1

ADVANCED
TRAUMA
LIFE SUPPORT
COVERING….. 2

Introduction
Initial Assessment and Management
ATLS Protocol…..
Impact
Conclusion
INTRODUCTION 3

 Training program for medical providers

 Simplified and standard approach to manage acute trauma cases
 “Treat the greatest threat first”
 Lack of definitive diagnosis or detailed history should not hinder
treatment
INTRODUCTION 4
INTRODUCTION 5

 1978 – first ATLS course

 1980 – American College of Surgeons Committee on
Trauma adopted ATLS
 ATLS currently being followed in around 60 countries
 ATLS usually undergoes revision every 04 years
 10th Edition - 2018
INITIAL ASSESSMENT AND 6

MANAGEMENT

 Trauma patients require quick assessment of injuries and

institution of life-preserving therapy
 Initial Assessment& Management - systematic approach, rapidly
and accurately applied
 Sequence reflects a linear progression of events
 In an actual situation, activities occur in simultaneously
INITIAL ASSESSMENT AND 7

MANAGEMENT

 Includes - Preparation
- Triage
- Primary survey
- Resuscitation
- Adjuncts to primary survey and
resuscitation
- Consider need for patient transfer
INITIAL ASSESSMENT AND 8

MANAGEMENT
 Includes (Continued)
- Secondary survey
- Adjuncts to the secondary survey
- Continued post-resuscitation monitoring and
reevaluation
- Definitive care
PREPARATION 9

 02 different clinical settings :

1. Pre-hospital Phase
2. Hospital Phase
PREPARATION 10

 Pre-hospital Phase
- “ Scoop and scoot”
- Notify the receiving hospital
- Emphasis on
> Airway maintenance
> Control of external bleeding and
shock
> Immobilization of the patient
> Obtaining and reporting info
PREPARATION 11

 Hospital Phase
- Advance planning for the trauma
patient’s arrival
- Pre-designated resuscitation area
with functional equipment
- Protocol to summon additional
assistance
- Established and operational
transfer agreements
- Universal safety precaution practices
TRIAGE 12

 Triage involves sorting of patients based on -

treatment priority
- Salvageability
- Available resources
- Appropriate receiving medical
facility

 Should be continuous and repetitive at each

level or site
 TRIAGE 13

 Casualties categorized into :

1. Multiple casualties
- Number of patients and severity of injuries do not exceed capability
- Treated first > Patients with life-threatening problems
> Multi-system injuries

2. Mass casualties
- Exceed the capability of facility and staff
- Treated first > Patients having the greatest chance of survival
> Requiring the least time and resources
TRIAGE 14
TRIAGE 15
TRIAGE 16

Life-threatening injury requiring immediate intervention

Injuries that may become life- or limb-threatening if care is delayed

beyond several hours

Walking wounded who have suffered only minor injuries

Dead patients
PRIMARY SURVEY 17

 Multidisciplinary team approach

 Sequence for rapid and efficient
assessment
 The abnormality that poses the greatest
threat to life
- identified and addressed first
 However these steps are frequently
accomplished simultaneously
PRIMARY SURVEY 18

 Sequential steps in order of importance :

PRIMARY SURVEY 19

 Airway maintenance and Cervical cord protection :

- Prompt effort to recognize airway compromise and secure a
definitive airway
- Equally important to recognize the potential for progressive airway
loss
- Frequent reevaluation
 PRIMARY SURVEY 20

 Airway maintenance
 Cervical cord protection
 Assume a cervical spine injury
- Blunt multisystem trauma
- Altered level of consciousness
- Blunt injury above the clavicle
 Protect spinal cord with appropriate immobilization devices
 Excessive hyperextension, hyperflexion or rotation … AVOID
PRIMARY SURVEY 21

 Breathing and Ventilation:

- Airway patency alone does not ensure adequate ventilation
- Ventilation requires adequate functioning of the lungs, chest wall
and diaphragm
- Rapid clinical evaluation is paramount
- Look out for
> Open/ Tension pneumothorax
> Massive haemothorax
> Flail chest
PRIMARY SURVEY 22

