The document outlines the Advanced Trauma Life Support (ATLS) protocol for treating trauma patients. It describes the 9 steps of ATLS as: 1) Preparation, 2) Triage, 3) Primary Survey (ABCDE), 4) Resuscitation, 5) Adjuncts to primary survey & resuscitation, 6) Secondary Survey, 7) Adjuncts to secondary survey, 8) Continued post-resuscitation monitoring & re-evaluation, and 9) Definitive care. The primary and secondary surveys involve a head-to-toe examination to identify life-threatening injuries and provide initial stabilization of airway, breathing, circulation, disability, and exposure.

2. ATLS
Dr. James Styner (1976), Aircraft
crash in rural Nebraska

4. 4
1. Preparation
2. Triage
3. Primary Survey (ABCDEs)
4. Resuscitation
5. Adjuncts to primary survey & resuscitation
6. Secondary Survey (head to toe evaluation & history)
7. Adjuncts to secondary survey
8. Continued post-resuscitation monitoring & re-
evaluation
9. Definite care.

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1. PREPARATION
A. Pre-hospital phase
Receiving hospital is notified first.
Send to the closest, appropriate facility.
B. In Hospital Phase
Advanced planning for the trauma pt arrival.
Method to summon extra medical assistance
Transfer agreement with verified trauma center established.
Protect from communicable disease.

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2. TRIAGE
A Multiple Casualties
no of pt & severity DO NOT EXCEED the
ability of the facility.
B Mass Casualties
no of pt & severity EXCEED the capability
of the facility & staff.

7. TRIAGE
• Priority 1- Immediate
• Priority 2-Urgent
• Priority 3- Delayed
• Priority 4- Dead

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3. PRIMARY SURVEY
A : Airway with cervical spine protect.
B : Breathing
C : Circulation --control external bleeding.
D : Disability or neurological status
E : Exposure (undress) & Environment (temp
control)

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PRIMARY SURVEY
Priorities for the care of Adult ,
Pediatrics & Pregnancy women are all
the same.
During the primary survey life
threatening conditions are identified
and management is instituted
SIMULTANEOUSLY.

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A. Airway Maintenance with Cervical Spine
Protection.
* GCS score of 8 or less require the placement of definite airway.
*Protection of the spine & spinal cord is the important management
principle.
*Neurological exam alone does not exclude a cervical spine injury.
*Always assume a cervical spine injury in any pt with multi-system trauma,
especially with an altered level of consciousness or blunt injury above the
clavicle.

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B. Breathing & Ventilation
* Airway patency does not assure adequate ventilation.
C. Circulation with Hemorrhage Control.
1. Blood Volume & Cardiac Output
a. level of consciousness.
b. skin color
c. Pulse.
d. blood pressure.
2. Bleeding
*external bleeding is identified & controlled in the
primary survey.
*Tourniquets should not be used.

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D. Disability ( Neurological Evaluation)
Simple Mnemonic to describe level of consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
Not forget to use also Glascow Coma Scale.

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E. Exposure / Environmental Control
*It is the pt’s body temp that is most important, not he comfort of the
health care provider.
*Intravenous fluid should be warm.
*Warm environment (room temp) should be maintained.
*early control of hemorrhage.

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Primary Survey
Potential problems
1.patients on beta blocker may not get
tachycardia as a response to bleeding
or anemia
2.Elderly patients have less reserve and
may deompensate quickly
3.Children have less reserve and will not
show signs of shock until severely
volume depleted
4.Multiple occult sources for blood loss
may exist in one patient

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4. RESUSCITATION
A. Airway
*definite airway if there is any doubt about the pt’s ability
to maintain airway integrity.
B. Breathing /Ventilation/Oxygenation
*every injured pt should receive supplement oxygen
C. Circulation
*control bleeding by direct pressure or operative
intervention
* minimum of two large caliber IV should be established
*pregnancy test for all female of child bearing age.
* Lactated Ringer is preferred & better if warm.

