2. ADVANCED TRAUMA LIFE SUPPORT (ATLS)
1. Primary survey and Resuscitation
• A = Airway and cervical spine
• B = Breathing
• C = Circulation and haemorrhage control
• D = Dysfunction of the central nervous system
• E = Exposure
2. Secondary Survey - Head to Toe Examination
• History
• Head. Face. Eyes Ears. Nose. Neck
• Chest, Abdomen & Pelvis
• Musculoskeletal
3. Definitive Treatment
1. Primary Survey and Resuscitation
A. Airway and Cervical Spine
• Secure the airway as the initial action in trauma resuscitation
• A cervical spine injury should be assumed until proven otherwise
• Place a collar until cervical spine has been confirmed to be intact
• If patient can talk then he is able to maintain own airway
• If airway compromised attempt a chin lift and clear airway of foreign bodies
• If gag reflex present insert nasopharyngeal airway
• If no gag reflex put in an endotracheal tube
• If unable to intubate do a cricothyroidotomy
3. • Give 100% oxygen through a mask
Airway assessment
• The patient should be asked a simple question
• If he responds appropriately
o The airway is patent
o Ventilation is intact
o The brain is being adequately perfused
• Confusion and agitation is usually a sign of hypoxia
Airway management
• These can be achieved with
• (a) Basic, (b) advanced and (c) surgical techniques
(a) Basic life support
• Foreign bodies should be removed from the mouth and throat
• Secretions and blood should be removed with suction
• Airway can usually be secured with a chin lift or jaw thrust
• An oropharyngeal airway may be required
• Oxygen should be given at a rate of 10-12 l/min
• Use a tight fitting mask
(b) Advanced measures
• If absent gag reflex, endotracheal intubation is required
• If no cervical spine fracture orotracheal intubation is preferred
• If cervical spine injury can not be excluded consider nasotracheal intubation
• The position of the tube should be checked
• Complications include:
o Oesophageal intubation
o Intubation of right main bronchus
o Failure of intubation
o Aspiration
(c) Surgical airways
• If unable to intubate the trachea a surgical airway is required
• There are few indications for an emergency tracheostomy
• Surgical airway can be achieved with a needle or surgical cricothyroidotomy
4. Needle cricothyroidotomy
• Cricothyroid membrane is punctured with a 12 or 14 Fr cannula
• Connected to oxygen supply via a Y connector
• Oxygen supplied at a rate of 15 l/min
• Jet insufflation achieved by occlusion of Y connection
• Insufflation provided one second on and four seconds off
• Jet insufflation can result in significant hypercarbia
• Should only be used for 30 - 40 minutes
Surgical cricothyroidotomy
• A small incision is made over cricothyroid membrane
• 5 mm incision made in membrane
• Small tracheostomy tube inserted
• Complications of surgical airways include:
o Aspiration
o Haemorrhage / haematoma
o Cellulitis
o False passage
o Subglottic stenosis
o Mediastinal emphysema
B. Breathing
o Check position of trachea, respiratory rate and air entry
o If clinical evidence of tension pneumothorax will need immediate
relief
o Place venous cannula through second intercostal space in the mid-
clavicular line
o If open chest wound seal with occlusive dressing
Ventilation
• In the non-intubated patient ventilation can be achieved with either
o Mouth to face-mask
o Bag-valve-face-mask
• The later is more efficient if performed with a two person technique
• One maintains face seal - other ventilates patient
• If endotracheal intubation required should be performed with cricoid pressure
• If rib fractures present need to insert chest drain on side of injury to prevent
pneumothorax
5. C. Circulation
o Assess pulse, capillary return and state of neck veins
o Identify exsanguinating haemorrhage and apply direct pressure
o Place two large calibre intravenous cannulas
o Take venous blood for FBC, U+E, and Cross match
o Take sample for arterial blood gasses
o Give intravenous fluids
o Crystalloid or colloid in adequate volume
o Attach patient to ECG monitor
o Insert urinary catheter
Hypovolaemic shock
Grades of hypovolaemic shock
• Grade 1
o 15% blood volume (~750 ml)
o Mild resting tachycardia
• Grade 2
o 15 - 30% blood volume (750 - 1500 ml)
o Moderate tachycardia, fall in pulse pressure, delayed capillary return
• Grade 3
o 30 - 40% blood volume (1500 - 2000 ml)
o Hypotension, tachycardia, low urine output
• Grade 4
o 40-50% blood volume (2000 -2500 ml)
o As above but with profound hypotension
Fluid resuscitation and blood transfusion
• Early volume intravascular volume replacement in trauma patients is essential
• The ideal resuscitation fluid is uncertain
• Timing and end-points of resuscitation unclear
A. STABLE PATIENT
1. 3L of crystalloid (Ringer Lactate or Normal Saline) / 24 hrs.
