THE ATLS PROTOCOL

DR. OHENEBA OWUSU-DANSO

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Advanced Trauma
Life Support
Developed by the
American College of Surgeons
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Introduction
• Trauma is the leading cause of death in the first four
decades of life in developed countries.
• There are more than 5 million trauma-related deaths
each year worldwide.
• Motor vehicle crashes cause over 1 million deaths per
year.
• Injury accounts for 12% of the world’s burden of
disease.
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Introduction
• Burns are the fourth most common type of trauma
worldwide, following traffic accidents, falls and
interpersonal violence
• Approximately 90 percent of burns occur in low to middle
income countries and regions which generally lack the
necessary infrastructure to reduce the incidence and severity
• The WHO estimates that an annual 265 000 deaths are
caused by burns most of which occur in low- and middle-
income countries and non-fatal burn injuries are a leading
cause of morbidity.
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Goals of the Protocol

• Rapid and accurate assessment
• Resuscitate and stabilize by priority
• Determine needs and capabilities
• Arrange for transfer to definitive care
• Ensure optimum care
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Objectives of the Protocol

• Demonstrate concepts and principles of primary
and secondary assessments.
• Establish management priorities.
• Initiate primary and secondary management.
• Demonstrate the skills necessary to assess and
manage critically injured patients.
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The Concept / Protocol
• ABCDE approach to evaluation and treatment
• Treat the greatest threat to life first
• Definitive diagnosis not immediately important
• Time is of great essence
• Do not cause further harm
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What Conditions are Life Threatening?

- Airway blockage (Obstruction)

- Breathing / Respiratory difficulty or Inadequacy

- Circulatory Failure
- ( Cerebral damage/ Failure)
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Some Causes of Airway Obstruction
 Blood clots

 Mucous discharge

 Detached or broken tooth

 Dislodged denture

 Inflammatory reaction of airway Epithelium

 Tumours: Malignant and benign lesions including

abscess, polyps etc

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Some Causes of Airway Obstruction
- Traumatic destruction and displacement of tissue
including cervical spine causing stenosis / occlusion
of the airway etc.
- Fall back of the tongue
- External (Extrinsic) factors; Sand, Stones, Weeds,
Pieces of metal, glass and wood etc from accident
sites
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Some Causes of Breathing / Respiratory Difficulty or
Inadequacy
- Due to airway obstruction
- Cervical spine injury
- Damage to respiratory nerves and/or muscles; muscular
dystrophy, spinal cord injuries and stroke.
- Cerebral damage
- Damage to soft tissues and ribs around the lungs;
Pneumothorax, Haemothorax, Pleural effusion,
- Chest wall collapse; Flail chest
- Pain
- Tumour
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Some Causes of Breathing / Respiratory Difficulty or
Inadequacy
- Thrombo-embolic lesions
- Lung diseases such as Pneumonia, Chronic obstructive
pulmonary disease (COPD), Acute respiratory distress
syndrome(ARDS), Cystic fibrosis
- Acute lung injuries such as inhaling harmful fumes or smoke
can injure your lungs
- Drug or alcohol overdose; These affects the area of the
brain that controls breathing and consequently breathing
becomes slow and shallow
- Abdominal diseases
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Some Causes of Circulatory Failure

 Haemorrhage – Concealed , Revealed

 Dehydration – Burns, Diarrhoea, Vomiting

 Cardiac Failure

 Septicaemia

 Anaphylaxis

 Spinal Cord Injury

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The Concept / Protocol

Airway with cervical-spine protection

Breathing and ventilation
Circulation with hemorrhage control
Disability: Neurological status
Exposure / Environmental control
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Initial Assessment & Management
 Primary survey and resuscitation of vital functions
are done simultaneously using a team approach.
 It should be a quick and simple assessment in about
10 seconds
 Materials for precautionary measures; Cap, Gown,
Gloves, Mask, Shoe covers and Protective eyewear
/ face shield
 The primary survey should be repeated frequently
to identify any deterioration in the patient's status
that indicates the need for additional intervention.
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A. Airway
 Establish patent airway and protect c-spine

 Check possible pitfalls such as Occult airway

injury, Progressive loss of airway, Equipment

failure and Inability to intubate.
 Prevention of hypoxemia requires a protected,

unobstructed airway and adequate ventilation,

which take priority over management of all other
conditions.
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A. Airway

How to assure airway is adequate

 Patient is alert and oriented.

 Patient is talking normally.

 There is no evidence of injury to the head or neck.

 You have assessed and reassessed for deterioration.

