ATLS
Advance Trauma Life Support
History:
An orthopedic surgeon involved in a plane crash in the 1970s recognized the
inadequate trauma care provided by a rural hospital in the USA. A group of local
surgeons, emergency room doctors, and nurses,
working with the Lincoln Medical Foundation and the University of Nebraska, took
on the task of developing a course to ensure optimal care of the injured patient.
The first ATLS course was given in 1978 and 1 year later was adopted by the
American College of Surgeons as an educational program. The ATLS courses are
now in their third decade and are taught in over 50 countries worldwide.
The ATLS programs were built around three core concepts which represented a
dramatic change in traditional “medical” thinking
1- Treat the greatest threat to life first. (ABCDE)
2- The second principle is that an indicated treatment should not wait for a
definitive diagnosis.
3- An extensive history is not a critical component of the initial evaluation of the
injured patient
ASSESSMENT PRINCIPLES
1- Preparation and transport
2- Primary Survey and resuscitation, including monitoring and radiography
3- Secondary survey, including special investigations such as CT scanning and
angiography
4- Ongoing reevaluation
5- Definitive care
PRIMARY SURVEY
ABCDE
Airway maintenance with cervical spine protection
Breathing and Ventilation
Circulation with haemorrhage control
Disability with neurological status
Exposure, environmental control
Airway maintenance with cervical spine protection
If a patient can talk, the airway is usually patent, continuously checking this sign
allows for monitoring of airway status
Causes of airway compromise
1- Tongue position
2- Aspiration of foreign bodies
3- Regurgitation of stomach contents
4- Mandibular, tracheal and facial fractures
5- Traumatic brain injury
6- Bleeding e.g. a retropharyngeal hematoma
What to do for the airway
1- Jaw thrust (safest method in patient with cervical spine injury)
2- Chin lift
3- Remove debris from airway manually
4- Tonsillar suction (
5- Placement of an oral or nasal airway (better tolerated)
6- In patient with GCS <8, definitive airway will be required (Endotracheal
intubation, Laryngeal mask airway, Fiberoptic intubation, percutaneous and
surgical surgical cricothyroidectomy, tracheostomy)
Assess difficulty for intubation by remembering LEMON (Look externally,
Evaluate 3-3-2 (3F mouth opening, 3F hyoid chin distance, 2F thyroid FOM
distance), Mallampati scale, Obstruction, Neck mobility)
What to do for the cervical spine
1- Placement of rigid cervical collar till injury is ruled out clinically or
radiographically
2- Holding cervical spine in neutral position using a backboard, bindings or
purpose built head immobilizer
BREATHING
Look for
1- Inequality in chest movement
2- Crepitus and stridor
3- Paradoxic thoracic cage movement
4- Abdominal wall movement
5- Use of accessory muscles
6- Pattern of breathing (spontaneous, shallow or deep)
7- Penetrating chest injury
8- Bleeding
9- Rib or sternal fractures
10- Subcutaneous emphysema
11- Tracheal shift
12- Jugular distension
13- Tachypnea
14- CNS depression or injury
What to do
1- Supplmental oxygen via face mask or nasal cannula
2- Artificial ventilation via bag valve mask or a bag attached to an endotracheal
tube
3- Hook the patient upto standard monitors with a capnometer and pulse
oximeter
4- Open pneumothorax: apply occlusive dressing on 3 sides of the defect, insert
chest tube (32-40F in adults and 26-30F in children in 2nd or 3rd intercostal
space in the midclavicular line or 4th and 5th intercostal space in the
midaxillary line) at a distant side from the defect to prevent tension
pneumothorax (insert a 14-16 gauge needle into the 2nd or 3rd intercostal space
in the midclavicular line)
5- For hemothorax, restore blood volume, control the airway and drainage of
accumulated blood via a 36-40F chest tube in the 5th or 6th intercostal space, if
no signs of improvement then go for a thoracotomy
6- For a flail chest: initial stabilization of loose segments with external splints,
followed by intercostal nerve blocks and finally with a volume cycled
respirator with endotracheal intubation (internal splinting)
CIRCULATION
Compromised by
1- Fracture of long bones
2- Internal haemorrhage into pelvis
3- External losses
Assessment
1- Level of consciousness
2- Pulse
3- Respiratory rate
4- Blood pressure
5- Skin color
6- Urinary output
7- Acid base balance
What to do
1- Identify source of bleeding with focus assessment with sonography for
trauma (FAST) for abdominal free fluid, chest and pelvis require independent
radiography.
