The document outlines the Advanced Trauma Life Support (ATLS) protocol for managing trauma patients. It describes the primary, secondary, and tertiary surveys that provide a standardized approach. The primary survey focuses on airway, breathing, circulation, disability, and exposure. The secondary survey involves a full history, physical exam, and ordering relevant tests. The tertiary survey identifies all injuries after initial resuscitation and surgery.

1. Dr.Adeel Riaz
PGR General
Surgery
CPTH. Lahore.
Advanced Trauma Life Support
(ATLS)

2. Advanced Trauma Life Support
(ATLS)
Most widely recognised and practiced protocol for the
management of a trauma patient worldwide.
ATLS PROTOCOL OBJECTIVES:
 A standardized approach to all traumatic patients.
 A comprehensive assessment and management of
patients in emergency situation.
 Best utilization of golden hour which lies between life
and death after a traumatic event.

3. ATLS PROTOCOL
 PRIMARY SURVEY
 RESUSCITATION
 SECONDARY SURVEY
 TERTIARY SURVEY

4. PRIMARY SURVEY
 A : AIRWAY & CERVICAL SPINE
IMMOBILIZATION
 B : BREATHING / VENTILATION
 C : CIRCULATION & HEMORRHAGE CONTROL
 D : DISABILITY ( NEUROLOGICAL
EVALUATION)
 E : EXPOSURE + ENVIRONMENTAL
CONTROL

5. AIRWAY MANAGEMENT & C. SPINE
 SUCTIONING OF NASOPHARYNGEAL AIRWAY
 CHIN LIFT
 JAW THRUST
ADVANCED METHODS:
 ENDOTRACHEAL INTUBATION
 CRICOTHYROIDOTOMY
 TRACHEOSTOMY
PREVENTION OF CERVICAL SPINE INJURY:
 IMMOBILIZE THE PATIENT
 AVOID HYPEREXTENSION OF NECK
 APPLY CERVICAL COLLAR

6. BREATHING / VENTILATION
 EXPOSE THE CHEST & ACCESS RR & RESP. TYPE.
 GIVE O2 INHALLATION
 CHECK CHEST WALL, LUNGS & DIAPHRAGM BY
INSPECTION, PALPATION, PERCUSSION &
AUSCULTATION.
 PULSE OXIMETER
 LOOK FOR CONDITIONS THAT IMPAIR VENTILATION
 Tension pneumothorax
 Massive hemothorax
 Flail chest
 Rib fractures
 Open pneumothorax
 Pulmonary contusion

7. CIRCULATION
IMPAIRMENT IN CIRCULATION CAN LEAD TO SHOCK
SO LOOK FOR SIGNS OF SHOCK i.e.
 SKIN COLOUR (PALLOR)
 NARROW PULSE PRESSURE
 HYPOTENSION
 TACHYCARDIA
 LEVEL OF CONSCIOUSNESS
 DIMINISHED URINE OUTPUT
CONTROL OF HEMORRHAGE :
 APPLY DIRECT PRESSURE
 PNEUMATIC SPLINTING DEVICES
 ACCESS THE NEED FOR SURGICAL INTERVENTION

8. CLINICAL CLASSIFICATION OF
SHOCK
CLASS I CLASS II CLASS III CLASS IV
BLOOD LOSS UPTO 750ml 750-1500ml 1500-2000ml >2000ml
% BLOOD
VOLUME
UPTO 15% 15-30% 30-40% >40%
PULSE RATE
(bpm)
<100 100-120 120-140 >140
SYSTOLIC B.P. NORMAL NORMAL DECREASED DECREASED
PULSE
PRESSURE
NORMAL OR
INCREASED
DECREASED DECREASED DECREASED
RESPIRATORY
RATE
14-20 20-30 30-40 >35
URINE
OUTPUT
(ml/hr)
>30 20-30 5-15 NEGLIGIBLE
CNS/MENTAL
STATUS
SLIGHTLY
ANXIOUS
MILDLY
ANXIOUS
ANXIOUS,
CONFUSED
CONFUSED,
LETHARGIC
FLUID
REPLACEMEN
CRYSTALLOI
DS
CRYSTALLOI
DS
CRYSTALLOI
DS & BLOOD
CRYSTALLOI
DS & BLOOD

