ATLS Advance Trauma Life Support

Melati Yalti Kaustar.S (406102025) Conselor : dr.Sjaiful Sp.B

Definition
Advanced Trauma Life Support (ATLS) is a training program for medical doctors in the management of acute trauma cases, developed by the American College of Surgeons Originally designed for emergency situations where only one doctor and one nurse are present, ATLS is now widely accepted as the standard of care for initial assessment and treatment in trauma centers

Initial assessment and management

1. Preparation & Triage 2. Primary survey 3. Resuscitation 4. Adjuncts to primary survey and resuscitation 5. Secondary survey 6. Adjuncts to secondary survey 7. Post resuscitation monitoring and reevaluation 8. Definitive care

Preparation & Triage

Pre-hospital phase Hospital phase

Pre-hospital phase
Which is between the field officer with the doctor. The main attention are:
maintenance of airway control bleeding and shock immobilization of the patient sending the patient to the nearest hospital. Collect also a description of the incident, causes and history of the patient.

Hospital phase
The preparation of equipment and medical personel that are needed in the Hospital

Triage
The way the selection of patients based on treatment needs and available resources. Therapy is based on the needs of ABC Used START method (Simple Treatment and Rapid Treatment)

START (Simple Treatment and Rapid Treatment)

Airway : Try to talk to the patient Breath : calculate the repiration rate Circulation : monitor blood pressure, pulse, or do capiler refill test (normal <2 minutes)

Primary survey
A = Airway maintenance with cervical spine protection B = Breathing and ventilation C = Circulation with hemorrhage control D = Disability : Neurological status E = Exposure/Environmental control : completely,
undress the patient,but prevent hypothermia

A = Airway maintenance with cervical spine protection

The first stage of the primary survey is to assess the airway LOOK Motion of the chest and abdomen Sign of respiratory distress Mucosal color, skin,awareness LISTEN Breath of air movement with FEEL Breath of air motion to cheek

Airway Maintenance
Is the Victim is conscious or not?
Put Collar neck until we are sure that there is no servical fracture

Unconscious

Conscious Try to talk to the victims

able to talk ?airway is clear (no obsrtruction)

Can the victim breath? (look-listen-feel)

Yes

No

Is there snoring,gargling,crowing? -Give artificial respiration -Give O2 NO YES Snoring put Guedel Gargling do suction Crowing Intubated

Airway is clear

Sign of Obstruction
Snoring: gravity pulls the tongue and jaw down to the back of the mouth and limits the air passageway. Gargling sounds: liquid inside the mouth Crowing(stridor): spasm / edema of the vocal cords

Collar Neck / Collar brace

Guedel (Oropharyngeal airway)

Guedel (Oropharyngeal airway)

Intubation

When are we doing Cricothyroidotomy?

Failed intubation because the airway is blocked Patients can not be given artificial respiration from above (nose mouth)

Cricothyroidotomy

Complication Cricothyroidotomy Aspiration Creation of false passage Subglotticstenosis/ edema Laryngeal stenosis Hematoma Laceration of esophagus/trachea Vocal cord paralysis

B = Breathing and ventilation

The chest must be examined by
Inspection
Look : is there trachea deviation? Lesion? Paradoxal breathing ? JVP (Jugular vein Pressure)

Palpation Percussion
Sonor Normal,if dull (+)fluid

Ausculation
VBS (Vesicular Breath Sound) are the right and left same?

The aim is to identify and manage five life threatening thoracic conditions as
Tension Pneumothorax, Massive Haemothorax, Open Pneumothorax, Flail chest segment with Pulmonary Contusion Cardiac Tamponade.

Flail chest, penetrating injuries and bruising can be recognized by inspection

Tension Pneumothorax
Spontaneous Primary Secondary
COPD Infection Neoplasm

Traumatic Blunt Penetrating

Tension Pneumothorax
One way valve (fenomena ventil) Intrapleura pressure increase The lungs collaps The Mediastinum is displaced to the Opposite side ,decreasing the The venous return and compressing the opposite Lungs

Tension Pneumothorax
Respiratory distress Distended neck veins Unilateral depression in breath sounds Hyperresonance Cyanosis (late)

Management :
Immediate Decompression with wide bore cannula in 2nd space MCL Put Chestube 5th ICS the tube connect to bottle that contains water

Massive Hemothorax
Sistematic / pulmonary vessel distruption Loss blood Over 1500 ml Flat versus distended neck veins Shock with no breath sounds and/ or percussion dullnes Management : - Rapid volume restoration - Chest decompression and X-ray - Autotransfusion - Operative Intervention

Open Pneumothorax
Penetrating / blunt trauma Ventilation / perfusion defect Hyperresonance Depression Breath sounds Tube thoracostomy

