name of person assisting with transfer Background: brief history of present illness and injury Assessment: vital signs, GCS, injuries identified, procedures performed Recommendation: level of care required, pending procedures or tests, anticipated problems during transport

1. ATLS UPDATES -10TH EDITION
Dr.Arunkumar sethuraman
A&E Specialty doctor
Fairfield General Hospital

2. vWhat we already know ? Brush up
vWhat are the new updates ?
vQuestions ?
Agenda of my talk

3. ROUTINE APPROACH
Definitive care
Continued post resuscitation monitoring
Secondary survey (head to toe evaluation &
patient history )
Primary survey – ABCDE with immediate
resuscitation of patients with life threatening injuries
Triage
Preparation
Adjuncts to primary survey & resuscitation
Adjuncts to secondary survey
Consideration of the need for patient transfer

4. PREPARATION PHASE
Prehospital phase
• Mobilisation of hospital trauma team
members
• Airway maintenance, external
bleeding control , shock management,
immobilization, immediate transport to
closest facility
• Information needed for receiving
hospital – triage ATMIST
• Trauma centre transport required or
not ?
Hospital phase
• Resus area preparation + equipments
• Warmed crystalloids
• Additional medical assistance / transfer
agreements with trauma centres –
operational status

5. TRIAGE
• Sorting of patient based on resources required for the treatment & resources
that are actually available
• ABC approach usually, Other factors – severity of injury; ability to survive;
available resources
• Trauma team activation - severe injuries
• Multiple casualty & Mass casualty
Do not exceed the capability of facility Does exceed the capability
Life threatening problem first, then
Multisystem injury patients
Patients with greatest chance of survival,
requiring least time, equipment or supplies –treated first

6. PRIMARY SURVEY WITH
SIMULTANEOUS RESUSCITATION
1. Airway maintenance with restriction of cervical spine motion
2. Breathing and ventilation
3. Circulation with hemorrhage control
4. Disability(assessment of neurologic status)
5. Exposure/Environmental control
Hands off handover unless life threatening condition
10 seconds quick assessment – asking patient his/her name & what happened

7. AIRWAY MAINTENANCE WITH RESTRICTION
OF CERVICAL SPINE MOTION
1. First step C-spine control – applying blocks & collar
2. Always assume spinal injury existence based on mechanism of trauma –
prevent excessive movement of the cervical spine during airway
management.
3. Clearing the airway regardless of other injury – 1st priority
4. Suction – oxygen - maneuveur – airway adjuncts – definitive airway
5. Establish definitive airway if there is any doubt on maintaining airway
integrity

8. BREATHING & VENTILATION
• Airway patency does not ensure adequate ventilation
• Injuries that impair ventilation to be identified & treated
• Every injured patient should receive supplemental oxygen
CIRCULATION WITH HEMORRHAGE CONTROL
• Bleeding; Blood volume; cardiac output - BBC
• Assess Level of consciousness; Skin perfusion; Pulse
• Hemorrhage – predominant cause of preventable death

9. CIRCULATION WITH HEMORRHAGE CONTROL
• Identify source of bleeding – external or internal
• External hemorrhage control during primary survey
– direct manual pressure → tourniquet
Internal hemorrhage
• Areas – chest ; abdomen , retroperitoneum , pelvis, long bones
• Identification – clinical examination & imaging
• Chest xray ; pelvic xray ; E-FAST
• Management – chest decompression; pelvic stabilizing device; surgical
consultation & early transfer

10. DISABILITY (NEUROLOGIC
EVALUATION)
• Level of consciousness; pupils; lateralizing signs; spinal cord injury level
• Hypoglycemia, alcohol, narcotics – alter conscious level as well accompany
brain injury.
• Until proven otherwise, always presume altered conscious level is due to Brain
injury.
• Patients with evidence of brain injury - neurosurgeon consult + early transfer to
resourceful facility
• Prevention of secondary brain injury –maintain oxygenation & adequate
perfusion
• Repetitive neuro examination is needed.

11. EXPOSURE & ENVIRONMENTAL
CONTROL
• Completely undress and facilitate a thorough examination
&assessment.
• Hypothermia a potentially lethal complication – occurs pre- or post
admission.
• Uncovered patient, Room temperature fluids or refrigerated blood as
a risk for hypothermia
• Prevention measures : warm → environment, blankets, fluids
• Control hemorrhage rapdily

12. ADJUNCTS TO PRIMARY SURVEY
• ECG , Pulse oximetry , Capnography, ABG
• Urinary & Gastric catheter
• Xray examination – AP Chest & Pelvic films
• FAST, EFAST, DPL
• Always important not to delay transfer to perform an
in-depth diagnostic evaluation
• Only undertake testing that enhances the ability to
resuscitate stabilize & ensure patient safe transfer.
CONSIDER NEED FOR PATIENT TRANSFER

