The document details a case presentation of a 20-year-old mill worker, Amir Waseem, who suffered severe back pain due to a fall. A comprehensive primary and secondary trauma assessment was conducted, revealing no life-threatening conditions, but signs of spine tenderness and bruising, leading to conservative management with IV fluids and pain medication. It also outlines the principles and steps of Advanced Trauma Life Support (ATLS), emphasizing the importance of immediate assessment and intervention in trauma cases.

1. ADVANCED TRAUMA
LIFE SUPPORT- ATLS
AZKA SIBGHAT ROLL NO: 02

2. CASE PRESENTATION
• The patient Amir Waseem, age 20yrs, resident of Faisalabad, mill
worker by profession, presented in surgical emergency on 13 May
with complaint of severe pain in back due to fall of a sack of
thread rolls on the back of his chest 2 hours ago
• Patient was brought to emergency by his co-workers

3. Primary survey: (ABCDE or cABCDE)
1. Airway and cervical spine control:
 In this patient, the Airway was intact as he could
speak coherently and was responsive and there was no
obstruction in the mouth.
 The cervical spine was immobilised with a cervical
collar, as we assume cervical spine injury in blunt
trauma patients until proven otherwise.

4. 2. Breathing and ventilation:
 There were no signs of respiratory distress (use of
accessory muscles, in-drawing, cyanosis, tachypnea)
 Breathing was normal with normal vesicular breathing
sounds and no added sounds on auscultation in all lung
fields on the front of chest.
 The respiratory rate was 18 per minute
 oxygen saturation on pulse oximeter was 98%.
 there was no visible chest injury or deformity.

5. 3. Circulation and control of hemorrhage:
 circulation was intact with no external bleeding.
 the blood pressure was 110/90
 the pulse rate was 86 per minute

6. 4. Disability and neurological assessment:
 The GCS was 15/15 and patient was concious.
 No weakness in limbs and no sensory loss was reported
by the patient, power in all 4 limbs was also normal when
tested objectively by asking the patient to raise the limbs
against gravity and against resistance.
 There was no complaint of loss of conciousness, vomiting,
seizures or any discharge from nose or ear following
trauma.

7. 5. Exposure and environment control:
 Maximum possible exposure was obtained and
the patient was examined from the front. No bruise or
swelling was visible.
 The back was examined by “log roll” technique,
there was bruise and spine tenderness was positive in
thoracic and lumbar regions, so the patient was placed
on a spine board.

8. SECONDARY SURVEY:
 There was no history of allergy, medication, past illness and
exposure to similar events . Last meal was a few hours ago. (AMPLE)
 Vitals were: BP 118/80, pulse 88per minute, respiratory rate
18per minute, O2 saturation 98% , temp 98F.
 On head and face examination, there were no bruises or
swelling, no scalp laceration, pupils normal and reactive, no signs of
anemia or jaundice in the eyes, no deformity of nose and pinna, no
discharge from nose or ear.
 On inspection of oral cavity there was no bleeding, tongue
laceration or dental malocclusion, no cyanosis on the tip of tongue.
 In neck, there was no venous distension, laryngeal deformity or
hematoma.

9. ¨On examination of front of chest, there was no rib, sternal or
clavicular fracture, shape of chest was normal and moving
symmetrically with respiration, vesicular breathing was present
on auscultation.
¨On auscultation of precordium, the heart sounds were normal
and there were no added sounds.
¨The abdomen was normal in shape and moving symmetrically
with respiration, umbilicus normal in position and inverted, no
bruises around umbilicus and on the flanks. On palpation it was
soft, non-tender, no mass on deep palpation and bowel sounds
were present on auscultation.
¨There was no bone tenderness on palpation of pelvis to
indicate a pelvic fracture.

