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Advanced trauma life support
1. A Presentation on
Advanced Trauma Life Support (ATLS)
Delivered by
Dr Ahmed Daniel (Registrar)
Department of Orthopedics & Traumatology
University of Uyo Teaching Hospital.
3. INTRODUCTION
Emergency of trauma management by Dr. James K. Styne.
ATLS course which held in 1978.
International disemmination of the ATLS course began about 2 years
thereafter.
ATLS is a course that enables health personnels apply organized, safe
and reliable techniques for the immediate treatment of injured persons
via team approach in a simultanous fashion.
4. INTRDUCTION CONTINUES
ATLS in Nigerian medical practice - 2009
D. Nnamdi Nwauwa as the course chairman and Dr. Bob Yellowe as the
course director.
6. INTRODUCTION CONTNUES
Trimodal Death Distribution:
THE FIRST PEAK occurs within seconds to minutes of injury.
THE SECOND PEAK occurs within minutes to several hours following
injury.
THE THIRD PEAK occurs several days to weeks after the initial injury.
7. ATLS may be defined as
A protocol that constitutes a set of diagnostic and therapeutic
interventions intended to identify and treat acute life threathening
injuries, beginining with the most immediate through collaborative and
simultaneous team effort that is hedged on world best practices.
10. TRIAGING (AND REFERRAL SYSTEM)
Simply the sorting of patients.
Aim:
Prevent avoidable deaths
Prevent further deterioration of injured patient
Ensure efficient utilization of resources
11. TRIAGING CONTINUES
Some triaging systems commonly employed are:
- START Triaging System
- JumpSTART Triaging system
- SALT Triaging System
12.
13. PRIMARY SURVEY “ABCDEs”
- A process that involves a SIMULTANEOUS team effort geared towards saving the
life of the patient using the ABCDE ATLS guidelines.
- The team approach allows for timely assessment and establishment of treatment
priorities.
Speaking to the patient, this serves as a quick assesstment of the degree of
cardiorespiratory and neurological compromise/injury. A communicating patient
may translate to:
- Prevailing airway patency
- Breathing isn’t severely compromised
- Appreciable cerebral function, invariably reflecting
- Current/transciently normotensive state
14. PRIMARY SURVEY
A simultaneous approach (not in sequence)
- Airway maintenance and spinal protection
- Breathing and ventilation
- Circulation with bleeding control
- Disability (AVPU/GCS)
- Exposures
16. AIRWAY MAINTENANCE AND SPINAL PROTECTION
CONTINUES
- All traumatized patients must be assumed to have sustained a spinal
injury until proven otherwise.
- Patient must be nursed on a hard spinal boardwith strappings
- Log-rolling maneuver.
- Do not apply traction until spinal injuries have been excluded
- C-spinal protection using an appropriately sized rigid cervical collar
and immobilizaton
- Chin lift/Jaw thrust
- Airway clearance and maintenance with minimal cervical motion.
23. AIRWAY MANAGEMENT - Intubation
Indications:
- Inability to maintain airway patency
- Inability to protect the airway against aspiration
- failure to ventilate
- failure to oxygenate
- Anticipation of a deteriorating course that may eventually lead to
respiratory failure
Drug Assisted Intubation:
Pre-LOAD + Anesthetic agent + Neuromuscular blocker
24. Intubation Continues
- Pre-oxygenation using a 100% oxygen at 10 - 15L/min via a non re-breathable mask for
3minutes OR via BVM in patients poorly ventilating or not ventilating.
- Lidocaine intraveous dosing
- Opoid anagelsic
- Atropine
- De-fasiculating agent
- Anesthetic agent
- Neuromuscular blocker
Then intubate, confirm position, ventilate and review response
Other airway management options:
Cricothyroidotomy
Tracheostomy
32. REMEMBER!
ATLS management IS NOT a sequential
but rather a simultaneous TEAM effort
towards saving the life of the patient.
33. CIRCULATION
Assessment:
- Feel for cool extremities
- Pulse rate: Infants 160bpm, pre-schoolers 140bpm, schoolage & teenagers
120bpm and adults 100bpm.
