The document provides guidelines for the stabilization and management of polytrauma patients according to ATLS protocols. It describes the initial assessment of a hypothetical patient involved in a motorbike accident using the ABCDE approach. This includes securing the airway with cervical spine protection, treating breathing issues like tension pneumothorax, controlling hemorrhage, and assessing neurological status. It then outlines the steps for secondary survey, potential indications for emergency procedures, and guidelines for patient transfer to definitive care.

1. TRAUMA AND EMERGENCY
Stabilization of Polytrauma
patient: ATLS Guidelines
Dr. Padmaja Pallavi (SR Trauma & Emergency)
Dr. Vinay Kumar Singh (JR-1 Emergency
Medicine)

2. Hypothetical Scenario
• 24 yr old male had motorbike accident with a tractor and was
under the tractor wheels for 10 min
• On arrival in ED (transport time 10-15 min):
– Wearing a helmet, obvious facial injuries, injury marks on
chest and abdomen, open femur fracture
– Helmeted, with cervical collar, on backboard
– Unresponsive, tolerating oro-pharyngeal airway
– Oxygen by venturi mask @15l/min
– Vomitus present in mask
– O/E :- noisy breathing, RR=40/min, shallow, SpO2=80%
– HR=140, BP=80/60,peripheries cold, No iv access
What is the next step in management?

3. Initial assessment and management
PRIMARY SURVEY
– Check “ABCDE”
– Frequent reassessment
– Life threatening injuries
10 second assessment
SECONDARY SURVEY
• ‘AMPLE’ history
Allergy
Medications currently used
Past illness, Pregnancy
Last meal
Events / Environment related
to injury
• Detailed examination
Head to toe
Back and front
• Detailed work up

4. AIRWAY
C SPINE PROTECTION‼
BREATHING &
VENTILATION
CIRCULATION
STOP BLEEDING‼
DISABILITY
NEUROLOGIC STATUS
EXPOSURE
ENVIRONMENT
6/13/2020 4
PRIMARY SURVEY (Initial assessment)
“ABCDE”

5. A: Secure & Maintain Airway Patency
with C-spine protection
• Signs of airway obstruction:
(Noisy breathing, labored breathing, stridor, cyanosis)
• Maneuvers:
 In-line stabilization of C spine
 Check airway patency
 Clear airway: secretions, vomitus, blood, dentures
• Suction equipment, Suction catheters, large bore tonsil suction
apparatus (Yankauer)
 Open airway:
• Chin lift (not head tilt)
• Jaw thrust
 Maintain airway patency:
• Oropharyngeal or nasopharyngeal airway
6/13/2020 5

6. AIRWAY & VENTILATORY MANAGEMENT

7. Open airway
(maintain in-line stabilization)
6/13/2020 7
Jaw thrustONLY Chin Lift

8. Maintain airway patency
(maintain in-line stabilization)
Oropharyngeal airway Nasopharyngeal airway
6/13/2020 8
Avoid nasopharyngeal airway
/nasal intubation:
Nasal/ cribriform plate fracture:
CSF leaks: rhinorrhea,
otorrhea
Basilar skull fracture:
Racoon eyes (periorbital
ecchymosis)
Battle sign (retroauricular
ecchymosis)

9. Definitive airway
(maintain in-line stabilization)
• Endotracheal tube (oral or nasal)
• Airway secured with tape
• Oxygen enriched assisted ventilation
6/13/2020 9
EMERGENT URGENT
Cardiac arrest Unconsciousness
Respiratory failure
Shock
Facial burns with risk of airway loss
Facial trauma with partial airway obstruction
Apnea
Loss of airway patency
Inhalational burns with
respiratory distress

10. AIRWAY (ATLS 10TH Edition), a clinical
update

11. NEEDLE CRICOTHYROIDOTOMY

12. SURGICAL CRICOTHYROIDOTOMY

13. TRACHEOSTOMY

14. • Prevention of hypoxia - top priority
• Adequate gas exchange to maximize oxygenation and CO2
elimination.
• Every injured patient should receive supplemental oxygen
– Face mask, Bag and mask, Definitive airway
• Detailed Examination of neck and chest to detect “life
threatening events”.
6/13/2020 14
B: Breathing and ventilation

16. ASSESSMENT MANAGEMENT
Airway obstruction Noisy breathing, labored
breathing, stridor, cyanosis
•Oropharyngeal or
nasopharyngeal airway
•Definitive airway
Tension pneumothorax •Tracheal deviation away
•Distended neck veins
•Tympany
•Absent/↓sed breath sounds
•Needle decompression
•Tube thoracostomy
Open pneumothorax •Open wound
•Tympany
•↓sed breath sounds
•Dressing on 3sides of
wound : Valve effect
•Tube thoracostomy
•Flail chest/ Tracheo-
bronchial Tree Injury
•Pulmonary contusion
•Rib fracture
•Labored breathing
•Cyanosis
•Paradoxical breathing
•Analgesia
•Oxygenation
•Judicious fluids
Massive haemothorax •Tracheal deviation
• Flat neck veins
• Dull note
• Absent/↓sed breath sounds
• Venous access
• Volume replacement
• Tube thoracostomy
• Thoracotomy
6/13/2020 16

17. E-FAST (ATLS 10Th Edition), a clinical
update

18. NEEDLE DECOMPRESSION

19. 6/13/2020 19
Tension pneumothorax
Open pneumothorax
Needle thoracentesis
Tube thoracostomy 36Fr
Dressing on 3sides of wound
Tube thoracostomy

20. 6/13/2020 20
Tube thoracostomy
Thoracotomy:
>1500 ml blood
immediately evacuated
>200ml/hr blood in
drains for 2-4 hrs
Analgesia
Oxygenation and
ventilation
Judicious fluids
*Flail Chest/
Tracheobronchial
Injury
*Pulmonary
Contusion
Massive hemothorax

