advanced trauma life support..pdf

Advanced Trauma Life Support (ATLS)
By: kanbiro Gedeno (BSc, MSc in ACA)
kanbgedeno45@gmail.com

Outline:
 Introduction
 Primary survey
 Secondary survey
 Tertiary survey
 References
5/11/2023 kanbgedeno45@gmail.com ATLS 2

Objectives:
At the end of this seminar, you will be
able to:
 Prioritize the management of trauma cases
 Resuscitate the patients during the primary
survey simultanesuly with assessment.
 Recognize life threatening injuries during
primary and secondary survey
 Stabilize a multiple injured patient during
tertiary survey

Case scenario:
 A 25-year-old man falls off the back of a truck
and hits his head. On arrival in your
hospital, he is unconscious and his breathing
is noisy.
How would you assess his airway quickly?
What are the signs of airway obstruction?
How would you open his airway?
Assess his breathing?
How would you assess his circulation?

Introduction:
 Trauma is a leading cause of morbidity and
mortality in all age groups and mortality rate
higher in developing countries.
 The third leading cause of death after heart
disease and cancer.
 Road traffic injuries are the leading cause of
injury-related deaths worldwide followed by
bullet injury, violence, burns, drowning, falls
and poisoning.
(WHO, Violence and Health. 2012)

 Trimodal death distribution:
1st peak: Seconds - minutes (50% deaths)=>
occurs at the time of the injury.
 Overwhelming primary injury to major organs or
structures: Brain, spinal cord, heart, & great vessels.
2nd peak: 1-2 hours (35% deaths)=> the "golden
hour".
 Due to: Head injury, chest, abdomen, fractures
causing large blood loss.
 Trauma care can prevent by avoidance of secondary
injury due to hypoxia, hemorrhage, shock,…

3rd peak: Days to weeks (15% deaths)=> usually
occurs in a high dependency area.
 Due to: Sepsis, & multiple organ failure.
 Improvements on initial management upon
admission will reduce morbidity and mortality
 Research done in the United States, shows that
receiving care at a Level I trauma center can
decrease the risk for death among seriously
injured patients by 25%.

Advanced Trauma Life Support (ATLS):
 Preparation
 Triage
 Primary survey
 Secondary survey
 Tertiary survey
 Stabilization & Transfer
 Definitive care

Triage:
Sorting of patients based on the:
 Resources required for treatment and the
resources that are actually available.
 Order of treatment is ABC priorities
 Severity of injury, ability to survive, and
available resources

Multiple Casualties:
 Do not exceed the capability of the facility to care.
 Patients with life-threatening problems and
sustaining multiple-system injuries are treated first.
Mass Casualties:
 Does exceed the capability of the facility and
staff.
 Patients having the greatest chance of survival
and requiring the least expenditure of time,
equipment, supplies, and personnel are
treated first.

Primary survey and Resuscitation:
 ABCDE or MARCH approach
 Rapid 2- 5 minute examination
 Simultaneous efforts to identify and treat life-
threatening injuries.
 Beginning with the most immediate.
 Focus on urgent problems first (“golden hour”).
 Better outcomes are achieved with faster diagnosis
and treatment.

ABCDE approach:
Airway and Cervical spine control:
Airway:
 Establishing and maintaining an airway is the
first priority.
 Provide sufficient oxygen to the tissues in order
to prevent secondary organ failure and central
nervous system damage.
 Ensure a clear and unobstructed airway

 If a patient can talk the airway is usually clear.
 If not, assess: Look, feel, listen
Colour, conscious state, foreign bodies,
Signs of airway obstruction: Noisy breathing
(snoring, gurgling, stridor), agitation (hypoxia),
use of accessory muscles, paradoxical chest
movement, cyanosis

Airway management:
Basic techniques:
 Chin lift
 Jaw thrust

Adjuncts:
 Suction
 Oropharyngeal airway
 Nasopharyngeal airway
 Bag valve mask (BVM)
Advanced Techniques
 Supraglottic airway eg: LMA
 Tracheal intubation
 Surgical Airway
Unable to intubate & unable to ventilate.

