General Surgery BDS 3rd year

1. ADVANCED
TRAUMA LIFE
SUPPORT
S A N A R A S H E E D
A K H TA R S A E E D M E D I C A L A N D D E N TA L C O L L E G E

2. THE STEPS IN THE ATLS PHILOSOPHY
Primary Survey
with simultaneous
resuscitation –
identify and treat
what is killing the
patient.
Secondary survey
– proceed to
identify all other
injuries.
Definitive care –
develop a
definitive
management plan

3. PRIMARY SURVEY AND
RESUSCITATION
• Patient management must consist of a rapid primary evaluation, resuscitation of vital
functions, a more detailed secondary assessment and, finally, the initiation of
definitive care.
• This is the heartbeat core of the ATLS system and constitutes the ABCDE of trauma
care.

5. AIRWAY WITH CERVICAL
SPINE PROTECTION

6. AIRWAY WITH CERVICAL
SPINE PROTECTION
• Check for verbal response. If its present, then the patient’s airway is not immediately at
risk.
• If there is no or limited response, then a rapid investigation and assessment for signs
of airway obstruction should be undertaken.
• This includes
• Inspection for foreign bodies,
• Maxillofacial or mandibular fractures,
• Tracheal or laryngeal injury
• Oedema

7. • Measures to ensure a patent airway should be instituted while protecting the cervical
spine.
• The chin lift or jaw thrust manoeuvres.
• A normal neurological examination should not exclude a cervical spine injury.
• Protection of the cervical spine should be maintained throughout either by
stabilisation equipment or by a member of the trauma team when it is required that
the patient be moved or turned.

8. BREATHING AND VENTILATION

9. BREATHING AND VENTILATION
• Oxygen must be administered to all trauma patients, usually at high flow and via a
reservoir mask.
• Ventilation requires an adequately functioning chest wall, lungs and diaphragm, and
each must be systematically evaluated.
• Signs of surgical emphysema,
• dilatation of the neck veins,
• symmetry of the chest wall,
• respiratory effort and rate
• should be evaluated and recorded.
• Percussion and auscultation should be performed both front and back after log rolling.

10. • Acute tension pneumothorax,
• flail chest with contusion,
• massive haemothorax and
• open pneumothorax
• are examples of life-threatening injuries that must be identified in the primary survey,
i.e. they are not radiological diagnoses.

11. • Critical findings include the
• Absence of or asymmetry of breath sounds,
• Tracheal deviation,
• Hyperresonance (consistent with tension pneumothorax)
• or dullness to percussion (haemothorax).

12. • Treat pneumothorax, haemothorax and tension
pneumothorax with a
• Tube thoracostomy.
• As an emergency measure in tension
pneumothorax, immediately decompress with
the insertion of a needle into the pleural space
in the mid-clavicular line two finger breadths
below the clavicle,
• followed by chest drain insertion.

13. TUBE THORACOSTOMY

14. CHEST DRAIN INSERTION

15. CIRCULATION AND CONTROL OF
BLEEDING

16. CIRCULATION AND CONTROL OF
BLEEDING
• Assessment here centres on three critical clinical observations:
• 1. Conscious level
• If this is impaired or altered, one must assume
• that the patient has lost a significant amount of blood as cerebral
• perfusion has become compromised.
• 2. Skin colour
• A patient with pink skin and warm peripheries is not hypovolemic.
• Critically hypovolemic: pale, ashen, grey-looking patient with ominous signs of
hypovolaemia.

17. CIRCULATION AND CONTROL OF
BLEEDING
• 3 Pulse
• Full, slow, regular peripheral pulses are usual signs of relative
• normovolaemia, whereas a rapid, thready pulse or, worse
• still, one that is not peripherally palpable is a grave sign of
• hypovolaemic shock, and blood volume must be rapidly
• restored

18. DISABILITY
• The GCS allows for a very rapid assessment of the patient’s level
• of consciousness, pupillary size and reaction, motor function and,
• therefore, injury level and is also a good prognostic indicator.
• It should be noted, however, that hypoglycaemia, alcohol and
• drug abuse may also alter the level of consciousness and should
• also be excluded.

