This document provides an overview of the Approach to Trauma- Advanced Trauma Life Support (ATLS) program. It discusses the history and concepts of ATLS, which was created in 1976 to standardize trauma care. The document outlines the ABCDE approach to the primary and secondary trauma surveys, which are designed to rapidly identify and treat life-threatening injuries. It covers steps for airway management, breathing and ventilation support, circulation stabilization, disability assessment, and full patient exposure and monitoring. Adjunct procedures like IV access, imaging, and fluid resuscitation are also reviewed.

1. Approach to Trauma- ATLS Update
Dr. Damodhar. M.V
Resident Surgeon,
Security Forces Hospital Dammam

2. *World Health Organization-Global status report on road safety 2013.www.who.int/violence_injury_prevention/road_safety_status/

3. *World Health Organization-Global status report on road safety2013.www.who.int/violence_injury_prevention/road_safety_status/

4. *World Health Organization-Global status report on road safety 2013.www.who.int/violence_injury_prevention/road_safety_status/

5. Approach to Trauma- ATLS Update

6. Approach to Trauma- ATLS Update
• History of ATLS has its origins in the United States in 1976,
when James K. Styner an orthopedic surgeon met with air
accident while piloting his flight.

7. Approach to Trauma- ATLS Update
• Trimodal distribution of trauma deaths.
• The first peak of deaths occurs within few seconds to minutes after
injury (50% OF ALL DEATHS). Virtually inevitable & very little can
be done.
• The second peak occurs between few minutes and an hour. Can be
reduced by prompt initial care in the pre-hospital phase, by early
hospital resuscitation and by prompt and competent definitive care.
This period has been labeled as “THE GOLDEN HOUR”.
• The third peak is between several days and weeks after initial injury
• The second and third peaks should be regarded as potentially
preventable.

8. Concepts of ATLS
 Treat the greatest threat to life first
 The lack of a definitive diagnosis should never impede the
application of an indicated treatment
 A detailed history is not essential to begin the evaluation
 “ABCDE” approach

9. Basics of Trauma Assessment
 Preparation
– Team Assembly
– Equipment Check
 Triage
– Sort patients by level of acuity (SATS)
 Primary Survey
– Designed to identify injuries that are immediately life threatening and to treat them as they are
identified
 Resuscitation
– Rapid procedures and treatment to treat injuries found in primary survey before completing the
secondary survey
 Secondary Survey
– Full History and Physical Exam to evaluate for other traumatic injuries
 Monitoring and Evaluation, Secondary adjuncts
 Transfer to Definitive Care
– ICU, Ward, Operating Theatre, Another facility

10. Preparation for Patient Arrival
Surgeon
Airway Doctor
Radiographer
IV Access and Medications
Circulation Nurse
Orthopedician
Scribe Nurse
Team Leader

11. Primary Survey
 Airway and Protection of Spinal Cord
 Breathing and Ventilation
 Circulation
 Disability
 Exposure and Control of the Environment

12. A- Airway
 Why first in the algorithm?
– Loss of airway can result in death in < 3 minutes
– Prolonged hypoxia = Inadequate perfusion, End-organ
damage
 Airway Assessment
– Vital Signs = RR, O2 sat
– Mental Status = Agitation, Somnolent, Coma
– Airway Patency = Secretions, Stridor, Obstruction
– Traumatic Injury above the clavicles
– Ventilation Status = Accessory muscle use, Retractions,
Wheezing

13. C-spine Immobilization
 Return head to neutral position
 Maintain in-line stabilization
 Correct size collar application
 Blocks/tape
 Sandbags

14. B- Breathing and Ventilation
 General Principle: Adequate gas exchange is required to maximize patient
oxygenation and carbon dioxide elimination
 Breathing/Ventilation Assessment:
– Exposure of chest
– General Inspection
 Tracheal Deviation
 Accessory Muscle Use
 Retractions
 Absence of spontaneous breathing
 Paradoxical chest wall movement
– Auscultation to assess for gas exchange
 Equal Bilaterally
 Diminished or Absent breath sounds
– Palpation
 Deviated Trachea
 Broken ribs
 Injuries to chest wall