 Airway assessment used to recognized the
possibility of a difficult airway use the “Lemon”
rule:
 Look externally
 Evaluate the 3-3-2 rule…finger breadth.
 Mallampati
 Obstruction
 Neck mobility

 A study showed that the modified LEMON score is
correlated with difficult intubation in adult trauma
patients compared with none difficult (3 [2-5] vs. 2
[1-3], respectively, P = 0.017), and limited neck
mobility independent predictor of intubation
difficulty (OR= 6.15; P = 0.002).
 Other study observed that the LEMON score is
60% sensitive and 96.15% specific, and positive
predictive value 83.33% => reduce the chance of
unexpectedly encountering difficult airway.
(Ji et al. 2018)
(Varsha Shinde et al. 2019)

 The “HEAVEN” criteria:
 Hypoxemia: SpO2≤93% at initial laryngoscopy
 Extremes of size: age ≤8 years or clinical obesity
 Anatomic challenge: trauma, swelling, foreign
body,
 Vomit/blood/fluid: fluid present in the
pharynx/hypopharynx at the time of
laryngoscopy
 Exsanguination: suspected anemia accelerate
desaturation during RSI-associated apnea
 Neck – limited cervical range-of-moon

 A study observed an inverse relationship between
total HEAVEN criteria and intubation success
(first-attempt success with no criteria = 94% and
with 5 + criteria= 43%)=> useful tool to predict
difficult airways in emergency RSI
 Another study showed that HEAVEN criteria high
sensitivity at predicting difficult airways.
(D.P. Davis, D.J. Olvera et al. 2017)
(E. Kuzmack et al. 2017)

 Indication for immediate intubation:
 Airway obstruction unrelieved by basic airway
maneuvers
 Impending airway obstruction
 GCS<9
 Hemorrhage from maxillofacial injuries
compromising the airway
 Respiratory failure secondary to chest or
neurological injury
 The need for resuscitative surgery

Challenges for airway management:
 Direct airway injuries
 Full stomach
 Difficult airway
 Head, open eye, and contained major
vessel injuries
 Cervical spine injury

Cervical spine control:
 Overall of C-spine injuries, 2% to 4% of blunt
trauma patients=> 7% to 15% are unstable
 Cervical spine injury is unlikely in alert patients
without neck pain or tenderness.
 National Emergency X-Radiography Utilization
Study (NEXUS) criteria:
1. Neck pain
2. Severe distracting pain
3. Any neurological signs or symptoms
4. Intoxication
5. Loss of consciousness at the scene.
(Crosby ET et al. 2006)
(Hoffman JR et al. 2000)

 A cervical spine fracture must be assumed if any
one of these criteria is present, even if there is no
known injury above the level of the clavicle.
 Neck hyperextension and excessive axial
traction must be avoided when ever cervical
spine instability is suspected.

 The Canadian C-spine rule:

 Comparison of these two sets of criteria showed
that the Canadian rule is more reliable than
those for NEXUS in diagnosing C-spine injury in
responsive patients.
 A prospective analytical study compare the
effectiveness showed that sensitivity for neck
radiography by both NEXUS and CCR found to
be 90%, while specificities 54.73% and 44.2% for
NEXUS and CCR respectively.
(Ala et al. 2018)
(Stiell IG et al. 2018)

 A systematic review found that the Canadian C
spine rule, sensitivity (0.90 to 1.00) and
specificity (0.01 to 0.77), and NEXUS, sensitivity
(0.83 to 1.00) and specificity (0.02 to 0.46). The
Canadian C spine rule have better diagnostic
accuracy than the NEXUS criteria.
 Magnetic resonance imaging (MRI) is a reliable
tool and gold standard for ruling out C-spine
injury.
(Zoe A et al. 2012)

Immobilize C-spine:
 Manual in-line stabilization (MILS)
 Sandbags
 Forehead Tape
 Axial traction
 Soft collar
 Philadelphia [hard] collar

