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ATLS(Advance Trauma Life Support)<br />Dr. Tanuj Paul Bhatia<br />

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History<br />Introduced by Dr. James Styner, an orthopedic surgeon in 1970s.<br />Now considered the ‘Gold standard’ in initial management and resuscitation of trauma cases.<br />

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Importance of ATLS‘The Golden Hour’<br />

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ATLS components<br />Primary survey<br />Resuscitation <br />Secondary survey<br />Definitive care<br />

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Aims of ATLS<br />Primary survey – To identify what is KILLING the patient.<br />Resuscitation – To treat what is killing the patient.<br />Secondary survey – To identify all other injuries.<br />Definitive care – Develop a definitive management plan.<br />

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Pre hospital care<br />Objectives – <br />assessment of the injury scene; <br />stabilization and monitoring of the injured patient; and <br />safe and rapid transportation of critically ill patients to the appropriate trauma center.<br />

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MVIT - Mechanism, Vital signs, Injury inventory, Treatment<br />

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Primary survey<br />A – Airway with cervical spine control<br />B – Breathing<br />C – Circulation<br />D – Disability<br />E - Exposure<br />

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Airway<br />Establishing a patent airway is highest priority.<br />To prevent irreversible brain damage .<br />A patient who is able to respond verbally has a patent airway.<br />For every patient - Oxygen administered (via nasal cannula or bag valve facemask) and an oxygen saturation monitor (i.e., pulse oximeter) placed. <br />

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Stabilizing cervical spine<br />O2<br />Pulse<br />Oxi.<br />C-spine<br />

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Airway (contd.)<br />Basic maneuvers <br />Simple suctioning.<br />Jaw-thrust maneuver.<br />Oropharyngeal airway.<br />Tracheal intubation<br />indicated in any patient in whom concern for airway integrity exist.<br />Adequacy of ventilation should be verified .<br />

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Airway (contd.)<br />Direct cricoid membrane airways.<br />Cricothyrotomy is the method of choice .<br />Percutaneoustranstracheal ventilation.<br />

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Breathing<br /> Once an airway is established, attention is directed at assessing the patient's breathing .<br />The chest wall motion is observed and axillae are auscultated to check delivery to the peripheral lung.<br />Life threats<br />Tension pneumothorax<br />Pneumothorax/hemothorax<br />Flail chest<br />Open pneumothorax<br />

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Pneumothorax<br />

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Treatment <br />Tube thoracostomy.<br />Mechanical ventilation.<br />

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Circulation <br />To identify and treat the presence of shock in the patient.<br />Initially, all active external hemorrhage is controlled with direct pressure.<br />The pulse is characterized, and a blood pressure (BP) is obtained.<br />Shock is defined as the inadequate delivery of oxygen and nutrients to tissue.<br />

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Etiologies of shock<br />Hypovolemic<br />Cardiogenic<br />Distributive <br />

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Hypovolemic shock<br />Most common in trauma(Haemmorhagic shock).<br />Decreased intravascular volume secondary to blood loss .<br />S/S - rapid pulse, decreased pulse pressure, diminished capillary refill, and cool, clammy skin.<br />

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Management<br />two large-bore intravenous lines placed (14- or 16-gauge).<br />The antecubital veins are the preferred sites.<br />A blood specimen should be simultaneously obtained for cross-matching.<br />Resuscitation should consist of an initial bolus of 2 L of a balanced salt solution, typically Ringer's solution.<br />

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Classification of hypovolemicShock<br />Class EBLTreatment<br />I <15% (<750ml) Fluids<br />II 15-30% (750-1.5L) Fluids<br />III 30-40% (1.5L-2.0L) Fluids + Blood<br />IV >40% (>2.0L) Fluids + Blood<br />

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Cardiogenic shock<br />heart is unable to provide adequate cardiac output.<br />In the trauma setting, such shock can occur in one of two ways:<br /> (1) extrinsic compression of the heart or <br />(2) myocardial injury causing inadequate myocardial contraction and decreased cardiac output.<br />

