ATLS

Advance Trauma Life Support

Definition
• Advanced Trauma Life Support (ATLS) is
a training program for medical doctors in the
management of acute trauma cases,
developed by the American College of
Surgeons

• Originally designed for emergency situations

where only one doctor and one nurse are
present, ATLS is now widely accepted as the
standard of care for initial assessment and
treatment in trauma centers
Initial assessment and management
1. Preparation & Triage
2. Primary survey
3. Resuscitation
4. Adjuncts to primary survey and
resuscitation
5. Secondary survey
6. Adjuncts to secondary survey
7. Post resuscitation monitoring and
reevaluation
8. Definitive care
 Preparation & Triage
• Pre-hospital phase
• Hospital phase
 Pre-hospital phase
• Which is between the field officer with
the doctor. The main attention are:
– maintenance of airway
– control bleeding and shock
– immobilization of the patient
– sending the patient to the nearest hospital.
– Collect also a description of the incident,
causes and history of the patient.
 Hospital phase
• The preparation of equipment and
medical personel that are needed in the
Hospital
 Triage
• The way the selection of patients based
on treatment needs and available
resources.
• Therapy is based on the needs of ABC
• Used START method (Simple Treatment
and Rapid Treatment)
 START (Simple Treatment and Rapid
Treatment)
• Airway : Try to talk to the patient

• Breath : calculate the repiration rate

• Circulation : monitor blood pressure,

pulse, or do capiler refill test (normal
<2 minutes)
 Primary survey

• A = Airway maintenance with cervical

spine protection
• B = Breathing and ventilation
• C = Circulation with hemorrhage control
• D = Disability : Neurological status
• E = Exposure/Environmental control :
completely,
– undress the patient,but prevent hypothermia
 A = Airway maintenance with cervical
spine protection
The first stage of the primary survey is to assess the airway

LOOK
•Motion of the chest and abdomen
•Sign of respiratory distress
•Mucosal color, skin,awareness

LISTEN
Breath of air movement with

FEEL
Breath of air motion to cheek
 Airway Maintenance
Is the Victim is conscious or not?

Put Collar neck until we are sure that there is Unconscious

no servical fracture
Conscious

Try to talk to the victims

able to talk ?airway is clear (no obsrtruction) Can the victim breath?
(look-listen-feel)

Yes
No

Is there snoring,gargling,crowing?
-Give artificial respiration
-Give O2

NO
YES
Snoring  put Guedel
Gargling  do suction
Airway is clear Crowing Intubated
 Sign of Obstruction
• Snoring: gravity pulls the tongue and
jaw down to the back of the mouth and
limits the air passageway.
• Gargling sounds: liquid inside the
mouth
• Crowing(stridor): spasm / edema of the
vocal cords
Collar Neck / Collar brace
Guedel (Oropharyngeal airway)
Guedel (Oropharyngeal airway)
Intubation
When are we doing Cricothyroidotomy?
• Failed intubation because the airway is
blocked
• Patients can not be given artificial
respiration from above (nose mouth)
Cricothyroidotomy
Complication Cricothyroidotomy
􀂄 Aspiration
􀂄 Creation of false passage
􀂄 Subglotticstenosis/ edema
􀂄 Laryngeal stenosis
􀂄 Hematoma
􀂄 Laceration of esophagus/trachea
􀂄 Vocal cord paralysis
 B = Breathing and ventilation
• The chest must be examined by
– Inspection
• Look : is there trachea deviation? Lesion?
Paradoxal breathing ? JVP (Jugular vein
Pressure)
– Palpation
– Percussion
• Sonor  Normal,if dull  (+)fluid
– Ausculation
• VBS (Vesicular Breath Sound)  are the right
and left same?
The aim is to identify and manage five life
threatening thoracic conditions as
– Tension Pneumothorax,
– Massive Haemothorax,
– Open Pneumothorax,
– Flail chest segment with Pulmonary
Contusion
– Cardiac Tamponade.

