This document outlines the general approach and concepts for treating traumatic patients according to Advanced Trauma Life Support (ATLS) guidelines. It describes treating the greatest threats to life first using the ABCDE approach to assess the airway, breathing, circulation, disability, and exposure. The primary survey involves rapid assessment and interventions to stabilize the patient, while the secondary survey entails a full physical exam and diagnostic testing. Key interventions discussed include intubation, chest tube insertion, hemorrhage control, and use of the Focused Assessment with Sonography for Trauma (FAST) exam to evaluate for internal bleeding. Definitive care may involve transfer to the operating room or intensive care unit based on specialty consultations.

1. General Approach to Traumatic
Patient

2. Trauma
• physiological wound caused by an external
source. It can also be described as "a physical
wound or injury, such as a fracture or blow".
• E.g. MVA accidents, falls, industrial accidents,
burns, knifings, and shootings.
• Leading cause of death in productive young
man

3. Concepts of ATLS
• Treat the greatest threat to life first
• The lack of a definitive diagnosis should never
impede the application of an indicated
treatment
• A detailed history is not essential to begin the
evaluation
• “ABCDE” approach

4. Primary Survey
• Patients are assessed and treatment priorities
established based on their injuries, vital signs,
and injury mechanisms
• ABCDEs of trauma care
– A Airway and c-spine protection
– B Breathing and ventilation
– C Circulation with hemorrhage control
– D Disability/Neurologic status
– E Exposure/Environmental control

5. A- Airway
• Airway should be assessed for patency
– Is the patient able to communicate verbally?
– Inspect for any foreign bodies
– Examine for stridor, hoarseness, gurgling, pooled
secrecretions or blood
• Assume c-spine injury in patients with
multisystem trauma
– C-spine clearance is both clinical and radiographic
– C-collar should remain in place until patient can cooperate
with clinical exam

6. Difficult Airway

7. Airway Interventions
• Supplemental oxygen
• Suction
• Chin lift/jaw thrust
• Oral/nasal airways
• Definitive airways
– RSI for agitated patients with c-spine
immobilization
– ETI for comatose patients (GCS<8)

8. B- Breathing
• Airway patency alone does not ensure
adequate ventilation
• Inspect, palpate, and auscultate
– Deviated trachea, crepitus, flail chest, sucking
chest wound, absence of breath sounds
• CXR to evaluate lung fields

9. Flail Chest

10. Subcutaneous Emphysema

11. Breathing Interventions
• Ventilate with 100% oxygen
• Needle decompression if tension
pneumothorax suspected
• Chest tubes for pneumothorax / hemothorax
• Occlusive dressing to sucking chest wound
• If intubated, evaluate ETT position

12. Chest Tube for GSW

13. C- Circulation
• Hemorrhagic shock should be assumed in any
hypotensive trauma patient
• Rapid assessment of hemodynamic status
– Level of consciousness
– Skin color
– Pulses in four extremities
– Blood pressure and pulse pressure

14. Circulation Interventions
• Cardiac monitor
• Apply pressure to sites of external hemorrhage
• Establish IV access
– 2 large bore IVs
– Central lines if indicated
• Cardiac tamponade decompression if indicated
• Volume resuscitation
– Have blood ready if needed
– Level One infusers available
– Foley catheter to monitor resuscitation

15. D- Disability
• Abbreviated neurological exam
– Level of consciousness
– Pupil size and reactivity
– Motor function
– GCS
• Utilized to determine severity of injury
• Guide for urgency of head CT and ICP monitoring

16. Disability Interventions
• Spinal cord injury
– High dose steroids if within 8 hours
• ICP monitor- Neurosurgical consultation
• Elevated ICP
– Head of bed elevated
– Mannitol
– Hyperventilation
– Emergent decompression

17. E- Exposure
• Complete disrobing of patient
• Logroll to inspect back
• Rectal temperature
• Warm blankets/external warming device to
prevent hypothermia

