This document outlines the principles of Advanced Trauma Life Support (ATLS) for treating trauma patients. It describes the primary and secondary surveys which involve assessing and stabilizing the ABCDEs (airway, breathing, circulation, disability, exposure). The primary survey focuses on life-threatening injuries through rapid evaluation of airway/breathing, circulation, disability, and exposure. The secondary survey involves a full physical exam and history to identify all injuries and guide further care. The goal of ATLS is to prevent avoidable deaths through systematic initial management within the critical golden hour after trauma.

1. ADVANCE TRAUMA LIFE SUPPORT
(ATLS)
INITIAL MANAGEMENT OF A TRAUMA PATIENT
BY: DR.HASSAN HAFEEZ KHAN
FCPS RESIDENT OMFS

2. TABLE OF CONTENTS
 INTRODUCTION
 TRIAGE
 ASSESSMENT OF SEVERITY OF INJURY
 PRIMARY SURVEY
 SECONDARY SURVEY
 DEFINTIVE CARE

3. INTRODUCTION
 Nearly 25% to 33% of deaths caused by injury can be prevented when an
organized and systematic approach is used.
Cales RH, Trunkey DD. Preventable trauma deaths: a review of trauma care systems development. JAMA 1985
 GOLDEN HOUR: the first hour after the traumatic injury where emergency
treatment is most likely to be successful
 ATLS consists of:
 Rapid primary evaluation
 Resuscitation of vital functions
 Detailed secondary assessment
 Initiation of definitive care.

4. TRIAGE
 French word; applied to the process of SORTING OUT.
 The process of categorizing victims or mass casualties based on their need for
treatment, chances for survival and availability of the resources.
 PRIMARY GOAL:
 Prevent avoidable deaths
 Ensure proper emergency care within minimal time frame
 Avoid misuse of the resources on hopeless cases.

5. ASSESSMENT OF SEVERITY OF INJURY
 REVISED TRAUMA SCORE
 Quickly assess the severity and extent of injury to the vital systems.

6. PRIMARY SURVEY
 First, most important thing, when you encounter a trauma patient is to
speak to him/her.
 A complete appropriate sentence spoken by the patient tells us that:
 Airway is patent
 Breathing is intact
 There is adequate cerebral circulation
 If patient is not able to speak, proceed with the ABCDE

7. PRIMARY SURVEY
Life, organ or limb-threatening conditions are identified and reversed
quickly.
Airway maintenance with cervical spine control
Breathing and oxygenation
Circulation and bleeding control
Disability
Exposure

8. AIRWAY MAINTENANCE WITH CERVICAL SPINE
CONTROL
 Highest priority (loss of airway can lead to death in < 3 mins)
 AIRWAY ASSESSMENT: look for airway patency and any obstruction.
 Assume spinal cord injury in all patients sustaining injuries above the clavicle, unless it has been
ruled out thru clinical and radiological exam
 SPINAL PROTECTION: Rigid backboard, bindings, and purpose-built head immobilizers or at
least cervical collars.
 Initially, HEAD TILT- CHIN LIFT or JAW-THRUST procedures maybe used to open the airway
 Clear the oropharynx manually or by tonsillar suction tips.
 Provide nasopharyngeal/oropharyngeal airway.
 DEFINITIVE ARIWAY:
 Endotracheal intubation  if patient is unconscious
 Cricothyroidotomy/tracheostomy  if intubation not possible as in gunshot wounds and ballistic
injuries

9. AIRWAY MANAGEMENT MANEVEURS
A. Occluded airway
B. JAW THRUST  SAFEST method of jaw
manipulation in a patient with suspected
CERVICAL SPINE INJURY
C. HEAD TILT-CHIN LIFT
OROPHYRANGEAL AIRWAY in
place to maintain airway
patency by elevating the base
of the tongue

10. BREATHING & OXYGENATION
 Signs of chest injury or impending hypoxia  anxiety, increased rate of breathing, and a
change in breathing pattern.
 Complete exposure of the chest
 INSPECT for: tracheal deviation, distended Juglar veins, use of accessory muscles, absence of
spontaneous breathing, paradoxical chest wall movement
 AUCULTATE for: equal bilateral resonance, diminished/absent breathe sounds
 PALPATE for: blunt injury to chest wall, broken ribs
 OXYGENATION:
 Deliver oxygen via facemask or ETT
 Oxygen administered through the endotracheal tube should be increased to an FiO2 of
100% (especially if the patient is comatose) until arterial blood gas measurements
confirms hemoglobin saturation (PaO2> 60–70 mmHg), at which point FiO2can be
lowered to between 40% and 60%.

