Advanced Trauma Life Support® (ATLS®)

1. Initial
Assessment and
Management for
Trauma

2. Outline
◈ Initial Assessment and Management
◈ Skill station
1. Cervical collar
2. Needle decompression
3. Tube thoracostomy
4. FAST
5. Application of pelvic binder or other pelvic
stabilization device
6. Oral endotracheal intubation
7. Principle of spine immobilization and logrolling

3. Initial assessment
◈ Preparation
◈ Triage
◈ Primary survey (ABCDEs) with immediate resuscitation of
patients with life-threatening injuries
◈ Adjuncts to the primary survey and resuscitation
◈ Consideration of the need for patient transfer
◈ Secondary survey (head-to-toe evaluation and patient
history)
◈ Adjuncts to the secondary survey
◈ Continued postresuscitation monitoring and reevaluation
◈ Definitive care

4. Primary survey
with
simultaneous
resuscitation

5. ◈ Airway maintenance with restriction of cervical spine
motion
◈ Breathing and ventilation
◈ Circulation with hemorrhage control
◈ Disability(assessment of neurologic status)
◈ Exposure/Environmental control

6. 10-second assessment
◈ asking the patient for his or her name, and asking
what happened
◈ appropriate response
○ no major airway compromise (i.e., ability to speak clearly),
○ breathing is not severely compromised (i.e., ability to generate
air movement to permit speech)
○ level of consciousness is not markedly decreased (i.e., alert
enough to describe what happened)

7. Airway maintenance with
restriction of cervical spine motion
◈ signs of airway obstruction
 inspecting for foreign bodies
 identifying facial, mandibular, and/or tracheal/laryngeal
fractures and other injuries that can result in airway
obstruction
 suctioning
 severe head injuries
◈ If the patient is able to communicate verbally, the
airway is not likely to be in immediate jeopardy

8. Airway maintenance with
restriction of cervical spine motion
◈ prevent excessive
movement of the cervical
spine

9. Resuscitation
◈ suction
◈ jaw-thrust or chin-lift
maneuver
◈ nasopharyngeal or
oropharyngeal airway
◈ definitive airway
◈ C-collar

10. Breathing and ventilation
◈ Neck and chest
 jugular venous distention
 position of the trachea
 chest wall excursion
◈ Auscultation, visual inspection, palpation,
percussion
◈ Significantly injuries
 tension pneumothorax
 massive hemothorax
 open pneumothorax
 tracheal or bronchial injuries

11. Breathing and ventilation
Tension Pneumothorax
◈ hyperresonant note on
percussion
◈ deviated trachea
◈ distended neck veins
◈ absent breath sounds

12. Breathing and ventilation
Massive hemothorax
◈ >1500 mL of blood or
≥1/3 of the patient’s blood
volume
◈ continuing blood loss
(200 mL/hr for 2-4 hours)
◈ persistent need for blood
transfusion

13. Breathing and ventilation
Open pneumothorax
◈ opening in the chest wall
is approximately ≥2/3 the
diameter of the trachea

14. Breathing and ventilation
◈ Use pulse oximeter
◈ Simple pneumothorax, simple hemothorax, fractured
ribs, flail chest, and pulmonary contusion
○ compromise ventilation to a lesser degree
○ identified during the secondary survey

15. Resuscitation
◈ Supplemental oxygen : mask-reservoir device
◈ Tx as causes

16. Circulation with hemorrhage control
Blood Volume and Cardiac Output
◈ Elements of clinical observation
 Level of Consciousness
 Skin Perfusion
 Pulse

18. Circulation with hemorrhage control
Bleeding : External hemorrhage
◈ direct manual pressure on the wound
◈ Tourniquets
 massive exsanguination
 risk of ischemic injury
 when direct pressure is not effective and the patient’s life is
threatened
◈ Blind clamping : damage to nerves and veins

19. Circulation with hemorrhage control
Bleeding : Internal hemorrhage
◈ Chest, abdomen, retroperitoneum, pelvis, and long
bones
◈ identified by physical examination and imaging
◈ Immediate management

20. Resuscitation
◈ Vascular access : 2 large-bore peripheral venous
catheters (≥18G)
◈ Blood samples for baseline hematologic studies are
obtained, including
○ pregnancy test for all females of childbearing age
○ blood type and cross matching
◈ Assess shock : blood gases and/or lactate

21. Resuscitation
◈ peripheral sites cannot be accessed
○ intraosseous infusion
○ central venous access
○ venous cutdown

22. Resuscitation
◈ initiate IV fluid therapy
○ warm
○ crystalloids
○ bolus of 1 L
○ isotonic solution
◈ If a patient is unresponsive to initial crystalloid
therapy, he or she should receive a blood
transfusion.