 Airway Management in C-spine injury:
 Almost all airway maneuvers result in some degree of C-
spine movement =>but neurologic deficits related to
airway management very few.
 A study reviewed for perioperative cervical cord, nerve
root, and spine injury showed that overall airway
management–related neurologic damage represented
11%.
 Manual in-line stabilization of the head and neck by an
assistant (two operators) should be used to stabilize the
cervical spine during laryngoscopy.
(Hindman et al. 2000)
(Crosby ET et al. 2006)

 The MILS suboptimal the direct laryngoscopy
glottic view in 10% to 15% of patients due to
limitation of neck extension.
Further compromised in patients with
prevertebral space hematoma from the
vertebral fracture.
 To visualize the larynx needs greater anterior
pressure to be applied to the tongue by the
laryngoscope blade => leads to unstable
vertebral segment.

 A study demonstrated that during various
phases of direct laryngoscopy and intubation,
the pressures exerted on the tongue and
indirectly to the spine were greater with MILS
than without MILS.
 This study confirmed, the another study of a
video fluoroscopic demonstrated significant
anteroposterior displacement when MILS was
applied to cadavers with destabilized C-spines.
(Santoni et al. 2009)
(Lennarson et al. 2001)

 Consider to use other advanced measures and
techniques:
(McCoy laryngoscope, Glidescope,..), gum
elastic bougie, awake FOB, translaryngeal
(retrograde) intubation, and
cricothyroidotomy
 Cricoid pressure should be applied with great
care it may produce excessive motion of the
unstable spine.

 In cooperation patient use of FOB in the awake
is preferred (absence signs of cranial base
fracture) due to=>
Minimal movement of the neck,
Positioning of the patient awake,
Maintenance of protective reflexes, and
The ability to assess the neurologic status after
intubation.

 The anterior portion of the hard collar limits
mouth opening => removed after
immobilization.
 Randomized prospective comparative study of
intubation success rates performing inline
stabilization with and without cervical hard
collar found that:
 The rate of successful intubation significantly
higher using manual stabilization without
cervical hard collar (96.8%) vs. (88.7%); p=0.048).
(Welawat Tienpratarn et al. 2020)

Breathing:
 Adequate gas exchange is required to maximize
oxygenation and carbon dioxide elimination.
 Ventilation requires adequate function of the
lungs, chest wall and diaphragm.
 Assessment of ventilation by the look, listen,
and feel approach.
 Give high flow 100% oxygen and assist
ventilation if necessary.

 Assess for immediate life threatening injuries:
 Tension pneumothorax,
 Open pneumothorax
 Massive hemothorax
 Cardiac tamponade
 Potentially life-threatening injuries:
 Simple pneumothorax
 Hemothorax
 Flail chest
 Pulmonary contusion
 Traumatic diaphragmatic injury

Tension Pneumothorax: ‘one-way valve’
 Air is forced in during inspiration and coughing, but
unable to escape during expiration.
 ↑ Intrathoracic pressure=> Mediastinal shift=> ↓ venous
return (↓ cardiac output) + Respiratory distress and
hypoxia.
 Classic signs:
 Cyanosis, tachypnea, hypotension, neck vein distention
(may absent in hypovolemia), tracheal deviation, and
diminished breath sounds on the affected side

 Do not delay treatment to obtain radiologic
confirmation=> clinical diagnosis
 Immediate decompression with insertion of a
large bore 14-gauge angiocatheter needle
through:
 The 2nd intercostal space mid clavicular line or 4th
intercostal space in the midaxillary line
 Chest wall thickness influences the success with
needle decompression.

 Evidence suggests that a 5-cm needle reach the
pleural space >50% of the time, whereas an 8-cm
needle reach the pleural space >90% of the time.
 A multicenter prospective cohort study found that
chances of successful needle decompression of a
tension pneumothorax are significantly higher in
ICS2-MCL compared to ICS 4/5-AAL.
(N. Azizi, E. ter Avest, A.E. Hoek et al. 2020)

 Successful needle decompression converts
tension pneumothorax to a simple
pneumothorax.
 Continual reassessment of the patient is
necessary: subsequent pneumothorax
 Tube thoracostomy (Formal chest drain)is
mandatory after needle or finger decompression
of the chest.

