2. Advanced Trauma Life Support
(ATLS)
Most widely recognised and practiced protocol for the
management of a trauma patient worldwide.
ATLS PROTOCOL OBJECTIVES:
ď A standardized approach to all traumatic patients.
ď A comprehensive assessment and management of
patients in emergency situation.
ď Best utilization of golden hour which lies between life
and death after a traumatic event.
4. PRIMARY SURVEY
ď A : AIRWAY & CERVICAL SPINE
IMMOBILIZATION
ď B : BREATHING / VENTILATION
ď C : CIRCULATION & HEMORRHAGE CONTROL
ď D : DISABILITY ( NEUROLOGICAL
EVALUATION)
ď E : EXPOSURE + ENVIRONMENTAL
CONTROL
5. AIRWAY MANAGEMENT & C. SPINE
ď SUCTIONING OF NASOPHARYNGEAL AIRWAY
ď CHIN LIFT
ď JAW THRUST
ADVANCED METHODS:
ď ENDOTRACHEAL INTUBATION
ď CRICOTHYROIDOTOMY
ď TRACHEOSTOMY
PREVENTION OF CERVICAL SPINE INJURY:
ď IMMOBILIZE THE PATIENT
ď AVOID HYPEREXTENSION OF NECK
ď APPLY CERVICAL COLLAR
6. BREATHING / VENTILATION
ď EXPOSE THE CHEST & ACCESS RR & RESP. TYPE.
ď GIVE O2 INHALLATION
ď CHECK CHEST WALL, LUNGS & DIAPHRAGM BY
INSPECTION, PALPATION, PERCUSSION &
AUSCULTATION.
ď PULSE OXIMETER
ď LOOK FOR CONDITIONS THAT IMPAIR VENTILATION
ď Tension pneumothorax
ď Massive hemothorax
ď Flail chest
ď Rib fractures
ď Open pneumothorax
ď Pulmonary contusion
7. CIRCULATION
IMPAIRMENT IN CIRCULATION CAN LEAD TO SHOCK
SO LOOK FOR SIGNS OF SHOCK i.e.
ď SKIN COLOUR (PALLOR)
ď NARROW PULSE PRESSURE
ď HYPOTENSION
ď TACHYCARDIA
ď LEVEL OF CONSCIOUSNESS
ď DIMINISHED URINE OUTPUT
CONTROL OF HEMORRHAGE :
ď APPLY DIRECT PRESSURE
ď PNEUMATIC SPLINTING DEVICES
ď ACCESS THE NEED FOR SURGICAL INTERVENTION
8. CLINICAL CLASSIFICATION OF
SHOCK
CLASS I CLASS II CLASS III CLASS IV
BLOOD LOSS UPTO 750ml 750-1500ml 1500-2000ml >2000ml
% BLOOD
VOLUME
UPTO 15% 15-30% 30-40% >40%
PULSE RATE
(bpm)
<100 100-120 120-140 >140
SYSTOLIC B.P. NORMAL NORMAL DECREASED DECREASED
PULSE
PRESSURE
NORMAL OR
INCREASED
DECREASED DECREASED DECREASED
RESPIRATORY
RATE
14-20 20-30 30-40 >35
URINE
OUTPUT
(ml/hr)
>30 20-30 5-15 NEGLIGIBLE
CNS/MENTAL
STATUS
SLIGHTLY
ANXIOUS
MILDLY
ANXIOUS
ANXIOUS,
CONFUSED
CONFUSED,
LETHARGIC
FLUID
REPLACEMEN
CRYSTALLOI
DS
CRYSTALLOI
DS
CRYSTALLOI
DS & BLOOD
CRYSTALLOI
DS & BLOOD
9. FLUID REPLACEMENT THERAPY
ď DOUBLE I/V LINES SHOULD BE MAINTAINED FOR
FLUID REPLACEMENT
ď ADULTS SHOULD BE GIVEN 2 L BOLUS FLUID
(PREFFERED FLUID IS RINGER LACTATE BETTER IF