12. 1. OPEN PNEUMOTHORAX

13. 2. Tension pneumothorax

14. 3.HEMOTHORAX
 Fluid collections > 200 to 300 mL can usually be seen on a good upright chest radiograph
as blunting of the costophrenic angle.
 Rx: transfusion of fluids or blood products, control of the airway and support of the
ventilation as required and drainage of the accumulated blood.

15. TUBE THORACOTOMY
A moderate-sized chest tube (32–40 Fr in adults or 26–30 Fr in children) is
generally placed in the fifth intercostal space midaxillary line.

16. 4. FLAIL CHEST
 Occurs when three or more adjacent ribs are fractured in at least two locations,
resulting in a freely moving segment of the chest wall during respirations.
 The pulmonary contusion under-lying major chest wall injuries may be the primary
cause of hypoxia and morbidity in patients with flail chest.
 Three treatment considerations—pain management, supplemental oxygen delivery,
and ventilation control.

17. 3. CIRCULATION AND BLEEDING CONTROL
 Most common cause of shock in the traumatized patient is
hypovolemia caused by hemorrhage.
 Clinical signs of shock:
 Altered level of consciousness
 Tachycardia (HR>100)  most common sign
 Arterial hypotension (SBP<120mmHg)
 Inadequate tissue perfusion
Pale, cool clammy skin
Delayed capillary refill (blanch test normal < 3 secs)
Decreased urine output (< 0.5 ml/kg/hr.)

18. HYPOVOLEMIC SHOCK

21. GENERAL MANAGEMENT PRINCIPLE
 A minimum of two large-bore (14–16 gauge) intravenous catheters should be
placed peripherally in the basilic or cephalic veins in the antecubital fossa of
both arms.
 Control bleeding by:
 Applying direct pressure
 Elevate the bleeding site
 Suturing the lacerations with 2.0 non-resorbable suture without esthetic
consideration.
 Immobilize the fracture
 Restore circulating volume
 Crystalloid resuscitation initially with lactated Ringer’s solution or 0.9% normal saline 2L
bolus over 10-15 mins (20ml/kg for children)
 Administer blood products

22. DISABILITY OR DEGREE OF CONCIOUSNESS
 GCS: Three variables included:
 Best motor response  reflects CNS function
 Best verbal response  shows CNS’s ability to integrate
information
 Eye opening  reflects brainstem activity
 AVPU scale:
 Alert
 Responds to Vocal stimuli
 Responds to Painful stimuli
 Unresponsive

23. EXPOSURE
 Completely disrobe the patient to avoid missing on any injury.
 Logroll the patient to examine patients back
 Avoid hypothermia

24. SECONDARY SURVEY
 Started only after the primary survey has been completed and patient has been
adequately resuscitated.
 No patient with abnormal vital physiologic signs should be proceeded for
secondary survey.
 Includes a brief history and detailed physical exam of each system
 Take AMPLE history:
 Allergies
 Medications
 Past medical/surgical history
 Last meal
 Events surrounding the injury

25. Physical & radiological examination
 Head and skull
 Chest
 Maxillofacial area and neck
 Spinal cord
 Abdomen
 Genitourinary tract
 Extremities

26. Head and skull
 Indications for brain CT scan:
 Seizure activity
 Unconsciousness lasting for > few mins
 Abnormal neurologic evaluation
 Abnormal mental status
 History of head trauma
 Suspected skull fracture
 Head injuries can result in intracranial hemorrhage that can cause cerebral
ischemia by elevating intracranial pressure and compressing vascular structures.
 NEUROLOGIC EXAMINATION:
 Evaluate LOC
 Motor and cranial nerve functions

28. MAXILLOFACIAL AREA
 PHYSICAL EXAMINATION:
 Soft tissue lacerations (examined for disruption of vital structures)
 Elevate eyelids (examine for neurologic or ocular damage)
 Facial symmetry and discoloration
 PALPATE the bony landmarks for any step-off or irregularity; beginning
with
Supra, infra and lateral orbital rims
Malar eminences
Zygomatic arches and nasal bones
 INSPECT oral cavity
Lost teeth
Lacerations
occlusion

29. DEFINITIVE CARE
 Secondary survey followed by radiographic evaluation
 CT scans or MRI
 Relevant laboratory investigations
 Consultation/referral
General surgery
Neurosurgery
Ophthalmic surgery
Plastic or vascular surgery
 Transport to definitive care
 Operating room
 ICU
 Higher level facility

30. THANK YOU
REFERENCE:
Peterson’s Principles of Oral & Maxillofacial Surgery vol:1 3rd Ed