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5. ADJUNCT TO PRIMARY SURVEY &
RESUSCITATION
A. Electro-cardiographic Monitoring
B. Urinary & Gastric Catheter
1. Urinary catheter.
Urethral injury should be suspected if
*Blood at the penile meatus
*Perineal ecchymosis
*Blood in the scrotum
*High riding or nonpalpable prostate
*Pelvic fracture

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C. Monitoring
1. Ventilatory rate & ABG
2. Pulse oximetry
does not measure ventilation or partial O2 pressure
3. Blood pressure
poor measure of actual tissue perfusion.
D. X-Ray & Diagnostic Studies
C-spine, CXR, Pelvic film, FAST.
Essential x-ray should not be avoided in pregnant pt.
*** Consider the need for patient transfer.

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6 SECONDARY SURVEY
Does not begin until the primary survey (ABCDEs)
is completed, resuscitative effort are well established
& the pt is demonstrating normalization of vital sign.
* Head to Toe evaluation & reassessment of all vital
signs.
* A complete neurological exam is performed including
a GCS score and examination of pupil
* Special procedure is ordered if needed.

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History
A : Allergies.
M : Medication currently used.
P : Past illness/ Pregnancy.
L : Last Meal
E : Events/Environment related to the injury.
*blunt trauma/penetrating
trauma/injuries due to cold & burn/hazardous
environment?

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Secondary survey
• – Total patient evaluation
• • history : AMPLE
physical examination
• – Complete neurologic examination
• – Head and skull
• – Maxillofacial
• – Neck
• – Chest
• – Abdomen
• – Perineum/rectum/vagina
• – Musculoskeletal
• – Tubes and fingers in every orifice!

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GCS

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PHYSICAL EXAMINATION
1. Head
Visual acuity
Pupillary size
Hemorrhage of conjunctiva and fundi
Penetrating injury
Contact lenses(remove before edema occurs)
Dislocation of lens
Ocular movement

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2. Maxillofacial Injury
no NG tube, definite airway?
3. Cervical Spine & Neck
*Pt with maxillofacial or head trauma should be presumed
to have and unstable cervical spine.
4. Chest
*elderly pt are not tolerant of even relatively minor
chest injury.
*Children often sustain significant injury to the
intrathoracic structure without evidence of thoracic
skeletal trauma.

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• • Physical examination – Chest
• • Visual evaluation of anterior and
posterior chest
• – open pneumothorax
• – flail chest
• • Pain , dyspnea , signs of hypoxia,
distended neck veins, distant heart
sound
• - Cardiac tamponade ,
• -tension pneumothorax

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5. Abdomen
*excessive manipulation of the pelvic should be
avoided.
6. Perineum/rectum/vagina
• contusion , hematoma , laceration , urethral bleeding
• rectal examination : blood , high-riding prostate ,
integrity of rectal wall , sphincter tone
• female :
– Vg exam.: blood , Vg laceration.
– pregnancy test

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7. Physical examination– Musculoskeletal
• • Inspection : contusion , deformity, external
wound
• • palpation : tenderness , abnormal movement
• • pelvic #: ecchymosis on iliac wings , pubis ,
labia ,scrotum , pain on palpation
of pelvic ring , Pelvic CompressionTest
• • Assessment of peripheral pulses and distal
neurological deficit
• Beware of compartment syndrome of
extremity
• • patient’s back examination-logroll

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8. Neurologic
* Protection of spinal cord is
required at all times until a spine
injury excluded, especially when the
pt is to be transfered.

