This document provides an overview of the Advanced Trauma Life Support (ATLS) protocol for managing trauma patients in the emergency room. It discusses the primary, secondary, and tertiary surveys used to systematically evaluate trauma patients and identify life-threatening injuries. The primary survey focuses on the ABCDEs - airway, breathing, circulation, disability, and exposure. The secondary survey involves a full physical exam and history. Adjunct tests help identify specific injuries. The tertiary survey re-examines patients within 24 hours to find any missed injuries, as up to 13% of injuries are initially overlooked.

1. ATLS, Management of Trauma
patient at ER
Presented by: Dr. Meron Zewde (Intern)
Moderator: Dr. Misale (General Surgeon)
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2. Outline
• Definition
• Epidemiology
• Primary survey
• Secondary survey
• Tertiary survey
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3. Introduction
• Trauma, or injury, is defined as cellular disruption caused by
environmental energy that is beyond the body’s resilience, which is
compounded by cell death due to ischemia/reperfusion.
• Trauma is the most common cause of death for all individuals
between the ages of 1 and 44 years, and is the third most common
cause of death regardless of age.
• It is also the leading cause of years of productive life lost.
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4. Epidemiology
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5. Emergency Approach to Trauma
Trimodal distribution of trauma deaths:
1. Immediate deaths (on scene): Hemorrhage due to great vessel
injury, severe TBI, High spinal cord injury etc.
2. Early deaths (1st 1-4 hours): chest trauma, abdomino thoracic
injuries, pelvic injuries most common
• Gives rise to the concept of the “golden hour”
3. Late deaths (hours-days-weeks): from secondary insult –
pneumonia, PE, sepsis, coagulopathy
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6. Trauma Death by Time of Injury
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7. Primary Survey
• Encompasses the ABCDEs of trauma care and identifies life-
threatening conditions by adhering to this sequence.
• Airway maintenance with restriction of cervical spine motion
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability(assessment of neurologic status)
• Exposure/Environmental control
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8. Airway Maintenance with restriction of
cervical spine motion
• This rapid assessment for signs of airway obstruction includes
inspecting for
• Foreign bodies;
• Identifying facial, mandibular, and/or tracheal/laryngeal fractures;
• Suctioning to clear accumulated blood or secretions
• In patients with severe head injuries with GCS score of 8 or lower the
tongue may fall backward and obstruct the hypopharynx; this can be
relieved by either a chin lift , jaw thrust or by inserting a
nasopharyngeal or oropharyngeal airway but endotracheal intubation
might be needed at last.
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10. Inserting Oral Airway.
A. In this technique, the oral airway is inserted upside down
until the soft palate is encountered.
B. The device is then rotated 180 degrees and slipped into
place over the tongue.
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11. Contd.
• Establishing a definitive airway (i.e., endotracheal intubation) is
indicated in patients with: -
• Apnea;
• Inability to protect the airway due to altered mental status;
• Impending airway compromise due to inhalation injury,
hematoma, facial bleeding, soft tissue swelling, or aspiration;
• Inability to maintain oxygenation.
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12. Contd.
• Patients in whom attempts at intubation have failed or who are
precluded from intubation due to extensive facial injuries require
operative establishment of an airway like: -
• Cricothyroidotomy or
• Emergent tracheostomy
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13. Contd.
While assessing and managing a patient’s
airway, take great care to prevent excessive
movement of the cervical spine. This can
be achieved manually (as in the picture) or
by using cervical collar
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14. Breathing and ventilation
• The following conditions constitute an immediate threat to life due to
inadequate ventilation and should be checked:
• Tension pneumothorax
• Open pneumothorax,
• Flail chest with underlying pulmonary contusion,
• Massive hemothorax, and
• Major air leak due to a tracheobronchial injury.
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15. Contd.
• Give supplemental oxygen to every injured patient.
• If the patient is not intubated, oxygen should be delivered by a mask-
reservoir device to achieve optimal oxygenation.
• Use a pulse oximeter to monitor adequacy of hemoglobin oxygen
saturation.