Flail chest, penetrating injuries and bruising

can be recognized by inspection
Tension Pneumothorax
• Spontaneous • Traumatic
–Primary –Blunt
–Secondary –Penetrating
• COPD
• Infection
• Neoplasm
Tension Pneumothorax
• One way valve
(fenomena ventil)
• Intrapleura pressure
increase
• The lungs collaps
• The Mediastinum is
displaced to the
Opposite side
,decreasing the The
venous return and
compressing the
opposite Lungs
Tension Pneumothorax
• Respiratory distress
• Distended neck veins
• Unilateral depression in
breath sounds
• Hyperresonance
• Cyanosis (late)

• Management :
– Immediate Decompression
with wide bore cannula in
2nd space MCL
– Put Chestube 5th ICS the
tube connect to bottle that
contains water
Massive Hemothorax
• Sistematic / pulmonary
vessel distruption
• Loss blood Over 1500 ml
• Flat versus distended neck
veins
• Shock with no breath sounds
and/ or percussion dullnes

Management :
- Rapid volume restoration
- Chest decompression and
X-ray
- Autotransfusion
- Operative Intervention
Open Pneumothorax
• Penetrating / blunt trauma
• Ventilation / perfusion defect
• Hyperresonance
• Depression Breath sounds
• Tube thoracostomy

Management :
- 3 side cover – over defect
• adhesive strap [sealed
from three sides, leaving
one side unsealed to allow
air exit during expiration &
prevent its entry during
inspiration]

- Chest tube
- Definitive operation
Open Pneumothorax
Flail chest / Pulmonary contusion
• “Free-floating”
chest segment,
usually from multiple
ribs fractures
• Pain and restricted
movement
• Paradoxical
movement of chest
wall with respiration
Flail chest / Pulmonary contusion
• Reexpand lung
• Oxygen
• Judicioces fluids
• Intubate as indicated
• Analgesia
Cardiac Tamponade
• Injuries caused by
penetrating / blunt injury
• Pericardium filled with blood
• Pericardial tissue structure
with a rigid
→ inhibit the activity and
cardiac filling

• TRIAS BECK
– Venous pressure increase
– Arterial pressure decrease
– Muffled heart sound
Cardiac Tamponade
Management :
- A = Patent airway
/ intubate
- B = Ventilate
oxygenasion
- C = Fast
/pericadiocentesis
operation (if delayed
leave catheter in
place)
C = Circulation with hemorrhage control

• Hemorrhage is the predominant cause

of preventable post-injury deaths.

• Hypovolemic shock is caused by

significant blood loss. Occult blood loss
may be into the chest, abdomen, pelvis
or from the long bones.
The main set are :
• Change the volume
• Stop the bleeding
ASSESSMENT OF CIRCULATION
• Color of the Akral
• Capillary refill
• Pulse
• Blood pressure
• Urine production
CLINICAL SIGNS OF SHOCK

• Rapid breathing, nervous consciousness until

coma
• Pulse pressure <20mmHg
• Skin cold, pale, wet, cyanosis
• Capillary refill time> 2 seconds
• Urine output <0.5 ml / kg / hour
Slightly Respirations
anxious 14-20/min

Urine
Heart rate
30 mL/hr <100/min ↔ BP

crystalloid
Mildly Respirations
anxious 20 –30/min
Heart rate
Urine
>100/min ↔ BP
20-30 mL/hr
↓Pulse
Crystalloid, pressure
? blood
Confused,
anxious Respirations
30-40/min
Urine
Heart rate
5-15 ml/hr
> 120/min   BP
Crystalloid,
 Pulse
blood, operation
pressure
Confused,
Respirations
lethargic
>35/min
Urine Heart rate
negligible >140/min
 BP
Rapid fluids,
 Pulse
blood, operation
pressure
Assessment of Stages of Shock
% Blood < 15% 15 – 30% 30 – 40% >40%
Volume loss
HR <100 >100 >120 >140