2- Direct pressure on external wounds and suturing of scalp lacerations with 2/0
non resorbable sutures
3- Two large peripheral IV lines (14-16 gauge)
4- Monitor urinary output, not below 0.5ml/kg/hour
5- Rule out cardiac tamponade and tension pneumothorax, perform
pericardiocentesis with 16-18 gauge syringe
6- For adults give 1L of normal saline 0.9% or Ringers Lactate as a bolus
followed by another litre as per vital signs, for children a dose of 20ml/kg.
7- No improvement should be followed by blood transfusion with cross
matched blood or O negative blood
8- FFP restores all clotting factors except platelets, platelets maybe transfused
independently if levels below 100,000/mm3
9- No improvement necessitates surgical exploration and suggest a misdiagnosis
of hypovolemic shock, signified by low CVP, other types of shock have a
higher CVP.
NEUROLOGIC ASSESSMENT
Done by AVPU, following initial assessment with GCS
Assessment by
1- Equal reactivity of pupils to light
2- Shape of pupils can suggest cause of consciousness (pinpoint pupil with
opiates, dilated pupils with meperidine HCl), both require reversal with
naloxone HCl 0.4mg initially
3- If cause is hyper or hypogylcemia, give initial bolus of 25g of glucose.
4- Evaluate CT for lenticular hematoma (epidural, caused by middle meningeal
artery) and crescentic hematoma (subdural, which also causes midline shift of
structures and caused by tear of bridging veins)
EXPOSURE
1- Complete disrobing of patient
2- Check for signs of injury, wounds, lacerations, fractures
3- Prevent hypothermia by use of air warming devices, warmed resuscitation
fluids
SECONDARY SURVEY
History from the patient or attendants (AMPLE = allergies, medications, past history,
last meal, events leading upto injury)
Inspection, percussion, palpation and auscultation of the patient from head to toe
Special studies such as peritoneal lavage, radiographic studies, and blood studies
maybe done at this time
Head and skull:
1- Examine the scalp for lacerations and foreign bodies
2- Examine the skull for signs of basilar skull fracture (Battles sign, CSF
Rhinnorhea or otorrhea, Hemotypanum, Racoon eyes)
3- Continuous reassessment of GCS
4- Abnormal extremity reflex (positive unilateral Babinski reflex = extension of
toe and flaring of the other digits upto plantar surface stimulation) seen in
corticospinal tract damage
5- Pupillary function, eye movements and eye opening, PERRLA (Pupil Equal
Round Reactive to Light and Accomodation)
6- Testing of brainstem:
- Corneal reflex (5th nerve)
- Occulocephalic manoeuvre: 7th and 8th nerve
- Caloric response: (occulovestibular reflex) for 3rd,4th,6th and 8th nerve)
7- Rectal sphincter tone (present in intra-cranial injury, lost in spinal injury)
8- Control of ICP
Chest
1- Check for hemothorax, pneumothorax,flail chest, pulmonary contusions,
ARDS and cardiac tamponade
2- Upright Chest x-ray for assessing air in mediastinum, widening of
mediastinum, fractures, shift towards midline
Maxillofacial area and neck:
1- Assess tongue position, can be made favourable with oral airway
2- Lacerations should be debrided and examined for injury to vital structures
such as facial nerve or parotid duct
3- Check symmetry of face for swelling and step deformity
4- Numbness across distribution of trigeminal nerve
5- Oral cavity examined for lacerations, lost teeth, change in occlusion
6- Check neck for subcutaneous air
7- Assess carotid pulse and palpate thyroid cartilage
Spinal chord
1- Neck and spine should be examined for deformity, edema, ecchymosis, and
tenderness
2- Loss of rectal tone
3- Hypoventilation causes by paralysis of intercostal muscles (lower cervical or
upper thoracic spinal chord)
4- Paralysis of diaphgram (involvement of C3 to C5 segment) will result in
abdominal breathing
5- Full series of Lateral, AP, Odontoid and right & left views of cervical spine,
followed by CT of neck if necessary
6- Recommended approach is cervical collar with a long spinal board for
diagnosed injuries
Abdomen
1- Abdominal rigidity and tenderness (signs of peritoneal irritation by blood or
internal contents)
2- Suction of gastric contents by NG tube
3- Diagnostic peritoneal lavage has been superdeeded by CT and ultrasound
4- Unexplained hypovolemia in patients are candidates for laparotomy
Genitourinary tract
1- Blood at urethral meatus (indicates urethral trauma)
2- Non palpable prostrate is sign of hematoma due to posterior urethral
disruption
3- A urine R/E showing more than 10RBC/HPF is sign of urinary system injury
Extremities:
Pelvic fractures: may cause loss of upto 1-5L of blood
Femus fractures: 1-4L
Arm fractures: 0.5-1L
Fat embolism due to fracture of long bones: prevented by early fixation of fractures
Checking of all peripheral pulses: unequal pulses suggest distal vasucular injuries