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Management <br />I.V. fluids<br />E.C.G.<br />Chest x ray<br />Tube thoracostomy if tension pneumothorax is the cause.<br />

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Distributive shock<br />as a result of an increase in venous capacitance leading to decreased venous return.<br />Loss of peripheral sympathetic tone is responsible.<br />often respond to an initial fluid bolus but will eventually require pharmacologic support.<br />Phenylephrine is the drug of choice.<br />

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Disability <br />Assessment of the neurologic status.<br />to identify and treat life-threatening neurologic injuries.<br />Intracranial injuries(Mannitol, 0.25–1.00 g/kg)<br />Spinal cord injuries(methylprednisolone)<br />Neurosurgical consultation.<br />

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Exposure <br />Last step<br />Exposure with environmental control.<br />Remove clothes and look for other dangerous injuries.<br />

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Completion of primary survey<br />Monitoring.<br />Laboratory values.<br />Adequacy of resuscitation.<br />Radiographic investigations.<br />FAST(focussed abdominal sonography for trauma)<br />CT SCAN.<br />

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FAST<br />

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Secondary surveyKEY COMPONENTS<br />History<br />Complete head-to-toe examination<br />“Tubes and Fingers in every orifice”<br />Complete Neuro exam<br />Special diagnostic tests<br />Reevaluation<br />

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HISTORY<br />A Allergies<br />MMedications<br />PPast Medical/Surgical History/Pregnancy<br />LLast meal<br />EEvents/Environment related to injury<br />

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HEAD<br />Complete Neuro exam<br />GCS Score<br />Comprehensive eye/ear exams<br /> MAXILLOFACIAL<br />Bony crepitus/stability<br />Palpable deformity<br />

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Cervical Spine<br />Palpate for tenderness/stepoffs/crepitus<br />Complete motor/sensory exams<br />Reflexes<br />C-spine imaging<br />

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Neck (soft tissues)<br />Mechanism: blunt vs penetrating<br />Symptoms: airway obstruction, hoarseness<br />Findings: crepitus, hematoma, stridor, bruit<br />

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Chest<br />Inspect<br />Palpate<br />Percuss<br />Auscultate<br />X-rays<br />

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Abdomen<br />Inspect, auscultate, palpate, percuss<br />Reevaluate frequently<br />Special studies<br />

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Musculoskeletal:Extremities<br />contusion, deformity<br />pain<br />perfusion<br />peripheral NV status<br />X-rays as indicated<br />

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Neurologic<br />Spine/Cord:<br />complete motor and sensory exams<br />reflexes<br />imaging as indicated<br />CNS:<br />frequent reevaluation<br />prevent secondary brain injury<br />Early neurosurgical consultation<br />

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Definitive care<br />Definitive hospital care is undertaken .<br />Ranging from emergent celiotomy to admission and further assessment.<br />Diagnostic evaluations are completed and therapeutic interventions performed.<br />

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Roles of the Trauma Team<br />Airway<br />Nurse<br />Team Member<br />Team Member<br />Boss<br />Attending<br />Nurse<br />

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Roles of the Trauma Team<br />Boss<br />Directs the team, communicates decisions<br />Free to roam<br />Attending speaks through Boss (or teaches directly)<br />

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Roles of the Trauma Team<br />Airway<br />A & B of primary survey<br />Intubation (if needed)<br />Head / Neck in secondary survey <br />Nurses<br />Attach monitors, give blood / fluids / meds<br />Recording nurse records at foot of bed<br />

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Roles of the Trauma Team<br />Team Members<br />Expose, examine (secondary survey)<br />Procedures as directed (by boss)<br />Chest Tubes<br />Lac repairs<br />Rectals, foleys routinely assigned to team member.<br />

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Overview of ATLS<br />

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HANK YOU<br />