9. FLUID REPLACEMENT THERAPY
 DOUBLE I/V LINES SHOULD BE MAINTAINED FOR
FLUID REPLACEMENT
 ADULTS SHOULD BE GIVEN 2 L BOLUS FLUID
(PREFFERED FLUID IS RINGER LACTATE BETTER IF
WARM)
 CHILDREN SHOULD BE GIVEN @ 20ml/Kg BOLUS
FLUID
3 FOR 1 RULE :
A rough guideline for the total
amount of crystalloid volume acutely is to replace
each ML of blood loss with 3 ML of crystalloid fluid, thus
allowing for restitution of plasma volume lost into the

10. DISABILITY ( NEUROLOGICAL
EXAMINATION)
CHECK THE LEVEL OF CONSCIOUSNESS ( AVPU/GCS )
 A: ALERT
 V: RESPONDS TO VOCAL STIMULI
 P: RESPONDS TO PAINFUL STIMULI
 U: UNRESPONSIVE TO ALL STIMULI
CHECK PUPIL SIZE & LIGHT REACTION
CHECK THE LEVEL OF SPINAL CORD INJURY LEVEL

11. EXPOSURE +ENVIRONMENTAL
CONTROL
 UNDRESS COMPLETELY (USE TRAUMA SCISSORS)
 PREVENT HYPOTHERMIA ( WARM BLANKETS &
WARM FLUIDS)
 EARLY HEMORRHAGE CONTROL
 WARM ROOM TEMPERATURE SHOULD BE
MAINTAINED

12. SECONDARY SURVEY
DOESNOT BEGIN UNTIL THE PRIMARY SURVEY (ABCDEs)
IS COMPLETED, RESUSCITATION EFFORTS ARE WELL
ESTABLISHED & THE PATIENT IS HAVING
NORMALIZATION OF VITAL SIGNS.IT INCLUDES:
 COMPLETE HISTORY
 COMPLETE HEAD TO TOE EXAMINATION
 REASSESSMENT OF VITAL SIGNS
 COMPLETE NEUROLOGICAL EXAMINATION (GCS)
 SPECIFIC PROCEDURES, SPECIFIC LAB.
INVESTIGATIONS

13. COMPLETE HISTORY
 A: ALLERGIES
 M: MEDICATIONS
 P: PAST ILLNESS/ PREGNANCY
 L: LAST MEAL
 E: EVENTS/ ENVIRONMENT/MECHANISM OF
INJURY:
BLUNT TRAUMA: AUTOMOBILE
COLLISIONS
PENETRATING TRAUMA:
FIREARMS/STABBING
THERMAL INJURIES: BURNS/EXPLOSIONS
HAZARDOUS INJURIES:
CHEMICALS/TOXINS/

14. PHYSICAL EXAMINATION
 HEAD
 MAXILLOFACIAL STRUCTURES
 CERVICAL SPINE & NECK
 CHEST
 ABDOMEN
 PERINEUM,RECTUM & VAGINA
 MUSCULOSKELETAL SYSTEM
 NEUROLOGICAL SYSTEM

15. HEAD
 VISUAL ACUITY
 PUPPILARY SIZE
 CONJUNCTIVAL HEMORRHAGE
 PENETRATING INJURY
 CONTACT LENSES (REMOVE BEFORE EDEMA
DEVELOPS)
 DISLOCATION OF THE LENS
 OCULAR ENTRAPMENT
MAXILLOFACIAL STRUCTURES
 PALPATE ALL BONY STRUCTURES
 INTRAORAL EXAMINATION
 ASSESSMENT OF SOFT TISSUES
 TRAUMA NOT RELATED TO AIRWAY OR BLEDDING CAN
BE DELAYED