Management : - 3 side cover over defect

adhesive strap [sealed from three sides, leaving

one side unsealed to allow air exit during expiration & prevent its entry during inspiration]

- Chest tube - Definitive operation

Open Pneumothorax

Flail chest / Pulmonary contusion

Free-floating chest segment, usually from multiple ribs fractures Pain and restricted movement Paradoxical movement of chest wall with respiration

Flail chest / Pulmonary contusion

Reexpand lung Oxygen Judicioces fluids Intubate as indicated Analgesia

Cardiac Tamponade
Injuries caused by penetrating / blunt injury Pericardium filled with blood Pericardial tissue structure with a rigid inhibit the activity and cardiac filling TRIAS BECK
Venous pressure increase Arterial pressure decrease Muffled heart sound

Cardiac Tamponade
Management : - A = Patent airway / intubate - B = Ventilate oxygenasion - C = Fast /pericadiocentesis operation (if delayed leave catheter in place)

C = Circulation with hemorrhage control

Hemorrhage is the predominant cause of preventable post-injury deaths. Hypovolemic shock is caused by significant blood loss. Occult blood loss may be into the chest, abdomen, pelvis or from the long bones.

The main set are : Change the volume Stop the bleeding

ASSESSMENT OF CIRCULATION
Color of the Akral Capillary refill Pulse Blood pressure Urine production

CLINICAL SIGNS OF SHOCK

Rapid breathing, nervous consciousness until coma Pulse pressure <20mmHg Skin cold, pale, wet, cyanosis Capillary refill time> 2 seconds Urine output <0.5 ml / kg / hour

Slightly anxious Urine Heart rate <100/min

Respirations 14-20/min

30 mL/hr
crystalloid

BP

Mildly anxious Urine 20-30 mL/hr Crystalloid, ? blood Heart rate >100/min Pulse pressure

Respirations 20 30/min BP

Confused, anxious Urine 5-15 ml/hr Crystalloid, blood, operation

Respirations 30-40/min Heart rate > 120/min Pulse pressure

BP

Confused, lethargic Urine negligible Rapid fluids, blood, operation Heart rate >140/min

Respirations >35/min

BP

Pulse pressure

Assessment of Stages of Shock

% Blood Volume loss HR SBP Pulse Pressure Cap Refill Resp CNS Treatment < 15% <100 N N or < 3 sec 14 - 20 anxious
12L crystalloid, + maintenance

15 30% >100
N

30 40% >120

>40% >140

> 3 sec 20 - 30 v. anxious

>3 sec or absent

absent >35 lethargic

30 - 40 confused

2L 2 L crystalloid, re-evaluate, crystalloid, re- replace blood loss 1:3 evaluate crystalloid, 1:1 colloid or blood products. Urine output >0.5 mL/kg/hr

Fluid Resuscitation of Shock

Crystalloid Solutions
Normal saline Ringers Lactate solution Plasmalyte

Colloid Solutions
Pentastarch Blood products (albumin, RBC, plasma)

Crystalloid Solutions
Normal Saline Lactated Ringers Solution Plasmalyte Require 3:1 replacement of volume loss e.g. estimate 1 L blood loss, require 3 L of crystalloid to replace volume

Colloid Solutions
Pentaspan Albumin 5% Red Blood Cells Fresh Frozen Plasma Replacement of lost volume in 1:1 ratio

D = Disability : Neurological status

A more detailed and rapid neurological evaluation is performed at the end of the primary survey.

This establishes the patient's level of consciousness, pupil size and reaction, lateralizing signs, and spinal cord injury level.

 The Glasgow Coma Scale is a quick method to determine the level of consciousness, and is predictive of patient outcome Hypoglycemia and drugs, including alcohol, may influence the level of consciousness. If these are excluded, changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise.

Glasgow Coma Scale

Eye Opening Response Spontaneous--open with blinking at baseline 4 points To verbal stimuli, command, speech 3 points To pain only (not applied to face) 2 points No response 1 point Verbal Response Oriented 5 points Confused conversation, but able to answer questions 4 points Inappropriate words 3 points Incomprehensible speech 2 points No response 1 point Motor Response Obeys commands for movement 6 points Purposeful movement to painful stimulus 5 points Withdraws in response to pain 4 points Flexion in response to pain (decorticate posturing) 3 points Extension response in response to pain (decerebrate posturing) 2 points
No response 1 point

E = Exposure/Environmental control : completely

The patient should be completely undressed, usually by cutting off the garments. It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient privacy should be maintained.