10. ¨On examination of limbs, there was no hematoma. The tone and
power was normal in all muscle groups and there was no sensory
abnormality. Planters were down going. No cyanosis on tips of
digits.
¨Exam of perineum /genitalia was not performed on this patient, it
should be done for following findings:
• Perineum/genitalia: stigmata of urethral injury and pelvic fracture
• Hematoma/bruising
• Blood at urethral meatus
• Vaginal lacerations
• Scrotal hematoma
• Anorectum
• Anal tone, voluntary contraction (sacral sparing with cord injury)
• Rectum: high-riding prostate, lacerations

11. •INVESTIGATIONS:
 X-ray cervical and thoracolumbar spine, AP and
lateral views
Other investigations that could be ordered in this case
include: FAST(focussed assessment sonogram for
trauma), CT cervical and thoracolumbar spine

13. •MANAGEMENT:
Patient was managed conservatively and was given IV fluid 1
litre and an IV injection of toradol(ketorolac).
He was observed for half hour then sent home with following
prescription:
ocapsule osimep 40mg (omeprazole), tab mutex(piroxicam)20mg,
twice daily for 8 days
otab emosis( multivitamin), tab can-D(vit d and ca) once daily for 8
days
Patient was advised to keep wearing a cervical collar and take bed
rest for 2 days.

14. ADVANCED TRAUMA LIFE
SUPPORT

15. INTRODUCTION
• Advanced trauma life support (ATLS) is a training program for the
management of acute trauma cases, developed by the American College of
Surgeons. Originally designed for emergency situations where only one doctor
and one nurse are present, ATLS is now widely accepted as the standard of
care for initial assessment and treatment in trauma centres.

16. PRINCIPLES
• Treat the greatest threat to life first.
• Definitive diagnosis is not immediately important.
• Time matters (“golden hour” emphasizes urgency).
• Do no further harm.
• Assess, intervene, reassess
• The golden hour refers to a time period lasting for one hour
following traumatic injury during which there is the highest
possibility that adequate treatment will prevent death.

17. STEPS
•Preparation
•Triage
•Primary survey (ABCDEs) with immediate resuscitation of
patients with life-threatening injuries
•Secondary survey (head-to-toe evaluation and patient
history)
•Definitive care

18. PREPARATION
• Training as a team
• Equipment maintained and ready for rapid use
• Appropriate supplies available
• Referral resources and transfer policies clearly defined

19. TRIAGE
The assignment of degrees of urgency to wounds or illnesses to decide the
order of treatment of a large number of patients or casualties.

20. PRIMARY SURVEY
• First and key part of the assessment of patients presenting with
trauma is called the primary survey. During this time, life-
threatening injuries are identified and
simultaneously resuscitation is begun
• Follow algorithm ABCDE

21. A: AIRWAY MAINTENANCE AND CERVICAL SPINE PROTECTION
• This assessment is of the patency of the patient’s airway. It is assessed by
asking a question. If the patient can speak coherently, the patient is
responsive, and the airway is open.
• Observe patient for signs of respiratory distress (use of accessory
muscles, in-drawing, cyanosis, tachypnea)
• Inspect the mouth for obstruction (e.g.. due to blood or vomitus)
• Perform either a chin lift or jaw thrust if upper airway obstruction
is identified; although, jaw thrust is preferred if cervical spine
injury is suspected.

22. • Chin lift by placing the thumb underneath the chin and lifting forward.
• Jaw thrust by placing the long fingers behind the angle of the
mandible and pushing anteriorly and superiorly.
• Clear the oropharynx of blood, mucus and foreign bodies with help of
rigid sucker.
• Falling back of tongue is prevented in unconscious (most common cause
of airway obstruction in unconscious) patient by maintaining
oropharyngeal airway.

23. • Lower airway definitely managed by intubation.
• If GCS score =<8, endotracheal intubation is next step as patient is
unconscious and unable to protect his airways.
• Severe maxillofacial fractures, laryngeal or tracheal injury, evolving airway
loss due neck hematoma – intubate
• If patient is in apnea or in respiratory distress -tachypnea >30,
hypoxia/hypercarbia- intubate as a conduit for ventilation.
• If patient has burn injuries with evidence of respiratory involvement patient is
intubated out of precaution.
• If it’s not possible, cricothyroidotomy is performed.

29. • Use hard collars to immobilize the neck to prevent spinal injury.
Use long spinal board to immobilize the whole body. Log roll
technique can be used to shift the patient.
• Assume cervical spine injury in blunt trauma patients until proven
otherwise.
• Spine precautions should only be discontinued when patients
gain back consciousness and are alert to communicate
sufficiently on spinal discomfort or neurologic sensations before
the spine is cleared.
• Log roll important to assess the dorsum of the cervical to the
sacral spine and to look out for any signs of bruising, open
wounds, tender points and to palpate the paravertebral tissue
and posterior processes.