Open pneumothorax: ”Sucking chest wound”
 Defect more than 0.75 times the diameter of the
trachea=> equilibration between intrathoracic
pressure and atmospheric pressure.
 During inspiration air entrained into the chest cavity
through the wound.
 Occlude wound (on 3 sides only) to provide a
‘flutter-valve effect’
 Cover and insert chest drain away from the
wound in the same hemi- thorax

Massive haemothorax: (>1500 ml of blood in
the hemi - thorax)
 ↓Breath sounds, percussion dull, ↓chest wall
movement, hypovolemic shock,..
 A single large bore chest drain tube (28-32
French) is inserted, at the fifth intercostal space,
just anterior to the midaxillary line, and
simultaneous volume replacement.
 Lung re-expansion may stop bleeding.

If bleeding persists need for urgent thoracotomy:
 1500 mL or more of blood
 Initial output of less than 1500 mL of blood, but
continue to bleed,
 The rate of continuing blood loss (200 mL/hr for
2 to 4 hours),
 The patient’s physiologic status

Cardiac tamponade:
 Compression of the heart by an accumulation of
fluid in the pericardial sac=> ventricles cannot
completely fill or contract.
 The presence of Beck's triad : Neck vein
distention, Hypotension, and Muffled heart
tones.
 Haemodynamic instability and PEA cardiac
arrest.

 Kussmaul’s sign (rise in venous pressure with
inspiration when breathing spontaneously) is a true
paradoxical venous pressure abnormality
 FAST scan s 90–95% accurate in identifying the
presence of pericardial fluid for the experienced
operator.
 Bedside echocardiography
 Rescustation and Pericardiocentesis
 May need cardiothoracic surgery

Circulation:
 Hemorrhage is the most common cause of
traumatic hypotension and shock.
 Primary goal is the urgent surgical control of the
source of bleeding.
 Recognize its presence: Peripheral colour,
capillary refill, heart rate, Peripheral
temperature, Blood pressure, Urine output

Adapted with permission from American College of Surgeons, Committee on Trauma. Shock,
Advanced Trauma Life Support Student Course Manual. 8th ed. Chicago: American College of
Surgeons; 2008:55–71.
 Hemorrhagic shock grading:

 A study showed that sensitivity of the shock
grading tool: 83%, and diagnostic accuracy: 0.86.
 Shock index (SI): HR/SBP
 More accurate indicator of early hemorrhagic shock
and a predictor of mortality than the individual vital
signs.
 Normal range= 0.58 - 0.64 (mean 0.61), but after
moderate degree of blood loss increases from 0.70 to
0.80 (mean 0.75).
(Lawton LD, et al. 2014)
(Zarzaur BL et al. 2010)

 A retrospective analysis found that the cutoff point
of SI for predicting MTP is 0.81 (sensitivity: 85%;
specificity: 64%; positive predictive value: 16%; and
negative predictive value: 98% and can be used
early to predict the need for MTP, laparotomy and
mortality.
 Prehospital SI and prehospital MSI showed
moderate accuracy in predicting MT AUROCs:
0.773 (95% [CI]: 0.746–0.798) and 0.765 (95% CI:
0.738–0.791), respectively.
(A. El-Menyar et al. 2018)
(I.-J. Wang et al. 2019)

 Identify the probable cause:
Hemorrhagic: is the most common cause of
shock after injury.
 Accounts 50% of deaths in the first 24 hours after
injury.
 Compressible / external: Usually peripheral
 Non-compressible: surgery required
 Pleural Cavity, Abdominal Cavity, Pelvic Fractures,
Femoral Shaft

Non haemorrhagic: Cardiogenic, neurogenic.
septic shock, obstructive shock
 Treatment should be initiated simultaneously:
 Control hemorrhage
 Restore volume
 Reassess patient
 Prevention of the lethal triad: hypothermia,
coagulopathy and acidosis.

