ATLS

1. Initial assessment
Trauma life support

2. WHAT ISTHIS?
WHAT ISTHE FIRST STEPYOU DO?

3. OBJECTIVE
Initial assessment
of trauma patients
Life saving
maneuvers
Practicing trauma
skills

4. TRAUMA SCENARIO
 MALE PATIENT 34YEARS OLD COMINGTO ER
AFTER ROAD TRAFFIC ACCIDENT:
HOARSNESSOFVOICE
BP 90/50
RR 30
PULSE 130
ABRASION ON LT CHESY
WHAT DOYOU DO?

5. Initial assessment of trauma
patient
1- primary survey
2- secondary survey

6. Standard Precautions
Cap
Gown
Mask
Shoe covers
Goggles / face shield
Check safety before start primary
survey

7. assess the patient in 10 seconds?
Ask patient
about his
name

8. Breathing / ventilation / oxygenation
Circulation with hemorrhage control
Disability
Expose / Environment / body temp.
Primary Survey
Airway with c-spine protection

9. Airway
 Patent and clear
 If not open air way :chin lift , jaw trust
 Use adjunct to airway:
Oropharyngeal , nasopharyngeal , LMA,ET
 GIVE HIGH FLOW O2TO ALLTRAUMA
PATIENT
 IF EIGHT INTUBATE
A

10. Sequence of air way maneuvers
chin lift
Jaw thrust
finger sweep
suction
Oropharyngeal/ orotrachial tube
Cricothyroidotomy
Tracheostomy

11. C- SPINE PROTECTION
 INLINE
IMMBOLIZATION
 NECK COLAR
 HEAD LOCK
 HARD BOARD
 bellets

12. BREATHING
 CHECK:
 CHEST MOVEMENT
 EQUALITY IN BOTH SIDE
 AIR ENTERY
 PERCUSSION
 O2 SATURATION
 RESPIRATORY RATE
B

13. Our task is to identify
 Five life threatening thoracic conditions:
 Tension Pneumothorax
 Massive Pneumothorax
 Open pneumothorax
 Flail segment
 Cardiac tamponade

14. Abnormal Findings
Un equality of chest movement
Hyper resonance on percussion
Decrease air entry
Tachypenic
Pneumo thorax
Needle decompression & chest tube

16. Abnormal Findings
Un equality of chest movement
Hyper resonance on percussion
Decrease air entry ,tachypenic
Deviated trachea ,congested neck vein
Tension Pneumo thorax
Needle decompression & chest tube

19. Abnormal Findings
Un equality of chest movement
Dullness on percussion
Decrease air entry
Tachypenic
heamothorax
chest tube

20. heamothorax

21. heamothorax

22. Abnormal Findings
Un equality of chest movement
Dullness on percussion
Normal air entry ,muffled heart sounds
Tachypenic, congested neck veins
Cardiac tamponade
pericardiocentesis

23.  (almost always seen with a penetrating
wound)
 Beck’s triad:
Hypotension
distended neck veins
Muffled heart sounds
Pulsus paradoxus

24. Cardiac tamponade

25. cardiac tamponade

27. Skills in B
Needle de compression
Chest tube (thoracostomy)
pericardiocentesis
Endo tracheal intubation

28. circulation
Check :
 Bp
 Pulse
 Capillary refill
 Search for External bleeding
 Search for Internal bleeding
 2 wide bore cannula
 Blood sample for ABO compatibility,
creatinine,urea,ABG
 GIVE 2 liters warmed crystalloid
C

29.  Tachycardia in a cold patient indicates shock
 Causes of shock following injury:
 Hypovolemic
 Cardiogenic
 Neurogenic
 Septic

30.  Adults- 2 lit of Ringer lact soln as initial fluid
challenge
 Children- 20mg/kg of body wt
 Response to initial fluid challenge:
 Immediate & sustained return of vital signs.
 Transient response with later deterioration
 No improvement.

31.  Urine output –
 0.5ml/kg/hr in adults
 1ml/kg/hr in children
 2ml/kg/hr in infants

32. Skills in C
 Direct compression in
site of external bleeding
 Splint of long bone
fractures
 FAST( E- FAST)
 X-ray chest , pelvis
 Consult surgeon

33. Disability
 Determine Glasgow
coma scale
 Check pupil for
(equality-reactivity)
 Signs of lateralization
 Neurological
assessment
D
A.-Alert
V.-Responds to
Voice
P.-Responds to
Pain
U.-Unresponsive
Pupil.-Size and
reaction

35. Exposure
 Remove clothes
 Log roll
 Prevent hypothermia
E

36. Resuscitation
ADJUNCTS
Vital signs
ABGs
Pulse
oximeter
and CO2
Urinary / gastric catheters
unless contraindicated
Urinary
output
ECG