22. TRAUMATIC CARDIAC ARREST

23. C: Circulation with hemorrhage control
• Pulse, skin color, peripheries, BP
• Hemorrhagic Shock: Most common type of shock in trauma
– Definitive control of hemorrhage
Step1. Direct pressure on wound, tourniquet, splint
Step2. Pelvic stabilization
Step3. Angio-embolization
Step4. Surgical ligation
– Aggressive fluid resuscitation
Step1. Two large calibre intravenous access
Step2. Samples for blood grouping and cross-match, appropriate labs,
toxicology studies
Step3. Prevent hypothermia - Warm fluids
Step4. PRBCS
– Look for occult hemorrhage
6/13/2020 23
STOP
BLEEDING
‼

24. SAVE A LIFE

25. Initial Assessment(ATLS 10TH Edition), a
clinical update

26. Signs and Symptoms of Haemorrhage by class (ATLS
10TH Edition)

27. Response to initial fluid resuscitation (ATLS Protocol)
1000-2000 ml isotonic crystalloids in adults; 20ml/kg bolus in children
RAPID
RESPONS
E
TRANSIENT
RESPONSE
MINIMAL or
NO RESPONSE
Reason for shock
10-20%
blood loss
20-40% blood loss
Ongoing loss
Inadequate
resuscitation
Non-hemorrhagic shock
>40% loss
Non-hemorrhagic shock
Need for more
crystalloid
Low High High
Need for blood Low Moderate to high Immediate
Blood preparation Type and
cross-
match
Type specific Type O PRBCs
Management of non-
hemorrhagic shock
Operative
intervention
Possible Likely Highly likely

28. Transient responders or Non-responders to initial resuscitation
Hemorrhagic shock (Class III/IV)
Non-hemorrhagic shock
Tension
pneumothorax
Cardiac tamponade
(Beck’s triad)
1. Distended neck veins (Raised JVP)
2. Muffled heart sounds
3. Low BP
Normal breath sounds
FAST
Blunt cardiac injury Arrhythmias, ischemic ECG changes
Others Neurogenic shock (Hypotension,bradycardia,
warm extremities) or Septic shock
6/13/2020 28

29. 29
Cardiac tamponade
(Beck’s triad)
Penetrating inury
Volume replacement
Pericardiocentesis
Thoracotomy
Blunt Cardiac injury
Invasive monitoring
Inotropic support
Consider operative intervention
Tension pneumothorax
NON-HEMORRHAGIC SHOCK
(besides neurogenic and septic shock)

30. HEMORRHAGIC SHOCK
Massive haemothorax
Intra-abdominal
hemorrhage
Distended abdomen
DPL / FAST +ve
Rectal, vaginal
examination
Volume replacement
LAPAROTOMY
Obvious external
bleeding
(musculoskeletal trauma)
Identify source of
external bleeding
Direct pressure
Splints
Pelvic stabilization
Closure of actively bleeding
wounds
Occult hemorrhage
6/13/2020 30
Source of occult hemorrhage:
“Blood on the floor × 4 more”
 Chest
 Retroperitoneum
 Pelvis
 Long bones

31. Pelvic fracture stabilization
Significant association with injuries to visceral or vascular structures
Delay in stabilization of pelvis allows continued hemorrhage
Repeated pelvic manipulation can aggravate hemorrhage
Severe pelvic injuries warrant early transfer to trauma center
31
Pelvic binder
Open book
Vertical shear
6 0 -7 0 %
Pelvic stabilization using
bedsheet
Lateral compression

34. Indications for Emergency Laparotomy
• Blunt trauma
– Hypotension with positive FAST/ DPL or clinical evidence
of intra-peritoneal bleeding
– Free air, retroperitoneal air, rupture of hemi-diaphragm
after blunt trauma
• Penetrating trauma
– Hypotension with penetrating abdominal wound
– Gunshot wounds traversing peritoneal cavity or retro-
peritoneum (visceral/vascular)
– Bleeding from stomach, rectum, genitourinary tract
– Evisceration
– Peritonitis (even if no shock)
6/13/2020 34

35. D: Neurological status
• Avoid hypotension (SBP < 90) and hypoxia (PaO2 < 60)
• Brief neurological examination:
– GCS:
• Best Motor Response
– Pupils:
• Ipsi-lateral pupillary dilatation with contra-lateral
hemiparesis suggestive of uncal herniation
– Lateralizing signs
6/13/2020 35
GCS Classification
13-15 Mild traumatic brain injury
(MTBI)
9-12 Moderate brain injury
3-8 Severe brain injury

39. E: Exposure and Environment
• Completely undress patient
• Warm environment
• Prevent hypothermia
6/13/2020 39
Core temperature < 35°C on admission:
Independent predictor of mortality after major trauma (SHOCK 2005)

40. SECONDARY SURVEY
STEP 1. Obtain AMPLE history from patient, family. Or pre-
hospital personnel.
STEP 2. Obtain history of injury-producing event and identify
injury mechanisms.
STEP 3. Assess the head and maxillofacial area.
STEP 4. Assess the cervical spine and neck.
STEP 5. Assess the chest
STEP 6. Assess the abdomen

41. .

42. SECONDARY SURVEY
STEP 7. Assess the perineum.
STEP 8. Perform a rectal assessment in selected patients to identify
the presence of rectal blood.
STEP 9. Perform a vaginal assessment in selected patients.
STEP 10. Perform a musculoskeletal assessment.
STEP 11. Perform a neurological assessment.

43. TRANSFER TO DEFINITIVE CARE