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A. Signs and Symptoms of Airway
Compromise
 High index of suspicion
 Change in voice / sore throat
 Noisy breathing (snoring and stridor)
 Dyspnea and agitation
 Tachypnea
 Abnormal breathing pattern
 Low oxygen saturation (late sign)
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A. Airway Management
 Supplemental oxygen; Mouth-to-Mouth
respiration, Pressurised Oxygen
 Basic techniques; Chin Lift Maneuver,
Jaw Thrust Maneuver
 Basic adjuncts; Oropharyngeal Airway,
Nasopharyngeal Airway
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Difficult airway adjuncts (for



Unexpected difficult airway, Predicted difficult

airway);
Cricothyroidotomy
Definitive airway


Cuffed tube in the trachea

Maintain C-spine stabilization

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B. Breathing and Ventilation

Assess and ensure adequate oxygenation and ventilation on the

following indicators;

● Respiratory rate
● Chest movement – depth
● Air entry
● Oxygen saturation

Check Pitfalls

- Airway versus ventilation problem?

- Iatrogenic pneumothorax or tension pneumothorax?
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B. Breathing / Ventilation
 Thoracic injury is common in the poly-trauma patient and

can pose life-threatening problems if not promptly

identified during the primary survey.
 Immediate life-threatening conditions in chest injuries

 Laryngeotracheal injury / Airway obstruction

 Tension pneumothorax
 Open pneumothorax
 Flail chest and pulmonary contusion
 Massive hemothorax
 Cardiac tamponade
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B. How to identify Thoraxic injury resulting
in breathing insufficiency
 Tachypnea

 Respiratory distress

 Hypoxia

 Tracheal deviation

 Abnormal breath sounds

 Percussion abnormalities

 Chest wall deformity

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B. What are the pathophysiologic

consequences of these chest injuries?

• Hypoxia
• Hypoventilation Manage in the
• Acidosis primary survey
• Respiratory as they are
• Metabolic identified
• Inadequate
tissue perfusion
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B. Specific Interventions
1. Laryngotracheal Injury
- Intubate cautiously
- Tracheostomy
2. Tension Pneumothorax
- Immediate decompression via
a. Neddle b. Chest tube ( Under-Water seal system)
3. Open Pneumothorax
- Chest tube (Under-Water seal system)
- Definitive surgery
4. Simple Haemothorax
- Tube thoracostomy
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B. Specific Interventions
5. Massive Haemothorax
- Chest decompression - Restore Circulatory
Volume
- Autotransfusion - Surgery
6. Flail Chest and Pulmonary Contusion
- Intubate - Re-expand the Lung
- Give Oxygen - Analgesia
7. Cardiac Tamponade
- Urgent Surgery
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C. Circulation
(including hemorrhage control)

Assess for organ perfusion

● Level of consciousness
● Skin color and temperature
● Pulse rate and character
● Blood Pressure
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C. Shock
 Shock is the state of circulatory insufficiency resulting

in inadequate organ perfusion and tissue oxygenation.

 Generalised state of Hypoperfusion

 Inadequate oxygen delivery

 Catecholamines and other responses

 Anaerobic metabolism
 Cellular dysfunction
 Cell death
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Signs of Shock
Change in the level of Consciousness
 Cold Skin and extremities

 Tachycardia

 Tachypnoea – with shallow respiration

 Hypotension

 Decreased urine output

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C. Management of Circulatory Failure

● Control hemorrhage
● Restore volume
● Reassess patient

Pitfalls

- Elderly - Athletes
- Children - Medications
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C. Therapeutic measures for

the management of Shock
Hemostatic Direct
resuscitation pressure/
tourniquet

Angio-embolization Reduce pelvic

volume

Splint fractures Operation

Hemostatic Agents
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C. Additional therapeutic measures for Shock Management
- Ensure adequate circulating volume by further
controlling haemorrhage and replacing lost
fluid by IV infusion.
- Relieve cardiac tamponade if any by long needle
aspiration.
- Apply external cardiac massage in case of
cardiac arrest.
- Catheterize the bladder to monitor the urine for
renal function.
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C. Indicators for improved organ perfusion
 Skin: warm, capillary refill
 Renal: increased urinary output
 Vital signs: Pulse, Blood Pressure,
 Respiratory rate
 CNS: Improved level of consciousness
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D. Disability
● Baseline neurologic evaluation
● Glasgow Coma Scale score
● Pupillary response

Caution
Observe for neurologic deterioration
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D. Disability
- Assess function of the Central Nervous System
CNS) on the Glasgow Coma Score (GCS). This
neurological examination indicates the level of
consciousness.

