Advance Trauma

Life Support (ATLS)

ATLS: Initial Assessment and
Management
1. Preparation
2. Triage
3. Primary Survey
4. Resuscitation
5. Adjuncts to Primary Survey and Resuscitation
6. Consider Need for Patient Transfer
7. Secondary Survey
8. Adjuncts to the Secondary Survey
9. Reevaluation
10. Definitive Care
 PREPARATION
Pre-hospital • Prehospital agencies and personnel
• Notify the receiving hospital
• Ensure all associated personnel and resources are
present
• Emphasis
1. Airway maintenance
2. Control of external bleeding and shock
3. Immbolization of the patient
4. Immediate transport
5. Information regarding the injury
Hospital • A resuscitation area
• Properly functioning strategically placed airway
equipment
• IV crystalloid solution
• Protocol to summon additional medical assistance
• Personal protection device for body fluids contact
 TRIAGE

• Sorting of patients based on their needs for treatment and the resources
available to provide that treatment
• Severity, salvageability and available resources
• Multiple casualties: treat life-threatening problems and sustaining multiple-
system injuries
• Mass casualties: treat patients with greatest chance of survival or requiring
the least time, equipment, supplies and personnel.
 ABCDE

AIRWAY MAINTENANCE WITH CERVICAL SPINE PROTECTION

BREATHING: VENTILATION AND OXYGENATION

CIRCULATION WITH HEMORRHAGE CONTROL

DISABILITY: BRIEF NEUROLOGIC EXAMINATION

E XPOSURE/ENVIRONMENTAL CONTROL
 Quick & Simple assessment of Airway within seconds :

RESPONSIVENESS
• What is your name?
• What happened?
• Are you injured anywhere?

If patient is able to answer your questions

• No major airway compromise
• Able to generate air movement to permit speech
• No major decrease in level of consciousness
AIRWAY MAINTENANCE WITH CERVICAL SPINE PROTECTION
STEP1. Assessment(look for airway obstruction)
A. Ascertain patency.
B. Rapidly assess for airway obstruction. If got foreign
body, remove first.

STEP2. Management—Establish a patent airway

A. Perform jaw-thrust maneuver.
B. Clear the airway of foreign bodies.
C. Insert an oropharyngeal airway.
D. Establish a definitive airway.
1) Intubation
2) Tracheostomy

STEP3. Maintain the cervical spine in a neutral position (not hyperextended,

hyperflexed, or rotated) with manual immobilization as necessary when
establishing an airway. Put a cervical spine collar to immobilize the neck
* Inline immobilization technique
 BREATHING: VENTILATION AND OXYGENATION
STEP1. Assessment(look for tension, open pneumothorax, massive haemothorax,
flail chest, cardiac tamponade)
A. Expose the neck and chest, while ensuring immobilization of the head and neck.
B. Determine the rate and depth of respirations.
C. Inspect and palpate the neck and chest for tracheal deviation, unilateral and
bilateral chest movement, use of accessory muscles, and any signs of injury.
D. Percuss the chest for presence of dullness or hyper-resonance.
E. Auscultate the chest bilaterally.
STEP2. Management
A. Administer high-concentration oxygen.
B. Ventilate with a bag-mask device.
C. Alleviate tension pneumothorax.
D. Seal open pneumothorax.
E. Attach a CO2 monitoring device to the endotracheal tube.
F. Attach a pulse oximeter to the patient.
 CIRCULATION WITH HEMORRHAGE CONTROL
STEP1. Assessment
A. Identify potential source of hemorrhage (internal or external).
B. Assess level of consciousness
C. Assess pulse: Quality, rate, regularity, and paradox.
D. Evaluate skin color.
E. Measure blood pressure, if time permits.
STEP2. Management
A. Apply direct pressure to external bleeding site(s).
B. Consider presence of internal hemorrhage and potential need for
operative intervention, and obtain surgical consult.
C. Insert two large-caliber IV catheters.
D. Simultaneously obtain blood for hematologic and chemical analyses;
pregnancy test, when appropriate; type and crossmatch; and ABCs.
E. Initiate IV fluid therapy with warmed crystalloid solution and blood
replacement.
 DISABILITY: BRIEF NEUROLOGIC EXAMINATION
STEP1. Determine the level of consciousness using the GCS.

STEP2. Check pupils for size and reaction.

STEP3. Assess for lateralizing signs and spinal cord injury by doing LOG
ROLL.

Altered consciousness indicates the need for immediate reevaluation of

oxygenation status and perfusion status.

