ATLS (Advanced Trauma Life Support)

Teaching Protocol

A. Pretest (30 min)

B. Context of Tutorial (2 hours)
1. General Principles
 Concept
 Inhospital phase clinical procedure/process
 Important points/ cautions/ pitfalls
 Brief discussion on traumatic shock/ blood transfusion
2. Thoracic Trauma
3. Abdominal Trauma
C. Answers of pretests (30 min)
D. Skills: (1hour)
1. Airway and Ventilatory management
a. Jet insufflation
b. Laryngoscope / Magill forcep / Suction device
c. Adult intubation
d. Infant intubation
e. Cricothyroidotomy

2. Immobilization
a. In-line immobilization/ log-roll techniques
b. Cervical collar
a. Long spine Backboard
b. Scoop stretcher
c. Traction Splint

3. Adjuncts to surveys /monitoring/ resuscitation

a. Pulse Oximeter
b. DPL
c. FAST
d. Needle decompression
e. Tube thoracostomy
f. Seal Open peumothorax
g. Pericardiocentesis
h. Intraosseous puncture
 Avanced Trauma Life Support

General Principles:

 The concept:
Three underlying concepts of ATLS program :

1.
Treat the greatest threat to life first
2.
The lack of a definite diagnosis should never impede the application
of an indicated treatment
3.
A detailed history was not essential to begin the evaluation of an
acutely injured patient

 Specific principles govern the management of trauma patients in ED:

1.
Organized team approach
2.
Priorities
3.
Assumption of the most serious injury
4.
Treatment before diagnosis
5.
Thorough examination
6.
Frequent reassessment
7.
Monitoring

 Inhospital phase clinical process:

 Systemic, organized approach to seriously injured patients is mandatory.

 Preparation
 Triage
  Primary survey (ABCDEs)
Resuscitation
Adjuncts to primary survey & resuscitation
 Secondary survey (Head to toe Evaluation)
Adjuncts to secondary survey
 Continued postresuscitation monitoring and reevaluation
 Definitive care

 The primary and secondary surveys should be repeated frequently

 In the actual clinical situation, many of these activities occur in parallel or
simultaneously.

 Organized Team Approach:

 Team Captain : Coordinate, control the resuscitation
Assessing the patient, ordering needed procedures/ studies
Monitring the patient’s progress.
 Procedures by other physician team members.
 Nurses

 Priorities In Management and Resuscitation

 Immediate / potential threats to life
 1. High-priority areas
Airway/ breathing
Shock/ external hemorrhage
Impending cerebral hemorrhage
Cervical spine

2. Low-priority areas
Neurologic
Abdominal
Cardiac
Musculoskeletal
Soft tissue injury

 Assumption of the Most Serious Injury

 Assume the worst possible injury
 Mechanism of injury
 Treatment Before Diagnosis
 Based on initial brief assessment
 The more unstable the patient, the less necessary to confirm alife-threatening diagnosis
before it is expeditiously treated

 Thorough Examination
 When time and the patient’s stability permit.
 Unconscious/ alcohol intoxicated patients

 Frequent Reassessment
 Dynamic process
 Some injuries take time to manifest
 Any sudden worsening in the physiologic status of the patients mandates a return to the
“ABCDEs”

 Monitoring
 Vital signs
 Pulse oximetry
 I/O
 Lab: ABG, Ht
 CVP

Inhospital Phase ATLS

 PREPARATION
 Resuscitation area
 Proper airway equipment
 Warmed IV crystalline solutions
 Monitoring capabilities
 Summon extra medical assistance
 Prompt response by lab and radiology personnel
 Transfer route
 Periodic review
 Standard precautions

 TRIAGE
 Based on the ABCDE priority
 PRIMARY SURVEY
 Airway with Cervical spine protection
 Breathing and ventilation
 Circulation with hemorrhage control
 Disability: Neurologic status
 Exposure/ Environmental control

Airway Maintenance with Cervical Spine Protection

 Q : What are the problems that lead to airway compromise ?
 Q : What are the indications for definite airway ?