SBP N N

Pulse N or
Pressure
Cap Refill < 3 sec > 3 sec >3 sec or absent
absent
Resp 14 - 20 20 - 30 30 - 40 >35
CNS anxious v. anxious confused lethargic
Treatment 1–2L 2L 2 L crystalloid, re-evaluate,
crystalloid, + crystalloid, re- replace blood loss 1:3
maintenance evaluate crystalloid, 1:1 colloid or blood
products. Urine output >0.5
mL/kg/hr
Fluid Resuscitation of Shock
• Crystalloid Solutions
– Normal saline
– Ringers Lactate solution
– Plasmalyte
• Colloid Solutions
– Pentastarch
– Blood products (albumin, RBC, plasma)
Crystalloid Solutions
• Normal Saline
• Lactated Ringers Solution
• Plasmalyte
• Require 3:1 replacement of volume loss
• e.g. estimate 1 L blood loss, require 3 L
of crystalloid to replace volume
Colloid Solutions
• Pentaspan
• Albumin 5%
• Red Blood Cells
• Fresh Frozen Plasma
• Replacement of lost volume in 1:1 ratio
D = Disability : Neurological status
• A more detailed and rapid neurological
evaluation is performed at the end of
the primary survey.

• This establishes the patient's level of

consciousness, pupil size and reaction,
lateralizing signs, and spinal cord injury
level.
• The Glasgow Coma Scale is a quick method
to determine the level of consciousness, and
is predictive of patient outcome
• Hypoglycemia and drugs, including alcohol,
may influence the level of consciousness. If
these are excluded, changes in the level of
consciousness should be considered to be
due to traumatic brain injury until proven
otherwise.
Glasgow Coma Scale
• Eye Opening Response
– • Spontaneous--open with blinking at baseline 4 points
– • To verbal stimuli, command, speech 3 points
– • To pain only (not applied to face) 2 points
– • No response 1 point

• Verbal Response
– • Oriented 5 points
– • Confused conversation, but able to answer questions 4 points
– • Inappropriate words 3 points
– • Incomprehensible speech 2 points
– • No response 1 point

• Motor Response
– • Obeys commands for movement 6 points
– • Purposeful movement to painful stimulus 5 points
– • Withdraws in response to pain 4 points
– • Flexion in response to pain (decorticate posturing) 3 points
– • Extension response in response to pain (decerebrate posturing) 2 points
– • No response 1 point
E = Exposure/Environmental control :
completely

The patient should be completely

undressed, usually by cutting off the
garments. It is imperative to cover the
patient with warm blankets to prevent
hypothermia in the emergency
department. Intravenous fluids should
be warmed and a warm environment
maintained. Patient privacy should be
maintained.
• 1. Cloths : cut all the cloths using sharp
scissors.

• 2. Warmth: cover with blankets

• 3. Intravenous fluids should be warmed

and a warm environment maintained
 Secondary survey

• Aim: The secondary survey is a head-to-toe

& front to back evaluation of the trauma
patient, including a complete history and
physical examination, including the
reassessment of all vital signs. X-rays
indicated by examination are obtained.
• -If at any time during the secondary survey
the patient deteriorates, another primary
survey is carried out as a potential life
threat may be present.
AMPLE history
– Allergies
– Medications
– Past medical history
– Last meal (for fear of aspiration
pneumonia)
– Event of injury (to predict site & extent of
injury
Adittional Examination

• FAST (Focused Abdominal Sonography

for Trauma) or CT, may show
– a. Injuries to liver, spleen, kidneys or
pancreas.
– b. Perisplenic or perihepatic hematoma.
– c. Retroperitoneal hematoma
– d. Free fluid in peritoneal cavity
• DPL (replaced by FAST)
• Diagnostic laparoscopy
 Post resuscitation monitoring and
reevaluation
• Repeat ABCDE
• Repeated resuscitation if necessary
 Definitive care
• Consult a specialist.
• Treatment measures according to the
problem
• Operation
Abdomen Trauma
Blunt trauma is more common.
• I. Injuries of solid organs [Spleen 46%, Liver 33%]
– Present with picture of internal hemorrhage

