Introduction to ATLS for medical students

1. Introduction to
Advanced Trauma Life Support
ATLS

2. Objectives
● Concepts of primary & secondary survey
● Priorities & Life threatening conditions
● Clinical & Surgical skills

3. Basic knowledge
● Rapid assessment
● Resuscitate & Stabilize (Prioritize)
● Patient's needs & facility's capabilities
● Appropriate transfer
● Optimum care

4. Initial Assessment & Management
● Preparation (Prehospital - Hospital)
● Triage
● Primary survey (ABCDE)
● Resuscitation
● Adjuncts to primary survey & resuscitation
● ->

5. Initial Assessment & Management
● Secondary survey
● Adjuncts to the secondary survey
● Postresuscitation monitoring
● Definitive care

6. Primary Survey
● Treatment priorities
● A: Airway maintenance + C-spine protection
● B: Breathing & Ventilation
● C: Circulation & Hemorrhage control
● D: Disability – Neuro
● E: Exposure / Environment control

7. A
● Airway
– Patency / Obstruction
– Severe head injury -> Definitive airway

8. Airway: Patency
● Maxillofacial trauma
● Neck trauma
● Laryngeal trauma (Hoarseness, Subcutaneous
emphysema, Palpable fracture)

9. A
● C-spine protection
– Multiple system trauma
– Altered level of consciousness
– Blunt injury above clavicle
– Manual in-line stabilization

10. A: Nexus
● Midline cervical tenderness
● Altered level of consciousness
● Evidence of intoxication
● Neurologic abnormality
● Presence of painful distracting injury

11. A
● Trauma patient is dynamic
● Repeated assessment

12. A: Resuscitation
● Jaw thust / Chin lift / Head tilt
● Naso / Oropharyngeal airway
● Combitube, LMA
● Definitive airway (Cuff in trachea)
– Oro / Naso tracheal intubation
– Surgical cricothyroidotomy

13. Endotracheal intubation
● Indication
– Provide patent airway
– Deliver supplemental oxygen
– Support ventilation
– Prevent aspiration

14. Endotracheal intubation
● Decision
– Apnea (orotracheal)
– Cannot maintain patent airway
– Protect aspiration / vomitus
– Impending compromise airway
– Closed head injury required assisted ventilation
– Inadequate oxygenation

15. Surgical Airway
● Cricothyroidotomy / Tracheostomy
● Indication
– Unable to intubate (severe maxillofacial injury,
failed intubation)
● Contraindication
– Airway transection

16. B: Breathing

17. B: Life Threatening Conditions
● Tension pneumothorax
● Flail chest with pulmonary contusion
● Massive Hemothorax
● Open pneumothorax
● Cardiac tamponade

18. Thoracic Trauma: Primary survey
● Looking, Palpation, Percussion,
Listening
– Tension pneumothorax
– Open pneumothorax (sucking chest wound)
– Flail chest
– Massive hemothorax
– Cardiac tamponade

19. Thoracic Trauma: Primary survey
● Tension pneumothorax
– Chest pain, Respiratory distress, Tachycardia,
Hypotension, Tracheal deviation, Absent breath sound,
Neck vein distension
– Immediate decompression
● Needle thoracostomy
● Intercostal drainage

20. Thoracic Trauma: Primary survey
● Open pneumothorax (sucking chest wound)
– > 2/3 of tracheal diameter
– 3 sided dressing
– Chest tube insertion

21. Open Chest Wound: 3-Sided
Dressing

22. Thoracic Trauma: Primary survey
● Flail chest
– >2 ribs fractures in 2 or more places
– Paradoxical chest wall movement
– Adequate ventilation
– Reexpand lungs: Intubation

23. Thoracic Trauma: Primary survey
● Massive hemothorax
– >1500 cc of blood (1/3 of blood volume) in chest
cavity
– IV resuscitation
– Chest tube
– Thoracotomy
● >1500 cc immediately
● 200 cc/h for 2-4 h

24. Thoracic Trauma: Primary survey
● Cardiac tamponade
– Penetrating injury
– Beck's triad
– DDx from Tension
pneumothorax
– FAST / Echo
– Pericardiocentesis

25. B: Resuscitation
● Supplemental oxygen
● Tension pneumothorax decompression

26. C: Circulation & Hemorrhage
control
● Circulation – Blood volume & Cardiac output
● Level of consciousness
● Skin color
● Pulse

27. C
● Hemorrhage control - External hemorrhage
– Manual pressure
– Splinting
– Tourniquet
– Hemostats

28. C: Resuscitation
● 2 large-caliber IV catheter
● “warm” NSS, RLS
● Blood
● Control bleeding
– Direct pressure
– Operative control
● Vasopressors

29. Shock
● Inadequate tissue perfusion / oxygenation
● Hemorrhagic / Non-hemorrhagic

30. Hemorrhagic shock
● Most common cause of shock in trauma
● External vs Internal hemorrhage
● Blood volume = 7% of BW
● Rx: Volume replacement
● Shock Classification