15. B- Breathing and Ventilation
 Identify Life Threatening Injuries
– Tension Pneumothorax
 Air trapping in the pleural space between the lung and chest wall
 Sufficient pressure builds up and pressure to compress the lungs and shift
the mediastinum
 Physical exam
– Absent breath sounds
– Air hunger
– Distended neck veins
– Tracheal shift
 Treatment
– Needle Decompression
 2nd Intercostal space, Midclavicular line
– Tube Thoracostomy
 5th Intercostal space, Anterior axillary line

16. Thoracic Trauma
• 8 lethal Injury
1. Simple pneumothorax
2. Hemothorax
3. Pulmonary contusion
4. Tracheo-bronchial tree injury
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Mediastinal traversing wounds.

17. B- Breathing and Ventilation
 Ventilate with 100% oxygen
 Needle decompression if tension pneumothorax suspected
 Chest tubes for pneumothorax / hemothorax
 Occlusive dressing to sucking chest wound
 If intubated, evaluate ETT position

18. Chest Tube Insertion

19. C- Circulation
 Hemorrhagic shock should be assumed in any hypotensive
trauma patient
 Rapid assessment of hemodynamic status
– Level of consciousness
– Skin color
– Pulses in four extremities
– Blood pressure and pulse pressure

20. C- Circulation
• Normal Blood Amount:
Normal adult blood volume : 7% of body weight
Normal blood volume for child : 8-9% of body weight
• Hemorrhage Classification :
Class I Hemorrhage : up to 15% loss
Class II Hemorrhage : 15-30% loss
Class III Hemorrhage : 30-40% loss
Class IV Hemorrhage : >40% loss

21. 3 for 1 Rule
• A rough guideline for the total amount of crystalloid volume is
to replace each ML of blood loss with 3 ML of crystalloid
fluid, thus allowing for restitution of plasma volume lost into
the interstitial & intracellular space

22. Initial Fluid Therapy
Lactated Ringer is preferred
• For adult 1-2 liters bolus
• For child 20ml/kg bolus

23. Fluid Therapy in
2nd or 3rd Degree Burn
• Total amount of first 24 hours:
• 4 ml of Ringer lactate x BW(kg) x BSA
– give 1/2 in first 8 hrs
– 1/2 in remaining 16 hrs

24. D- Disability
 Abbreviated neurological exam
– Level of consciousness
– Pupil size and reactivity
– Motor function
– GCS
• Utilized to determine severity of injury
• Guide for urgency of head CT and ICP monitoring

25. GCS
• Mild : GCS 14-15
• Moderate : GCS 9-13
• Severe : GCS 3-8
• Coma = GCS score of 8 or less

26. Disability Interventions
 Spinal cord injury
– High dose steroids if within 8 hours
 ICP monitor- Neurosurgical consultation
 Elevated ICP
– Head of bed elevated
– Mannitol
– Hyperventilation
– Emergent decompression

27. E- Exposure
 Complete disrobing of patient
 Logroll to inspect back
 Rectal temperature
 Warm blankets/external warming device to prevent
hypothermia

28. Always Inspect the Back

29. ADJUNCT TO PRIMARY SURVEY &
RESUSCITATION
• A. Electro-cardiographic Monitoring
• B. Urinary & Gastric Catheter
– Urinary catheter.
– Urethral injury should be suspected if
– Blood at the penile meatus
– Perineal ecchymosis
– Blood in the scrotum
– High riding or nonpalpable prostate
– Pelvic fracture

30. Secondary Survey
 Physical exam from head to toe, including rectal exam
 Frequent reassessment of vitals

31. Secondary Survey
 AMPLE History
– Allergies
– Medications
– Past Medical History, Pregnancy
– Last Meal
– Events surrounding injury, Environment
 History may need to be gathered from family members or
ambulance service

