The document provides a comprehensive overview of advanced trauma life support, including initial assessment, the primary and secondary surveys, and guidelines for cardiopulmonary resuscitation (CPR). Key procedures involve assessing and managing airway, circulation, and definitive care, along with standardized CPR techniques emphasizing the importance of compressions. It also highlights methods for recognizing cardiac arrest and performing effective chest compressions tailored for different age groups.

1. Advanced Trauma
Life Support
Maj Mayank Jain
Resident Orthopedics
Base Hosp Delhi Cantt

2. Approach to Initial Assesment
● Preparation
● Triage
● Primary survey (ABCDEs) with immediate
● Adjuncts to the primary survey and resuscitation
● Consideration of the need for patient transfer
● Secondary survey (head-to-toe evaluation)
● Adjuncts to the secondary survey
● Continued postresuscitation monitoring/reevaluation
● Definitive care

3. Field Triage

4. Field Triage

5. Field Triage

6. Clinicians can quickly assess A, B, C, and D
in a trauma patient (10-second
assessment) by identifying themselves,
asking the patient for his or her name, and
asking what happened.

7. Primary Survey : Airway
● Establish a definitive airway if there is any doubt about
the patient’s ability to maintain airway integrity.
● While assessing and managing a patient’s airway, take
great care to prevent excessive movement of the cervical
spine. Based on the mechanism of trauma, assume that a
spinal injury exists.
Cervical spine motion restriction technique

8. Primary Survey : Airway
● To adequately assess jugular venous distention, position
of the trachea, and chest wall excursion, expose the
patient’s neck and chest.
● Perform auscultation to ensure gas flow in the lungs.
● Visual inspection and palpation can detect injuries to the
chest wall that may be compromising ventilation.
● Percussion of the thorax can also identify abnormalities,
but during a noisy resuscitation this evaluation may be
inaccurate.

9. A simple pneumothorax can be converted
to a tension pneumothorax when a patient
is intubated and positive pressure
ventilation is provided before
decompressing the pneumothorax with a
chest tube.

10. Primary Survey : Circulation
● The elements of clinical observation that yield important
information within seconds are
○ level of consciousness
○ skin perfusion
○ pulse
● Definitive bleeding control is essential, along with
appropriate replacement of intravascular volume
● Aggressive and continued volume resuscitation is not a
substitute for definitive control of hemorrhage.

11. Fluids are administered judiciously, as aggressive
resuscitation before control of bleeding has been
demonstrated to increase mortality and morbidity.

12. Hypothermia
Hypothermia can be present when the patient arrives, or it
may develop quickly in the ED if the patient is uncovered and
undergoes rapid administration of room-temperature fluids
or refrigerated blood. Because hypothermia is a potentially
lethal complication in injured patients, take aggressive
measures to prevent the loss of body heat and restore body
temperature.

13. Adjuncts to Primary Survey
● Electrocardiography
● Pulse oximetry
● Carbon dioxide (CO2) monitoring
● Ventilatory rate
● Arterial blood gas
● Urinary catheters
● Gastric catheters
● Blood lactate

14. Physiologic parameters such as pulse rate, blood
pressure, pulse pressure, ventilatory rate, ABG levels,
body temperature, and urinary output are assessable
measures that reflect the adequacy of resuscitation.
Values for these parameters should be obtained as
soon as is practical during or after completing the
primary survey, and reevaluated periodically

15. Adjuncts to Primary Survey
Chest and Aelvis AP radiography can provide valuable
information to aid resuscitation efforts.
FAST, eFAST, and DPL are useful tools for quick detection of
intraabdominal blood, pneumothorax, and hemothorax

16. Secondary Survey
The secondary survey does not begin until the primary survey
(ABCDE) is completed, resuscitative efforts are underway,
and improvement of the patient’s vital functions has been
demonstrated. It includes
● History
● Physical Examination
● Systemic evaluation

17. Adjuncts to Secondary Survey
Specialized diagnostic tests may be performed
● additional x-ray examinations of spine and extremities
● CT scans of the head,chest, abdomen, and spine;
● contrast urographyand angiography
● transesophageal ultrasound
● bronchoscopy
● esophagoscopy

18. Basic Life
Support in
Adults

19. 1957
External defibrillation
first described by
Kouwenhoven
History of CPR

20. 1957
External defibrillation
first described by
Kouwenhoven
1958
Elam and Safar
described the
technique of mouth to
mouth ventilation

21. 1957
External defibrillation
first described by
Kouwenhoven
1958
Elam and Safar
described the
technique of mouth to
mouth ventilation
1960
Kouwenhoven,
Knickerbocker, and
Jude described the
benefits of external
chest compressions