23. Resuscitation
◈ massive transfusion protocols
◈ tranexamic acid

24. Disability (neurologic evaluation)
◈ level of consciousness
◈ pupillary size and reaction
◈ lateralizing signs
◈ spinal cord injury level

25. Exposure and environmental control
◈ completely undress

26. Resuscitation
◈ warm blankets or external warming device
◈ Warm intravenous fluids
◈ warm environment

27. Adjuncts to the
primary survey with
resuscitation

28. ◈ continuous ECG, pulse oximetry, CO2 monitoring,
and assessment of ventilatory rate, and ABG
measurement
◈ urinary catheters, gastric catheters
◈ blood lactate
◈ x-ray examinations and DPL

29. Urinary and gastric catheters
Urinary Catheters
◈ C/I : urethral injury
○ blood at the urethral meatus or perineal ecchymosis
◈ do not insert a urinary catheter before examining the
perineum and genitalia

30. Urinary and gastric catheters
Gastric Catheters
◈ C/I: fracture of the cribriform plate
○ insert the gastric tube orally to prevent intracranial passage

31. X-ray examinations and diagnostic studies
◈ AP chest and AP pelvic films
◈ FAST, eFAST, and DPL

32. Consider need for
patient transfer

33. ◈ It is important not to delay transfer to perform an in-
depth diagnostic evaluation.
◈ Only undertake testing that enhances the ability to
resuscitate, stabilize, and ensure the patient’s safe
transfer.

34. Secondary survey

35. ◈ secondary survey does not begin until the primary
survey is completed
◈ head-to-toe evaluation
◈ AMPLE

36. Reevaluation

37. ◈ Continuous monitoring: vital signs, oxygen
saturation, and urinary output
◈ relief of severe pain
◈ Tetanus vaccine
◈ Antibiotic

38. Skill station

39. Cervical collar
◈ supine position
◈ extended fingers against the patient’s neck
◈ Your little finger should almost be touching the
patient’s shoulder
◈ Count how many of your fingers it takes to reach the
jawline.
◈ Find the appropriately sized collar
◈ Have another provider restrict the patient’s cervical
spinal motion

40. Cervical collar
◈ Slide the posterior portion of the collar behind the
patient’s neck
◈ Place the anterior portion
◈ Secure the collar with the hook and loop fasteners

41. Cervical collar
http://www.rch.org.au/clinicalguide/guideline_index/Cervical_Spine_Injury/

42. Needle decompression
◈ 4th-5th ICS anterior to midaxillary line
◈ over-the-needle catheter 3 in. (5 cm for smaller
adults; 8 cm for large adult) with a Luer-Lok 10 cc
syringe attached
◈ Adding 3 cc of saline may aid the identification of
aspirated air.
◈ prepare for chest tube insertion

43. Tube thoracostomy
◈ chest tube: 28-32 F
◈ site
○ 4th-5th ICS or level of the nipple/inframammary fold
○ Between anterior and midaxillary lines
◈ estimated depth: placing the tip near the clavicle
with a gentle curve of chest tube toward incision.
◈ finger sweep

44. FAST
Subxiphoid view
◈ Start with the heart
◈ Place the probe in the
subxiphoid space

45. FAST
RUQ view
◈ coronal plane in anterior
axillary line
◈ visualize the diaphragm,
liver, and kidney

46. FAST
LUQ view
◈ coronal plane
◈ midaxillary line
◈ Visualize the diaphragm,
spleen, and kidney

47. FAST
Suprapubic view
◈ Place the probe above
the pubic bone
◈ Rotate the probe 90°

48. Application of pelvic binder or other pelvic
stabilization device
◈ Landmarks: greater trochanters
◈ Internally rotate
◈ Slide the device from caudal to cephalad, entering it
over the greater trochanters.
◈ Alternative: Logroll
◈ If using a sheet, cross the limbs of the sheet and
secure with clamps or towel clamp.

50. Application of pelvic binder or other pelvic
stabilization device

51. Application of pelvic binder or other pelvic
stabilization device

52. Oral endotracheal intubation
◈ Direct an assistant to restrict cervical motion.
◈ Take off the collar

53. Oral endotracheal intubation

54. Principles of Spine Immobilization and
Logrolling
◈ 4 people
○ restrict cervical motion
○ restrict motion of the torso (including the pelvis and hips)
○ pelvis and legs
○ direct the procedure and insert the spine board

55. Principles of Spine Immobilization and
Logrolling

56. Principles of Spine Immobilization and
Logrolling
◈ apply semirigid cervical collar
◈ logroll the patient as a unit toward the two assistants
at the patient’s side
◈ Place the spine board beneath the patient

57. Principles of Spine Immobilization and
Logrolling
◈ Padding and tape the
patient’s head and neck
◈ straps
○ across the patient’s thorax
○ just above the iliac crests
○ across the thighs
○ just above the ankles

58. Take home message
◈ Primary survey (ABCDEs)
◈ Resuscitation
◈ Adjuncts to primary survey and resuscitation
◈ Consideration of the need for patient transfer

59. Reference
◈ ATLS 10th Student Manual
◈ EMS -- A Practical Global Guidebook by Tintinalli,
Cameron, and Holliman