18. Always Inspect the Back

19. Secondary Survey
• AMPLE history
– Allergies, medications, PMH, last meal, events
• Physical exam from head to toe, including
rectal exam
• Frequent reassessment of vitals
• Diagnostic studies at this time
simultaneously
– X-rays, lab work, CT orders if indicated
– FAST exam

20. Physical Exam
Battle Sign
Raccoon's Eyes
Cullen’s Sign
Grey-Turner’s Sign
20

21. Seatbelt Sign

22. Adjuncts to Secondary Survey
 Radiology
– Standard emergent films
C-spine, CXR, Pelvis
– Focused Abdominal Sonography in Trauma (FAST)
– Additional films
Cat scan imaging
Angiography
 Foley Catheter
– Blood at urethral meatus = No Foley catheter
 Pain Control
 Tetanus Status
 Antibiotics for open fractures
22

23. Classic Radiographic Findings
 Epidural Hematoma
– Middle Meningeal Artery
 Subdural Hematoma
– Bridging Veins
23

24. Classic Radiographic Findings
Diaphragmatic rupture w/ spleen herniation
24

25. Classic Radiographic Findings
Widened Mediastinum – Aortic Injury
25

26. Abdominal Trauma
• Common source of traumatic injury
• Mechanism is important
– Bike accident over the handlebars
– Car with steering wheel trauma
• High suspicion with tachycardia, hypotension,
and abdominal tenderness
• Can be asymptomatic early on
• FAST exam can be early screening tool

27. Abdominal Trauma
• Look for distension, tenderness, seatbelt
marks, penetrating trauma, retroperitoneal
ecchymosis
• Be suspicious of free fluid without evidence of
solid organ injury

28. FAST Exam
• Focused Abdominal Scanning in Trauma
• To find free fluid (blood) around heart
(pericardiac eff.) or abdominal organ
(hemoperitoneum) after trauma
• 4 views:
– Cardiac
– RUQ (Morison’s Pouch)
– LUQ (Perispleenic Space)
– Pelvic (Pouch of Doughlas)

29. Splenic Injury
• Most commonly injured organ in
blunt trauma
• Often associated with other injuries
• Left lower rib pain may be indicative
• Often can be managed non-
operatively

30. Liver injury
• Second most common solid organ injury
• Can be difficult to manage surgically
• Often associated with other abdominal
injuries

31. Hollow Viscous Injury
• Injury can involve stomach, bowel, or
mesentery
• Symptoms are a result from a combination of
blood loss and peritoneal contamination
• Small bowel and colon injuries result most
often from penetrating trauma
• Deceleration injuries can result in bucket-
handle tears of mesentery
• Free fluid without solid organ injury is a
hollow viscus injury until proven otherwise

32. Definitive Care
 Secondary Survey followed by radiographic
evaluation
– CatScan
– Consultation
Neurosurgery
Orthopedic Surgery
Vascular Surgery
 Transfer to Definitive Care
– Operating Room
– ICU
– Higher level facility
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33. Bucket-handle Tear of Mesentery

34. Conclusion
 Assessment of the trauma patient is a standard algorithm
designed to ensure life threatening injuries do not get
missed
 Primary Survey + Resuscitation
– Airway
– Breathing
– Circulation
– Disability
– Exposure
 Secondary Survey
 Definitive Care
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35. References
1. Bailey and Love’s Short Practice of Surgery. 25th Edition.
2. Kumar MV (2014) Clinical Companion in Surgery. 2nd
Edition
3. Davidson’s Principles and Practice of Medicine 21st Edition
4. Carmont MR (2005). "The Advanced Trauma Life Support
course: a history of its development and review of related
literature". Postgraduate Medical Journal 81(952): 87–91.
5. Styner, Randy (2012). The Light of the Moon - Life, Death
and the Birth of Advanced Trauma Life Support. Kindle
Books: Kindle Books. p. 267.
6. Committee on Trauma, American College of
Surgeons (2008). ATLS: Advanced Trauma Life Support
Program for Doctors (8th ed.). Chicago: American College
of Surgeons.