16. CERVICAL SPINE AND NECK
 PATIENTS WITH HEAD TRAUMA OR MAXILLOFACIAL
TRAUMA SHOULDE BE PRESUMED TO HAVE
UNSTABLE CERVICAL INJURY (FRACTURE/LIGAMENT
INJURY), NECK SHOULD BE IMMOBILIZED
IMMEDIATELY, UNTIL INVESTIGATED.
 CERVICAL SPINE TENDERNESS, SUBCUTANEOUS
EMPHYSEMA, TRACHEAL DEVITATION & LARYNGEAL
FRACTURES OR PENETRATING INJURIES SHOULD
BE SEEN DURING EXAMINATION OF NECK.
CHEST
 A THOROUGH EXAMINATION OF CHEST WALL
SHOULD BE DONE TO RULE OUT OPEN OT
TENSION PNEUMOTHORAX, HEMOTHORAX,
FLIAL CHEST OR CONTUSIONS.

17. ABDOMEN
 AFTER INITIAL EXAMINATION, CLOSE OBSERVATION
AND FREQUENT RE-EVALUATION OF THE ABDOMEN
SHOULD BE DONE BY THE SAME OBSERVER TO
NOTE ANY INTRAABDOMINAL INJURY AND IT
SHOULD BE DEALT AGGRESSIVELY.
PERINEUM, RECTUM & VAGINA
 PERINEUM SHOULD BE EXAMINED FOR
CONTUSIONS,LACERATIONS,HEMATOMA &
URETHRAL BLEEDING
 RECTUM MUST BE EXAMINED FOR BLOOD IN
BOWEL LUMEN, PELVIC FRACTURES OR HIGH
RIDING PROSTATE.
 VAGINAL EXAMINATION SHOULD BE DONE IN

18. MUSCULOSKELETAL SYSTEM
 THE EXTREMITIES MUST BE INSPECTED FOR
CONTUSIONS & DEFORMITIES.
 BONES SHOULD BE PALPATED & MOVEMENTS AT
THE JOINTS SHOULD BE CHECKED.
 ASSESSMENT OF PERIPHERAL PULSES SHOULD BE
DONE FOR VASCULAR INJURIES.

19. REASSESSMENT OF VITAL SIGNS
DONE BY:
 CLINICAL REASSESSMENT
 MONITORING OF LOC, PR, BP MONITORING, ABGs &
UOP
 REVIEW OF DIAGNOSTIC RESULTS
 USE OF ANALGESIA
COMPLETE NEUROLOGICAL
EXAMINATION
 LOC/GCS
 CNs EXAMINATION
 DETERIORATION/IMPROVEMENT IN LOC/GCS

20. SPECIFIC PROCEDURES, SPECIFIC
LAB. INVESTIGATIONS
 AFTER HISTORY & EXAMINATION, RELEVANT
INVESTIGATIONS SHOULD BE ADVISED e.g.
 FOR SUSPECTED CERVICAL SPINE INJURY X-RAYS
SHOULD BE DONE AS:
1. LATERAL VIEW: OCCIPUT TO TOP OF T1
2. ANTERO-POSTERIOR VIEW: SPINOUS PROCESSES
C2-C7
• Additional X-rays Extremities, Spine
• CT-SCAN
• Contrast X-rays, Urography, Angiography
• Endoscopy

21. DEFINATIVE CARE & TRANSFER
 ACCORING TO CLINICAL AND OTHER DATA PATIENT
IS SHIFTED TO ICU , OT OR OTHERS RESPECTIVELY.
 OR TRANSFRRED TO OTHER FACILITY ACCORDING
TO PATIENT’S NEED OR INSTITUTION’S CAPABILITY.
TERTIARY SURVEY
 DEFINED AS PATIENT’S EVALUATION THAT
IDENTIFIES AND CATALOGUES ALL INJURIES AFTR
INITIAL RESUSSITATION AND OPERATIVE
INTERVENTIONS
 PATIENT IS MORE AWAKE
 MORE INFORMATION ABOUT MODE OF INJURY BY
PATIENT IS GATHERED

22. ATLS OUTLINE
 PRIMARY SURVEY (ABCDE)
 SECONDARY SURVEY 1. HISTORY
2. PHYSICAL
EXAMINATION
3. RELEVANT
INVESTIGATIONS
 RE-EVALUATION
 DEFINATIVE CARE
 TRANSFER