ATLS(Advance Trauma Life Support)

Dr. Tanuj Paul Bhatia

History

• Introduced by Dr. James Styner, an orthopedic surgeon in 1970s.

• Now considered the ‘Gold standard’ in initial management and resuscitation of trauma cases.

Importance of ATLS‘The Golden Hour’

ATLS components

1. Primary survey2. Resuscitation 3. Secondary survey4. Definitive care

Aims of ATLS

1. Primary survey – To identify what is KILLING the patient.

2. Resuscitation – To treat what is killing the patient.

3. Secondary survey – To identify all other injuries.

4. Definitive care – Develop a definitive management plan.

Pre hospital care

• Objectives – (1) assessment of the injury scene; (2) stabilization and monitoring of the injured patient;

and (3) safe and rapid transportation of critically ill patients

to the appropriate trauma center.

• MVIT - Mechanism, Vital signs, Injury inventory, Treatment

Primary survey

• A – Airway with cervical spine control• B – Breathing• C – Circulation• D – Disability• E - Exposure

Airway

• Establishing a patent airway is highest priority.• To prevent irreversible brain damage .• A patient who is able to respond verbally has a

patent airway.• For every patient - Oxygen administered (via

nasal cannula or bag valve facemask) and an oxygen saturation monitor (i.e., pulse oximeter) placed.

Stabilizing cervical spine

O2

C-spine

PulseOxi.

Airway (contd.)

• Basic maneuvers – Simple suctioning.– Jaw-thrust maneuver.– Oropharyngeal airway.

• Tracheal intubation– indicated in any patient in whom concern for

airway integrity exist.– Adequacy of ventilation should be verified .

Airway (contd.)

• Direct cricoid membrane airways.– Cricothyrotomy is the method of choice .– Percutaneous transtracheal ventilation.

Breathing

• Once an airway is established, attention is directed at assessing the patient's breathing .

• The chest wall motion is observed and axillae are auscultated to check delivery to the peripheral lung.

• Life threats– Tension pneumothorax– Pneumothorax/hemothorax– Flail chest– Open pneumothorax

Pneumothorax

Treatment

• Tube thoracostomy.• Mechanical ventilation.

Circulation

• To identify and treat the presence of shock in the patient.

• Initially, all active external hemorrhage is controlled with direct pressure.

• The pulse is characterized, and a blood pressure (BP) is obtained.

• Shock is defined as the inadequate delivery of oxygen and nutrients to tissue.

Etiologies of shock

1.Hypovolemic 2.Cardiogenic3.Distributive

Hypovolemic shock

• Most common in trauma(Haemmorhagic shock).

• Decreased intravascular volume secondary to blood loss .

• S/S - rapid pulse, decreased pulse pressure, diminished capillary refill, and cool, clammy skin.

Management

• two large-bore intravenous lines placed (14- or 16-gauge).

• The antecubital veins are the preferred sites.• A blood specimen should be simultaneously

obtained for cross-matching.• Resuscitation should consist of an initial bolus

of 2 L of a balanced salt solution, typically Ringer's solution.

Classification of hypovolemic Shock

Class EBL Treatment

I <15% (<750ml) Fluids

II 15-30% (750-1.5L) Fluids

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

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

Cardiogenic shock

• heart is unable to provide adequate cardiac output.

• In the trauma setting, such shock can occur in one of two ways:

(1) extrinsic compression of the heart or (2) myocardial injury causing inadequate

myocardial contraction and decreased cardiac output.

Management

• I.V. fluids• E.C.G.• Chest x ray• Tube thoracostomy if tension pneumothorax is

the cause.

Distributive shock

• as a result of an increase in venous capacitance leading to decreased venous return.

• Loss of peripheral sympathetic tone is responsible.

• often respond to an initial fluid bolus but will eventually require pharmacologic support.

• Phenylephrine is the drug of choice.

Disability

• Assessment of the neurologic status.• to identify and treat life-threatening

neurologic injuries.• Intracranial injuries(Mannitol, 0.25–1.00 g/kg)• Spinal cord injuries(methylprednisolone)• Neurosurgical consultation.

Exposure

• Last step• Exposure with environmental control.• Remove clothes and look for other dangerous

injuries.

Completion of primary survey

• Monitoring.• Laboratory values.• Adequacy of resuscitation.• Radiographic investigations.• FAST(focussed abdominal sonography for

trauma)• CT SCAN.

FAST

Secondary surveyKEY COMPONENTS

• History• Complete head-to-toe examination• “Tubes and Fingers in every orifice”• Complete Neuro exam• Special diagnostic tests• Reevaluation

HISTORY

• A Allergies• M Medications• P Past Medical/Surgical

History/Pregnancy• L Last meal• E Events/Environment related to injury

HEAD

• Complete Neuro exam• GCS Score• Comprehensive eye/ear exams MAXILLOFACIAL• Bony crepitus/stability• Palpable deformity

Cervical Spine

• Palpate for tenderness/stepoffs/crepitus• Complete motor/sensory exams• Reflexes• C-spine imaging

Neck (soft tissues)

• Mechanism: blunt vs penetrating• Symptoms: airway obstruction,

hoarseness• Findings: crepitus, hematoma, stridor,

bruit

Chest

• Inspect• Palpate• Percuss• Auscultate• X-rays

Abdomen

• Inspect, auscultate, palpate, percuss

• Reevaluate frequently• Special studies

Musculoskeletal:Extremities

• contusion, deformity• pain• perfusion• peripheral NV status• X-rays as indicated

Neurologic

• Spine/Cord:– complete motor and sensory exams– reflexes– imaging as indicated

• CNS:– frequent reevaluation– prevent secondary brain injury

• Early neurosurgical consultation

Definitive care

• Definitive hospital care is undertaken .• Ranging from emergent celiotomy to

admission and further assessment.• Diagnostic evaluations are completed and

therapeutic interventions performed.

Roles of the Trauma Team

Airway

Nurse

Boss

Attending

Team Member

Team Member

Nurse

Roles of the Trauma Team

• Boss– Directs the team, communicates decisions– Free to roam– Attending speaks through Boss (or teaches

directly)

Roles of the Trauma Team

• Airway– A & B of primary survey– Intubation (if needed)– Head / Neck in secondary survey

• Nurses– Attach monitors, give blood / fluids / meds– Recording nurse records at foot of bed

Roles of the Trauma Team

• Team Members– Expose, examine (secondary survey)– Procedures as directed (by boss)

• Chest Tubes• Lac repairs

– Rectals, foleys routinely assigned to team member.

Overview of ATLS

D e fin it ive C a re

D a ta / In fo rm a tio n /R e spo n se to T h era py

S e co nd a ry S u rvey

R e su sc ita tion

P rim a ry S u rvey(A B C D E 's )

HANK YOU