37. CONSIDER EARLY PATIENT TRANSFER
Do not delay transfer for
diagnostic tests
Use time before transfer for
resuscitation

39. Secondary Survey
AMPLE History
Allergies
Medications
Past illnesses
Last meal
Events / Environment

40. HEAD
 Inspection
 Palpation
 Signs of fracture base
 Eye (PUPIL)
 Nose (RHINORRHEA)
 Maxilla (FRACTURE)
 Mouth
 Ear(HAEMOTYPMANUM

41. Fracture base skull
 Haemotympnym
 Otorrhea
 Rhinorrhea
 Rakon eyes
 Battle s signs

46. NECK
 Inspection
(abrasion-cut wounds)
 Palpation
(mass , surgical emphysema ,trachea ,
carotid pulse -Cervical spine fractures)
Auscultation
carotid bruit

47. CHEST
Inspection
Palpation
Percussion
auscultation

48. Search for potentially life threatening injuries
 Pulmonary complication
 Myocardial contusion
 Aortic tear
 Diaphragmatic tear
 Oesophageal tear
 Tracheobronchial tear
 Early thoracotomy if initial
 haemorrhage > 1500 ml

49. ABDOMEN
 Inspection
 Auscultation
 Palpation
 percussion

50. PELVIS
 Clinical assessment of stability
 X-ray
 stabilize pelvis with fixator/clamps –pelvic
binder
 If urethral injury is suspected
high up prostate in PR
 blood in meatus
 perineal haematoma

51. Inspection
•Wounds
•Swelling
•Source of bleeding
Palpation
•Peripheral pulsation
•Click of fracture
•Compartmental
syndrome
EXTERMITIES

53.  Radiography:The "trauma triple" is a portable
cervical spine, anteroposterior chest, and
anteroposterior pelvis radiographs.
 Laboratory studies: Obtain a complete blood cell
count and chemistry, including a sodium level,
potassium level, renal function assessment,
urinalysis, urinary toxicology screen, and a beta-
human chorionic gonadotropin value in all females
of childbearing age.
ADJUCANTS

54.  Blood preparations: Order a type and screen, and
consider cross-matching 2-4 units of RBCs,
depending on the severity of the trauma and
shock.
 Urinary and gastric catheterization
 Temperature, ECG and oxygen saturation
monitoring

56. TRAUMA SCENARIO
 MALE PATIENT 34YEARS OLD COMINGTO ER
AFTER ROAD TRAFFIC ACCIDENT:
HOARSNESSOFVOICE
BP 90/50
RR 30
PULSE 130
ABRASION ON LT CHESY
WHATYOU DO?

57. THEANSWER
A
B
C
D
E

58. Current concepts
Permissive hypotension
Maintain systolic B.P. at 85 - 95 mm of Hg
Turn off the tap and do not infuse too much
of fluid and blood products

59. Complications
 Tetanus
 A.R.D.S.
 Fat embolism
 D.I.C.
 Crush syndrome
 Multisystem organ
failure (M.S.O.F.)

60. A.R.D.S.
 Tachypnoea
 Dyspnoea
 Bilateral infiltrates in C XR
Treated with mechanical ventilation
CPAP with or without PEEP
Glucocorticoids
Inhaled nitric oxide

61. Fat embolism
 Around 72 hours
 Tachycardia
 Tachypnoea
 Dyspnoea
 Chest pain
 Petechial haemorrhage
Treated with ----- mechanical ventilation
------anticoagulants
------fixation of fractures

62. Disseminated intravascular coagulation
 Follows severe blood loss and sepsis
 Restlessness , confusion,neurological
dysfunction,skin infercation,oligurea
 Excessive bleeding
 Prolonged PT,PTT,TT,hypofibrinogenemia
Treatment– prevention and early correction and shock

63. Crush syndrome
 When a limb remains compressed for many hours
 Compartment syndrome and further ischaemia
 Cardiac arrest due to metabolic changes in blood
 Renal failure
Treatment
 Prevention-ensure high urine flow during extrication
 IV Crystalloids,Forced mannitol alkaline diuresis
 Fasciotomy and excision of devitalised muscles
 Amputation

64. M.S.O.F.
Progressive and sequential dysfunction of physiological
systems
Hypermetabolic state
It is invariably preceded by a condition known as
Systemic Inflammatory Response Syndrome (SIRS)
Characterised by two or more of the following
 Temperature >38º C or < 36ºC
 Tachycardia >90 /min
 Respiratory rate >20/min
 WBC count >12,000/cmm or <4,000/cmm

65. M.S.O.F.
Treatment : Key word is PREVENTION
 Prompt stabilisation of fracture
 Treatment of shock
 Prevention of hypoxia
 Excision of all dirty and dead tissue
 Early diagnosis and treatment of infection
 Nutritional support

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67. THANKYOU