The document outlines the steps of the Advanced Trauma Life Support protocol. It includes: 1) preparing equipment and summoning a trauma team, 2) performing triage on multiple casualties, 3) conducting a primary survey to address life threats like airway, breathing, circulation, disability and exposure, 4) providing resuscitation as needed, 5) using adjuncts like monitoring, IVs and diagnostics, 6) performing a full secondary survey and history, 7) using additional adjuncts, 8) continued re-evaluation of the patient, and 9) arranging for their definite care. The protocol aims to quickly identify and treat life threats in a trauma patient.

1. Advanced Trauma Life Support®
Dr/ Saleem AL Adhroai

2. 1. Preparation
2. Triage
3. Primary Survey (ABCDEs)
4. Resuscitation
5. Adjuncts to primary survey & resuscitation
6. Secondary Survey (head to toe evaluation & history)
7. Adjuncts to secondary survey
8. Continued post-resuscitation monitoring & re-
evaluation
9. Definite care.

3. Primary
Hospital
Tertiary
Hospital METHAN
E
METHAN
E
METHAN
E
CCS

4. Scene size –up :--
1. Body substance isolation (BSI) review
2. Scene safety (you-patient)
3. Initial triage (total N of patients)
4. Essential equipment / additional
resources needed on scene( units-
extraction eq.- MCI protocols)
5. Mechanism of injury
A Pre-hospital phase

5. Scene size –up
Body substance isolation (BSI)
CapCap
GownGown
GlovesGloves
MaskMask
Shoe coversShoe covers
Goggles / face shieldGoggles / face shield

6. Scene size up
Scene safety
 RescuerRescuer
 SceneScene
 PersonalPersonal

7. Scene size up
Essential equipment
1.1. Personal protectionPersonal protection
equipmentsequipments
2.2. Long backboard +headLong backboard +head
restriction devicerestriction device
3.3. Rigid cervical extractionRigid cervical extraction
collarcollar
4.4. Oxygen and airway eq.Oxygen and airway eq.
5.5. Trauma box (bandage- bpTrauma box (bandage- bp
cuff-stethoscope )cuff-stethoscope )

8. Scene size up
Mechanism of injury
1.1. BluntBlunt
1.1. Rapid forwardRapid forward
(collision)(collision)
2.2. Rapid vertical (falls)Rapid vertical (falls)
3.3. Energy transfer fromEnergy transfer from
blunt instrumentsblunt instruments
2.2. Penetrating injuriesPenetrating injuries
1.1. ProjectilesProjectiles
2.2. KnivesKnives
3.3. Fall on fixed objectsFall on fixed objects

9. General impressionGeneral impression
 A B C D E PRIORITYA B C D E PRIORITY
 AGEAGE
 SEXSEX
 POSITIONPOSITION
 ACTIVETYACTIVETY
 MAJOR TRAUMAMAJOR TRAUMA
 L O CL O C
 A B C D E PRIORITYA B C D E PRIORITY

10. 2. TRIAGE2. TRIAGE
AA Multiple CasualtiesMultiple Casualties
No of severity & pt do not exceed the ability of
the facility.
B Mass Casualties DISATER
No & severity of pt EXCEED the capability of
the facility & staff.

11. Color Codes Triage TagColor Codes Triage Tag
RED : Most critical injury
YELLOW : Less critical injured
GREEN : No life or limb threatened injury
BLACK : Death or obviously fatal injury

12. Good trauma teamGood trauma team
 Quiet – leader speaks, others answer report,Quiet – leader speaks, others answer report,
not everyone trying to scream over eachnot everyone trying to scream over each
otherother
 Organized – pre-assigned roles andOrganized – pre-assigned roles and
responsibilities of team membersresponsibilities of team members

13. Preparation for TraumaPreparation for Trauma
 Gather your Troops: Nurses, Medics,Gather your Troops: Nurses, Medics,
Physicians, RadiologyPhysicians, Radiology
 Divide each to bedsDivide each to beds
 Gather SuppliesGather Supplies
 Airway suppliesAirway supplies
 IV lines, tubing, warm IVF bags, Pressure bagsIV lines, tubing, warm IVF bags, Pressure bags
 BlanketsBlankets
 MedicationsMedications
 Ensure ALL electrical sources are workingEnsure ALL electrical sources are working
 Active Management as you surveyActive Management as you survey

14. B In Hospital Phase
 Advanced planning for the
trauma pt arrival.
 Method to summon extra
medical assistance
 Transfer agreement with
verified trauma center
established.
 Protect from communicable
disease.

16. Color Codes Triage TagColor Codes Triage Tag
RED : Most critical injury
YELLOW : Less critical injured
GREEN : No life or limb threatened injury
BLACK : Death or obviously fatal injury

17. CAN PATIENT WALK?
NO YES
DELAYEDIs PATIENT BREATHING?
YES NO
Open AirwayCHECK BREATHING
< 30 > 30
IMMEDIATECHECK CIRCULATION
PR < 12O
CRT < 2 sec
PR > 120
CRT > 2 sec
CHECK LEVEL OF
CONSCIOUSNESS
IMMEDIATE
GOOD DIMINISHED
URGENT IMMEDIATE
Not Breathing
Dead

18. RAZ
Treatment Area
Triage
Area
Urgent Treatment Area
obs
Reserved
Staff
Media
Center
OR
Mortuary

19. 3. PRIMARY SURVEY3. PRIMARY SURVEY
A :A : Airway with cervical spine protect.
B :B : Breathing
C :C : Circulation --control external bleeding.
D :D : Disability or neurological status
E :E : Exposure (undress) & EEnvironment (temp control)

20. PRIMARY SURVEY
 Priorities for the care of Adult , Pediatrics &
Pregnancy women are all the same.
 During the primary survey life threatening
conditions are identified and management is
instituted SIMULTANEOUSLY.

