patient?
 Response after
resuscitation
The patient have rapid response
after application of pelvic sheet
and fluid resuscitation (given 1-2L
saline)
• BP: 100/60 mmHg
• HR : 98 x/min
• RR : 18 x/min
• Temp : 36.8
• GCS : 456
• Urine output: 60 cc/h
(N = (50-100 cc/h)
PARAMETER VALUE NORMAL PARAMETER VALUE NORMAL
Hb 7.6 g/dL  
WBC 18. x 103   pH 7.29 7.35-7.45
Plt 145 x 103  
HCT 30%   pCO2 39 mmHg 35-45
Ureum 25 8-20 pO2 88.6 mmHg 80-100
Creatine 1.3 0.7-1.3
Na 128 mmol/L 135-145 HCO3 19 mEq/L 22-26
Lactate 15 mmol/L 0.5-2.0
K 5.5 mmol/L 3.5-5.0
Cl 101 mmol/L 98-106

Ca 9 mmol/L 9-10.5
• A (Airway and C-spine control) : identify and manage the
airway problem and identify C-spine problem and secure C-
spine
• B (Breathing) : identify and manage breathing problem.
Patient give O2 rebreathing mask 10 lpm.
• C (Circulation) : identify and manage circulation problem,
this patient present with the classic signs of inadequate
perfusion, including marked tachycardia and tachypnea, cold
extremity, significant changes in mental status, and a
measurable fall in systolic blood pressure, in accordance with
the class III haemorrhagic shock.
• Priorities for managing circulation include controlling
obvious
• hemorrhage, obtaining adequate intravenous access, and
assessing tissue perfusion. Put on large bore IV needle and give 1-
2L saline while preparing blood samplefor transfusion. Bleeding
from external wounds in the extremities usually can be controlled
by direct pressure to the bleeding site. A pelvicsheet or pelvic
binder must be used to control bleeding from pelvic fractures.
• Monitoring urine output via catheterization also allows for
continuous evaluation of renal perfusion. Important to remember,
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. In this patient, no bloody discharge on urethral
meatus. For wound at perineum, control bleeding by packing with
gauze
• D (Disability) : Identify problem with brain. Patient
with GCS 356, slight mental change due to
haemorrhagic shock
• E (Exposure): expose all body surface and identify the
potential problem. Open wound at right perineal
region extend to anal canal.

• Adjunct to primary survey:

• X-ray thorax: normal
• FAST ultrasound: normal
• X-ray Pelvic: on screen
@chirurgien.bss
THANK YOU