2. Introduction
• Caused by massive blood loss or
neurologic injury
50 % within the first
minutes of sustaining the
injury
• Most commonly from shoc, hupoxia or
neurologic injury
30 % within hours after
arrival to hospital
• Multi system organ failure and infection
are leading causes
20 % within days to
weeks following injury
• Trauma is a major public health problem with high disability, death, and
societal cost
https://www.orthobullets.com/trauma/1005/evaluation-resuscitation-and-dco
3. Three Underlying concepts Of ATLS
program
Treat the greates threat to lfe first
Nover allow lack of definitive diagnosis to impede the application of an
indicated treatment
A detailed history is nor essential to begin the evaluation of a patient with
acute injuries
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
4. Initial assessment
Preparation
Triage
Primary Survey (ABCDE) with immediate resuscitation of patients with life-threatening
injuries
Adjuncts to the primary survey and resuscitation
Consideration of the need fot patient transfer
Secondary Survey
Continued postresuscitation monitoring
Definitive care
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
5. Preparation
• To notifiy the receiving hospital before personnel transport the
patient from the scene
• Immediate transport to the closest appropriate facility, preferably a
verified trauma center
Pre-hospital
Phase
• A resuscitation area is available fot trauma patients
• Properly functioning airway equipment
• Warmed Intravenous crystalloid solutions
• A protocol to summon medical assistance is in place
• Transfer agreement with verified trauma centers are established and
operational
Hospital phase
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
7. Triage
Multiple Casualties
• Members of patients and the severity of the injuries do not exceed the capability to render care
Patiens with life treathening problem should be treated first
Mass Casualties
• Members of patients and the severity of their injuries does exeed the capability of the facility
and staff Patient with greatest chance of survival should be treated first
Sorting pf Patients in the field to help determine the appropriate
receiving medical facility
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
8. Primary survey with Simultaneous
resuscitation
The primary survey identifies life threatening conditions by adhering to
this sequence
Airway maintenance with restrtiction of C – Spine control motion
Breathing and ventilation
Circulation with Hemorrhage control
Disability (assessment of neurologic status)
Exposure / Enviromental control
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
9. Airway Maintenance and C – Spine
control
Evaluation
The patient is able to communicate verbally?
Altered GCS score < 8?
Examine any additional sound (such as stridor, girgling) and pooled of secretion
or blood
Assume C – Spine control
The spine must be protected from excessive mobility
Cervical spine is protected with a cervical collar
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
13. Breathing and ventilation
Adequate exchande is required to maximize oxygenation and carbon dioxide elimination
Ventilation requires adequate function of the lungs, chest wall, and diaphragm should
examine and evaluate each component
Every injured patient should receive supplemental oxygen
Inspection, palpation, percussion and auscultation
Asymmetrical chest movement? Any wound or haematome? Cyanosis?
Tenderness? Crepitation?
Hypersonor or dull?
Decreased or absent breathing sound?
Use oximeter to monitor the Haemoglobin oxygen saturation
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
15. Circulation with hemmorage control
The first step in managing shock in trauma patients is to recognize its presence.
Level of consciousness?
Skin perfusion?
Pulse?
Identify the source if bleeding as external or internal
External bleeding is managed by direct manual pressure on the wound
The major areas of internal hemmorhage are chest, abdomen, retroperitoneum, pelvis and long
bones
Management include, chest decompression, pelvic stabilizing device and extremity
splints
Definitive bleeding control is essential along with appropriate replacement of
intravascular volume
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
16. Circulation with hemmorage control
Any injured patient who is cool to touch and is tachycardic should be considered to be
in shock until proven otherwise
Massive blood loss may produce only a slight decrease in initial hematocrit or
hemoglobin concentration.
Obtain access to the vascular system promptly.
2 Large bore Ivs
Central venous access if indicated
As intravenous lines are started, draw blood samples for type and crossmatch
Massive transfusion
Early administration of pRBCs, plasma and platelets in balanced ratio
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
17. Hemmorage shock grade
Class I Class II Class III Class IV
Blood loss (liter) Up to .075 0.75 – 1.5 1.5 – 2.0 > 2
% TBV 15 % 30 % 40 % > 40 %
Pulse rate < 100 >100 > 120 > 140
Respiratory rate 14 – 20 20 – 30 30 – 40 > 40
Urine output (ml/hr) > 30 20 – 30 5 - 15 Neglible
Mental status Slightly anxious Mild anxious Anxious / confused Confused / lethargic
Fluid replacement Crystalloid Crystalloid Crystalloid and
blood
Crystalloid and
blood
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
18. Disability (Neurologic Evaluation)
A rapid neurologic evaluation establishes the patient’s level of consciousness and
pupillary size and reaction
Identifies the presence of lateralizing signs
Determines spinal cord injury level if present
The GCS is a quick, simple, and objective method of determining the level of
consciousness.