Note that hypoglycemia, alcohol, narcotics and other drugs can also alter
level of consciousness
 E XPOSURE/ENVIRONMENTAL CONTROL

• Completely undress the patient, but prevent hypothermia.

• Patient’s garment usually will be cut to facilitate thorough examination,

however after the assessment, the patient should be covered with warm
blankets or an external warming device to prevent hypothermia in the
trauma receiving area
 ADJUNCTS TO PRIMARY SURVEY

• Step1. Obtain ABG analysis and ventilator rate

• Step2. Monitor the patient’s exhaled CO2 with an appropriate monitoring
device
• Step3. Attach an ECG monitor to the patient
• Step4. Insert urinary and gastric catheters unless contraindicated, and monitor
the patient’s hourly output of urine.
• Step5. Consider the need for and obtain AP chest and AP pelvic Xrays
• Step6. Consider the need for and perform FAST(focus assessment sonography
in trauma) and DPL(diagnostic peritoneal lavage).

REASSESS PATIENT’S ABCDEs

CONSIDER NEED FOR PATIENT TRANSFER
•Airway obstruction or disruption
•Tension pneumothorax
•Open pneumothorax
•Massive haemothorax
•Flail chest
•Cardiac tamponade
•Haemorrhage
 ATOM FCH
AIRWAY OBSTRUCTION OR DISRUPTION

Signs
• External neck deformity or hematoma, crepitus from
laryngeal fracture, surgical emphysema, hoarse voice or
gurgling
• Complete airway obstruction — silent chest, paradoxical
chest movements
• Partial airway obstruction — stridor, respiratory distress
• Cyanosis
 ATOM FCH
AIRWAY OBSTRUCTION OR DISRUPTION

Management
• High flow oxygen 15 L/min via non-rebreather mask
• Use airway maneuvers and adjuncts (jaw-thrust, suction,
oropharyngeal airway)
• Proceed to definitive airway (ETT) if airway disruption
confirmed
• If a disrupted airway is visible through an open neck wound
attempt to secure the distal trachea with forceps (retraction)
and intubate through the wound
 ATOM FCH
AIRWAY OBSTRUCTION OR DISRUPTION
Management
• Surgical airway
(cricothyroidotomy) may
be required as
endotracheal intubation
with direct laryngoscopy
may not be possible due
to distorted anatomy
 ATOM FCH
TENSION PNEUMOTHORAX
 ATOM FCH
TENSION PNEUMOTHORAX
What is Tension Pneumothorax?
• “one-way valve” air leak  Air is forced into the pleural
space  completely collapsing the affected lung
mediastinum is displaced to the opposite side 
decreasing venous return  obstructive shock

• common cause:
• mechanical ventilation with positive-pressure ventilation in
patients with visceral pleural injury.
• simple pneumothorax following penetrating or blunt chest trauma
in which a parenchymal lung injury fails to seal,
• a misguided attempt at subclavian or internal jugular venous
catheter insertion.
 ATOM FCH
TENSION PNEUMOTHORAX
How to diagnose Tension Pneumothorax?
• Is a clinical diagnosis, treatment should not wait for radiologic
confirmation
• Easily confused with cardiac tamponade
• Symptoms & Signs:
• Chest pain, Air hunger
• Respiratory distress, Tachycardia, Hypotension
• Respiratory system examination
• Tracheal deviation to the contralateral side
• Ipsilateral hyperexpansion and decreased chest movement
(Elevated hemithorax wihout respiratory movement) To differentiate
from
• Hyper-resonance ipsilaterally cardiac
• Decreased breath sounds ipsilaterally tamponade

• Neck vein distention

 ATOM FCH
TENSION PNEUMOTHORAX
How to manage Tension Pneumothorax?
• High flow oxygen 15L/min via non-rebreather
• Immediate needle thoracostomy with a large bore (14/15G)
intravenous venula at the 2nd intercostal space along the mid-
clavicular line of the ipsilateral side (‘decompression’).
• This procedure will enable the release of raised intrathoracic pressure
and allow for adequate filling of the right ventricle and hence recovery
of cardiac output.
• Tube thoracostomy (chest drain) will be need to be done soon after
decompression to resolve the created open pneumothorax
 ATOM FCH