(In the secondary survey disability is assessed in all other

systems for loss of function; cardiovascular, respiratory,
alimentary, genito-urinary, locomotor, Peripheral Nervous
System assessment for other neurological deficits)
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E. Exposure & Environment

Completely undress the patient

Pitfalls – Missed Injuries

Caution – Prevent Hypothermia

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E. Exposure / Environment
Ensure that the environment for examining the patient is
safe; has no threat to cause further injury and/or discomfort
- The area should be well lit and has good ventilation
- Environment must have optimal temperature conditions
- Expose the patient fully, including removal of all clothing
to allow a rapid ‘head to toe’ assessment of external injury
and some internal injury e.g. concealed haemorrhage.
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SUMMARY - Resuscitation Measures

 Protect and secure airway

 Ventilate and oxygenate

 Haemostasis

 Crystalloid / blood infusion

 Protect from hypothermia

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The Secondary Survey – History

Following the primary survey and resuscitative
interventions a rapid history must be obtained from the
patient, if possible, or from ambulance personnel and other
witnesses of the event/accident. The history should
include:
 Time of the accident

 Nature and speed of impact

 Consciousness level of patient – Comprehensive tracking

of events before, during and after the accident / incident

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Secondary Survey - History
 Estimate period of unconsciousness (if any)

 An estimation of blood loss at the scene of accident

 Details of drugs, fluids and other treatments already

administered from accident scene and ambulance

staff
 The patient’s state of health including past medical

history, drugs and allergy history

 Details of prior food or alcohol.
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Secondary Survey
Re-check the following by a systematic and detailed examination;
 Airway, Breathing, Circulation and neurological Disability

(including ability to move all limbs), ensure full and safe

Exposure/Exposure
 State of consciousness (GCS)

 Signs of distress – difficulty in breathing

 Appearance of tongue and conjunctiva for evidence of cyanosis

and pallor
 Vital signs – pulse rate, blood pressure, respiratory distress

 Presence of gross or complicated injury

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MEDICATIONS

- Broad spectrum antibiotics - for cases of

open wounds and chest injuries.
- Anti-Tetanus Serum (If immunization
against tetanus is inadequate)
- Analgesic – use effective drug with minimal
central effect to relieve pain
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CLEANSING & SUTURING
- All open wounds should be cleaned followed by suturing and/
or
gauze-packing with firm bandaging.
- If open wound arrived contaminated and / or is being handled
at least 6-8 hours or longer after the injury, sterile packing is the
option.
Then NO or VERY MINIMAL SUTURING (Adaptation
Suturing) should be considered
- Haemostatic sutures must be done (Exclusively) at all times
when indicated!
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 STABILIZATION
Immobilize all areas with fracture or severely injured parts,
notably the spine and extremities by strapping on firm but
comfortable bed/ and splints (precast, POP) etc
 REFER AND TRANSPORT

- Be mindful that a Referral decision must be timely !!!

- Patient should be transported by ambulance or other convenient
and safe transport accompanied by a competent health staff to the
appropriate center.
* Comprehensive Referral note must accompany patient
This should include the timely record of the Glasgow Coma Score
(GCS), vital signs, therapies etc
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Transfer to Definitive care
If definitive care cannot be provided at a local hospital,
the patient requires transfer to a hospital that has the
resources and capabilities to care for him or her.
Transfer Objectives
1. Identify injured patients who require transfer to
a higher level of care.
2. Discuss optimal preparation for safe patient
transfer.
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Transfer Principles
• Know institutional capabilities
• Be prepared and anticipate patient needs.
• Do not cause further harm.
• Identify patients whose needs exceed local resources
• Perform only essential procedures.
• Establish direct communication between referring and receiving
doctors.
• Transport to closest, appropriate facility.
• Use most appropriate mode of transport
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Transfer Decisions – Who is to be
transported?
● Patients with multiple injuries
● Patients whose needs exceed institutional
capabilities
● Patients with comorbidities
● Extremes of age
● Pre-existing disease
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Transfer Decisions – Where should the patient
be sent to?
● Transfer to an institution capable of providing equipment
and resources
● Transfer to an appropriate, qualified physician who can:
● Make the diagnosis
● Treat the patient’s injuries
● Provide commitment and resources
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Transfer Decisions – When should the patient be
transported?
● Transfer after life-threatening problems are
managed.
● Transfer after disabling injuries are stabilized.
● Transfer after arrangements are made.
● Transfer before performing unnecessary tests and
procedures.
Avoid delay!
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Transfer Decisions – How should the patient be
transported?

This is determine by;

● Care required en route
● Patient destination
● Available resources
● Existing transfer agreements
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The Impact
• Documented improvements in care of injured
patients after implementation of the protocol in
the care of trauma patients
• Organized trauma care reduces injury
mortality
• Retention of organizational and procedural
skills.
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THANK
YOU!