 Circulation and Hemorrhage control :

- Haemorrhage - predominant cause of preventable deaths
after injury
- Identifying and stopping hemorrhage is crucial
- Clinically > Level of consciousness
> Skin color
> Pulse

- Bleeding > External

> Internal
PRIMARY SURVEY 23

 Disability (Neurological Evaluation) :

- Performed at the end of the primary survey
- Aimed at prevention of secondary brain injury
- Establish > Patient’s level of consciousness
> Pupillary size and reaction
> Lateralizing signs
> Spinal cord injury
PRIMARY SURVEY 24

 Disability (Neurological Evaluation) :

- GCS a quick, simple method
- Decrease in the level of consciousness may indicate

> Decreased cerebral oxygenation/ perfusion

> Direct cerebral injury
- Hypoglycemia, alcohol, narcotics and other drugs can mimic
- Frequent neurologic reevaluation
PRIMARY SURVEY 25

 Exposure and Environment control:

- Patient should be completely undressed to
facilitate thorough examination
- Post assessment blankets to be placed

- The patient’s body temperature is more

important than comfort of the healthcare
providers
PRIMARY SURVEY 26

“10 seconds assessment”

- Identifying yourself
- Asking the patient for his or her name
- Asking what happened

 Appropriate response - No airway compromise

- Breathing not
compromised
- Alert
RESUSCITATION 27

 Resuscitation and management of life-threatening

injuries, as they are identified, are essential to maximize
patient survival

 Follows the ABC sequence and occurs simultaneously with

evaluation
RESUSCITATION – AIRWAY

 Suctioning
 Reduce a posterior dislocation or fracture of the
clavicle by extending the patient’s shoulders or
grasping the clavicle with a penetrating towel
clamp, which may alleviate the obstruction
 Insertion of oropharyngeal or nasopharyngeal
airway
 Video laryngoscope for intubation
RESUSCITATION – AIRWAY

 In severe maxillofacial
injuries
 Emergency airway –
Needle
cricothyroidotomy
 Definitiveairway -
Tracheostomy
RESUSCITATION 30
 31
RESUSCITATION - BREATHING
AND VENTILATION
- Supplemental oxygen
- Mask-reservoir device or intubation
- Chest decompression if pneumothorax
BREATHING – TENSION
PNEUMOTHORAX
Management
 Needle thoracostomy
 5th IC space slightly anterior
to the anterior axillary line
 8 cm needle will reach the
pleural space in 90 %
 Finger thoracostomy
 Tube thoracostomy is
mandatory
RESUSCITATION - CIRCULATION 33

AND HEMORRHAGE CONTROL

 Minimum of two large-caliber intravenous (IV) catheters

 Upper-extremity peripheral IV access is preferred

 Blood should be drawn for
> Typing and cross-matching
> Baseline hematologic studies
> Blood gases and/or lactate levels
RESUSCITATION - CIRCULATION
AND HEMORRHAGE CONTROL
 Massive haemothorax
 Cardiac tamponade
 Traumatic circulatory arrest
 Shock (PR> 100/min, BP < 100 mmHg)
 1 ltr of warm isotonic crystalloids for adults
 Children < 40 kg, 20 ml/kg
 Non responders – PRBC: Plasma: Platelets – 1:1:1
 Use of Tranexamic acid
RESUSCITATION - CIRCULATION 35

AND HEMORRHAGE CONTROL

 Aggressive and continued volume resuscitation is not a
substitute for definitive control of hemorrhage
 If ongoing hemorrhage is suspected then consider
> Fracture/ Pelvic stabilization
> Angioembolization
> Surgery (DCS)
ADJUNCTS TO PRIMARY SURVEY 36

1. Electrocardiographic monitoring
- Dysrhythmias/ ST changes > Blunt Cardiac Injury
>
Hypothermia
- PEA > Cardiac tamponade
> Tension pneumothorax
> Profound hypovolemia
- Bradycardia/ aberrant conduction/ premature beats
> Hypoxia and hypo-perfusion
ADJUNCTS TO PRIMARY SURVEY 37