• II. Injuries of hollow organs

– Present with picture of peritonitis (usually delayed for 48-72
hours)

• Management
– I. All penetrating trauma: immediate exploration (laparotomy)
– II. Blunt trauma:
• a. Hemodynamic stable: urgent investigations
• b. Hemodynamic unstable: immediate exploration
• - Investigations
– I. Plain X-ray: fracture ribs – air under diaphragm
– fluid level in ileus.
– II. FAST:
• a. Detects free fluid (perihepatic, perisplenic, pelvic,
pericardium)
• b. Disadvantages
– 1. Doesn’t detect source of bleeding.
– 2. Amount of fluid must be > 250 ml
– 3. Doesn’t detect non-bleeding injuries.
– 4. Can’t detect retroperitoneal hematoma.
– 5. Limitations in obese. III. CT: Gold standard [DON’T
send unstable patient to CT] IV. DPL
Burn Injury
• Estimation of Burn Size -- calculating per cent Total Body
Surface Area burned (%TBSA)
Rule of Nines
• Adults Infants
 head and neck 9% 18%
 each upper
extremity 9% 9%
 anterior
trunk 18% 18%
 posterior
trunk 18% 18%
 each lower
extremity 18% 14%
 perineum 1% 1%
100% 100%
Assessment of Burn Depth – related to temperature, time
of exposure, and thickness of skin

• 1.First degree burn

– a.caused by sunburn or flash
– b.involves epidermal layer only
– c.usually appears red to pink
– d.is painful to touch
– e.may become slightly edematous
– f.heals in 3-5 days (rarely leaves any scar)
– g.does NOT count in the burn size calculation
• Second degree burn (partial-thickness)
– a. Usually caused by flash, scalds, or brief contact
with hot object
– b. Involves the epidermis and part of the dermis
– c. Has vesicles and bullae
– d. Moist appearance – usually red to pale pink
– e. Tactile and pain sensibility is intact – very
painful
– f. Develops significant edema
– g. Heals in 7-21+ days with variable amounts of
scarring
• 3.Third degree burn (full-thickness)
– a. Usually caused by flame, high intensity flash,
electricity, chemicals, or prolonged contact with
hot liquids or hot objects
– b. Extends through the epidermis and dermis
– c. Usually appears white, brown or black; may
have thrombosed veins
– d. Wound appears dry
– e. Elasticity of the wound is destroyed, so wound
becomes leathery and feels firm to the touch
– f. Marked edema and decreased elasticity may
necessitate escharotomies
– g. Generally painless to touch
 Fluid Management Burn Injury
• Parkland formula

• Initial 24 hours: Ringer's lactated (RL) solution 4 ml/kg/% burn

for adults and 3 ml/kg/% burn for children. RL solution is added
for maintenance for children:
– 4 ml/kg/hour for children weighing 0-10 kg
– 40 ml/hour +2 ml/hour for children weighing 10-20 kg
– 60 ml/hour + 1 ml/kg/hour for children weighing 20 kg or higher
This formula recommends no colloid in the initial 24 hours.
• Next 24 hours: Colloids given as 20-60% of calculated plasma
volume. No crystalloids. Glucose in water is added in amounts
required to maintain a urinary output of 0.5-1 ml/hour in adults
and 1 ml/hour in children.
 Fluid Management
• Maintance for Adult
– M= 40 cc / weight (kg)/24 hour
• Maintance for children
– M= 0-10 kg : 100cc /weight(kg)/ 24 hour
– M= 10-20 kg : 1000+(X * 50 ) /24 hour
– M= Over 20 kg : 1500 + (X *20) / 24 hour
• X = the overmeasure weight
Fluid Management for Dehydration
• Grade of Dehydration
– Mild : 4 % (adult) 6% (children)
– Moderate : 6% 8%
– Severe : 8% 10%

– D = Grade of dehydration x (weight)Kg x 1000

 Fluid Management for 24 Hours
• First 6 hour
– ½ D + ¼ M = (X) cc
• Next 18 hour
– ½ D + ¾ M = (Y) cc
THANK YOU