The document outlines the initial management of trauma patients according to ATLS protocols. It discusses the systematic approach including preparation, triage, primary and secondary surveys, monitoring and definitive care. The primary survey focuses on the ABCDE approach - controlling hemorrhage, establishing airway and breathing, assessing circulation, neurological status and conducting full body exposure. Adjunct tests and special considerations for different patient groups are also reviewed.

1. INITIAL MANAGEMENT OF TRAUMA
DR NABARUN BISWAS
REGISTRAR SURGERY
UNIT 2, MMCH

2. James K. Styner with
three of his children
who all received
severe head trauma
in the crash
1976

3. TRAUMA
• IT IS PHYSICAL FORCE EXERTED ON A PERSON THAT LEADS TO PHYSICAL INJURY
• MAJOR TRAUMA: DENOTES INJURY TO MORE THAN ONE BODY REGION AND
ORGAN SYSTEM AND WHICH IS LIFE THREATENING.

4. SYSTEMATIC APPROACH OF MX OF TRAUMA
PATIENT
Preparation
Triage
Primary survey &
resuscitation
Adjunct to primary
survey
Need to transfer
Secondary survey
Monitoring &
reevaluation
Definitive care

6. AIM OF MANAGEMENT
 Prevent death
 Mainly second
peak of death
 GOLDEN HOUR!

7. TRIMODAL DISTRIBUTION OF TRAUMA
DEATH
• FIRST PEAK :SECONDS-MINUTES
• HEART,BRAIN,LARGE VESSEL &SPINAL CORD INJURY
• BEST TREATED BY PREVENTION
• SECOND PEAK:MINUTES-HOURS
• EPI/SUB DURAL HEMATOMA,HEMO/PNEUMO THORAX,SPLEEN/LIVER INJURY
• BEST TREATED BY APPLYING PRINCIPLES OF ATLS
• THIRD PEAKS: DAYS TO WEEKS
• SEPSIS,MSOF
• DIRECTLY CORRELATED TO EARLIER TREATMENT

8. STEPS IN MANAGEMENT
Prehospital
Hospital Mx
(ATLS)
Triage

9. 1.PREPARATION
‘Scoop and run’ concept!
• Pre hospital phase
• Notify receiving hospital
• Send to the closest, appropriate
facility
• In hospital phase
• Team assembly
• Equipment's made readily available
• Ancillary departments informed
• Hospital personal protection

10. PRE HOSPITAL INFORMATION &HAND OVER
M-I-S-T
• MECHANISM OF INJURY
• INJURIES IDENTIFIED
• SIGNS- VITALS PULSE,BP,RESPIRATORY RATE,GCS
• TREATMENT INITIATED

11. TEAM LEADER CHECKLIST
TRAUMA TEAM ACTIVATION
PRIOR TO ARRIVAL
• UNIVERSAL PRECAUTION IN PLACE
• GOWNS IN PLACE
• WARMED IV FLUID HANGING
• O-VE BLOOD READY, BLOOD WARMER
& RAPID INFUSER READY
• OR NOTIFIED
• RADIOLOGY NOTIFIED

12. 2.TRIAGE
• SORTING OF PATIENTS BASED ON
THE RESOURCES REQUIRED &
AVAILABILITY FOR RX
• MULTIPLE CASUALTY:
 NUMBER OF PATIENTS & THEIR
SEVERITY DO NOT EXCEED THAN
THE RESOURCES
• MASS CASUALTY:
 NUMBER OF PATIENTS & THEIR
SEVERITY DOSE EXCEED THE
RESOURCES
Urgent
Immediate
Not urgent
Unsalvagea
ble

13. TRIAGE

14. 3.PRIMARY SURVEY
Patients are assessed and treatment priorities established
based on their injuries, vital signs, and injury mechanisms
cABCDE of trauma care
• c Control Exsanguinating external haemorrhage
• A Airway and c-spine motion restriction
• B Breathing and ventilation
• C Circulation with hemorrhage control
• D Disability/Neurologic status
• E Exposure/Environmental control

15. DON’T GET DISTRACTED WITH UGLY “INJURIES”

16. SPECIAL GROUPS
1. PEDIATRICS
• Same Priorities and Approach
• Need for different amounts of fluids and
medications
• Need for equipment of varying sizes
2.PREGNANT WOMEN
• Same Priorities and approach
• Anatomic and physiologic changes
• Potential two patients not one
• “TREAT THE MOTHER TO TREAT THE FETUS”