 Initial fluid resuscitation: 2 L, 20 mL/kg
(children) of RL or NS over 15 to 30 minutes.
 Risks of aggressive early volume resuscitation:
 Dilution of red cell mass reduces O2 delivery
 Hypothermia and coagulopathy
 Increased arterial blood pressure leads to increased
bleeding
 A study demonstrated that hypotensive
resuscitation has better outcome in penetrating,
but not in blunt trauma.
(Dutton RP et al.2002)

 The goals of resuscitation assessed by:
Base deicit and blood lactate:
 A study found that an admission base deicit
below –5 to –8 mmol/L correlates with increased
mortality.
 Failure to clear lactate within 24 hours after
reversal of circulatory shock is a predictor of
increased mortality.
Serial Hct measurements: useful in deciding the
timing and amount of transfusion.
(Rossaint R et al. 2010)
(Rossaint R et al. 2010)
(Zehtabchi S et al. 2006)

 Response to initial fluid resuscitation:

 Immediate transfusion: type O, Rh-positive, AB-
negative fresh frozen plasma (FFP) is satisfactory
in most situations, but
 A review demonstrated that only 1 of the 10 Rh-
negative males receiving O, Rh-positive blood
developed alloantibodies
 Timely initiation of massive transfusion or
hemostatic resuscitation protocol is associated
with improved survival and reduced transfusion.
(Edelman BB, et al. 2005)
(Cotton BA et al. 2009)

 Five massive transfusion trigger variables:
 SBP < 90 mmHg, Hgb < 11 g/dL, body
temperature < 35.5°C, INR>1.5, and base deicit<
-6.
 The presence of three or more suggests a greater
likelihood for the need of massive transfusion.
 Rapid thromboelastography (r-TEG) useful to
decide on early (<1hour) administration of FFP
and platelets.
(Callcut et al. 2011)
(Hatch QM, et al. 2011)

Hemostatic resuscitation:
Damage control resuscitation model:
 Limited crystalloid administration, target SBP=
70-100 mm Hg, uncrossmatched RBCs and FFP
until crossmatched blood available
 A study found a mortality rate of 65% in patients
receiving less than 1 unit plasma for every 4
units RBCs, but only 20% in those with a ratio of
1:2 or above.
 Currently a ratio of 1:1:1 is recommended.
(Cannon et al. 2017)
(Borgman MA et al. 2007)

Goal-directed hemostatic resuscitation
approaches:
 Based viscoelastic monitoring combined with
the prompt administration of hemostatic
concentrates.

Disability:
 Rapid neurological assessment:
 AVPU:
A: Alert
V: Responding to Voice
P: Responding to Pain
U: Unresponsive
 Pupils: size and reaction to light

 A Cross sectional study showed that the
Correlation between AVPU and median GCS:
A=15, V=14, P=8, U=3
 Another study showed that the GCS
significantly more accurate predictors of
mortality than AVPU.
 Score ‘P’ or ‘U’ need intubation.
 Checking glucose levels
(Zadravecz FJ et al. 2015)
(Nuttall AGL, et al. 2018)

Exposure:
 Undress the patient completely.
 Are there any hidden injuries under clothing?
 Protect from hypothermia with warm blankets
or a hot air blower.

MARCH approach:
 Massive Hemorrhage: immediate control of
life threatening bleeding.
Tourniquets, pressure bandages
Surgical control: for catastrophic internal
hemorrhage within the abdomen or chest
cavities.

 Airway: rapid and aggressive opening of
the airway
 Respiration and Breathing support
 Circulation: shock resuscitation
 Hypothermia prevention

Adjuncts to the primary survey with
resuscitation:
 Monitoring:
ECG, pulse oximetry, carbon dioxide (CO2 )
monitoring, UOP, and ABG
 Tests include:
FBC, blood lactate, x-ray examinations (chest
and pelvis), FAST, and DPL

Secondary Survey:
 After primary survey, when ABC stable.
 History
 Head to toe examination, looking for all injuries.
 Return to primary survey if any deterioration.
 Special Investigations if available.

History:
 “AMPLE” history should be obtained as a
minimum.
Allergies
Medication
Past history / Pregnancy
Last meal
Events / Environments of injury
 Obtain history of injury-producing event and
identify mechanisms of injury.

