Advanced Trauma Life

Support
Objectives
• By the end of this session students should be able to
1. Identify the correct sequence of priorities for assessment of an
injured patient.
2. Apply the principles outlined in the primary and secondary surveys
to the assessment of an injured patient.
3. Explain how a patient’s medical history and the mechanism of injury
contribute to the identification of injuries.
Introduction
• Resuscitation is a dynamic and intense period of medical care guided
by the initial and continuous assessment of the patient.
• It combines diagnostic and therapeutic manoeuvres to rapidly
identify and treat life-threatening disorders in order of clinical priority.
• This systematic approach to the care of the injured is exemplified by
the Advanced Trauma Life Support (ATLS) course.
ATLS in practice
• ATLS was designed in 1978 by Dr. Styner and colleagues and is still
applicable to every trauma patient in every scenario.
• Advocates importance of initial emergency assessment of the patient over
a detailed history and a definitive diagnosis.
• It comprises three protocol-driven phases with the aim of identifying and
addressing injuries in life-threatening order of priority using an ABCDE
approach.
• 3 phases include
• Primary survey
• Secondary survey
• Tertiary survey
Initial Assessment & Management
• Preparation (Prehospital - Hospital)
• Triage
• Primary survey (ABCDE)
• Resuscitation
• Adjuncts to primary survey
• Secondary survey
• Adjuncts to secondary survey
• Post resuscitation monitoring
• Definitive care
ATMIST handover from prehospital team
to trauma team
• While commencing the ATLS
primary survey the prehospital
providers should handover to
the trauma team using the
ATMIST system.
PRIMARY SURVEY &
RESUSCITATION
• The survey focuses on rapid
identification of life-threatening
conditions in a prioritised
sequence, based on the effect of
injuries on patient physiology.
• This should take less than 30
seconds to perform
ABCDE: initial management options of the
common life-threatening conditions

(A)Airway
• High index of suspicion
• Quality of voice, air exchange, added noises, e.g., grunting, snoring and stridor
• Dyspnea and agitation
• Tachypnea
• Low oxygen saturation (late sign)
• There are three goals of airway management in trauma patients
• Ensure adequate oxygenation
• Ensure adequate ventilation
• Protect from aspiration.

• When to intervene in a patient with a patent airway?

• Impending airway compromise (Airway problem)
• Need for ventilation (Breathing problem)
• Inability to protect the airway (Disability problem)
• There are three levels of airway
management
1. Basic
• Airway positioning, e.g., chin lift
and jaw thrust to relieve obstruction
caused by tongue and soft palate
• Oropharyngeal airway
• Oxygen therapy
• Suction to clear blood and
secretions.
2. Advanced
• Bag and valve masks
• Laryngeal masks
• Endotracheal intubation under
direct vision & Cricoid pressure to
limit risk of aspiration.
• Indications for ETI
• Airway obstruction,
• Hypoventilation,
• Persistent hypoxemia (SaO2 ≤ 90%) despite supplemental oxygen,
• Severe cognitive impairment (Glasgow Coma Scale [GCS] score ≤ 8),
• Severe hemorrhagic shock, and Cardiac arrest.
• Impending airway obstruction as follows:
• Moderate-to-severe facial burn;
• Moderate-to-severe oropharyngeal burn,
• Moderate-to-severe airway injury seen on endoscopy.
• Facial or neck injury with the potential for airway obstruction,
• Early ETI is indicated in cervical spinal cord injury with any evidence
of respiratory insufficiency
3. Surgical
• Cricothyroidotomy is the
preferred option in trauma
• needle cricothyroidotomy using
a large gauge cannula is at best a
temporising manoeuvre.
• A definitive airway is a tube in
the trachea with the cuff inflated
to prevent aspiration
• C-spine stabilization
• The cervical spine (c-spine)
is protected initially with in-
line manual stabilisation
(i.e., it is held still by one
member of the team using
both hands) and if it cannot
be cleared clinically it is
immobilised with a collar
(B) Breathing
• Tracheal deviation
• Neck veins
• Chest wall movements
• Palpate the chest wall
• Percuss the chest wall
• Breath sounds
• There are four conditions that require immediate management
1. Tension pneumothorax secondary to an unrelieved build up of air in
the pleural space
• immediate treatment by finger thoracostomy
- this involves a surgical cut down where a chest drain would be sited
- a finger is used to penetrate and decompress the pleural space
- this is followed by tube thoracostomy with an underwater seal drainage
(definitive)
• needle thoracostomy is recommended by ATLS but has significant
disadvantages over finger thoracostomy, including bleeding, air
embolism and inadequate decompression
2. Open pneumothorax secondary
to penetrating chest injury with
collapse of the lung
- immediate treatment with an
occlusive dressing taped on three
sides to allow air out of the chest
but not in
- definitive treatment with a chest
drain.
3. Massive haemothorax defined
by blood in the pleural cavity
- immediate management with a
chest drain
- may require surgical control with
emergency thoracotomy i.e. initial
drainage > 1500mls or 250mls/hr
for 3 subsequent hrs.
4. Flail chest secondary to at least
two/three fractures per rib in at
least two ribs.
- immediate management with
intubation and ventilation is only
required in cases of significant
respiratory distress
- subsequent management includes
analgesia, regional anaesthesia (e.g.,
nerve block or epidural) and
aggressive physiotherapy with
pulmonary hygiene/toilet
(C) Circulation
• Mentation
• Skin colour and temperature
• Capillary refill
• Pulse, blood pressure
• Neck veins
• External bleeding