13. SPECIAL POPULATION
• Children, pregnant women, older adults obese patients,
athletes.
• Priorities of care are same for all trauma patients
• Anatomical & physiological differences needs consideration
Noteworthy features
Children Good Physiologic reserve; bloods, fluids & drug dose vary
Pregnant women Early pregnancy recognition & fetal assessment
Older adults Comorbidites, long term drugs & decreased physiological
reserve
Obese patients Procedural & diagnostic difficulties
Atheletes Excellent conditioning & masking of signs & symptoms

14. SECONDARY SURVEY
• Do not begin until the primary survey is completed , resuscitative
efforts are underway & patient vital signs have improved.
• AMPLE history
• Knowledge of mechanism of injury is important
• Type of injury : Blunt & penetrating injuries
• Other injury – thermal injury & hazardous environment related injury

15. SECONDARY SURVEY
Examination
1. Head & eye
2. Maxillofacial structures
3. C-spine & Neck
4. Chest
5. Abdomen & Pelvis
6. Perineum, Rectum & vagina
7. Musculoskeletal system
ADJUNCTS TO SECONDARY SURVEY
• Additional X-rays
• CT head/chest/abdomen/spine
• Contrast angiography & urography
• Use CT for spine Injury if clinically
suspected.

16. Re-evaluation
• Constant re-evaluation to identify deterioration in previously noted findings
• Continuous monitoring – vitals signs, SPO2, urinary output
Definitive care
• Patient’s treatment needs exceed the capability of receiving institution –
transfer is needed
Records & legal consideration
• Precise chronological record keeping needed due to medicolegal concerns
• Consent for treatment unless life threatening emergencies
• Forensic evidence – collections of clothing & bullets.

17. So,what are the updates ?

18. AIRWAY & VENTILATION
• The methodology of the rapid assessment of the airway remain
unchanged.
• RSI to Drug assisted intubation
• Video guided laryngoscopy
• Trauma team activation

19. SHOCK
• Class of haemorrhage table amended: Base excess
• Early use of blood and blood products
• Management of coagulopathy
• Tranexamic acid
• Trauma team activation

20. IV fluid
resuscitation
Adults – 1 litre
Unresponsive to crystalloid
Source Control
of bleeding
Pediatrics – 20ml/kg in
<40kg
Blood transfusion
Aggressive volume resuscitation
– NOT A DEFINITIVE CONTROL OF HEMORRHAGE
FLUID RESUSCITATION APPROACH

21. ATLS CLASSIFICATION OF HYPOVOLEMIC SHOCK
PARAMETER CLASS I CLASS II (MILD)
CLASS III
(MODERATE)
CLASS IV
(SEVERE)
Approximate blood
loss
<15% 15–30% 31–40% >40%
Heart rate ↔ ↔/↑ ↑ ↑/↑↑
Blood pressure ↔ ↔ ↔/↓ ↓
Pulse pressure ↔ ↓ ↓ ↓
Respiratory rate ↔ ↔ ↔/↑ ↑
Urine output ↔ ↔ ↓ ↓↓
Glasgow Coma
Scale score
↔ ↔ ↓ ↓
Base deficit 0 to –2 mEq/L –2 to –6 mEq/L –6 to –10 mEq/L –10 mEq/L or less
Need for blood
products
Monitor Possible Yes
Massive Transfusion
Protocol
Diagnosis of shock can be missed when only single parameter is used

22. EARLY USE OF BLOOD & BLOOD
PRODUCTS
• Early resuscitation with blood and blood products must be
considered in patients with evidence of class III and IV
hemorrhage.
• Early administration of blood products at a low ratio of
packed red blood cells to plasma and platelets can
prevent the development of coagulopathy and
thrombocytopenia.

23. MANAGEMENT OF
COAGULOPATHY
• Uncontrolled blood loss can occur in patients taking antiplatelet or
anticoagulant medications.
PREVENTION
• Obtain medication list as soon as possible.
• Administer reversal agents as soon as possible.
• Where available, monitor coagulation with thromboelastography
(TEG) or rotational thromboelastometry (ROTEM).
• Consider administering platelet transfusion, even with normal platelet
count.

24. TRANEXAMIC ACID (TXA)
• European and American military studies demonstrate
improved survival when TXA is administered over 10 minutes
within 3 hours of injury.
• When bolused in the field, follow up infusion TAX 1 gram
over 8 hours in the hospital.