2. Other monitoring:
- Pulse rate, BP, ventilatory rate, ABG levels, Body temperature
- Adequacy of resuscitative measures
- Parameters should be obtained as soon as it is practical
ADJUNCTS TO PRIMARY SURVEY 38

3. Urinary catheterization :
- Sensitive indicator of volume status and renal perfusion
- Should not be inserted before the rectum and genitalia have
been examined
- Urethral injuries should be suspected
> Blood at urethral meatus
> Perineal ecchymosis
> High-riding or non-palpable prostate
- Aseptic measures
 ADJUNCTS TO PRIMARY SURVEY 39

4. Gastric catheterization :
- Indicated for > Stomach decompression
> Decreases risk of
aspiration
> Detect UGI hemorrhage

- Considerations > Positioning

> Uncooperative patient
> Nasopharyngeal injuries
> Functional suction device
ADJUNCTS TO PRIMARY SURVEY 40

5. Imaging :
- Should be done judiciously
- Should not delay patient resuscitation
- Chest and pelvic films - information that can
guide resuscitative measures
- Specialized trauma centres
> Portable x-ray units
> USG (FAST/ eFAST)
> WBCT *
 CONSIDER NEED FOR 41

PATIENT TRANSFER
 Primary survey and resuscitation phase –
indications to transfer
 Once the decision to transfer is made
> Communication between the referring
and receiving doctors
> Ongoing evaluation and resuscitative
measures
> Immediate transfer process
> Appropriate mode and reroute facilities
SECONDARY SURVEY 42

 The secondary survey begins after

> Primary survey (ABCDEs) is completed
> Resuscitative efforts are underway
> Normalization of vital functions has been demonstrated

 Secondary survey can simultaneously be conducted with Primary survey

> Adequate personnel
> Without interfering with resuscitative measures
SECONDARY SURVEY 43

 Consists of
> Detailed history including “AMPLE”
> Interaction with relatives and prehospital personnel
> Hazardous environmental factors
> Repeated physical head to toe exam
> Neurological exam
> Vital parameters
> Appropriate imaging
> Lab tests
SECONDARY SURVEY 44

 Look out for

- Exam of eyes and visual acuity
- Patients with maxillofacial or head trauma -
presume unstable cervical spine injury
- Blunt injury neck - late clinical signs and symptoms
- Wounds extending through Platysma - not to be
explored, probed or treated by individuals in ED
- Unexplained or isolated paralysis of an upper
extremity - cervical nerve root injury
SECONDARY SURVEY 45

 Look out for

- Blunt trauma abdomen - repeated evaluation
preferably by same observer
- Avoid excessive manipulation of the pelvis
- Musculoskeletal examination is not complete
without examining patient’s back
- High level of suspicion for Compartment
Syndrome
- High index of suspicion in elderly and children
ADJUNCTS TO SECONDARY 46

SURVEY

 Aimed at minimizing missed injuries

 Doneafter careful examination and
hemodynamic stability
 Consists of specialized diagnostic tests
REEVALUTION 47

 Trauma patients must be reevaluated constantly to ensure

- new findings are not overlooked
- discover deterioration in previously noted findings

 Underlyingmedical problems, significant to ultimate prognosis, may

become evident
DEFINITIVE CARE 48

 Transfer should be considered when treatment needs exceed the

capability of the receiving institution

 Inter-hospital triage criteria determined by the level, pace and

intensity of initial treatment
OTHER IMPORTANT POINTS 49

 Disastermanagement plans must be developed, reevaluated and

rehearsed frequently

 Relevance of legal considerations including records, consent for

treatment and forensic evidence

 Teamwork – role of a team leader *

CONCLUSION 50

 ATLSprinciples guide assessment and resuscitation of

trauma patients

 Designated multidisciplinary team

 Judgment is required to determine which procedures are

necessary
CONCLUSION 51

 Re-Triage and Re-evaluate at every level and site

 Earlyidentification of patients requiring transfer to a

higher level of care improves outcomes

 Should be rehearsed frequently

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