21. A. Airway Maintenance withA. Airway Maintenance with
Cervical Spine ProtectionCervical Spine Protection
 Protection of the spine & spinal
cord is the important management
principle.
 Neurological exam alone does not
exclude a cervical spine injury.
 Always assume a cervical spine
injury in any pt with multi-system
trauma, especially with an altered
level of consciousness or blunt
injury above the clavicle.

22. Indication For Definite Airway
1. * Unconscious
2. * Severe maxillo-facial fracture
3. * Risk for aspiration : Bleeding/ vomiting
4. * Risk for obstruction : neck hematoma/laryngeal,tracheal
injury/ stridor
5. * Apnea : Neuromuscular paralysis/unconscious
6. * Inadequate respiratory effort:
tachypnea/hypoxia/hypercapnia/cyanosis
7. * Severe closed head injury need for hyperventilation

23. AirwayAirway
 SNORINGSNORING
 GURGLIGGURGLIG
 STRIDORSTRIDOR
 SILENCESILENCE

24. B. Breathing & VentilationB. Breathing & Ventilation
 Airway patency does not assure adequate
ventilation.
 lock – lesson – feel
 Idication treatment imediatelyIdication treatment imediately
 TentionpnumothoraxTentionpnumothorax
 Open pnumothoraxOpen pnumothorax
 Flaial chestFlaial chest
 HaemothoraxHaemothorax

25. C. Circulation with HemorrhageC. Circulation with Hemorrhage
ControlControl..
 1. Blood Volume & Cardiac
Output
 a. level of consciousness.
 b. skin color
 c. Pulse.
 2. Bleeding
 *external bleeding is
identified & controlled in
the
 Tourniquets should not be
use.
 Control obvious externalControl obvious external
hemorrhagehemorrhage
 clamp vesselsclamp vessels
 Direct pressure is still effectiveDirect pressure is still effective
 Identify and Treat ShockIdentify and Treat Shock
 2 Large bore IV’s or central2 Large bore IV’s or central
venous accessvenous access
 Warm IVFWarm IVF  Normal Saline vs.Normal Saline vs.
Ringers LactateRingers Lactate
 Emergency release bloodEmergency release blood

26. D. Disability ( Neurological Evaluation)D. Disability ( Neurological Evaluation)
Simple Mnemonic to describe level of consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
Not forget to use also Glascow Coma Scale.

27. E. Exposure / EnvironmentalE. Exposure / Environmental
ControlControl
 Completely UndressCompletely Undress
 Must occur when patient hitsMust occur when patient hits
the doorthe door
 Don’t miss injuriesDon’t miss injuries
 Roll the patientRoll the patient
 Look in creases/ back ofLook in creases/ back of
head/neckhead/neck
 Keep WarmKeep Warm
 Hypothermia leads toHypothermia leads to
coagulopathy and increasedcoagulopathy and increased
blood lossblood loss

28. 55. ADJUNCT TO PRIMARY SURVEY &. ADJUNCT TO PRIMARY SURVEY &
RESUSCITATIONRESUSCITATION
A. Electro-cardiographic Monitoring
B. Urinary & Gastric Catheter
1. Urinary catheter.
Urethral injury should be suspected if
1. Blood at the penile meatus
2. Perineal ecchymosis
3. Blood in the scrotum
4. High riding or nonpalpable prostate
5. Pelvic fracture

29. C. Monitoring
1. Ventilatory rate & ABG
2. Pulse oximetry
does not measure ventilation or partial O2 pressure
3. Blood pressure
poor measure of actual tissue perfusion.
D. X-Ray & Diagnostic Studies
1. C-spine,
2. CXR,
3. Pelvic film
Essential x-ray should not be avoid in pregnant pt.
C1
C2
C3
C5
C6
C7
C4

30. Secondary SurveySecondary Survey
 HistoryHistory
 A AllergiesA Allergies
 M MedicationsM Medications
 P PMHP PMH
 L Last MealL Last Meal
 E Events relatingE Events relating
to injuryto injury
 Physical ExamPhysical Exam
 Head and NeckHead and Neck
 ChestChest
 AbdomenAbdomen
 PelvisPelvis
 Genital/RectalGenital/Rectal
 ExtremitiesExtremities
 BackBack

31. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
1. Head
• Visual acuity
• Pupillary size
• Hemorrhage of conjunctiva and fundi
• Penetrating injury
• Contact lenses(remove before edema occurs)
• Dislocation of lens
• Ocular movement

32. 2. Maxillofacial Injury
no NG tube, definite airway?
3. Cervical Spine & Neck
*Pt with maxillofacial or head trauma should be presumed
to have and unstable cervical spine.
4. Chest
*elderly pt are not tolerant of even relatively minor
chest injury.
*Children often sustain significant injury to the
intrathoracic structure without evidence of thoracic
skeletal trauma.

33. 5. Abdomen
*excessive manipulation of the pelvic should be
avoided.
6. Perineum/rectum/vagina
7. Musculoskeletal
8. Neurologic
* Protection of spinal cord is required at all times until a
spine injury excluded, especially when the pt is transfer.

34. 7. ADJUNCT TO THE SECONDARY SURVEY7. ADJUNCT TO THE SECONDARY SURVEY
include additional x-ray and all other special procedure.
8. RE-EVALUATION8. RE-EVALUATION
Adult urine output 0.5ml/kg/hr
Pediatric urine output 1mg/kg/hr
*Pain relief -- IM should be avoid.
9. DEFINITE CARE9. DEFINITE CARE

35. QuestionQuestion ??