2. Advance Trauma Life Support
⢠Simultaneous diagnostic and therapeutic activities
intended to identify and treat life and limb-
threatening injuries, beginning with the most
immediate.
⢠This focus on urgent problems is first captured by the
âGolden hourâ catch phrase and is one of the most
important lessons of ATLS.
⢠The GOLDEN HOUR, the first hour after a traumatic
injury, when emergency treatment is most likely to be
successful.
3. Basics of Trauma Assessment
ďŽ Preparation
ďŽ Triage
ďŽ Primary Survey (A,B,C,D and E)
ďŽ Resuscitation
ďŽ Secondary Survey
ďŽ Monitoring and Evaluation, Secondary
adjuncts
ďŽ Transfer to Definitive Care
4. TRIAGE
⢠The process of categorizing victims or
mass casualties based on their need for
treatment and the resources available.
⢠GOALS:
1. Prevent avoidable deaths.
2. Ensure proper initial treatment within a minimal time frame.
3. Avoid misusing assets on hopeless cases
5. PRIMARY SURVEY
⢠First, most important thing when you
encounter a trauma patient is to speak to
him!
⢠A complete sentence spoken by the
patient tell us:
1. Airway is patent.
2. Breathing is intact.
3. Good cerebral circulation
6. PRIMARY SURVEY
ďŽAirway and Protection of Spinal Cord
ďŽBreathing and Ventilation
ďŽCirculation
ďŽDisability
ďŽExposure and Control of the Environment
7. AIRWAY MANAGEMENT
ďŽWhy first in the algorithm?
â Loss of airway can result in death in < 3 minutes.
â Prolonged hypoxia means Inadequate perfusion, End-
organ damage.
ďŽAirway Assessment
â Initial airway assessment involves evaluating for airway
obstruction or patency which can be determined by
assessing for snoring, stridor, drooling, hoarseness,
edema, and facial trauma or burns.
8. PROTECTION OF SPINAL CORD
⢠General Principle:
⢠Protect the entire spinal cord until injury has been excluded by
radiography or clinical physical exam in patients with potential spinal cord
injury.
⢠Spinal Protection
⢠Rigid Cervical Spinal Collar = Cervical Spine
⢠Long rigid spinal board or immobilization on flat surface such as stretcher
= T/L Spine
⢠Clinical Pearls
⢠Treatment (Immobilization) before diagnosis.
⢠Return head to neutral position.
⢠Do not apply traction.
⢠Diagnosis of spinal cord injury should not precede resuscitation.
⢠Motor vehicle crashes and falls are most commonly associated with spinal
cord injuries.
10. AIRWAY MANAGEMENT
⢠The head-tilt chin-lift maneuver, a
maneuver that gently extends the head
slightly into the "sniffing positionâ and lifts the
tongue from the back of the throat, is the most
reliable method of opening the airway when
cervical spine injury is not suspected.
⢠The oropharyngeal airway comes in a
variety of adult and pediatric sizes and is
sized from the corner of the mouth to the
earlobe. With a tongue blade to depress the
tongue, the OPA is inserted over the tongue.
⢠The Jaw Thrust in which mandible is pushed
forward via index fingers. When the mandible
is displaced forward, it pulls the tongue
forward and prevents it from obstructing the
entrance to the trachea.
11. AIRWAY MANAGEMENT
⢠A bag valve mask, abbreviated to BVM and
sometimes generically as a manual
resuscitator or "self-inflating bag", is a hand-
held device commonly used to provide
positive pressure ventilation to patients who
are not breathing or not breathing adequately.
⢠The non-rebreather mask is utilized for
patients with physical trauma, chronic airway
limitation, cluster headache, smoke
inhalation, and carbon monoxide poisoning,
or any other patients who require high-
concentration oxygen, but do not require
breathing assistance.
12. AIRWAY MANAGEMENT
⢠Tracheal intubations, usually simply referred to as intubations, is the placement
of a flexible plastic tube into the trachea to maintain airway, procedures commonly
used are Direct Laryngoscopy, Video Laryngoscopy, Digital Intubations etc,
patient needs to be preoxygenated, sedated and paralyzed before performing
intubations!
13. AIRWAY MANAGEMENT
⢠Cricothyroidotomy, also
known as cricothyrotomy, is
an important emergency
procedure that is used to
obtain an airway when
other, more routine methods
are ineffective or
contraindicated. It is
specially indicated in
Maxillofacial Injuries and if
the cervical spine is
immobilized. Only
contraindication is AGE!
⢠Tracheostomy is an
operative procedure that
creates a surgical airway in
the cervical trachea.