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ADJUNCT TO THE SECONDARY SURVEY
include additional x-ray and all other special
procedure.
Adjuncts to secondary survey
– hemodynamic status
• CT scan
• Contrast x-ray studies
• Extremitry x-ray
• Endoscopy and ultrasonography

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Tertiary Survey
• UNRECOGNISED INJURIES MAY
OCCUR IN 65% OF PATIENTS AND
ARE SIGNIFICANT IN 15 % OF
PATIENTS .THEREFORE, AN
ADDITIONAL THOROUGH SURVEY IS
DONE TYPICALLY WITHIN 24 HOURS
OF ADMISSION

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• 8. RE-EVALUATION
• re-evaluation for new findings or
overlooked
• continuous monitoring of vital signs ,
and urinary output
urine output> 0.5ml/kg/hr
• ABG , ECG , pulse oximetry
• Effective analgesia

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9. DEFINITE CARE
• After identifying the patient’s injuries
• Managing life-threatening problems
• Obtaining special studies
• Transfer if the patient’s injuries exceed the
institution’s treatment capabilities

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Indication For Definite Airway
* Unconscious
* Severe maxillo-facial fracture
* Risk for aspiration : Bleeding/ vomiting
* Risk for obstruction : neck hematoma/laryngeal,tracheal
injury/ stridor
* Apnea : Neuromuscular paralysis/unconscious
* Inadequate respiratory effort:
tachypnea/hypoxia/hypercapnia/cyanosis
* Severe closed head injury need for hyperventilation

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Normal Blood Amount:
Normal adult blood volume : 7% of body weight
Normal blood volume for child : 8-9% of body weight
Hemorrhage Classification :
Class I Hemorrhage : up to 15% loss
Class II Hemorrhage : 15-30% loss
Class III Hemorrhage : 30-40% loss
Class IV Hemorrhage : >40% loss

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3 for 1 Rule
a rough guideline for the total amount
of crystalloid volume acutely is to
replace each ML of blood loss with 3 ML
of crystalloid fluid, thus allowing for
restitution of plasma volume lost into
the interstitial & intracellular space

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Initial Fluid Therapy
Lactated Ringer is preferred
* For adult 1-2 liters
bolus
* For child 20ml/kg bolus

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Intraosseous Puncture/Infusion
Children less than 6 y of age for
whom IV access is impossible due to
circulatory collapse or for whom
percutaneous peripheral venous
cannulation had failed on two attempt.

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Head Injury Classification:
Mild : GCS 14-15
Moderate : GCS 9-13
Severe : GCS 3-8
Coma = GCS score of 8 or less

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Determining the level of
quadriplegia
a. Raise elbow to level of shoulder -- Deltoid
C5
b. Flexes the forearm -- Biceps C6
c. Extend the forearm -- Triceps C7
d. Flexes wrist & finger -- C8
e. Spread finger -- T1

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Thoracic Trauma
8 lethal Injury
1. Simple pneumothorax
2. Hemothorax
3. Pulmonary contusion
4. Tracheo-bronchial tree injury
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Mediastinal traversing wounds.

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Fluid Therapy in
2nd or 3rd Degree Burn
Total amount of first 24 hours:
4 ml of Ringer lactate x BW(kg) x BSA
* give 1/2 in first 8 hrs
* 1/2 in remaining 16 hrs

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Referral to Burn Center
* 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y of age
* 2nd or 3rd degree burn > 20% BSA in other age group
* 2nd or 3rd degree burn of face/eye/ear/hands/feet/
genitalia/perineum or major joints
* 3rd degree burn >5% in any age group
* Significant electrical/lightning injury
* Significant chemical burn
* Inhalation injury

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Priorities with multiple injuries
1. Thoracic trauma or tamponade
2. Abdominal hemorrhage
3. Pelvic Hemorrhage
4. Extremity Hemorrhage
5. Intra-cranial Injury
6. Acute Spinal Cord Injury

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TAKE HOME MESAGES
1. To improve survival, injury management must be prioritized
in the multiply injured patient
2.The order of priority among injuries is related to time and
degree of life threat posed by each injury.
3. Immediate priority is given to airway control and to
maintenance of ventilation, oxygenation, and perfusion.
4. Cervical spine protection is crucial during airway intubation.
5.A trauma team leader is important to coordinate
management in
the multiply injured patient.

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Thank You