 1. Cloths : cut all the cloths using sharp scissors. 2. Warmth: cover with blankets 3. Intravenous fluids should be warmed and a warm environment maintained

Secondary survey
Aim: The secondary survey is a head-to-toe & front to back evaluation of the trauma patient, including a complete history and physical examination, including the reassessment of all vital signs. X-rays indicated by examination are obtained. -If at any time during the secondary survey the patient deteriorates, another primary survey is carried out as a potential life threat may be present.

AMPLE history
Allergies Medications Past medical history Last meal (for fear of aspiration pneumonia) Event of injury (to predict site & extent of injury

Adittional Examination
FAST (Focused Abdominal Sonography for Trauma) or CT, may show
a. Injuries to liver, spleen, kidneys or pancreas. b. Perisplenic or perihepatic hematoma. c. Retroperitoneal hematoma d. Free fluid in peritoneal cavity

DPL (replaced by FAST) Diagnostic laparoscopy

Post resuscitation monitoring and reevaluation

Repeat ABCDE Repeated resuscitation if necessary

Definitive care
Consult a specialist. Treatment measures according to the problem Operation

Abdomen Trauma
Blunt trauma is more common. I. Injuries of solid organs [Spleen 46%, Liver 33%]
Present with picture of internal hemorrhage

II. Injuries of hollow organs

Present with picture of peritonitis (usually delayed for 48-72 hours)

Management

I. All penetrating trauma: immediate exploration (laparotomy) II. Blunt trauma:

a. Hemodynamic stable: urgent investigations b. Hemodynamic unstable: immediate exploration

 - Investigations
I. Plain X-ray: fracture ribs air under diaphragm fluid level in ileus. II. FAST:
a. Detects free fluid (perihepatic, perisplenic, pelvic, pericardium) b. Disadvantages
1. Doesnt detect source of bleeding. 2. Amount of fluid must be > 250 ml 3. Doesnt detect non-bleeding injuries. 4. Cant detect retroperitoneal hematoma. 5. Limitations in obese. III. CT: Gold standard [DONT send unstable patient to CT] IV. DPL

Burn Injury

Estimation of Burn Size -- calculating per cent Total Body Surface Area burned (%TBSA)
Rule of Nines Adults 9% 9% 18% 18% 18% 1% 100%

head and neck each upper extremity anterior trunk posterior trunk each lower extremity perineum

Infants 18%
9% 18% 18% 14% 1% 100%

Assessment of Burn Depth related to temperature, time of exposure, and thickness of skin

1.First degree burn

a.caused by sunburn or flash b.involves epidermal layer only c.usually appears red to pink d.is painful to touch e.may become slightly edematous f.heals in 3-5 days (rarely leaves any scar) g.does NOT count in the burn size calculation

 Second degree burn (partial-thickness)

a. Usually caused by flash, scalds, or brief contact with hot object b. Involves the epidermis and part of the dermis c. Has vesicles and bullae d. Moist appearance usually red to pale pink e. Tactile and pain sensibility is intact very painful f. Develops significant edema g. Heals in 7-21+ days with variable amounts of scarring

 3.Third degree burn (full-thickness)

a. Usually caused by flame, high intensity flash, electricity, chemicals, or prolonged contact with hot liquids or hot objects b. Extends through the epidermis and dermis c. Usually appears white, brown or black; may have thrombosed veins d. Wound appears dry e. Elasticity of the wound is destroyed, so wound becomes leathery and feels firm to the touch f. Marked edema and decreased elasticity may necessitate escharotomies g. Generally painless to touch

Fluid Management Burn Injury

Parkland formula

Initial 24 hours: Ringer's lactated (RL) solution 4 ml/kg/% burn for adults and 3 ml/kg/% burn for children. RL solution is added for maintenance for children:
4 ml/kg/hour for children weighing 0-10 kg 40 ml/hour +2 ml/hour for children weighing 10-20 kg 60 ml/hour + 1 ml/kg/hour for children weighing 20 kg or higher This formula recommends no colloid in the initial 24 hours.

Next 24 hours: Colloids given as 20-60% of calculated plasma volume. No crystalloids. Glucose in water is added in amounts required to maintain a urinary output of 0.5-1 ml/hour in adults and 1 ml/hour in children.

Fluid Management
Maintance for Adult
M= 40 cc / weight (kg)/24 hour

Maintance for children

M= 0-10 kg : 100cc /weight(kg)/ 24 hour M= 10-20 kg : 1000+(X * 50 ) /24 hour M= Over 20 kg : 1500 + (X *20) / 24 hour
X = the overmeasure weight

Fluid Management for Dehydration

Grade of Dehydration
Mild : 4 % (adult) Moderate : 6% Severe : 8% 6% (children) 8% 10%

D = Grade of dehydration x (weight)Kg x 1000

Fluid Management for 24 Hours

First 6 hour
D + M = (X) cc

Next 18 hour
D + M = (Y) cc

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