Physical examination:
 Head and face:
 Scalp (bruising, lacerations)
 Skull (tenderness, depression)
 Eyes (pupils, conjunctiva)
 Ears, nose mouth (blood, CSF)
 Facial bones

 Neck:
 Penetrating wounds
 Subcutaneous emphysema
 Tracheal deviation
 Expanding hematomas
 Assume neck is injured.
 Immobilize in neutral position.

Neurological examination:
 Repeated Glasgow Coma Score
 Motor Function
 Sensation
 Reflexes

 Chest:
 Inspection: flail chest, open wound,..
 Palpation: tenderness,…
 Percussion: heamothorax, pneumothorax,..
 Auscultation
 Review the chest X-ray

 Abdomen and Pelvis:
 Look: open wound,..
 Feel: tenderness,..
 Listen: bowel sound,..
 Beware hidden bleeding
 The FAST scan

 Limbs:
 All four limbs should be thoroughly
reexamined for deformity, wounds and
neurovascular status.
 Look: deformity, bruising, laceration, colour
 Feel: tenderness, distal pulses, movement
 Power & sensation
 Compartment syndrome

 Spine and back: Log roll
 Full in-line spinal stabilization is maintained
throughout.
 A team of five is required.
 The patient is rolled away from the injured
side.
 Inspects and palpates the spine and back.

Transfer to definitive care:
 Patient outcome is directly related to time
elapsed between injury and definitive care.
 Timing of transfer is based on the stability of
the patient.
 Good communication between referring and
receiving facilities is crucial.
 Tubes and lines should fully secured and the
patient has adequate analgesia or sedation.

Tertiary survey
 After the initial resuscitation and operative
intervention
 Record of remaining injuries and problems is
made.
 Second complete head to toe examination as well
as a review of all imaging, within 24 hours of
admission.

 Meta-analysis showed that tertiary survey better
detection of missed injuries compared to
patients who did not have tertiary survey (OR =
2.65, (95% CI:1.40–5.01), P = 0.003), and
 Fewer injuries were missed (OR = 0.63, (95% CI:
0.44–0.90), P = 0.01).
(Hajibandeh S, et al. 2015)

References:
 Clinical anesthesia/edited by Paul G. Barash . . . [et al.]. – 7th ed
 Advanced Trauma Life Support® Student Course Manual,..10th ed
 MILLER’S ANESTHESIA, EIGHTH EDITION
 Ji SM, Moon EJ, Kim TJ, Yi JW, Seo H, Lee BJ. Correlation between modified LEMON score and
intubation difficulty in adult trauma patients undergoing emergency surgery. World Journal of
Emergency Surgery. 2018 Dec;13(1):1-6.
 Azizi N, ter Avest E, Hoek AE, Admiraal-van de Pas Y, Buizert PJ, Peijs DR, Berg I, Rosendaal AV,
Boeije T, Rietveld V, Olgers T. Optimal anatomical location for needle chest decompression for
tension pneumothorax: A multicenter prospective cohort study. Injury. 2021 Feb 1;52(2):213-8.
 Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW. Accuracy of the Canadian C-spine
rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt
trauma: a systematic review. Cmaj. 2012 Nov 6;184(16):E867-76.
 Saragiotto BT, Maher CG, Lin CW, Verhagen AP, Goergen S, Michaleff ZA. Canadian C-spine rule
and the National Emergency X-Radiography Utilization Study (NEXUS) for detecting clinically
important cervical spine injury following blunt trauma. Cochrane Database of Systematic
Reviews. 2018(4).
 Nuttall AG, Paton KM, Kemp AM. To what extent are GCS and AVPU equivalent to each other
when assessing the level of consciousness of children with head injury? A cross-sectional study of
UK hospital admissions. BMJ open. 2018 Nov 1;8(11):e023216.
 Cannon JW, Khan MA, Raja AS, Cohen MJ, Como JJ, Cotton BA, Dubose JJ, Fox EE, Inaba K,
Rodriguez CJ, Holcomb JB. Damage control resuscitation in patients with severe traumatic
hemorrhage: a practice management guideline from the Eastern Association for the Surgery of
Trauma. Journal of Trauma and Acute Care Surgery. 2017 Mar 1;82(3):605-17.

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