19. GLASGOW COMA SCALE (GCS)
• The GCS is composed of eye (E), verbal (V) and motor (M)
• Responses. The best possible score is 15/15 and the worst possible score is 3/15.

20. EXPOSURE
• The patient must be fully exposed and examined front and back
• using a carefully controlled log roll. Spinal alignment must be
• maintained during this procedure with in-line traction. Hypothermia
• can be rapid following trauma, and warming air blankets
• are vitally important in the resuscitative phase.

22. SECONDARY SURVEY
• This starts after completion of the primary survey and once initial
• resuscitative measures have commenced.
• The purpose of the secondary survey is to identify all injuries and perform a more
• thorough ‘head to toe’ examination.
• If possible, it is here that the patient’s history is reviewed.

24. Subsequent physical examination
• Examine each region of the body for signs of injury, bony instability and tenderness to
palpation.
Head and face
• Evaluate the head and face for
• Maxillofacial fractures,
• Ocular injury,
• Open head injury and
• any evidence of bleeding or discharge from the ears suggestive of a basal skull fracture.
• Inspect the mouth, mandible, zygoma, nose and ears.
• This excludes midfacial injury and potential airway compromise.

25. Neck
• Inspect and palpate the cervical spine anteriorly and posteriorly for haematomas,
crepitus, tenderness and evidence of steps on palpation.
• In trauma where the cause and energy of injury is uncertain and where there has been
a significant maxillofacial or head injury, assume a cervical spine injury until definitively
excluded with radiology and clinical evaluation.
• The spine is held immobilised with a hard collar, sandbag and tape across the
forehead.
• Wounds should be fully evaluated and formally explored in theatre if deeper than the
platysma muscle layer.

26. Chest.
• Review the primary survey and perform full palpation and auscultation of the chest
wall front and (once log rolled) back.
• Palpate the entire chest wall including the clavicle, sternum and ribs.
• Sternal fractures have a high incidence of damage to the underlying cardiovascular
structures, and
• monitoring must be present for 24–48 hours after injury.
• Distended neck veins, distant heart sounds and narrow pulse pressure may suggest
cardiac tamponade

27. Neurological
• Examine the GCS repeatedly (at least every 15 min).
• Perform a full neurological examination if the patient’s condition allows.
• Any evidence of sensory and motor disturbance requires full spinal immobilisation and
urgent review by the neurosurgeons or spinal orthopaedic surgeons with imaging as
appropriate.

28. Abdomen and pelvis
• Inspect for distension, explore low velocity local wounds to assess the depth of
involvement; high-velocity injuries should be urgently evaluated in the operating
room.
• Palpate the iliac crests for instability to detect significant fractures.
• Inspect the perineum for evidence of ecchymosis or bleeding.
• A rectal examination is needed to assess tone, prostate level and to look for bleeding.
• A high index of suspicion is often required with abdominal injuries, so frequent re-
evaluation is important as injuries may not manifest themselves in the early stages.

29. Extremities
• Unless there is severe haemorrhage, the injury to the limb is not immediately life
threatening and focus must be maintained on the primary survey and sequence as
above.
• Obviously deformed limbs should be manipulated into as near anatomical alignment
as possible, remembering to document neurovascular status before and after the
intervention.
• Palpate the upper and lower limbs meticulously and systematically and document all
findings.
• Remember to move the relevant joints to exclude dislocations.
• Neurovascular status must be recorded for each limb especially if a fracture is
identified proximally

30. Log roll
• Once the patient has been evaluated anteriorly, it is imperative that a log roll is performed
to inspect the back.
• One member of the team is responsible for maintaining in-line spinal stabilisation (usually
the anaesthetist when the patient is intubated), and it is on this person’s orders that a
gentle log roll is performed.
Remember that at least four people are required for a safe log roll procedure:
• one for the spinal in-line traction,
• one for the torso and
• one for the pelvis and lower limbs (which ideally should be strapped together).
• The fourth person removes the spinal board and performs a detailed assessment of the
back. Inspect the entire spine from occiput to sacrum for bony abnormalities. Identify any
penetrating injuries or exit wounds from gunshot injuries and dress accordingly.
• Percuss, palpate and auscultate the posterior chest wall.

31. REFERENCES
• Bailey and Love's Short Practice of Surgery
• McGraw Hill Company