OPEN PNEUMOTHORAX
(aka sucking chest wound)
 ATOM FCH
OPEN PNEUMOTHORAX
What is Open Pneumothorax?
• Large chest-wall defect with equilibrium of intrathoracic
and atmospheric pressure
• Normal breathing pattern is affected at the usual negative
intra-thoracic pressure is abolished by open chest wound
• It is thought that once a chest wound is >2/3rds the
diameter of the trachea, air will enter wound preferentially
 ATOM FCH
OPEN PNEUMOTHORAX
How to diagnose Open Pneumothorax?
• Symptoms & Signs:
• Open wound on chest wall
• Respiratory distress, Tachycardia
• Respiratory system examination
• Decreased chest movement ipsilaterally
• Decreased breath sounds ipsilaterally
• Hyper-resonance ipsilaterally
 ATOM FCH
OPEN PNEUMOTHORAX
How to manage Open Pneumothorax?
• High flow oxygen 15L/min via non-rebreather
• Cover with sterile/clean non-porous dressing taped only on 3 sides
leaving one side free to act as flutter valve. Do not tape on all sides as
it may create tension pneumothorax!
• Perform tube thoracostomy (chest drain) 1 to 2 intercostal spaces
below the open wound (in separate intercostal space)
• The open chest wound would likely need exploration and closure by
cardiothoracic team
 ATOM FCH
MASSIVE HAEMOTHORAX
 ATOM FCH
MASSIVE HAEMOTHORAX
What is Massive haemathorax?
• is defined by blood loss > 1,500 mL inside the chest
• or 1/3rd of blood volume
• Blood loss >200 mL/h (3 mL/kg/h) for 2-4 hours
• Commonly caused by a penetrating wounds that disrupts
the systemic or hilar vessels and can also result from a blunt
trauma.
• The source of bleeding can be from the lungs, major
vessels, intercostal vessels or even the heart
 ATOM FCH
MASSIVE HAEMOTHORAX
How to diagnose Massive haemathorax?
• Hemorrhagic shock — pallor, cold peripheries, tachycardia,
weak pulse volume, hypotension
• External evidence of thoracic injury
• Respiratory system examination
• Decreased chest movement ipsilaterally
• Ipsilateral dullness
• Decreased breath sounds ipsilaterally
• Persistent blood loss following intercostal catheter insertion
 ATOM FCH
MASSIVE HAEMOTHORAX
How to manage Massive Haemothorax?
• High flow oxygen 15L/min via non-rebreather
• Principle is rapid restoration of blood volume combined with
concurrent drainage of thorax.
• Set large-caliber IV lines for fluid and blood resuscitation
• Intercostal catheter insertion on affected side (do not drain >1 L of
blood at any one time as it will lead to acute hemodynamic instability).
• Hemostatic resuscitation – activate massive transfusion protocol, use
of autotransfuser is ideal (blood from the chest cavity is collected for
auto-transfusion)
• Beware of sudden cessation of drainage (check for blocked tube
 ATOM FCH
MASSIVE HAEMOTHORAX
• Consider emergency thoracotomy
• Indication of emergency thoracotomy:
• Initial blood drainage >1500 ml
• Ongoing drainage of > 500ml/hr for the first hour, 300 ml/hr for 2
consecutive hours, or 200 mL/hr for 3 consecutive hours
• Persistent blood transfusion requirements
• Large retained pneumothorax especially if associated with
continual bleeding
• Continued haemodynamic instability
• Suspicion of oesophageal, cardiac, great vessel or major bronchial
injury
FLAIL CHEST

• Occurs when a segment of the thoracic cage is separated from the

rest of the chest wall
• defined as fractures of 2 or more ribs in 2 or more locations
• Paradoxical movement : the segment moves inwards on inspiration as
the rest of the chest expands and outwards on expiration as the rest
of the chest deflates
 ATOM FCH
FLAIL CHEST
 ATOM FCH
FLAIL CHEST
What is Flail Chest?
• ≥ 2 contiguous ribs (share common border) have been fractured
in ≥ 2 places (radiological diagnosis)
• This results in a segment of the chest wall that is no longer in
continuity with the rest of the thoracic cage
• Paradoxical movement results, the segment moves inwards on
inspiration as the rest of the chest expands and outwards on
expiration as the rest of the chest deflates
• Hypoxaemia in flail chest is mainly due to underlying pulmonary
contusion and resultant V/Q mismatch. Pain from the fracture
will result in restricted chest wall movement, further
compounding the mismatch
 ATOM FCH
FLAIL CHEST
How to diagnose Flail Chest?
• Pain on respiratory effort
• Paradoxical chest wall movement
• Respiratory distress
• External evidence of chest trauma
• Bony crepitus