2. Transfuse if Hb < 8 gm / dl; use clinical judgement
- 1 unit over 4 hrs for each gram below 8 gm / dl
B. UNSTABLE PATIENT
6. - (Blood group & X match 4 units. Active bleeding: 6-8 units.)
1. 2L of crystalloid (Ringer Lactate or Normal Saline- Rapidly)
2. Assess clinical response:
• Rapid response : Reduce rate
• Transient response: Continue fluids. Initiate B/T.
• Minimal or no response: Rapid Blood Transfusion.
- Consider O –ve blood in urgent situation
- Transfuse 1 unit of blood over each 15 min.
- Increase rate if BP fails to rise or falls.
- Stop blood if patient stable and maintain IV fluids.
(Massive transfusion – citrate toxicity/ K+ toxicity / coagulation disorders)
• Aim - Maintain vital signs : P, BP, CVP
- Maintain urinary catheter output > 30 ml/hr
- Maintain Hct at over 30%
3. If CVP is measured
• Infuse until CVP > 5 cm water
• If CVP > 12 cm & BP > 100 mm Hg – Stop infusion/ Frusemide
• If CVP > 12 cm & BP < 100 mm Hg - Transfer to ICU
- Dopamine 5mcg/kg/min or
- Dobutamine 2.5-5 mcg/kg/min
- Involve physician
Crystalloid versus Colloid
• None of the trials of crystalloid vs. colloid resuscitation has shown either type
of fluid to be associated with a reduction in mortality
• No single type of colloid has been shown to be superior
• Albumin solution may be associated with slight increase in mortality
• Colloids can more rapidly correct hypovolaemia
• Also maintain intravascular oncotic pressure
• Crystalloids require large volume but are equally effective
• Cheaper and have fewer adverse side effects
7. Hypertonic solutions
• Subjected to recent intensive investigation
• Can resuscitate patient rapidly with a reduced volume of fluid
• May reduce cerebral oedema in patients with severe head injuries
Oxygen therapeutic agents
• Currently being extensively investigated in clinical trials
• Not widely used at present outside of clinical trials
• Potential advantages over blood include:
o Free potential viral contamination
o Longer shelf life
o Universal ABO compatibility
o Similar oxygen carrying capacity to blood
• Agents being studied include:
o Perflurocarbons
o Human haemoglobin solutions
o Polymerised bovine haemoglobin
IV. Dysfunction
o Assess level of consciousness using AVPU method
(A = alert, V = responding to voice, P = responding to pain, U= unresponsive)
o Or use the GCS
o Assess pupil size, equality and responsiveness
V. Exposure
o Fully undress the patient for a complete- head to toe examination
o Avoid hypothermia
8. Secondary Survey & Definitive Management
History
AMPLE
• Allergies
• Medications
• Past illnesses
• Last meal
• Events/environment related to injury
1. Blunt trauma - Direction and speed of impact
2. Pentrating trauma
3. Thermal injury
4. Exposure to chemicals/radiation and toxins
Examination
• Shock
Shock is a state characterized by inadequate tissue and organ perfusion
1. Haemorrhagic shock
2. Cardiogenic shock
3. Tension pneumothorax
4. Neurogenic shock
5. Septic shock
• Head and Neck
• Chest
• Abdomen
• Musculoskeletal System
• Neurological
For patients in shock and those planned for surgery:
9. • Ensure adequate perfusion
• Catheterize provided there is no blood at meatus or in scrotum, and prostate is
palpable
• Nasogastric tube
• Preoperative prophylactic antibiotic cover