Indications For Definite Airway

Need for Airway Protection Need for Ventilation
Unconscious Apnea
GCS ≤ 8 Neuromuscular paralysis
Unconscious
Severe maxillofacial fractures Inadequate respiratory effort
Tachypnea
Hypoxia
Hypercarbia
Cyanosis
Risk for aspiration Severe closed head injury with
Bleeding need for hyperventilation
Vomiting
Risk for obstruction
 Assessment:
 Ascertain patency
 Rapidly assess for airway obstruction
 Foreign bodies, facial / mandibular / tacheal / larygeal fractures.
 Management:
 Chin lift / jaw thrust maneuver
 Clear the airway of FB
 Insert an orotracheal / nasopharyngeal airway
 Establish a definitive airway
1. Orotracheal / nasotracheal intubation
2. Surgical cricothyroidotomy
 Jet insufflation
 Maintain the cervical spine in a neutral position with manual immobilization as
necessary when establishing an airway
 Immobilization of the c-spine with appropriate devices after establishing an airway.
 Important Notes:
 NE does not exclude a cervical spine injury
 Assume a cervical spine injury in any patient with multisystem trauma, especially
with an altered level of consciousness or a blunt injury above the clavicle
 Pitfalls:
 Equipment failure
 Cannot be intubated after paralysis and accompanied with difficult surgical airway
 Unknown laryngeal fracture / incomplete airway transection.

Breathing and Ventilation

 Q : What are the injuries that may acutely impair ventilation in the primary
survey?
Injuries that should be identified in the Primary survey :
1. Tension pneumothorax
2. Flail chest with pulmonary contussion
3. Massive hemothorax
4. Open pneumothorax

 Assessment :
Inspection / palpation /Auscultation / Percussion
 Expose the neck and chest
 Respiratory rate and depth
 Inspect and palpate: tracheal deviation ? symmetrical chest movement ? use of
accessory muscles ? signs of injury ? subcutaneous emphysema ?
 Cyanosis ?
 Auscultate the chest
 Percussion : dullness? hyperresonance?
 Management :
 Administer high concentrations of oxygen
 Ventilate with BVM
 Alleviate tension pneumothorax : needle decompression / Place chest tube
 Indication for thoracotomy
 Seal an open pneumothorax
 Pulse oximeter
 Important Notes :
 Always check for one-lung intubation, chest X-rays should be performed
 Pitfalls :
 If the ventilation problem is produced by a pneumothrax, intubation with MV could
 lead to deterioration.
 The procedure itself may produce a pneumothorax

Circulation with Hemorrhage Control

 Q : What are the elements that provide the information about the hemodynamic
status of the injured patients.
These elements are:

1. Level of consciousness
2. Skin color
3. Pulse ( quality, rate, regularity )
 Presence of a carotid pulse  SBP 60 mmHg
femoral pulse  SBP 70 mmHg
radial puse  SBP 80 mmHg

 External bleeding is identified and controlled in the primary survey.

 Operative intervention for internal bleeding control.

 Q : What are the injuries that may acutely impair circulation status ?
These injuries are :
1. External/internal bleeding with hypovolemic shock
2. Massive hemothorax
3. Cardiac tamponade

 Assessment:
 Identify source of external hemorrhage
 Identify potential source(s) of internal hemorrhage /
 Pulse / skin color, capillary refill / Blood pressure
 Management:
 Apply direct pressure to external bleeding site.
 Internal hemorrhage ? Need for surgical intervention ?
 Establish IV access / central line / IO
 Fluid resuscitation / blood replacement
 Important Notes :
 Hypotension following injury must be considered to be hypovolemic in origin until
proved otherwise.
 Pitfalls :
 The elderly, children, athletes and others with chronic medical conditions do not
respond to volume loss in similar manner
 Disability
 Assessment :
 Level of consciousness in the AVPU scale
Alert
Voice illicits response
Pain illicits response
Unresponsive
 GCS
 Pupils size, equality and reaction
 Management :
 Intubation and allow mild hyperventilation
 Administer IV mannitol ( 1.5-2.0g/kg )
 Arrange for brain CT
 Important notes :
 CT is contraindicated when the patient is hemodynamically unstable
 A decrease in the level of consciousness may due to:
a.
Decreased cerebral oxygenation (A,B)
b.
Decreased cerebral perfusion (C)
c.
Direct cerebral injury (D)
d.
Alcohol / drugs
Always rule out hypoxemia and hypovolemia first.
 Reevaluation
 Pitfalls :
 Lucid interval of acute EDH, reevaluation is important.
Exposure / Environment Control
 Completely undressed the patient.
 Prevent hypothermia
 Injured patients may arrive in hypothermic condition
 Log-roll

