BASIC TRAUMA LIFE SUPPORT MANUAL

OF THE
INTERNATIONAL MEDICAL UNIVERSITY,
MALAYSIA

Revised on 16.2.2012 by
A/Prof Lum Siew Kheong
FRCSEd, FACS, FAMM, FAMS

INTRODUCTION
The manual highlights the significance of trauma in Malaysia and describes
a systematic manner a trauma patient is managed in accordance with
advanced trauma life support (ATLS) principles. The principles in the initial
assessment and management of the trauma patients highlight the
management priority in the care of poly-trauma patients
Trauma is a common cause of admission and is a major cause of
premature death and disability. It is the leading cause of death of
individuals between the ages of 1 and 44 and is the fourth leading cause
overall in the world. In Malaysia, trauma ranks as the third principal
cause of hospitalization and the fourth principal cause of death in the
Ministry of Health Hospitals after heart disease, septicemia and
cerebrovascular accident. Hence, all medical graduates must have
advanced trauma life support (ATLS) skills to manage poly-trauma
patients presenting to the emergency department before their
graduation.
Course Objectives:
At the completion of the Basic Trauma Life Support Course of IMU
(BTLS IMU) you should be able to:
1. understand the principles and concepts of Primary and Secondary
assessment
2. establish management priorities in a managing a poly trauma
patient.
3. acquire the skills necessary in the initial assessment and
management of trauma patients.

Course Description
The BTLS IMU comprise of e-learning
material, audio-visual
presentations, hands on practical stations and
simulated clinical
scenarios. The programme teaches students a rapid systematic
assessment of a trauma patients condition followed by its management.
Management priorities and acquisition of skills in initial assessment and
management of poly-trauma patients is emphasized throughout the
course.

Hands on Practical Stations and Skills to be Acquired:

1. Recognition of airway obstruction and airway clearance
2. Airway maneuvers
3. Airway adjuncts and their uses
4. Oxygen therapy and delivery devices
5. Bag -valve-mask ventilation
6. Intubations and Ventilation
7. Chest Xray interpretation
8. Hemorrhage Control
9. Obtaining IV access
10. Treatment of shock
11. Assessment of head injury
12. Prevention of spinal injury
13. Cervical Spine stabilization
14. Stabilization of fractures
15. Triage
16. Detailed patient assessment

Advanced Trauma Life Support (ATLS)

ATLS is the standard of care for trauma patients. The premise of ATLS is
to treat the greatest threat to life first. The lack of definitive diagnosis
and detailed history should not delay the treatment of life threatening
injury. Management of the trauma victim should not follow a linear flow
chart with one action following another i.e. take history, do physical
examination, order some tests, make a diagnosis and then treat the
patient. In dealing with the trauma victim, one must treat as information
is gathered.

Timing of Death Resulting from Trauma

40
35
30
25
20
15
10
5
0

min
First phase

hours
days
Second phase Third phase
(GOLDEN HOUR)

Trimodal distribution of death (%)

Mortality due to injury occurs during one of the following time periods:
1. Immediate death
2. Later death due to hemorrhage or direct organ compromise
3. Delayed death due to complications and organ failure.
1. Trauma Deaths First Peak (60-70%)
Early deaths may occur anytime from seconds to minutes after the
injury. Death are due to overwhelming primary injury to major organs
or structures such as brain, heart or great vessels. In most situations
injuries are irrecoverable, although rapid treatment and transfer may
salvage some patients. Primary prevention has a major role in reducing
the incidence of these injuries.

2. Trauma Deaths Second Peak (20-30%)

Death in the second peak occurs within minutes to several hours.
Avoidance of secondary injury due to hypoxia, haemorrhage or any
process that leads to inadequate tissue perfusion will prevent many
deaths during this period. Reversible conditions during this period include
intracranial haematomas, major haemorrhage, pneumothorax etc. This
period is often termed the 'golden hour, as skilled assessment and
treatment should reduce mortality and disability.