32. B: BREATHING AND VENTILATION
• Attach pulse oximeter to all trauma patients to monitor oxygen saturation and
provide them with 100% oxygen.
• Inspect chest wall- look for symmetry/asymmetry of movements, paradoxical
movements, rate and pattern of respiration, signs of respiratory distress
• Inspect neck veins for jugular venous distension.
• Palpate the trachea and chest wall - look for tenderness, crepitus, emphysema,
fractures.
• Percuss the chest wall- look for resonance or dullness.
• Auscultate the chest wall – look for decreased/absent breath sounds.

33. Aim is to identify and treat six life-threatening conditions:
• Airway obstruction,
• Tension pneumothorax,
• Massive hemothorax,
• Open pneumothorax,
• Flail chest and
• Cardiac tamponade.

34. • Tension pneumothorax (Severe respiratory distress, deviated trachea,
absent breath sounds, resonant percussion note + hemodynamic instability,
hypotension) - needle decompression (second intercostal space, mid-
clavicular line), followed by chest tube placement.
• Simple pneumothorax - anterior chest tube
• Open pneumothorax with 3 way occlusive chest wall dressing and followed
by anterior chest tube (Open chest wounds should be covered immediately
with a bandage taped on three sides to prevent the entry of atmospheric air
into the chest. If the bandage is taped on all four sides it may create a
tension pneumothorax)
• Massive hemothorax with posterior chest tubes en route to operating room.

35. • Flail chest/severe pulmonary contusion with intubation and
oxygenation/mechanical ventilation + analgesia.
• Cardiac tamponade- perform needle pericardiocentesis until
definitive management which is thoracotomy and repair of
lesion.

36. C: CIRCULATION AND HAEMORRHAGE CONTROL
• Hemorrhagic shock is the most common form of shock in trauma. It develops
when there is loss of 1.5L of blood. Blood can be lost externally or it can go
into thorax, abdomen, pelvis, long bones (multiple fractures).

37. • Assess for and stop external haemorrhage.
• Direct manual pressure.
• For traumatic amputation/severe mangled extremity,
application of a tourniquet
• Assess circulatory status, pulse (central: carotids and
femoral and peripheral pulses), heart rate, blood
pressure (skip to end if it delays rest of primary
survery)
• Gain vascular access.
• Draw blood for blood typing and cross match

38. • Administer initial volume, first 1 L to 2 L isotonic solutions,
such as normal saline or lactated Ringer, but it should then
be followed by blood products or plasma expanders.
• If on-going haemorrhage, transfuse specific blood type or type O-
ve blood.
• Patients with severe shock resulting from trauma can present with
or develop coagulopathy from blood loss, dilution from large
volume crystalloid fluid resuscitation, or hypothermia.
• If significant haemorrhage and persistent hemodynamic
instability, transfuse platelets, RBC and plasma in 1:1:1 - the use
of 1:1:1 both treats and prevents coagulopathy associated with
trauma and massive transfusion of blood

39. • Perform FAST especially in haemodynamically unstable
patients, may be part of secondary survey if patient
haemodynamically stable.
• Consider and intervene to stop hidden sources of bleeding.
• Pelvis: pelvic binder
• Long bone fracture: reduce and splint
• Laceration: closure
• Anterior/posterior nasal packing
• Emergency Thoracotomy
• Emergency Laparotomy
• Consider non-hemorrhagic sources of shock
• Tension pneumothorax
• Cardiac tamponade
• Neurogenic shock (relative hypovolemia due to vasodilatation)

41. D: DISABILITY/NEUROLOGICAL STATUS
• Assess level of consciousness (Glasgow Coma Scale),
• Assess pupils (size, reactivity)
• Look for lateralizing signs like hemiparesis
• Raised intracranial pressure should be ruled out and if present, managed
immediately.
Hypoglycemia and drugs, including alcohol, are to be excluded. If these are
excluded, changes in the level of consciousness should be considered to be due
to traumatic brain injury until proven otherwise.