22. 1957
External defibrillation
first described by
Kouwenhoven
1958
Elam and Safar
described the
technique of mouth to
mouth ventilation
1960
Kouwenhoven,
Knickerbocker, and
Jude described the
benefits of external
chest compressions
1963
American Heart
Association formally
endorsed CPR

23. 1957
External defibrillation
first described by
Kouwenhoven
1958
Elam and Safar
described the
technique of mouth to
mouth ventilation
1960
Kouwenhoven,
Knickerbocker, and
Jude described the
benefits of external
chest compressions
1963
American Heart
Association formally
endorsed CPR
1966
Standardized AHA
guidelines for CPR to
lay rescuers

24. Random Fact
*Abella BS, Alvarado JP, Myklebust H, et al. Quality of
cardiopulmonary resuscitation during in-hospital cardiac arrest.
JAMA 2005; 293:305.
*Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of
cardiopulmonary resuscitation during out-of-hospital cardiac arrest.
JAMA 2005; 293:299.
“Multiple studies assessing both
in-hospital and prehospital
performance of CPR have shown
that trained health care providers
consistently fail to meet basic life
support guidelines..”*

25. What is BLS ?

26. What is BLS ?
Basic life support consists of
cardiopulmonary resuscitation and,
when available, defibrillation using
automated external defibrillators
(AED)

27. AHA 2010: Adult BLS for Healthcare Providers

29. Why C-A-B ?

30. Initially pulmonary alveoli are likely
to contain adequate levels of oxygen
and the pulmonary vessels and heart
likely contain sufficient oxygenated
blood to meet markedly reduced
demands, the importance of
compressions thus supersedes
ventilations.
Why C-A-B ?
(It’s Compression-Airway-Breathing….
But u already knew that)

31. Phases of Cardiac Arrest
Electrical
First 4 to 5 minutes
Immediate DC
cardioversion and
excellent chest
compressions are
required . Highest chance
of survival.

32. Phases of Cardiac Arrest
Electrical
First 4 to 5 minutes
Immediate DC
cardioversion and
excellent chest
compressions are
required . Highest chance
of survival.
Hemodynamic
From 4 to 10 minutes
Excellent chest
compressions continued
until just before
cardioversion. Resume
CPR immediately after
shock.

33. Phases of Cardiac Arrest
Electrical
First 4 to 5 minutes
Immediate DC
cardioversion and
excellent chest
compressions are
required . Highest chance
of survival.
Hemodynamic
From 4 to 10 minutes
Excellent chest
compressions continued
until just before
cardioversion. Resume
CPR immediately after
shock.
Metabolic
10 minutes without pulse
Post resuscitative
measures including
hypothermia therapy.
Do not usually survive if
not quickly converted
into a perfusing rhythm.

34. Is it beneficial during the hemodynamic
phase to delay defibrillation in order to
perform 2 to 3 minutes of CPR ?

35. Salient points : AHA Guidelines
● Immediate recognition of sudden cardiac arrest (SCA) by
noting unresponsiveness or absent/gasping breathing.
● Immediate initiation of excellent CPR – "push hard, push
fast" (but not too hard nor too fast) – with continuous
attention to the quality of chest compressions, and to the
frequency of ventilations.

36. Salient points : AHA Guidelines
● Minimizing interruptions in CPR
● For health care professional rescuers, taking no more
than 10 seconds to check for a pulse
● For single untrained rescuers, encouraging performance
of excellent chest compression-only CPR

37. Salient points : AHA Guidelines
● Using automated external defibrillators as soon as
available
● Activating emergency medical services as soon as
possible

38. Recognition of Cardiac Arrest
● Rescuer approaches the victim and confirms
unresponsiveness by tapping the person on the shoulder
and shouting: "are you all right?"
● Lay rescuers should not attempt to assess the victim's
pulse and, unless the patient has what appear to be
normal respirations, should assume the patient is apneic.

39. Recognition of Cardiac Arrest
● If the person does not respond, the rescuer calls for help,
activates the emergency response system, and initiates
excellent chest compressions.
● A knowledgeable clinician may check for a carotid pulse;
however, no more than 10 seconds should be spent
assessing pulselessness alongside apnea.

40. Excellent Chest
Compressions
Coronary perfusion pressure and
return of spontaneous circulation
(ROSC) are maximized when
excellent chest compressions are
performed.
Abella BS, Sandbo N, Vassilatos P, et al. Chest compression rates
during cardiopulmonary resuscitation are suboptimal: a prospective
study during in-hospital cardiac arrest. Circulation 2005; 111:428.
Guidelines 2000 for cardiopulmonary care: international consensus
on science. Circulation 2000; 102(suppl):384.