Patients with evidence of brain injury should be treated at a facility that has the
personnel and resources to anticipate and manage the needs of these patients.
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
19. Exposure / Enviromental control
Completely undress the patient
Cover patient with warm blankets or extetnal warming device to prevent
hypothermia
Hypothermia can be present when the patient arrives,or it may develop
quickly in the ED if the patient is uncovered and undergoes rapid
administration of room-temperature fluids or refrigerated blood.
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
20. Adjuncts to the Primary survey with
resuscitation
Electrocardiographic monitoring
Pulse Oximetry
Ventilatory rate, capnography and arterial blood gases
Urinary and gastric chateters
X-Ray Examinations and diagnostic studies
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
21. Ventilatory rate, capnograghy an
arterial blood gases
To monitor the adequacy of patients respirations
In addition to providing information concerning the adequacy of
oxygenation and ventilation, ABG value provide acid base information.
Low pH and base excess levels indivate shock can reflect improvements
with resuscitation
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
22. Urinary Chateter
Sensitive indicator of the patient’s volume status and reflects renal perfusion.
Monitoring urinary output is best accopmplished by insertion f an indwelling
Suspect a urethral injury in the presence of either blood at the urethral meatus perineal
ecchymosis DO NOT insert chateter if present
Adequate volume replacement during resuscitation should produce OU:
Adult 0.5 mL/kg/hr
Pediatric 1 mL/kg/hr
Infant (<1 Y.O) 2mL/kg/hr
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
23. X – ray Examinations and Diagnostic
studies
Use X-Ray judiciously and DO NOT DELAY Patient
resuscitation or transfer to definitice care who require a
higher level of care
Chest AP
Pelvic AP
FAST, eFAST and DPL are useful tools for quick detection
of intraabdominal blood, pneumothorax, and
hemothorax
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
26. Consider need for Patient Transfer
During the primary survey with resuscitation, the evaluating doctor
frequently obtains sufficient information to determine the need to transfer
the patient to another facility for definitive care
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.
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
27. Secondary Survey
The secondary survey DOES NOT BEGIN until primary survey is completed,
resuscitative efforts are under way and improvement of the patient’s vital
functions has been demonstrated.
Head to toe evaluation of the trauma patient
Complete history and physical examination, including reassessment of all
vital sign
28. History
Every complete medical assessment includes a history of the mechanism of
injury taken from prehospital personnel and family
A : Allergies
M : Medications
P : Past illnesses/Pregnancy
L : Last meal
E : Events / Environment related to the injury
The patient’s condition is greatly influenced by the mechanism of injury
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
31. Head to Toe Physical examination
Head : Visual acuity, pupillary size, hemmorhage of the conjungtiva and/or
fundi, Penetrating injury, contact lenses, dislocation of the lens ocular
entrapment
Maxillo
facial
: bony structures, occlusion, intraoral examination, and assessment of
soft tissues
Cervical
spine and
neck
: C spine tenderness, Radiographic evaluation can be avoided in patients
who meet The National Emergency X-Radiography Utilization
Study (NEXUS) Low-Risk Criteria (NLC) or Canadian C-Spine Rule
Active and passive movement of knee joint can not be evaluated due
to decreased level of consciousness
Chest : Inspection to indentify contusions or wound,
Palpation of the chest wall requires palpation of entire chest wall
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
33. Canadian C – spine rule
Insurance Regulatory Authority NSW, S. (1117). Instructions for using the Canadian C-Spine Rule.
34. Abdomen and
pelvis
: Abdominal injuries must be identified and treated aggressively. Pelvic fractures can be
suspected by the identification of ecchymosis over the iliac wings, pubis, labia, or
scrotum. Pain on palpation of the pelvic ring is an important finding in alert patients.
Perineum,
rectum and
vagina
: Contusions, hematomas, lacerations and urethral bleeding
Musculoskelet
al system
: Look for contusions and deformities, palpation of the bones and examinations for
tenderness and abnormal movement. Impaired sensation and/or loss of voluntary
muscle contraction strength can be caused by nerve injury or ischemia, including that
due to compartment syndrome
Neurological
system
: examinations includes motor and sensory evaluation of the extremities, as well as
reevaluation of patient’s GCS and pupillary reflex
Protection of the spinal cord is required at all times until a spine injury is excluded. Early
consultation with a neurosurgeon or orthopedic surgeon is necessary if a spinal injury is
detected
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
35. Definitive care
Whenever the patient’s treatment needs exceed the capability of the
receiving institution, transfer is considered.
This decision requires a detailed assessment ofthe patient’s injuries and
knowledge of the capabilitiesof the institution, including equipment,
resources, and personnel
Student Course Manual ATLS ® Advanced Trauma Life Support ®. (2018).