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16. Tension Pneumothorax
• Develops when a “one-way valve” air leak occurs from the lung or
through the chest wall.
• Air is forced into the pleural space with no means of escape,
eventually collapsing the affected lung.
• The mediastinum is displaced to the opposite side, decreasing venous
return and compressing the opposite lung causing hypotension
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17. Contd.
• is characterized by some or all of the following signs and symptoms:
• Chest pain,
• Respiratory distress
• Tachycardia and Hypotension
• Tracheal deviation away from the side of the injury
• Unilateral absence of breath sounds
• Neck vein distention
• Cyanosis
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18. Contd.
• Treatment is Immediate decompression either by
• Large-bore needle insertion into the 2nd ICS in the MCL of the
affected hemithorax or
• A chest tube through the 5th ICS in the anterior axillary line.
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19. Open Pneumothorax
• Large injuries to the chest wall that remain open can result in a
sucking chest wound causing a disequilibrium in airway pressure
• Air passes preferentially through the chest wall defect with each
inspiration. Effective ventilation is thereby impaired, leading to
hypoxia and hypercarbia.
• Treatment is by
• 3-sided cover over defect
• Chest tube insertion
• Definitive operation
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20. Flail Chest
• Three or more contiguous ribs are fractured in at least two locations
• Treatment
• Mechanical ventilation until fibrous union of broken ribs occur
• Oxygen administration
• Adequate analgesia & physiotherapy
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21. Circulation with hemorrhage control
• Blood pressure and pulse should be measured at least every 5
minutes in patients with significant blood loss until normal vital sign
values are restored.
• Look for external bleeding, extremity hematoma, abdominal or pelvic
bruises or lacerations.
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22. Contd.
Signs of inadequate circulation:
• Skin Perfusion - skin is cool, clammy, pale
• Pulse - tachycardia, feeble pulse
• Altered Mental Status
• Tachypnea
• Hypotension
• Decreased urine output
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24. Contd.
• External control of any visible hemorrhage should be achieved
promptly while circulating volume is restored. For open wounds with
ongoing bleeding, manual compression should be done with a single
4 × 4 gauze and a gloved hand.
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25. Contd.
• Intravenous (IV) access for fluid resuscitation and medication
administration is obtained with two peripheral catheters, 16-gauge or
larger in adults.
• For patients in whom IV access is difficult, intraosseous (IO) needles
can be placed in the proximal humerus or tibia.
• Fluid resuscitation begin with a 1 L (adult) or 20 mL/kg (child) IV bolus
of isotonic crystalloid, typically RL.
• If hypotension persists, initiate RBC and FFP also for patients with
class III and IV hemorrhage it should be considered earlier on.
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26. Contd.
• This life-threatening injuries must be identified promptly:
• Massive hemothorax,
• Cardiac tamponade,
• Massive hemoperitoneum,
• Mechanically unstable pelvic fractures with bleeding.
• Critical tools used to differentiate these in the multisystem trauma
patient are the chest and pelvis radiographs, and extended focused
abdominal sonography for trauma (eFAST)
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27. Contd.
• Management
• Massive hemothorax – Chest Tube insertion
• Cardiac tamponade - Pericardiocentesis
• Massive hemoperitoneum – Exploratory Laparotomy
• Mechanically unstable pelvic fractures with bleeding – Stabilize the
pelvis and definite surgery
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28. Disability
• Determine the patients Glasgow Coma Scale (GCS)
• The GCS is a quantifiable determination of neurologic function that is
useful for triage, treatment, and prognosis.
• Severity of head Injury
• 13 to 15 indicate mild head injury,
• 9 to 12 moderate injury, and
• ≤8 severe injury
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30. Contd.
Look for signs of increased ICP: -
• Bradycardia
• Hypertension
• Progressively deteriorating mental status
• Irregular respiratory pattern
• Papilledema in fundoscopy
• Vomiting, headache
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31. Contd.