3. Trauma Deaths Third Peak (10-20%)

Death in the third peak occurs several days to weeks after injury. Death
occurs as result of sepsis and multiple organ failure. Inadequate
resuscitation during immediate or early post-injury phases, contributes
to the mortality during this period
GENERAL APPROACH TO TRAUMA PATIENT
PREHOSPITAL CARE
Prehospital care is designed to identify, triage, treat, and transport
victims with serious injuries. The major benefits of prehospital care are
realized during the second phase of trauma, when the timely provision
of care can limit or halt the cascade of events that otherwise quickly
leads to death or lifelong disability. This early period is known as the
"golden hour" and is the time before irreversible pathological changes
begin. The golden hour is usually from the time of injury to definitive
management-for example, surgery. Without prehospital care, many
people who might otherwise survive their injuries die at the scene or enroute to the hospital. Most deaths in the first hour after injury are the
result of airway compromise, respiratory failure or uncontrolled
haemorrhage. All three of these conditions can be readily treated with
basic first aid measures
On arrival, the paramedics act to prevent any further risk to victims,
onlookers, and rescuers. As little time as possible is spent with the
victim at the scene. In prehospital management, the "platinum 10
minutes" are most important in all emergencies where the victim is not
trapped.
The primary survey is performed to look for obvious injuries and it
includes immobilization of the cervical spine, securing of an airway,
assurance of adequate ventilation, and control of any severe
hemorrhage. Extrication of the victim is done after the cervical spine is
stabilized. Airway, ventilation, and intravenous lines can be established
while the patient awaits removal. The victim is placed on a long backboard, with towel rolls and tape to protect the cervical spine. Rescuers
place IV lines in the ambulance if time allows. The receiving hospital is
notified of the patients status while en-route.

TRAUMA TRIAGE
Trauma Triage is the prioritizing of patients for treatment or transport
according to their severity of injury. Primary Triage is carried out at
scene of injury and Secondary Triage at the hospital A&E centre. The
objective of primary triage is to prioritize patients with a high likelihood
of early clinical deterioration in the field and safely transport them to a
designated trauma center where appropriate care is immediately
available. It takes into consideration patients vital signs and prehospital clinical course, mechanism of injury, patient age, and comorbid
conditions. Patients with multiple injuries, extremes of age, evidence of
severe neurologic injury, unstable vital signs, and pre-existing
comorbidity will warrant urgent attention
Triage is a dynamic process and patients should be reassessed
frequently. The triage system used in the UK is as follows:
(Red): Immediate priority (T1): require immediate life-saving
intervention
(Yellow): Urgent priority (T2): require significant intervention within
two to four hours
(Green) : Delayed priority (T3): require intervention, but not within
four hours
(Blue) : Expectant priority (T4): treatment at an early stage would
divert resources from potentially beneficial casualties, with no
significant chance of a successful outcome

INITIAL ASSESSMENT AND MANAGEMENT

The Advanced Trauma Life Support (ATLS) guidelines advocate a fourphased approach to evaluating the trauma patient.

This comprises:
Preparation
Primary survey focused on A,B,C,D and E and resuscitation
Secondary survey
Definitive treatment or transfer for definitive care

PREPARATION
Before the arrival of the trauma patient the following preparatory events
need to be attended to:
1. Alert the receiving team members of arrival of patient ( trauma
team, radiology, laboratory)
2. Check equipment Airway/ Breathing/Circulation (airways,
laryngoscope, ambu bag, intubation tubes, chest tube, catheter, iv
drips, solutions, monitoring equipment)
3. Personal protective garments (eye protection,face mask, gloves,
aprons, boots)
PRIMARY SURVEY
Primary survey is first and the most important part in the management
of a trauma victim. It is a structured assessment that aims to identify
and treat immediate and life threatening problems. The primary survey
can take ten seconds to several minutes. Life-threatening problems are
diagnosed and treated immediately.
The primary survey is a sequence of evaluations based on the acronym
ABCDE which is :
A - Airway control with cervical spine protection
B - Breathing adequately
C - Circulation with hemorrhage control
D - Disability or neurologic status
E - Exposure while protecting patient from hypothermia
In a one man approach these are viewed as separate and distinct
components. However, in a team approach, these components are
assessed and treated simultaneously by different members of the team
under the direction of a team leader.

A- AIRWAY CONTROL WITH CERVICAL SPINE PROTECTION

Securing the airway is the single most important priority in the initial
management of a trauma patient. An inadequate airway initiates a
cascade of irreversible events resulting in failure of ventilation and
oxygenation leading to death. In a seemingly confusing situation with

multiple conflicting priorities, airway management airway management

has the supreme priority in a patient with multiple injuries, .
The most common cause of airway obstruction is due to the altered level
of
consciousness which results in the tongue to fall backwards
obstructing the posterior pharynx. Other causes of airway obstruction
include massive swelling, foreign bodies, blood and secretions and loss
of bony support
Assessment of the airway begins by asking simple questions. A response
in a normal voice suggests that the airway is not in immediate jeopardy.
Hoarseness, weak voice, breathlessness, or absent response are signs of
airway compromise. Agitation and combativeness may be due to hypoxia
arising from airway compromise. Patients with an inadequate airway
have been misdiagnosed as being intoxicated or having head injury.
Noisy breathing, cyanosis, and use of accessory muscles of respiration
are all strongly suggestive of airway obstruction.
The airway can be cleared by simple suctioning of blood and secretions.
To maintain airway passage, the tongue must be lifted off the posterior
pharynx. This is achieved by the chin lift maneuver or by inserting
nasopharyngeal or oropharyngeal tubes.
If bleeding is excessive and continuous and where there is no gag reflex
intubation is indicated. Orotracheal intubation is preferred in most
situations. Patients with major facial and laryngeal trauma will require a
surgical airway in the form of cricothyroidotomy or tracheostomy.
Cervical spine control
All trauma patients are assumed to have cervical spine injury and it is
mandatory to immobilze C-spine in a neutral position. This is achieved
with a stiff collar or with towel rolls/sandbags on both sides of the head.