25. THORACIC TRAUMA
• Life Threatening Injuries
• Flail chest out
• Tracheobronchial injury now in
• Tension pneumothorax (Needle thoracocentesis - 5th ICS MAL for adult
Unchanged 2nd ICS for child )
• Hemothorax : 28-32 Fr chest drain (not 36-40 Fr)
• Algorithm for circulatory arrest approach
• Aortic rupture management with short acting Beta Blocker(esmolol) to a
target heart rate < 80 bpm and BP control with target MAP 60-70 mmHg is
recommended.

26. LIFE-THREATENING INJURIES
DURING PRIMARY SURVEY
AIRWAY
Airway Obstruction
Tracheobronchial Tree Injury
BREATHING
Tension Pneumothorax
Open Pneumothorax
CIRCULATION
Massive Hemothorax
Cardiac Tamponade
Traumatic Circulatory Arrest

27. TENSION PNEUMOTHORAX
• Extended FAST (eFAST) assessment for tension pneumothorax can be
used for diagnosis :seashore, bar code, or stratosphere sign in M
mode.
• Needle decompression:
Recent evidence supports placing the large, over-the-needle catheter
at the fifth interspace, slightly anterior to the midaxillary line
• 28-32 Fr chest tube for hemothorax (not 36- 40Fr)

28. ALGORITHM FOR
MANAGEMENT
OF TRAUMATIC
CIRCULATORY
ARREST
• ECM – externall cardiac
massage
• OTI – orotracheal intubation
• IVL – intravenous line
• IOL – iNTRAOSSEOUS LINE

29. ABDOMINAL AND PELVIC TRAUMA
• Palpation of prostate gland no
longer recommended for
urethral injury
• Flow chart for pelvic fracture with
hemorrhage amended
PELVIC FRACTURES &
HEMORRHAGIC SHOCK MANAGEMENT

30. HEAD TRAUMA
• Detailed guidance on SBP management
•Updated GCS
• Anticoagulation reversal guidance
• Seizure prophylaxis

32. CATEGORY PARAMETER NORMAL VALUES
Clinical
Parameters
Systolic BP ≥ 100 mm Hg
Temperature 36–38°C
Laboratory
Parameters
Glucose 80–180 mg/dL
Hemoglobin ≥ 7 g/dl
International normalized ratio
(INR)
≤ 1.4
Na 135–145 meq/dL
PaO2 ≥ 100 mm Hg
PaCO2 35–45 mm Hg
pH 7.35–7.45
Platelets ≥ 75 X 103/mm3
Monitoring
Parameters
CPP ≥ 60 mm Hg*
Intracranial pressure 5–15 mm Hg*
PbtO2 ≥ 15 mm Hg*
Pulse oximetry ≥ 95%
GOALS OF
TREATMENT OF
BRAIN INJURY :
CLINICAL
LABORATORY &
MONITORING
PARAMETERS

33. ANTICOAGULANT TREATMENT COMMENTS
Antiplatelets (e.g., aspirin,
plavix)
Platelets
May need to repeat; consider
desmopressin acetate
(Deamino-Delta-D-Arginine
Vasopressin)
Coumadin (warfarin)
FFP, Vitamin K, prothrombin
complex concentrate
(Kcentra), Factor VIIa
Normalize INR; avoid fluid
overload in elderly patients
and patients who sustained
cardiac injury
Heparin Protamine sulfate Monitor PTT
Low molecular weight heparin,
e.g., Lovenox (enoxaparin)
Protamine sulfate N/A
Direct thrombin inhibitors
dabigatran etexilate (Pradaxa)
idarucizumab (Praxbind)
May benefit from prothrombin
complex concentrate (e.g.,
Kcentra)
Xarelto (rivaroxaban) N/A
May benefit from prothrombin
complex concentrate (e.g.,
Kcentra)
ANTICOAGULANT REVERSAL

34. MILD BRAIN INJURY - ADMIT OR
TRANSFER TO APPROPRIATE FACILITY
• Abnormal CT scan
• All penetrating head injuries
• Prolonged loss of consciousness
• Deteriorating level of consciousness
• Moderate or severe headache
• Significant alcohol/drug intoxication
• Skull fracture
• CSF leak : rhinorrhoea or otorrhoea
• No reliable companion at home
• Abnormal GCS <15
• Persistent focal neurologic deficit

35. SEIZURE PROPHYLAXIS
• Prophylactic use of phenytoin (Dilantin) or valproate (Depakote) is not
recommended for preventing late posttraumatic seizures (PTS).
• Phenytoin is recommended to decrease the incidence of early PTS (within 7
days of injury).
• Early PTS has not been associated with worse outcomes .