41. Keep your elbow straight

42. Use your body weight

43. Excellent Chest Compressions
● Maintain the rate of chest compression at 100 to 120
compressions per minute.
● Compress the chest at least 5 cm (2 inches) but no more
than 6 cm (2.5 inches) with each down-stroke

44. Excellent Chest Compressions
● Allow the chest to recoil completely after each
down-stroke
● Minimize the frequency and duration of any
interruptions

45. What is proper recoil ?

46. What is proper recoil ?
It should be easy to pull a piece of paper
from between the rescuer's hand and the
patient's chest just before the next
down-stroke.

47. Minimizing Interruptions
● Interruptions in chest compressions are reduced by
changing the rescuer performing compressions at the
2-minute interval when the rhythm is assessed, and the
patient is defibrillated if needed.
● Pulse checks and rhythm analysis without compressions
should only be performed at preplanned intervals (every
2 minutes)

48. Minimizing Interruptions
● Such interruptions should not exceed 10 seconds, except
for specific interventions, such as defibrillation.
● No more than three to five seconds should elapse
between stopping chest compressions and shock
delivery.

49. Airway
Management
Inadequate ventilation can result
from low respiratory effort and
airway obstruction. While the latter
is more prominent due to abnormal
sounds, professionals often fail to
determine adequacy of respiratory
efforts.

50. lemon assessment for difficult
intubation
L = Look Externally
E = Evaluate the 3-3-2 Rule
M = Mallampati class
O = Obstruction
N = Neck Mobility

51. lemon assessment for difficult
intubation
The 3 -3 -2 Rule
• The distance between the patient’s incisor teeth should be
at least 3 finger breadths (3)
• The distance between the hyoid bone and chin should be at
least 3 finger breadths (3)
• The distance between the thyroid notch and floor of the
mouth should be at least 2 finger breadths (2)

53. Airway Maneuvers
● Head-tilt chin-lift - This technique has been shown in
multiple studies to improve airway patency.
● The clinician uses two hands to extend the patient's neck
and open the airway. While one hand applies downward
pressure to the patient's forehead, the tips of the index
and middle finger of the second hand lift the mandible at
the mentum, which lifts the tongue from the posterior
pharynx.

54. Airway Maneuvers
● The jaw-thrust maneuver - is used to relieve upper
airway obstruction by moving the tongue anteriorly with
the mandible.
● Performed by placing the heels of both hands on the
parieto-occipital areas on each side of the patient's head,
then grasping the angles of the mandible with the index
and long fingers, and displacing the jaw anteriorly.

55. Which one to be performed in a patient
with suspected cervical spine injury ?

56. Which one to be performed in a patient
with suspected cervical spine injury ?
The jaw-thrust maneuver

57. Compression Ventilation Ratio
● A ratio of 30 excellent compressions to 2 ventilations
until an advanced airway has been placed.
● Following placement of an advanced airway, excellent
compressions are continuous, and asynchronous
ventilations are delivered approximately 10 times per
minute.

58. Asynchronous
Ventilations ?

59. Asynchronous
Ventilations ?
Ventilations need not be
coordinated with chest
compressions and prompt
resumption of compressions.

60. Proper Ventilation
● Not exceeding one second per breath
● Avoid excessive ventilation. Positive pressure ventilation
raises intrathoracic pressure which causes a decrease in
venous return, pulmonary perfusion, cardiac output, and
cerebral and coronary perfusion pressures.

61. How much volume per ventilation ?

62. How much volume per ventilation ?
Provide only enough tidal volume to see
the chest rise (approximately 500 to 600
mL, or 6 to 7 mL/kg)

63. Defibrillation
● Defibrillate using the highest available energy (generally
200 J with a biphasic defibrillator and 360 J with a
monophasic defibrillator)
● Compressions should not be stopped until the
defibrillator has been fully charged.

64. Compression
only CPR
(CO-CPR)
Lay rescuers should not interrupt
excellent chest compressions to
palpate for pulses or check for the
return of spontaneous circulation,
and should continue CPR until an
AED is ready to defibrillate, EMS
personnel assume care, or the
patient wakes up.

65. Compression
only CPR
(CO-CPR)
If a sole lay rescuer is present or
multiple lay rescuers are reluctant to
perform mouth to mouth ventilation,
the AHA Guidelines encourage the
performance of CPR using excellent
chest compressions alone.
Note that CO-CPR is not
recommended for children or arrest
of noncardiac origin (eg, near
drowning)

66. Findings of a
retrospective
observational study
The first group was treated between 2001 and 2003
according to the 2000 AHA Guidelines (standard
compressions and ventilations), while the second group
was treated between 2004 and 2007 according to the
2005 AHA Guidelines (compression-only CPR without
ventilations). Among 92 patients in the first group, 18
survived of whom 14 (15 percent) were neurologically
intact. Of the 89 patients in the second group, 42
survived of whom 35 (39 percent) were neurologically
intact.
Kellum MJ, Kennedy KW, Barney R, et al. Cardiocerebral
resuscitation improves neurologically intact survival of
patients with out-of-hospital cardiac arrest. Ann Emerg
Med 2008; 52:244.