 RESUSCITATION
 To reverse immediately life-threatening situations and maximize patient survival
 TREATMENT PRIORITY NECCESSARY PROCEDURE
Airway 1. Jaw thrust/chin lift/
2. Suction
3. Intubation
4. Cricothyroidotomy
( with protection of C-spine )
Breathing/Ventilation/oxygenation 1. Chest needle decompression
2. Tube thoracostomy
3. Supplemental oxygen
4. Seal open pneumothorax
Circulation/hemorrhage control 1. IV line/ central line
2. Venous cutdown
3. Fluid resuscitation/Blood transfusion
4. Thorocostomy for massive
hemothorax
5. Pericardiocentesis for cardiac
tamponade
Disability 1. Burr holes for trans-tentorial
herniation
2. IV mannitol
Exposure/Environment 1. Warmed crystalloid fluid
2. Temperature

 ADJUNCTS TO PRIMARY SURVEY AND RESUSCITATION

 Electrocardiographic Monitoring.
 Urinary Catheter
 Gastric Catheter
 Monitoring
 ABG
 Pulse oximeter
 Blood pressure
 X-rays
 AP CXR
 AP pelvis
 C-spine
 Diagnostic peritoneal lavage
 Abdominal ultrasonography (FAST)

 CONSIDER NEED FOR PATIENT TRANSFER

 SECONDARY SURVEY
 The secondary survey does not begin until:
 the primary survey is completed,
 resuscitation efforts are well established,
 the patient is demonstrating normalization of vital functions.
 Head-to-toe evaluation
 Complete history and PE
 Reassessment of all vital signs.
 Complete NE.
 Indicated x-rays are obtained.
 Special procedures
 Tubes and fingers in every orifice

 History:
AMPLE history
Allergies
Medications currently used
Past illness/ Pregnancy
Last meal
Events/ Environment related to the injury
Mechanism/blunt/penetrating/burns/cold/hazardous environment

 Physical Examination:
Table 1.

 Pitfalls:
 Facial edema in patients with massive facial injury or patients in coma can preclude
a complete eye examination.
 Blunt injury to the neck may produce injuries in which clinical signs and symptoms
develop late.(e.g. Injury to the intima of the carotid a.)
 The identification of cervical n. root/brachial plexus injury may not be possible in
the comatose patient.
 Decubitus ulcer from immobilization on a rigid spine board/cervical collar.
 Children often sustain significant injury to the intrathoracic structures without
evidence of thoracic skeletal trauma.
 A normal initial examination of the abdomen does not exclude a significant
intraabdominal injury.
 Patients with impaired sensorium secondary to alcohol/drugs are at risk.
 Injury to the retroperitoneal organs may be difficult to identify.
  Female urethral injury are difficult to detect.
 Blood loss from pelvic fractures can be difficult to control and fatal hemorrhage may
result.
 Fractures involving the bones of extremities are often not diagnosed.
 Most of the diagnostic and therapeutic maneuvers increase ICP.

 ADJUNCTS TO THE SECONDARY SURVEY

These specialized tests should not be performed until the patient’s hemodynamic status has
been normalized and the patient has been carefully examined.
 Additional x-rays of the spine and extremities
 CT of the head, chest, abdomen, and spine
 Contrast urography
 Angiography
 Bronchoscopy
 Esophagoscopy
 Others

 REEVALUATION
 The trauma patient must be reevaluated constantly to assure that new findings are not
overlooked.
 A high index of suspicion
 Continuous monitoring of vital signs and urinary output is essential.
 ABG/cardiac monitoring/ pulse oximetry
 Pain relive- IV opiates/anxiolytics.

 DEFINITIVE CARE
 Transfer to a trauma center or closest appropriate hospital.

 TRAUMATIC SHOCK

 Recognition of Shock :
 Early: Tachycardia and cutaneous vasoconstriction
 Normal heart rate varies with age, tachycardia is present when
Infant: >160 BPM
Preschool age child: >140 BPM
School age to puberty: >120 BPM
Adult: >100 BPM
  The elderly patient may not exhibit tachycardia because of the limited cardiac
response to catecholamine stimulation / use of medications

 Differentiation of shock:
 Hemorrhagic shock  hypovolemic shock
 Nonhemorrhagic shock:
a. Cardiogenic shock: Blunt cardiac injury, cardiac tamponade, air embolus,
myocardial infarction.
b. Tension pneumothorax
c. Neurogenic shock
d. Septic shock

 The normal blood volume of adult is 7 % of body weight. Whereas that of a child is 8-9%
of body weight.