B- BREATHING ADEQUATELY
Once airway patency has been established, it is necessary to ensure
that ventilation is adequate. Adequacy of chest expansion, air entry,
tachypnea, presence of penetrating or open chest wounds and crepitus
from fracture ribs are noted.

Immediate life-threatening chest injuries include:

1. Tension pneumothorax
2. Flail chest with pulmonary contusions
3. Open / sucking pneumothorax
4. Massive haemothorax
5. Cardiac tamponade
Potentially life-threatening chest injuries include:
1. Simple pneumothorax
2. Hemothorax
3. Pulmonary contusion
4. Trachea-bronchial injury
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Blunt oesophageal rupture

1. Tension pneuthorax
Tension pneumothorax is the accumulation of air under pressure in the
pleural space. The condition develops when communication between
alveolus and pleural forms a 1-way valve, allowing air to enter the
pleural space and preventing the air from escaping naturally. As the
pneumothorax enlarges, the lung collapses, the mediastinum is pushed
to the opposite hemithorax and venous return to the heart is reduced.
This results in circulatory instability and collapse Patients with tension
pneumothorax have difficulty breathing. Clinical examination reveal
decreased or absent breath sounds and hyper resonance to percussion
on the affected side. Crepitus from fracture ribs and tracheal shift away
from the affected side may be elicted.
Emergency treatment involves insertion of a large-bore needle or
plastic intravenous cannula into the pleural space in the second
intercostal space along the mid-clavicular line. The pressure is released
and the tension pneumothorax is converted to a simple pneumothorax.
Needle decompression mandates an immediate follow up with a tube
thoracostomy.

2. Flail chest with pulmonary contusions

Flail chest is a serious lie-threatening injury, often accompanied by lung
contusion. It occurs in blunt trauma to the chest when each of 2 or more
adjacent ribs are broken in two places resulting in separation of a

segment of rib cage from the main chest wall. This results in paradoxical
or reverse motion of the flail segment during spontaneous breathing.
Flail chest is diagnosed by careful inspection and palpation of the chest
wall. Patients with large flail segments will almost always require
prompt endotracheal intubation and mechanical ventilation, both to
stabilize the flail segment and to optimize gas exchange. Smaller flail
segments may treated with adequate analgesia, oxygen, intensive chest
physio-therapy and judicious fluid therapy.
3. Open / sucking pneumothorax
When an open wound of the chest wall results in a communication
between the pleural space and the atmosphere, air enters the chest
cavity with each respiratory cycle resulting in progressive collapse of
the ipsilateral lung. The larger the defect in the chest wall, the greater
is the rate at which pleural air accumulates, and the more rapid is the
collapse of the ipsilateral lung
Emergency treatment consists of placing an occlusive dressing over the
chest wall defect taped on three sides to act as a flutter-type valve. A
chest tube should be placed and the chest wall defect is closed.
4. Massive Haemothorax
Haemothorax is a collection of blood in the pleural space. It may be
caused by blunt or penetrating trauma. Most haemothorax are the
result of bleeding from rib fractures, lung parenchymal and minor
venous injuries and are self-limiting. These injuries cause potentially life
threatening haemothorax. Life threatening haemothorax are caused by
major arterial and venous injuries and these injuries may require
surgical repair. Fortunately, they are less common.
Clinical finding of patents with haemothorax consists of decreased chest
expansion, dullness to percussion, reduced breath sounds on
auscultation in the affected hemithorax and mediastinal or tracheal
deviation if there is a massive haemothorax.
In most instances clinical features are subtle in the emergency situation
and diagnosis is usually made by imaging studies. The first step in the
management of traumatic haemothorax is the placement of a chest
tube. The majority of haemothorax will stop bleeding spontaneously and
simple drainage is all that is required.