36. SPINE & SPINAL CORD TRAUMA
• C-spine protection changed to ‘Restriction of spinal motion’
• New myotome diagram (American spinal injury association)
• Canadian C-Spine Rule (CCR) and NEXUS Criteria
• Prolonged backboard usage (> 2hours) should be avoided to reduce the risk
of skin ulcer formation.
• Trauma team support

37. KEY MYOTOMES –MYOTOMES FOR
EVALUATING LEVEL OF MOTOR FUNCTION

40. C-spine collars & blocks may be
removed in patients without
need for imaging as per
Canadian C-spine rule & NEXUS
CRITERIA
Two options for patients requiring
imaging
1. CT whole spine – in available
settings
2. Xray film from occiput to T1
vertebrae – CT not available

41. MUSCULOSKELETAL TRAUMA
• Weight based IV antibiotic regime
• Catastrophic External bleeding addressed in primary survey before
ABCDE
• The use of a tourniquet to control severe extremity bleeding is now
recommended.
• Increased morbidity & mortality with bilateral femur fractures

42. • Fluid resuscitation
in burns has been
adjusted to mirror
the changes in
trauma fluid
resuscitation
• Fluid
administration
titrated to urine
output
THERMAL INJURIES

43. PEDIATRIC TRAUMA
• Needle thoracocentesis UNCHANGED 2nd ICS
• Balanced crystalloid resuscitation
• Paediatric Emergency Care Applied Research Network (PECARN)
Criteria for Head CT

44. Pediatric
Emergency Care
Applied Research
Network (PECARN)
Criteria for Head
CT

45. SURGICAL
CONSULTATION &
PEDIATRIC MASS
TRANSFUSION
PROTOCOL
• Initial 20 mL/kg bolus of
isotonic crystalloid followed by
weight-based blood product
resuscitation with 10-20 mL/kg
of RBC and 10-20 mL/kg of FFP
and platelets.

46. GERIATRIC TRAUMA
A lower threshold for imaging in the elderly population is now
recommended
High risk factors for trauma related mortality/morbidity
1. IHD
2. DM
3. Cirrhosis
4. Coagulopathy
5. Pelvic trauma(increased mortality & length of stay)

48. TRANSFER TO DEFINITIVE CARE
• Performing unnecessary tests in the primary hospital can have a
negative impact on patient outcomes
• CT scans should be avoided in the primary hospital
• Do not perform diagnostic procedures (e.g., DPL or CT) that do not
change the plan of care.
• However, procedures that treat or stabilize an immediately life-
threatening condition should be rapidly performed.
• ABC-SBAR template for communication

49. ABC-SBAR TEMPLATE FOR
TRANSFER OF TRAUMA PATIENTS
• Airway, Breathing, and Circulation - problems identified and interventions
performed
• Situation: patient name, age, referring facility, referring physician name,
reporting nurse name, indication for transfer, IV access site, IV fluid and rate,
other interventions completed
• Background: event history, AMPLE assessment, blood products, medications
given (date and time), imaging performed, splinting
• Assessment: vital signs, pertinent physical exam findings, patient response to
treatment
• Recommendation: transport mode, level of transport care, medication
intervention during transport, needed assessments and interventions

50. TAKE HOME MESSAGE
Chapter New recommendations
Initial assessment Restriction to only 1 L of crystalloid fluid during initial assessment.
Airway & ventilation Drug-assisted intubation has now replaced rapid sequence intubation (RSI).
Videolaryngoscopy highlighted as useful.
Shock Early use of blood products advocated.
Tranexamic acid is now recommended within 3 hours.
Thoracic trauma Flail chest replaced by tracheobronchial tree injury as a life-threatening injury.
New location for needle thoracocentesis in adults
Modified FAST recommended for identification of pneumothorax.
Traumatic circulatory arrest algorithm introduced.
Abdominal & pelvic
trauma
Prostate examination no longer recommended as part of the evaluation.
Preperitoneal pelvic packing included in haemorrhage protocol.
Head trauma Anticoagulation reversal table is now included in the guidance.
Revised version of the GCS introduced.
Spine & spinal cord
trauma
CCR and NEXUS guidelines are now recommended.
“Spinal immobilisation” has been replaced with “spinal motion restriction.”
Prolonged backboard usage (>2 hours) should be avoided.

51. TAKE HOME MESSAGE
Chapter New recommendations
Musculoskeletal trauma The use of a tourniquet to control severe extremity bleeding is now
recommended.
Antibiotics dosing regimens for open fractures introduced.
Thermal injuries New fluid resuscitation formula (2 ml/kg/%TBSA)
Paediatric trauma The PECARN traumatic brain injury algorithm now recommended.
Geriatric trauma Lower threshold for imaging in the elderly population is now recommended.
High-risk pre-existing conditions highlighted.
Trauma in pregnancy Vaginal fluid pH greater than 4.5 is an indicator of amniotic fluid leakage.
Transfer to definitive care CT scans should now be avoided in the primary hospital.
SBAR communication tool now recommended.

52. THANK YOU FOR
YOUR PATIENT
LISTENING…….