17. 3.ELDERLY
• Diminished physiologic reserve
• Comorbidities
• Heart disease, Diabetes, lung disease
• Multiple medication use
• Increased risk of death for
any given injury compared
to younger patient

18. EXSANGUINATING EXTERNAL BLEEDING
• MASSIVE ARTERIAL BLEEDING NEEDS
TO BE CONTROLLED EVEN BEFORE
AIRWAY IS MANAGED.
• GUNSHOT/ BLAST WOUND
• PACKS/ PRESSURE/ TORNIQUET

19. Airway should be assessed for patency
• Is the patient able to communicate verbally?
• Inspect for any foreign bodies
• Examine for stridor, hoarseness, gurgling,
pooled secretions or blood
Management
• Jaw thrust if not improved head tilt, chin
lift
• Clean & suction airway
• Airway tube/ endotracheal tube
• If GCS <8 tracheostomy
AIRWAY ASSESSMENT AND C-SIPNE MOTION
RESTRICTION

20. JAW THRUST

23. C-SIPNE MOTION RESTRICTION
Stabilize C-spine with neck
brace/ cervical collar, sand
bag & tape

24. BREATHING & VENTILATION
1. Look
2. Listen
3. Feel

25. BREATHING & VENTILATION
• LOOK
1. CYANOSIS
2. ABNORMALITY IN CHEST WALL
3. RATE & DEPTH OF RESPIRATION
4. ENGORGED NECK VEIN
5. SUPRASTERNAL RECESS
6. PARADOXICAL MOVEMENT
7. VISIBLE INJURY
• Listen:
 Breath sound
• Feel
1. Tracheal position
2. Apex beat
3. Surgical emphysaema
4. Fracture ribs
5. Chest wall expansion
Assessment:

26. LOOK

27. LISTEN
Abnormal or absent breath sounds

28. FEEL
Perform percussion:
Looking for hyper resonance or
dullness

29. BREATHING & VENTILATION
• MANAGEMENT
HIGH FLOW O2
HAEMO/PNEUMOTHORAX 
NEEDLE DECOMPRESSION
PERICARDIAL TAMPONADE
NEEDLE DECOMPRESSION
SUCKING CHEST WOUND 3SIDED
DRESSING

30. CIRCULATION & CONTROL OF
HAEMORRHAGE
• ASSESSMENT FOR SHOCK
 SKIN
 TEMPERATURE
 PULSE RATE
 BP
 URINE OUTPUT

31. CIRCULATION & CONTROL OF
HAEMORRHAGE
• SIGNS OF ON GOING BLEEDING
• PHYSICAL
 RISING PULSE
 FALLING BP
 RISING RR
 RISING LACTATE
• ANATOMICAL
 VISIBLE BLEEDING
 RETAINED MISSILE
One in floor & four more

33. CIRCULATION & CONTROL OF
HAEMORRHAGE
• MANAGEMENT
• 2WIDEBORE IV CANNULA
• BLOOD FOR GROUPING & CROSSMATCHING
• START FLUID
• PERMISSIVE HYPOTENSION(70-90 MM OF HG, >90 IN HEAD INJURY)
• BOLUS FLUID (250 ML OF BLOOD OR NORMAL SALINE)
• AVOID EXCESSIVE CRYSTALLOID
• WARMING
• MASSIVE TRANSFUSION IN SEVERELY INJURED (PCV: FFP: PLATELET= 1:1:1)
• TRANAXAMIC ACID ; 1GM IV OVER 10 MIN-- 8 HRLY (WITHIN 3 HRS OF INJURY)
• PELVIC BINDER

34. DISABILITY &NEUROLOGICAL ASSESSMENT
DISABILITY ASSESSED BY AVPU SCALE
• A. ALERT I.E. OBEYS COMMANDS
• V. VOCALIZES-INAPPROPRIATE OR
INCOMPREHENSIBLE
• P. RESPONDS TO PAIN
• U. UNRESPONSIVE
NEUROLOGIC ASSESSMEN
• GCS scale
• Pupil reaction to light,
• Limb movement
Consider possible injuries-depressed skull fractures,
SDH, SAH, DAI, spinal injury