• acute blood loss may be in one of five places

- ‘on the floor or four more’
- i.e., external bleeding or in the chest, abdomen, pelvic fracture or long bone fracture
• There are two conditions which require immediate management
1. Massive haemorrhage
• One relatively recent modification to the ABC approach is the <C>ABC
approach adopted by the military, where<C> reminds us to gain,
‘temporary control of external catastrophic bleeding’.
• This is a paradigm shift to rapidly deal with avoidable exsanguination
while addressing A or B issues.
• It is achieved through simple manoeuvres such as direct manual
pressure, tourniquets or dressings
• 2 Large-bore intravenous access—preferably two 14G peripheral lines in the
antecubital fossae (resuscitate with crystalloid fluids and blood products
accordingly)
• Blood is drawn for laboratory studies and cross-match at the time of gaining
IV access
• Arterial blood gas provides a rapid window on haemoglobin and
haematocrit, acid–base balance and gas exchange
• Additional tubes such as urinary catheters and nasogastric tubes should be
used when indicated and only after addressing life-threatening issues
• Basic monitoring: electrocardiogram (ECG), pulse oximetry, blood pressure
cuff
• Temporary splinting of long bone fractures reduces pain, minimises
blood loss, and may restore the anatomical position to reduce adjacent
vessel compromise and associated distal ischaemia
• Pelvic binders are useful temporising adjuncts to reduce blood loss
and pain associated with pelvic fractures
2. Cardiac tamponade
• blood in the tight, fibrous pericardial
space results in poor atrial filling,
reduced ventricular filling and
decreased cardiac output: a form of
obstructive shock
• pericardiocentesis is recommended
by some to decompress the
pericardial space by aspirating blood
through a needle
• Thoracotomy with direct cardiac
repair
(D) Disability and neurological evaluations
• Check for:
• Mental status
• Pupillary reflex
• Lateralizing signs, etc.
(E) Exposure/Environmental control
• Remove all clothing to allow full external inspection,
• check temperature, avoid hypothermia
• Cover the patient
• Remember: IV fluids should be warm
• Log roll with spinal precautions to allow inspection and palpation of
the spine
Practical tips
• A quick and simple way to assess the trauma patient in the first 10
seconds:
• Introduce yourself to reassure the patient then ask their name and what
happened
• An appropriate response implies that there is no immediate ABC or D
issue
- airway patency sufficient to permit speech
- breathing sufficient to generate air movement
- circulation sufficient to perfuse brain
- disability—conscious level sufficient to process information.
• Note that that this does not exclude a major or evolving injury
SECONDARY SURVEY
• This involves a full clinical examination and a focused history.
• Head-to-toe examination
- including spine and digital rectal exam
- take care to inspect the ‘hidden zones’ such as axillae, perineum and natal cleft.
• AMPLE history
- Allergies
- Medications currently taking
- Past medical history
- Last ate/drank
- Events related to injury
• Imaging
- determined by physiology, mechanism and anatomy of injury and the clinical
question.
• The secondary survey may be delayed until life-saving procedures are
performed, including surgery or interventional radiology.
TERTIARY SURVEY
• The primary and secondary surveys are repeated within 24 hours to
identify evolving or previously missed injuries. A ‘problem list’ is then
created for each injury with a coherent management plan and the
details of involved specialties.
Summary
References
• ATLS manual 10th Ed, American College of Surgeons
• Principles and Practice of surgery 8th Ed
• J Trauma. 73(5):S333-S340, November 2012