31. Hemorrhagic shock classification
● Class I
– 15% blood loss
– P < 100
– BP normal
– PP normal
– RR 14-20
– Urine output >30 cc/h
– Mental status: Slightly anxious

32. Hemorrhagic shock classification
● Class II
– 15-30% blood loss
– P > 100
– BP Normal
– PP decreased
– RR 20-30
– Urine output 20-30 cc/h
– Mental status: mildly anxious

33. Hemorrhagic shock classification
● Class III
– 30-40% blood loss
– P >120
– BP decreased
– PP decreased
– RR 30-40
– Urine output 5-15 cc/h
– Mental status: confused

34. Hemorrhagic shock classification
● Class IV
– >40% blood loss
– P >140
– BP decreased
– PP decreased
– RR > 35
– Urine output ---
– Mental status: confused / lethargic

35. Fluid replacement
● Class I, II: Crystalloid
● Class III, IV: Crystalloid, Blood
● Initial fluid therapy
– 1-2 L for adult
– 20 cc/kg for children
● “3-for-1” rule
– 1 cc blood loss = 3 cc crystalloid replacement

36. Response to fluid resuscitation
● Rapid response
– <20% blood loss
– Cross-match, Surgical consultation
● Transient response
– 20-40% blood loss
– On going blood loss
– Blood transfusion, Surgical intervention

37. Response to fluid resuscitation
● No response
– Immediate operative intervention

38. Non-hemorrhagic shock
● Cardiogenic shock
● Tension pneumothorax
● Neurogenic shock
● Septic shock

39. Cardiogenic shock
● Cardiac contusion
● Cardiac tamponade: “Beck's triad”
– Tachycardia
– Muffled heart sound
– Distended neck vein
● Echo / FAST

40. Cardiac Tamponade
● Penetrating injury
● Beck's triad
● DDx from Tension pneumothorax
● FAST / Echo
● Rx: Pericardiocentesis

41. Tension pneumothorax
● One-way valve
● Respiratory distress
● Subcutaneous emphysema
● Absent breath sound
● Hyperresonance on percussion
● Tracheal shift
● Distended neck vein
● Rx: Needle / Tube thoracostomy

42. Neurogenic shock
● Isolated intracranial injuries do not cause shock
● Loss of sympathetic tone: Spinal cord injury
● Hypotension without tachycardia
● Initially treated as Hypovolemia
● DDx of non-responder

43. D
● Neurological status
– Level of consciousness (AVPU / GCS)
– Pupil size & Light reaction
– Lateralizing sign
– Spinal cord injury level

44. D
● A: Alert
● V: Verbal command
● P: Painful stimuli
● U: Unresponsive

45. D
● Factors affect level of consciousness
– Oxygenation ( ABC )
– Ventilation ( ABC )
– Perfusion ( ABC )
– Hypoglycemia
– Drugs / Alcohol

46. D
● Reevaluation

47. E
● Uncloth patient
● Logroll patient
● Prevent hypothermia
– Warm blanket
– Warm IV fluid

48. E
● Rectal examination
– Sphinctor tone
– Position of prostate (high-riding?) = urethral injury
– Gross blood (penetrating abdominal injury)
– Pelvic fractures

49. Primary survey: Adjuncts
● Monitor
● Diagnosis

50. Primary survey: Adjuncts: Monitor
● EKG monitor
● Foley's catheter
● “Gastric” catheter
● Respiratory rate
● ABG
● Pulse oximetry

51. Primary survey: Adjuncts:
Diagnosis
● CXR, Pelvis AP, Lateral C-spine
● DPL, FAST
● Should not interrupt
resuscitation process

52. Foley's catheter
● Contraindicated in Urethral injury
● Suspected urethral injury
– Inability to void
– Unstable pelvic fracture
– Blood at meatus
– Scrotal hematoma
– Perineal ecchymoses
– High-riding prostate

53. Gastric tube
● Relieve gastric dilatation
● Decompress stomach before DPL
● Reduce risk of aspiration
● NG tube: contraindicated in basilar skull fracture

54. Secondary Survey
● Not begin until primary survey is completed
● History (AMPLE)
● Head-to-toe evaluation
● GCS
● X-rays

55. Secondary Survey: Adjuncts
● Specialized diagnostic tests (CT, US, scope)
● Should not be performed until hemodynamic
stabilization

56. Secondary Survey
● History: AMPLE
– A: Allergies
– M: Medications
– P: Past illnesses / Pregnancy
– L: Last meal
– E: Events

57. Secondary Survey
● Physical examination
● Head-to-toe examination

58. Thoracic Trauma: Secondary Survey
● Simple pneumothorax
● Hemothorax
● Pulmonary contusion
● Tracheobronchial tree injury
● Blunt cardiac injury
● Traumatic aortic disruption
● Traumatic diaphragmatic injury
● Mediastinal transvering wound