36. GCS

37. MX
• CLEARING THE CERVICAL SPINE
• NO SPINAL TENDERNESS
• NORMAL CONSCIOUS STATE,
• NORMAL NEUROLOGICAL
EXAMINATION,
• NO MAJOR DISTRACTING INJURY
COLLAR MAY BE REMOVED
AND NO FURTHER
INVESTIGATION REQUIRED
• Spinal cord injury
- High dose steroids if within
8 hours
• ICP monitor
- Neurosurgical consultation
• Elevated ICP
• Head of bed elevated, O2
• Mannitol
• Hyperventilation
• Emergent decompression

38. MANAGEMENT OF RAISED ICP
Features of raised ICP
• Headache
• Vomiting
• Bradycardia
• Restless
• Hypertension
• Confusion
• Blurred vision
• Dilated & non
reacting pupil

39. EXPOSURE & ENVIRONMENTAL CONTROL
• You can’t treat what you don’t find!
• If you don’t look, you won’t see!
• Logroll the patient to examine patient’s back
• Maintain cervical spinal immobilization
• Palpate along thoracic and lumbar spine
• Minimum of 3 people, often more providers required
• Avoid hypothermia
• Apply warm blankets after removing clothes
• Hypothermia = Coagulopathy
• Increases risk of hemorrhage

40. ALWAYS INSPECT THE BACK

41. Trauma Logroll
• One person = Cervical spine
• Two people = Roll main body
• One person = Inspect back and
palpate spine

42. PRIMARY SURVEY ADJUNCTS
MONITOR
• VITALS
• ECG
• URINARY CATHETER
• GASTRIC TUBE
• ABG
• PULSE OXIMETER
• URINE OUTPUT
TEST: CBC, X-RAY, EFAST, WBCT, ELECTROLYTES, UREA, CLOTTING SCREEN, GLUCOSE.

43. NOT IN TRAUMA
Never try to remove any impaled
foreign object (may cause severe
uncontrollable bleeding, tamponade
and sudden death)
Never try to put the intestinal loops
back into abdomen in stab injuries
(may cause strangulation)
Never insert anything nasally
in head injury patients
especially when there are
signs of basal skull #

44. SECONDARY SURVEY
• HISTORY
• PHYSICAL EXAM: HEAD TO TOE
• COMPLETE NEUROLOGICAL
EXAM
• SPECIAL DIAGNOSIS TESTS
• RE-EVALUATION

45. HISTORY

46. ADJUNCTS TO SECONDARY SURVEY
• Special diagnostic tests
• CT
• Contrast x-ray studies
• Extremity x-ray
• Endoscopy
• Ultrasound

47. DEFINITIVE CARE
• ACCORDING TO INJURY
• MULTIDISCIPLINARY APPROACH
OR
• ICU
• TRANSFER

48. TERTIARY SURVEY
• IF ANY IS INTUBATED OR UNRESPONSIVE AFTER EXTUBATION OR ALERT
IDENTIFY MISSED MINOR INJURIES
• E.G. SCAPULAR#, ROTATOR CUFF TEAR.

49. DAMAGE CONTROL SURGERY
POLYTRAUMA PT.  TRIAD OF DEATH (COAGULOPATHY,
HYPOTHERMIA, ACIDOSIS- INTERFERENCE WITH SURGICAL
MANAGEMENT.
• GOAL
• CONTROL HRG.
• PREVENT CONTAMINATION
• PREVENT FURTHER INJURY

50. DAMAGE CONTROL SURGERY
STAGE
1. PATIENT SELECTION
2. CONTROL OF HRG. &
CONTAMINATION
3. RESUSCITATION IN ICU
4. DEFINITIVE SURGERY
5. ABDOMINAL CLOSURE
Criteria
1. Hypothermia (<340C)
2. Acidosis (pH <7.2)
3. Lactate >5 mmol/L
4. Coagulopathy PT>16
Sec
5. BP < 70 mm of Hg
6. Transfusion > 10 unit
7. Injury severity score
>3

51. TO SUMMARISE
• ORGANIZED TEAM APPROACH
• PRIORITIES IN MANAGEMENT AND RESUSCITATION
• RULE OUT MORE SERIOUS INJURIES
• THROUGH EXAMINATION
• FREQUENT REASSESSMENT
• MONITORING