42. E: EXPOSURE AND ENVIRONMENTAL CONTROL
• Temperature of ER is maintained before uncovering the patient.
• Undress the patient completely for thorough examination.
• Warm blankets are used to cover the patient after examination
• IV fluids should be warmed
• Patient privacy should be maintained
• Log roll important to assess the dorsum of the cervical to the sacral spine and to look out for
any signs of bruising, open wounds, tender points and to palpate the paravertebral tissue and
posterior processus.

43. ADJUCNTS TO PRIMARY SURVEY
• Foley placement to monitor urinary output; withhold for evidence of
urethral injury (blood at the urethral meatus, perineal hematoma, high-
riding prostate)
• Gastric tube placement to prevent gastric dilatation; no nasal placement
in setting of facial fractures
• ECG for cardiac rhythm
• Arterial blood gas/pH and lactate monitoring (for shock)
• CBC, electrolytes, glucose, creatinine (relevant for contrast
administration), INR (relevant to detect antecedent anticoagulation), type
and screen vs. crossmatching

44. • Assessment for intraperitoneal injury
• Focused Assessment by Sonography in Trauma (FAST)
• Looks for fluid in 4 areas (hepatorenal, splenorenal, pelvic, and
pericardial spaces)
• Diagnostic peritoneal lavage (DPL)
• Radiographs
• AP chest, to assess for tube and line placements, as well as
subclinical hemopneumothoraces.
• Pelvis, to assess for pelvic fracture as a source of hidden bleeding
• Cervical spine. As long as the cervical spine is protected with
immobilization, this radiologic evaluation can be moved to the
secondary survey. CT imaging of the cervical spine has replaced
Xray (lateral, AP, and open-mouth odontoid).
• Other area as needed based on clinical examination.

45. SECONDARY SURVEY
• Consists of:
Detailed history
Head to toe physical examination of the patient
Reassessment of vital signs
• Started when:
Primary survey is completed
Resuscitative efforts are underway
Patient’s vital signs are normalizing

46. SECONDARY SURVEY
History:

47. SECONDARY SURVEY
Physical examination
• Neurological Assessment
GCS
Pupillary size and light reaction
Lateralising signs
Peripheral nerve injuries
Spinal injuries
• Head:
• Scalp contusions, lacerations, fractures and crepitus
Ear and Eye injuries

48. • Maxillofacial structures
Palpation of all bony structures for crepitus
Malocclusion
Intraoral examination
Assessment of soft tissues
• Cervical spine and neck
• Cervical spine tenderness
• Subcutaneous emphysema
• Hoarseness
Carotid bruit

49. • Chest:
• Breath sounds
• Hyper-resonance or dullness to percussion
• Rib, sternal, and clavicular fractures
Subcutaneous emphysema
• Abdomen and pelvis
• Scars and open wounds
• Distention
• Tenderness
Peritoneal signs
Pelvic fractures

50. •Perineum, rectum and vagina
Perineum: contusions, hematomas, lacerations, and urethral
bleeding
Rectum: assess for the presence of blood within the bowel lumen,
integrity of the rectal wall, and quality of sphincter tone
Vagina: lacerations
•Musculoskeletal examination
Visible injuries
Abnormal movements

51. ADJUNCTS TO SECONDARY SURVEY
Include specialized diagnostic tests to identify specific injuries such
as:
• X-ray examinations of the spine and extremities
• CT scans of the head, chest, abdomen, and spine
• Contrast urography and angiography
• Transesophageal ultrasound
• Bronchoscopy
• Esophagoscopy
• Diagnostic laparoscopy
and other diagnostic procedures

52. MANAGEMENT
• Clean and dress all bleeding wounds
• Oxygenation with continued cervical spine care
• Pack eviscerated gut with warm, moist packs
• Laparotomy (blunt or penetrating abdominal trauma, peritonitis, evisceration)
• Apply pelvic binder if pelvic fracture is suspected
• Splinting of limb fractures
• Management of compartment syndrome by fasciotomy

53. DEFINITIVE CARE (TERTIARY SURVEY)
• Transfer of patient to concerned ward is required when the patient’s
treatment needs exceed the capability of the receiving institution
• Tertiary survey consists of :
Evaluating adequacy of resucitation
Reviewing all imaging
A careful and complete examination to recognize missed injuries and
related problems, allowing a definitive care management.

54. THANK YOU