 Estimated Fluid and Blood Losses: ( For a 70-kg man )

Class I Class II Class III Class IV
Blood Loss (ml) Up to 750 750-1500 1500-2000 >2000
Blood Loss Up to 15 % 15-30 % 30-40 % >40 %
(% Blood Volume)
Pulse Rate <100 >100 >120 >140
Blood Pressure Normal Normal Decreased Decreased
Pulse Pressure Normal or Decreased Decreased Decreased
(mmHg) increased
Respiratory Rate 14-20 20-30 30-40 > 35
Urine Output >30 20-30 5-15 Negligible
(mL/hr)
CNS/Mental status Slightly Mildly Anxious, Confused,
anxious anxious Confused lethargy
Fluid Repacement Crystalloid Crystalloid Crystalloid Crystalloid
(3:1 rule) and blood and blood

 Fluid Therapy:
 Fluid bolus: 1-2 liters for an adult and 20mL/kg for a pediatric patient
 3:1 rule
 39  C ( 1 liter fluid, microwave, high power, 2 minutes )

 Blood Replacement:
 PRBC/Whole blood
  Crossmatched/type-specific/ type O blood
 FFP ( 1U FFP for every 5 U PRBC)

 CVP monitoring
Thoracic Trauma

 PATHOPHYSIOLOGY
 1. Hypoxia: a. Hypovolemia (blood loss); b. Pulmonary ventilation / perfusion
mismatch (contusion, hematoma, alveolar collapse); c. Changes in intrathoracic pressure
relationships (tension pneumothorax, open pneumothorax)
 2. Hypercarbia: a. Inadequate ventilation due to changes in intrathoracic pressure; b.
Depressed level of consciousness
 3. Metabolic acidosis: Hypoperfusion of the tissues (shock)

 ASSESSMENT & MANAGEMENT:

 Must consist of:
1. Primary survey
2. Resuscitation of vital functions
3. Detailed secondary survey
4. Definitive care

 PRIMARY SURVEY ( Life-threatening injuries )

 Airway:
 Recognition of: Stridor, change of voice quality, obvious trauma
 Major problems:
1. FB obstructions,
2. Laryngeal injury,
3. Posterior dislocation / fracture dislocation of the sternoclavicular joint.
 Management: Establishing a patent airway/ ET intubation; closed reduction.

 Breathing:
 Recognition of: Neck vein distention, respiratory effort and quality changes,
cyanosis
 Major problems:
1. Tension pneumothorax:

Clinical diagnosis

Chest pain, air hunger, respiratory distress, tachycardia, hypotension, tracheal
deviation, unilateral absence of breath sounds, neck vein distention,
 cyanosis. (V.S. cardiac tamponade)

Hyperresonant percussion.

Immediate decompression: Needle decompression/ chest tube.
2. Open pneumothorax:

2/3 of the diameter of the trachea – impaired effective ventilation

Sterile occlusive dressing, taped securely on 3 sides.

Chest tube (remote)
3. Flail chest:

 2 ribs fractured in two or more places.

Severe disruption of normal chest wall movement.

Paradoxical movement of the chest wall.

Crepitus of ribs.

The major difficulty is underlying lung injury ( pulmonary contusion)

Pain.

Adequate ventilation, humidified oxygen, fluid resuscitation.

The injured lung is sensitive to both underresuscitation of shock and fluid
overload.
4. Massive hemothorax:

Compromise respiratory efforts by compression, prevent adequate ventilation.

 Circulation:
 Assessment: Pulse quality, rate and regularity. BP, pulse pressure, observing and
palpating the skin for color and temperature. Neck veins.
 Important notes: Neck veins may not be distented in the hypovolemic patient with
cardiac tamponade, tension pneumothorax,or traumatic diaphragmatic injury.
 Monitor with: Cardiac monitor/pulse oximeter.
  Major problems:
1.
Massive hemothorax:

Rapid accumulation of > 1500 mL o blood in the chest cavity.

Hypoxia

Neck veins may be flat secondary to hypovolemia

Absence of breath sounds and/or dullness to percussion on one side of the chest

Management: Restoration of blood volume and decompression of the chest cavity.

Indication of thoracotomy: a. Immediately 1500 mLof blood evacuated. b.
200mL/hr for 2-4 hrs. c. Patient’s physiology status. d. Persistent blood
transfusion requirements.
2.
Cardiac tamponade:

Beck’s triad: venous pressure elevation, decline in arterial pressure, muffled heart
tones.

Pulsus paradoxicus.

Kussmaul’s sign.

PEA

Echocardiogram.

Management: Pericardiocentesis.

 RESUSCITATIVE THORACOTOMY
 Left anterior thoracotomy
 The therapeutic maneuvers that can be effectively accomplished with a resuscitative
thoracotomy are:
 Evacuation of pericardial blood causing tamponade.
 Direct control of exsanguinating intrathoracic hemorrhage
Open cardiac massage
Cross cramping of the descending aorta to slow blood loss below the diaphragm and
increase perfusion to the brain and heart.