14. Breathing and Ventilation
ďŽ Breathing/Ventilation Assessment:
â Exposure of chest
â General Inspection (LOOK)
ďŽTracheal Deviation
ďŽAccessory Muscle Use
ďŽRetractions
ďŽAbsence of spontaneous breathing
ďŽParadoxical chest wall movement
â Auscultation to assess for gas exchange (LISTEN)
ďŽEqual Bilaterally
ďŽDiminished or Absent breath sounds
â Palpation (FEEL)
ďŽDeviated Trachea
ďŽBroken ribs
ďŽInjuries to chest wall
15. BREATHING AND VENTILATION
ďŽIdentify Life Threatening Injuries
âMassive hemothorax
âFlail chest
âRib fractures
âOpen pneumothorax
âPulmonary contusion
âTension Pneumothorax
16. BREATHING AND VENTILATION
Tension Pneumothorax
ďŽAir trapping in the pleural space between the lung and
chest wall
ďŽSufficient pressure builds up and pressure to compress the
lungs and shift the mediastinum
ďŽPhysical exam
â Absent breath sounds
â Air hunger
â Distended neck veins
â Tracheal shift
ďŽTreatment
â Needle Decompression
ďŽ 2nd
Intercostals space, Midclavicular line
â Tube Thoracostomy
ďŽ 5th
Intercostals space, Anterior axillary line
18. BREATHING AND VENTILATION
Hemothorax
â Blood collecting in the pleural space
and is common after penetrating and
blunt chest trauma
â Source of bleeding = Lung, Chest wall
(intercostal arteries), heart, great
vessels (Aorta), Diaphragm
â Physical Exam
ďŽ Absent or diminished breath sounds
ďŽ Dullness to percussion over chest
ďŽ Hemodynamic instability
â Treatment = Large Caliber Tube
Thoracostomy
ďŽ 10-20% of cases will require Thoracostomy for
control of bleeding
19. BREATHING AND VENTILATION
Flail Chest
â Direct injury to the chest resulting in an unstable segment of
the chest wall that moves separately from remainder of
thoracic cage
â Physical exam = paradoxical movement of chest segment
â Treatment = improve abnormalities in gas exchange
ďŽEarly intubation for patients with respiratory distress
ďŽAvoidance of overaggressive fluid resuscitation
20. BREATHING AND VENTILATION
ďŽ TUBE THORACOSTOMY
ďŽ Insertion site
â 5th
intercostal space,
â Anterior axillary line.
21. CIRCULATION
ďŽ Shock
ďŽ Impaired tissue perfusion
ďŽ Tissue oxygenation is inadequate to meet metabolic
demand
ďŽ Prolonged shock state leads to multi-organ system failure
and cell death
ďŽ Clinical Signs of Shock
â Altered mental status
â Tachycardia (HR > 100) = Most common sign
â Arterial Hypotension (SBP < 120)
â Inadequate Tissue Perfusion
ďŽ Pale skin color
ďŽ Cool clammy skin
ďŽ Delayed cap refill (> 3 seconds)
ďŽ Altered LOC
ďŽ Decreased Urine Output (UOP < 0.5 ml/kg/hr)
22. CIRCULATION
ďŽ Types of Shock in Trauma
â Hemorrhagic
ďŽ Assume hemorrhagic shock in all trauma patients until proven otherwise
ďŽ Results from Internal or External Bleeding
â Obstructive
ďŽ Cardiac Tamponade
ďŽ Tension Pneumothorax
â Neurogenic
ďŽ Spinal Cord injury
ďŽ Sources of Bleeding
â Chest
â Abdomen
â Pelvis
â Bilateral Femur Fractures
23. CIRCULATION
ďŽ General Treatment Principles
⢠Stop the bleeding
ďŽ Apply direct pressure
ďŽ Temporarily close scalp lacerations
â Close open-book pelvic fractures
ďŽAbdominal pelvic binder/bed sheet
â Restore circulating volume
ďŽCrystalloid Resuscitation (2L)
ďŽAdminister Blood Products
â Immobilize fractures
ďŽ Responders vs. Non-responders
â Transient response to volume resuscitation = sign of ongoing blood
loss
â Non-responders = consider other source for shock state or operating
room for control of massive hemorrhage
24. CIRCULATION
ďŽ Pericardial Tamponade
â Pericardium or sac
around heart fills with
blood due to
penetrating or blunt
injury to chest.
â Treatment
ďŽRapid evacuation of
pericardial space
ďŽPerformed through a
Pericardiocentesis
(temporizing measure)
ďŽOpen thoracotomy.
26. DISABILITY
ďŽ Baseline Neurological Exam
â Pupillary Exam
ďŽ Dilated pupil â suggests transtentorial herniation
on ipsilateral side
â AVPU Scale
ďŽ Alert
ďŽ Responds to verbal stimulation
ďŽ Responds to pain
ďŽ Unresponsive
â Gross Neurological Exam â Extremity
Movement
ďŽ Equal and symmetric
ďŽ Normal gross sensation
â Glasgow Coma Scale: 3-15
â Rectal Exam
ďŽ Normal Rectal Tone
27. DISABILITY
ďŽ Key Principles
â Prevention of further injury and identification of
neurological injury is the goal.
â Maintenance of adequate cerebral perfusion is
key to prevention of further brain injury.
ďŽAdequate oxygenation
ďŽAvoid hypotension
â Involve neurosurgeon early for clear intracranial
lesions.
28. EXPOSURE
ďŽ Remove all clothing
â Examine for other signs of injury
â Injuries cannot be diagnosed until seen by
provider
ďŽ Logroll the patient to examine patientâs
back
â Maintain cervical spinal immobilization
â Palpate along thoracic and lumbar spine
â Minimum of 3 people, often more providers
required
ďŽ Avoid hypothermia
â Apply warm blankets after removing clothes
â Hypothermia = Coagulopathy
ďŽIncreases risk of hemorrhage
30. SECONDARY SURVEY
ďŽSecondary Survey is started after primary
survey is completed and patient has been
adequately resuscitated.
ďŽNo patient with abnormal vital signs should
proceed to a secondary survey.
ďŽSecondary Survey includes a brief history
and complete physical exam!
33. DEFINITIVE CARE
ďŽ Secondary Survey followed by radiographic
evaluation
â CatScan
â Consultation
ďŽNeurosurgery
ďŽOrthopedic Surgery
ďŽVascular Surgery
ďŽ Transfer to Definitive Care
â Operating Room
â ICU
â Higher level facility