32. Adjuncts to Secondary Survey
 Radiology
– Standard emergent films
C-spine, CXR, Pelvis
– Focused Abdominal Sonography in Trauma (FAST)
– Additional films
Cat scan imaging
Angiography
 Pain Control
 Tetanus Status
 Antibiotics for open fractures

33. Diagnostic Aids
 Standard trauma labs
– CBC, K, Cr, PTT, ABG
 Standard trauma radiographs
– CXR, pelvis, lateral C-spine
 CT/FAST scans

34. FAST Exam
• Focused Abdominal Sonography in Trauma
• 4 views of the abdomen to look for fluid.
– RUQ/Morrison’s pouch
– Sub-xiphoid – view of heart
– LUQ – view of spleno-renal junction
– Bladder – view of pelvis

35. FAST Exam
• Sensitivity of 94.6%
• Specificity of 95.1%
• Overall accuracy of 94.9% in identifying the presence of intra-
abdominal injuries*
*Yoshil: J Trauma 1998; 45

36. FAST-Right Upper Quadrant - Morrison’s
• Between the liver and
kidney in RUQ.
• First place that fluid collects
in supine patient
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

37. FAST – Sub-xiphoid
• Evaluate for pericardial fluid
• View through liver
– Transhepatic or
Parasternal
• Searches for fluid between
heart and pericardium
University of Louisville ED.
www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

38. FAST – Left Upper Quadrant
• View between the spleen and
kidney
• Another dependent place that fluid
collects
• Also see diaphragm in this view
University of Louisville ED,
www.louisville.edu/medschool/emergmed/ultrasoundfast.htm

39. FAST- Bladder view

40. Simple Pneumothorax

41. Tension Pneumothorax

42. Hemothorax

43. Widened Mediastinum
www.trauma.org/index.php/main/image/45/prin

44. Bilateral Pubic Ramus Fractures and
Sacroiliac Joint Disruption
Author unknown, http://www.itim.nsw.gov.au/images/Open_book_pelvic_fracture_xray.jpg

45. http://rad.usuhs.mil/medpix/tachy_pics/thumb/synpic4098.jpg

46. Abdominal contents up in the chest
http://commons.wikimedia.org/wiki/File:Diaphragmatic_rupture_spleen_herniation.jpg

47. Trauma in Special Populations
Pregnancy
– Supine Hypotensive Syndrome
After 20 weeks, enlarged uterus with fetus and amniotic
fluid compresses inferior vena cava
Decreases venous return and decrease cardiac output
Keep pregnant patients in left lateral decubitus position
to avoid excessive hypotension
– Optimal maternal and fetal outcome is determined by
adequate resuscitation of mother
– Fetal Monitoring

48. Priorities with multiple injuries
1. Thoracic trauma or tamponade
2. Abdominal hemorrhage
3. Pelvic Hemorrhage
4. Extremity Hemorrhage
5. Intra-cranial Injury
6. Acute Spinal Cord Injury

49. Definitive Care
Secondary Survey followed by radiographic evaluation
Consultation:
• Neurosurgery
• Orthopedic Surgery
• Vascular Surgery
Transfer to Definitive Care:
• Operating Room
• ICU
• Higher level facility

50. ATLS 9th Edition Compendium of changes

51. ATLS 9th Edition Compendium of changes

52. ATLS 9th Edition Compendium of changes

53. Source
American College of Surgeons. Advanced Trauma Life Support.
9th. 2012
Hockberger, Robert et al. Rosen’s Emergency Medicine:
Concepts and Clinical Practice. 6th Edition. Mosby. 2006.
Tintinalli et al. Tintinalli’s Emergency Medicine: A
Comprehensive Study Guide. 6th Edition. McGraw Hill. 2003.

54. Thank you,
Have a nice day…