C-CIRCULATION WITH HAEMORRHAGE CONTROL

The third priority in the management of a trauma patient is to establish
adequate circulation. Shock is defined as inadequate perfusion and tissue
oxygenation. In a trauma patient this often due to hypovolaemia. The 6
major sites of bleeding are in the chest, abdomen, retroperitoneum,
pelvis, long bones and externally. The causes of major blood loss include
injury to the liver, spleen and kidneys, mesenteric tears, retroperitoneal
hemorrhage, fracture pelvis, massive haemothorax, multiple major
fractures of long bones and large scalp and skin wounds. Other causes
of shock and hypo-perfusion from conditions like tension pneumothorax,
cardiac tamponade, myocardial contusion and neurogenic shock must
also be considered in trauma patients.
The patient is examined for signs of hypoperfusion. The character of the
pulse, its rate, the skin colour, blood pressure, capillary refill and level
of consciousness is assessed. Rapid pulse with cool extremities will
signify hypoperfusion from blood loss. Failure to feel the pulse may
signify hypotension in the order of 70 to 80 mm Hg. Haemorrhage may
be classified into the following categories based on blood volume loss.
Classes of Hemorrhage
Class
Blood loss
Treatment

Pulse

BP

Mental

nil

I
Fluids

<15% (<750ml)

<100

II
Fluids

15-30% (750-1.5L)

100-120

anxiety+

Decreased

anxiety++

III
30-40% (1.5L-2.0L)
Fluids + Blood

120-140

IV
>40% (>2.0L)
Fluids + Blood

>140

Decreased

confused

The most important management principle in treating haemorrhagic

shock is to find the source of blood loss and control of the bleeding.

Bleeding from external wounds is treated by direct pressure at wound

site. Two important Xrays are done in polytrauma cases CXR and Xray
pelvis. Intra-abdominal bleeding is assessed by focused abdominal
sonography for trauma (FAST) or diagnostic peritoneal lavage. In
patients in shock, commence resuscitation by inserting two (2) large
bore (>16g) iv cannulae and infuse 1-2 litres of Hartmanns or normal
saline. Take blood for investigations (FBC, blood for grouping and cross
match and relevant biochemistry).
Monitor patient: pulse, BP, pulse oximeter, urine output, CVP
DISABILTY
The initial assessment and resuscitation of a brain-injured patient is
based on the key principle of preventing secondary brain injury
secondary to hypoperfusion and hypoxemia and control of brain oedema.
A rapid neurological examination is done to assess the level of
consciousness, pupil size and reaction and gross motor function. The
Glasgow Coma Scale (GCS) should be used to quantify the level of
consciousness. The 3 components of GCS are eye opening, gross motor
function and verbalization by the patient. Mild head injury is present
when the GCS is between 13 to 15, moderate injury is between 9 to 12
and patients with GCS of 8 and less have severe head injury. They
should be intubated regardless of their airway and breathing status.
Pupillary asymmetry or dilation, impaired or absent light reflexes,
hemiplegia or weakness suggest impending herniation of the cerebrum
through the incisura tentorii due to an expanding intracranial mass or
diffuse cerebral edema
It is important to recognize that altered levels of consciousness may be
caused by factors other than the trauma to the central nervous system.
These include alcohol intoxication, central nervous system stimulants or
depressants, diabetic ketoacidosis, cerebrovascular accident, and
hypovolemic shock.
Intracranial mass lesions with pressure effect account for only around
1020% of comatose patients. However, timely decompression of these
lesions improves outcome significantly. Treatment of these lesions is
greatly facilitated by the availability of computerized tomography (CT).
Disability caused by injuries to extremities can be reduced if promptly
recognized and appropriately managed. All fractures must be reduced
and immobilized to avoid further blood loss and neurovascular injuries.
Injuries to cervical and thoracolumbar spine must by immobilized to limit
secondary neurological damage.

EXPOSURE AND PREVENTION OF HYPOTHERMIA

The final step in the primary survey include complete exposure of the
patient so that no injuries are missed. All clothing are removed and
examination of the entire body surface for bruises, laceration, open
fractures etc is done. The back, thoracic and lumbar spine are also
examined taking care to avoid unnecessary movement. The gluteal
region and perineum is also examined for injuries. The patient is
covered with a warm blanket when examination is complete to prevent
hypothermia.
SECONDARY SURVEY
Secondary survey is performed only after the primary survey has been
completed and all immediate threats to life have been optimised. It
involves a more complete history taking and a systematic head-to-toe
examination designed to identify any injuries that might have been
missed.
The essential elements in the history is described by the mnemonic
AMPLE
A: Allergies to medications
M: Medications taken
P: Past medical/surgical history
L: Last meal - Important to determine risk of aspiration
E: Events leading up to trauma
A through physical examination from head to toe is done. If
unexpected deterioration occurs during the secondary survey, it is
important to repeat the primary survey (airway, breathing and
circulation) before continuing with the secondary survey.
Specialized diagnostic tests may be performed at this time and these
include formal ultrasonography, CT scanning, extremity radiography and
endoscopy.
Constant re-evaluation of changes by physical examination and laboratory
findings must be done.
Intravenous opiates or anxiolytics in small doses may be administered to
minimize pain and anxiety without obscuring subtle injuries or causing
respiratory depression. Tetanus toxoid may be given at this stage.