67. For patients receiving high-quality CPR
from trained emergency medical
personnel, the use of continuous chest
compressions (ie, ventilations are
performed without interrupting CPR) may
not improve outcomes significantly*
*Nichol G, Leroux B, Wang H, et al. Trial of Continuous or
Interrupted Chest Compressions during CPR. N Engl J Med
2015; 373:2203.

68. BLS in
Children

69. Cardiopulmonary arrest among infants
and children is typically caused by
progressive tissue hypoxia and acidosis as
the result of respiratory failure and/or
shock, in contrast to adults, for whom the
most common cause of cardiac arrest is
ischemic cardiovascular disease.

70. 78%
Rate of acute resuscitation survival among children with in-hospital
cardiopulmonary arrest.

71. Conventional CPR may increase
one-month survival with favorable
neurologic outcomes compared with
CO-CPR for children 1 to 17 years of age
whose arrest is due to noncardiac causes.

72. No normal breathing but pulse is present
● Start rescue breathing by providing 1 breath every 3 to 5
seconds (12 to 20 breaths/min).
● Add compressions if pulse remains ≤60/min with poor
perfusion.
● Activate EMS, if not already done.
● Continue rescue breathing. Check pulse every 2 minutes.
If no pulse, start CPR.

73. No breathing or only gasping and no
definite pulse after 10 seconds
● If this is not a witnessed sudden collapse then the
provider should immediately start cardiopulmonary
resuscitation for 2 minutes and then activate EMS.
● If this is a witnessed sudden collapse, then the provider
should activate EMS and use an AED available and then
initiate CPR.

74. Pediatric CPR
● Start compressions BEFORE performing airway or
breathing maneuvers (C-A-B).
● After 30 compressions (15 compressions if two rescuers),
open the airway and give 2 breaths.
● If the pulse is ≥60 beats per minutes, after about 2
minutes of CPR, continue ventilation.
● Apply the AED or defibrillator as discussed.

75. Proceed based upon AED analysis
● Shockable rhythm – Give 1 shock and resume CPR
immediately for about 2 minutes or until prompted by the
AED.
● No shockable rhythm – Resume CPR immediately for
about 2 minutes or until prompted by the AED.

76. Compressions
Chest compressions should be
performed over the lower half of the
sternum. Compression of the xiphoid
process can cause trauma to the
liver, spleen, or stomach, and must
be avoided.

77. Effective Chest Compressions
● The chest should be depressed at least one-third of its
anterior-posterior diameter with each compression.
● The optimum rate of compressions is approximately 100
to 120 per minute. Each compression and decompression
phase should be of equal duration.

78. Compression
in Infants
Chest compressions for infants
(younger than one year) may be
performed with either two fingers or
with the two thumb-encircling hands
technique.

79. Two fingers Technique-
Compressions are performed with
index and middle fingers, placed on
the sternum just below the nipples.
Because of the infant's large occiput,
slight neck extension and the
placement of a hand or rolled towel
beneath the upper thorax and
shoulders may be necessary to
ensure that the work of compression
is focused on the heart.

80. Two thumb-encircling hands —
The two thumb-encircling hands
technique is suggested when there
are two rescuers. The thorax is
encircled with both hands and
cardiac compressions are performed
with the thumbs. The thumbs
compress over the lower half of the
sternum, avoiding the xiphoid
process, while the fingers are spread
around the thorax.

81. Older Children
From one year until the start of
puberty, compressions should be
performed over the lower half of the
sternum with either the heel of one
hand or with two hands.

82. One handed Two handed

83. Ventillations
Ventilations can be provided with
mouth-to-mouth, mouth-to-nose, or
with a bag and mask.

84. Ventilation in Children
● A child with a pulse ≥60 bpm who is not breathing should
receive 1 breath every 3 to 5 seconds.
● Each rescue breath should be delivered over 1 second,
just enough to see the chest wall rise.

85. Compression Ventilation Ratio
● For lone rescuers, two ventilations should be delivered
during a short pause at the end of every 30th
compression.
● For two rescuers, two ventilations should be delivered at
the end of every 15th compression.

86. Compression Ventilation Ratio
● Once the trachea is intubated, ventilation and
compression can be performed independently.
● Ventilations are given at a rate of 8 to 10 per minute after
intubation.

87. For infants and children <8 years of age, an
AED with a pediatric dose attenuating
system should be used whenever possible.
However, if it is not available, then use of
an AED without a dose attenuator is
advised.

88. Thank you