Look for signs of neurogenic shock: -
• Hypotension with relative bradycardia,
• Paralysis,
• Decreased rectal tone,
• Priapism
• Patients with high spinal cord disruption are at greatest risk for
neurogenic shock due to physiologic disruption of sympathetic fibers;
treatment consists of volume loading and a dopamine infusion.
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32. Exposure
• All clothing is removed at this time to allow for an adequate
examination, core body temperature measurement, and any required
intervention.
• Prevent hypothermia with blankets, heating elements, elevated
room/operating room (OR) temperature, and warmed resuscitative
fluids.
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33. Adjuncts to the Primary Survey
• Continuous electrocardiography, pulse oximetry, carbon dioxide (CO2)
monitoring,
• Assessment of ventilatory rate, and arterial blood gas (ABG)
measurement.
• Insertion of urinary catheters to monitor urine output and assess for
hematuria.
• Gastric catheters to decompress distention.
• Chest and pelvis x-ray
• FAST
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34. Secondary Survey
• does not begin until the primary survey is completed, resuscitative
efforts are under way, and improvement of the patient’s vital
functions has been demonstrated.
• Comprises history and a thorough head-to-toe physical examination.
• AMPLE history
• Allergies
• Medications
• Past illnesses or Pregnancy
• Last meal
• Events related to the injury
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35. Contd.
• Ask about the mechanism of injury (e.g. blunt, penetrating trauma,
thermal injury)
Physical Examination
• It should be literally head to toe, with special attention to the
patient’s back, axillae, and perineum, because injuries here are easily
overlooked
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36. Contd.
HEENT
• Inspect the face and scalp. Look for any lacerations or bruising,
including mastoid or periorbital bruising.
• Gently palpate for any depressions or irregularities in the skull.
• Assess the ears for any signs of cerebrospinal fluid leak, bleeding or
blood behind the tympanic membrane.
• Look in the eyes for any foreign body, subconjunctival hemorrhage.
• Gently palpate the cervical vertebrae. Note any cervical spine pain,
tenderness or deformity.
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37. Contd.
Chest
• Palpate for rib tenderness and subcutaneous emphysema.
• Auscultate the lung fields; note any percussion abnormality, lack of
breath sounds, wheezing or crepitations.
• Check the heart sounds: apex beat and presence and quality of heart
sounds.
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38. Contd.
Abdomen and Pelvis
• Inspect the abdomen. Palpate for areas of tenderness especially over
the liver, spleen, kidneys and bladder. Look for any bruising,
lacerations or penetrating injuries.
• Auscultate bowel sounds.
• Inspect the perineum and external genitalia for bruising or
hemorrhage.
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39. Contd.
Perineum, Rectum, and Vagina
• The perineum should be examined for contusions, hematomas,
lacerations, and urethral bleeding.
• A rectal examination may be performed to assess for the presence of
blood within the bowel lumen, integrity of the rectal wall, and quality
of sphincter tone.
• Vaginal examination to assess for the presence of blood in the vaginal
vault and vaginal lacerations.
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40. Contd.
Musculoskeletal system
• Inspect all the limbs and joints, palpate for bony and soft-tissue
tenderness and check joint movements, stability and muscular power.
• Log roll the patient. Palpate the spine for any tenderness or steps
between the vertebrae.
Neurological examination
• includes motor and sensory evaluation of the extremities, as well as
reevaluation of the patient’s level of consciousness and pupillary size
and response.
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41. Adjuncts to the Secondary Survey
• Specialized diagnostic tests may be performed to identify specific
injuries.
• 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;
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42. Tertiary Survey
• Structured and comprehensive reexamination that takes place within
24 hours of initial assessment.
• 7-13% of patients have injuries that are missed during the initial
evaluation.
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43. References
• Schwartz principles of surgery 11th edition
• ATLS 2018 Student Course Manual
• UpToDate 2022
• Nebyou Seyoum, A Azaj, Berhanu Nega, Trauma in Ethiopia
Revisited: A systematic Review; East Cent. Afr. J. surg, 2013,
Volume 18 (2)
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