• Chest x-ray may suggest multiple rib fractures, but may not
show costochondral separation
 ATOM FCH
FLAIL CHEST
How to manage Flail Chest?
• Ensure adequate O2 (High flow oxygen 15L/min via non-
rebreather)
• Provide judicious fluid therapy
• The key is to provide analgesia to improve ventilation
• paracetamol 1g qid po, NSAIDs if not contraindicated, titrated opiates IV
• Early use of regional anesthesia (intercostal nerve blocks, paravertebral
block, epidural anesthesia) due to risk of respiratory depression.
• Respiratory monitoring and support (saO2, ABG, respiratory rate)
• patients tend to gradually deteriorate and may require intubation and
mechanical ventilation.
 ATOM FCH
FLAIL CHEST
• Indication for early mechanical ventilation in flail
chest:
• Hypoxia and hypercarbia
• Shock
• >3 associated injuries
• Severe head injury
• Previous pulmonary disease
• Fracture of > 8 ribs
• Age ≥65 years old
 ATOM FCH
CARDIAC TAMPONADE
 ATOM FCH
CARDIAC TAMPONADE

What is Cardiac Tamponade?

• clinical syndrome caused by the accumulation of fluid in
the pericardial space, resulting in reduced ventricular filling
and subsequent hemodynamic compromise.
• Pericardial tamponade is more common in penetrating
thoracic trauma than blunt trauma
• As little as 75 mL of blood accumulating in the pericardial
space acutely can impair cardiac filling, resulting in
tamponade and obstructive shock
 ATOM FCH
CARDIAC TAMPONADE
How to diagnose Cardiac Tamponade?
• Diagnosis requires high index of suspicion.
• Certain combination of features points towards possibility
• Chest trauma and obstructive shock [tachycardia,
hypotension, cool peripheries]
• Beck’s triad: muffled heart sounds, hypotension and
distended neck veins
• Chest trauma and pulseless electrical activity
• Kussmaul’s sign (increased neck distension during inspiration and pulsus
paradoxus)
pulsus paradoxus = SBP drop ≥ 10mmHg on inspiration
 ATOM FCH
CARDIAC TAMPONADE

• Other supporting evidence may include:

• An enlarged cardiac shadow on CXR (rare)
• Small ECG voltages (uncommon)
• Need to be differentiated from pneumothorax and needs to
be actively sought
• Mostly diagnosed following identification of a pericardial
effusion on bedside ultrasound as part of the FAST exam 
later perform formal echocardiography
 ATOM FCH
CARDIAC TAMPONADE
How to manage Cardiac Tamponade?
• High flow oxygen 15L/min via non-rebreather
• Establish 2 large bore IV lines
• Give IV fluid bolus 500 ml stat and repeat to maintain mean
arterial pressure at more than 90 m Hg
• Treat pericardial tamponade by pericardiocentesis
• ECG guided (with ECG lead attached to pericardiocentesis needle)
• 2D Echo guided. Can be diagnostic or
• The inpatient cardiothoracic/vascular team should be alerted
immediately for consultation
• Emergency thoracotomy may be necessary in the event of cardiac
arrest
 ATOM FCH
CARDIAC TAMPONADE
 ATOM FCH
HAEMORRHAGE
What is the source of haemorrhage?
• External bleeding wound
• Internal bleeding – pain, suggestive symptoms
• Hypovolaemic shock
 ATOM FCH
HAEMORRHAGE
How to manage Haemorrhage?
• Apply direct pressure to external bleeding site(s).
• Consider presence of internal hemorrhage and potential
need for operative intervention, and obtain surgical consult.
• Insert two large-caliber IV catheters.
• Simultaneously obtain blood for hematologic and chemical
analyses; pregnancy test, when appropriate; type and
crossmatch; and ABCs.
• Initiate IV fluid therapy with warmed crystalloid solution
and blood replacement.
• Prevent hypothermia.
SECONDARY SURVEY

1. Aortic injury
2. Thorax injuries (non-massive heamothorax, simple
pneumothorax)
3. Oesphageal perforation
4. Muscular diaphragmatic injury
5. Fistula (bronchopleural) and other tracheobronchial injury
6. Contusion to the heart or lungs
References

• Advanced Trauma Life Support (9th Edition)

• Guide to The Essentials in Emergency Medicine 2nd edition Shirley
Ooi
• http://lifeinthefastlane.com/ccc/thoracic-trauma/