- Pulse pressure
- Altered mental status
- Pulse volume
- Capillary refill
- Pallor
- Systolic blood pressure (Continous cardiac monitoring)
If in shock, assume hemorrhagic shock until proven otherwise
34. CIRCULATION CONTINUES
What are the possible sources of concealed hemorrhage?
Note, the most effective way of restoring adequate cardiac output, end-organ
perfusion and tissue oxygenation is by restoring venous return to normal by
locating and stopping source of hemorrhage. Volume replacement will correct
shock only after bleeding has been arrested. ARREST BLEEDING, THIS IS THE
ULMITATE GOAL.
Resuscitative Effort:
Secure 2 wide bore cannula in large veins (Blood samples)
Alternatives:
- Intra-osseous access
- Venous cut-down
- Central IV access
36. CIRCULATION CONTINUES
Sites of Intraosseous Access
- Sternum
- Humerus
- Distal femur
- Proximal tibia: 1 cm to 2 cm inferior and medial to the tibial
tuberosity in the flat portion of the tibia
- Distal tibia: 2 cm proximal to the medial malleolus in the flat portion
of the tibia.
38. CIRCULATION CONTINUES
Resuscitative Effort:
- Arrest hemorrhage.
- IV crystalloids (Normal salline/lactated ringers) 1L or 20ml/kg in
pediatric patients <40kg stat.
- Commence blood transfusion immediately if still in shock after 2nd
bolus of IV crystalloids resuscitation while actively searching for
possible causes of ongoing hemorhage.
- Prevent hypothermia.
- Monitor efforts.
39. CIRCULATION CONTINUES
Resuscitative Efforts Continues
- IV Tranexamic acid given within 3hours of trauma over 10minutes, follow up dose 1g
is given over 8hours
- Use of FFP and platelet concentrate may be employed as necessary particularly in the
face of massive blood transfusion.
- FAST: Sonographic images are targeted *Morisons pouch, Subxiphoid pericardial
view, perisplenic view, suprapubic window (pouch of douglas).
- DPL: Diagnosis indicated by *10ml of gross blood on peritneal tap; >500ml/mm3
WBC; 100,000ml/mm3 RBC; Enteric/vegetable matter upon sampling.
40. CIRCULATION CONTINUES
- All severely traumatized patient can be safely considered as having a pelvic
fracture and managed acutely with a pelvic binder until proven other wise.
- Sources of Concealed Massive Hemorrhage:
Hemothorax
Femoral Fractures
Pelvic fractures
Intra-abdominal viscus injuries
- Brain CT Scan in acute care of trauma patient.
43. EXPOSURE
- Remove all clothings carefully and examine from head to toe
judicously
- Avoid hyporthermia
- Log roll the patient to expose the back, then inspect and palpate the
spine.
44. Adjuncts of Primary Survey
- Trauma x-ray series
- Other specialized imaging investigations
- Gastric catheters
- SpO2 or Capnography
- ABG level
*Vitals are constantly being monitored throughout primary survey.
45. SECONDARY SURVEY
Commenced after patient has been successfully resuscitated and
stabilzed in primary survey.
AMPLE history
- Events leading to/surrounding the injury (complications, care)
- Past medical history
- Medications
- Allergies
- Last meal
47. SECONDARY SURVEY CONTINUES
Adjuncts of secondary survey:
These include specialized interventions employed to determine the
extent of injury, to reveal or rule out sinister injuries.
- Consultatons/referral
- Supportive care
- Rehabiliitative care
48. CONCLUSION
ATLS is an extensive course that summarily entails immediate
assessment, resuscitation and stabilization of an injured person in a
timely fashion with eventual definitive therapy.
It employs an organized, simultanous team approach via researched
methods.
49. BIBLIOGRAPHY
- Advance Trauma Life Support 10th Edition
- Medscape, ATLS
- Trauma in a Flash, Arizona Trauma Association
- Ultimate ATLS 10 Prep Course Update 2021, Ultimate ATLS Prep
- Evaluation of Trauma PAtients ATLS Protocol - Everything you need to
know, Dr Nabil Ebraheim
- Trauma (ATLS) Asssessment - Multiple Injury, Oxford Medical
Education