59. Abdominal Trauma

60. Abdominal Trauma
● External anatomy
– Anterion
– Flank
– Back

61. Abdominal Trauma
● Internal anatomy
– Peritoneal cavity
– Pelvic cavity
– Retroperitoneal space

62. Abdominal Trauma
● Mechanism of injury
– Blunt
– Penetrating

63. Abdominal Trauma: Assessment
● History
● Physical Exam
– Inspection, Auscultation, Percussion, Palpation
– Evaluation of penetrating wound
– Pelvic stability
– Penile, Perineal, Rectal exam
– Vaginal, Gluteal exam

64. Celiotomy: Indications
● Blunt abdominal trauma with hypotension &
evidence of intraperitoneal bleeding
● Blunt abdominal trauma with positive DPL or
FAST
● Hypotension with penetrating abdominal wound
● GSW traversing the peritoneal cavity / visceral /
vascular retroperitoneum
● Evisceration

65. Celiotomy: Indications (cont.)
● Penetrating trauma with Bleeding from stomach,
rectum, GU
● Peritonitis
● Free air, retroperitoneal air, ruptured
hemidiaphragm after blunt trauma
● Ruptured hollow viscus

66. Diagnostic Studies
● Diagnostic peritoneal lavage: DPL
● FAST
● CT scan
● Urethrography, Cystography, IVP

67. Diagnostic Peritoneal Lavage:DPL
● Indications
– Altered level of conscious / Spinal cord injury
– Injury to adjacent structures
– Equivocal physical exam
– Prolonged loss of contact with patient
– Lap-belt sign

68. Diagnostic Peritoneal Lavage:DPL
● Contraindications
– Existing indication for celiotomy
● Relative contraindications
– Previous abdominal operations
– Morbid obesity
– Advanced cirrhosis
– Coagulopathy

69. Diagnostic Peritoneal Lavage:DPL
● 1 L of LRS
● Fluid return: >30% of infused volume
● Positive Interpretation (blunt abdominal injury):
– Gross blood > 10 cc
– RBC >100,000 /mm3
– WBC > 500 /mm3
– Food particles
– Gram stain +ve

70. Head injury

71. Head Injury
● Classification
– Mechanism (Blunt, Penetrating)
– Severity (mild, moderate, severe)
– Morphology (Skull fractures, Intracranial)

72. Head Injury: Severity
● Mild: GCS 13-15
● Moderate: GCS 9-12
● Severe: GCS 3-8

73. Head Injury: Morphology
● Skull fractures
● Intracranial
– Epiduralhematoma
– Subdural hematoma
– Intracerebral hematoma
– Diffuse brain injury

74. Skull fractures
● Cranium
● Maxillofacial
● Basilar skull fractures

75. Basilar skull fracture
● Raccoon's eyes
● Battle's sign
● CSF rhinorrhea / otorrhea

76. Epidural Hematoma
● Arterial origin (middle
meningeal a.)
● CT: lenticular shape

77. Subdural Hematoma
● Venous origin
● CT: Crescent shape

78. Intracerebral Hematoma
● Brain laceration

79. Head Injury: Management
● Mild HI (GCS 13-15)
– Observe
– CT:
● Lost of conscious > 5 min
● Amnesia
● Severe headache
● Focal neurological deficit

80. Head Injury: Management
● Moderate HI (GCS 9-12)
– CT brain
– Admit observe neurosigns
– F/U CT brain 12-24 h

81. Head Injury: Management
● Severe HI (GCS < 9)
– Prompt diagnosis & treatment
– Don't delay patient transfer to obtain CT scan

82. Monro-Kellie Doctrine

83. Brain resuscitation
● Maintain adequate
– Cerebral Perfusion Pressure (CPP)
– Oxygenation
– Normocapnia

84. Cerebral Perfusion Pressure
● CPP = MAP – ICP
– MAP = Mean Arterial Pressure
– ICP = Intracranial Pressure

85. Cerebral Perfusion Pressure
● CPP = MAP – ICP
– MAP = Mean Arterial Pressure
● Stabilize Vital signs
● IV fluids
– ICP = Intracranial Pressure
● Hyperventilation (limited usage)
● Mannitol (1g/kg)
● Furosemide

86. Brain resuscitation
● Oxygenation
– Oxygen supplement
– Anticonvulsants
● Normocapnia
– Hyperventilation -> CO2 -> Cerebral vasoconstriction
-> CPP

87. Conclusions
● Initial Assessment (Primary survey, Secondary
survey)
● Adjuncts
● Priority: Life threatening first
● Knowledge & Skills for specific conditions
● DOs & DON'Ts

88. Q?

89. http://www.slideshare.net/narenthorn/introduction-to-atls-presentation/