WARM)
ď CHILDREN SHOULD BE GIVEN @ 20ml/Kg BOLUS
FLUID
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
10. DISABILITY ( NEUROLOGICAL
EXAMINATION)
CHECK THE LEVEL OF CONSCIOUSNESS ( AVPU/GCS )
ď A: ALERT
ď V: RESPONDS TO VOCAL STIMULI
ď P: RESPONDS TO PAINFUL STIMULI
ď U: UNRESPONSIVE TO ALL STIMULI
CHECK PUPIL SIZE & LIGHT REACTION
CHECK THE LEVEL OF SPINAL CORD INJURY LEVEL
11. EXPOSURE +ENVIRONMENTAL
CONTROL
ď UNDRESS COMPLETELY (USE TRAUMA SCISSORS)
ď PREVENT HYPOTHERMIA ( WARM BLANKETS &
WARM FLUIDS)
ď EARLY HEMORRHAGE CONTROL
ď WARM ROOM TEMPERATURE SHOULD BE
MAINTAINED
12. SECONDARY SURVEY
DOESNOT BEGIN UNTIL THE PRIMARY SURVEY (ABCDEs)
IS COMPLETED, RESUSCITATION EFFORTS ARE WELL
ESTABLISHED & THE PATIENT IS HAVING
NORMALIZATION OF VITAL SIGNS.IT INCLUDES:
ď COMPLETE HISTORY
ď COMPLETE HEAD TO TOE EXAMINATION
ď REASSESSMENT OF VITAL SIGNS
ď COMPLETE NEUROLOGICAL EXAMINATION (GCS)
ď SPECIFIC PROCEDURES, SPECIFIC LAB.
INVESTIGATIONS
13. COMPLETE HISTORY
ď A: ALLERGIES
ď M: MEDICATIONS
ď P: PAST ILLNESS/ PREGNANCY
ď L: LAST MEAL
ď E: EVENTS/ ENVIRONMENT/MECHANISM OF
INJURY:
BLUNT TRAUMA: AUTOMOBILE
COLLISIONS
PENETRATING TRAUMA:
FIREARMS/STABBING
THERMAL INJURIES: BURNS/EXPLOSIONS
HAZARDOUS INJURIES:
CHEMICALS/TOXINS/
14. PHYSICAL EXAMINATION
ď HEAD
ď MAXILLOFACIAL STRUCTURES
ď CERVICAL SPINE & NECK
ď CHEST
ď ABDOMEN
ď PERINEUM,RECTUM & VAGINA
ď MUSCULOSKELETAL SYSTEM
ď NEUROLOGICAL SYSTEM
15. HEAD
ď VISUAL ACUITY
ď PUPPILARY SIZE
ď CONJUNCTIVAL HEMORRHAGE
ď PENETRATING INJURY
ď CONTACT LENSES (REMOVE BEFORE EDEMA
DEVELOPS)
ď DISLOCATION OF THE LENS
ď OCULAR ENTRAPMENT
MAXILLOFACIAL STRUCTURES
ď PALPATE ALL BONY STRUCTURES
ď INTRAORAL EXAMINATION
ď ASSESSMENT OF SOFT TISSUES
ď TRAUMA NOT RELATED TO AIRWAY OR BLEDDING CAN
BE DELAYED
16. CERVICAL SPINE AND NECK
ď PATIENTS WITH HEAD TRAUMA OR MAXILLOFACIAL
TRAUMA SHOULDE BE PRESUMED TO HAVE
UNSTABLE CERVICAL INJURY (FRACTURE/LIGAMENT
INJURY), NECK SHOULD BE IMMOBILIZED
IMMEDIATELY, UNTIL INVESTIGATED.
ď CERVICAL SPINE TENDERNESS, SUBCUTANEOUS
EMPHYSEMA, TRACHEAL DEVITATION & LARYNGEAL
FRACTURES OR PENETRATING INJURIES SHOULD
BE SEEN DURING EXAMINATION OF NECK.
CHEST
ď A THOROUGH EXAMINATION OF CHEST WALL
SHOULD BE DONE TO RULE OUT OPEN OT
TENSION PNEUMOTHORAX, HEMOTHORAX,
FLIAL CHEST OR CONTUSIONS.
17. ABDOMEN
ď AFTER INITIAL EXAMINATION, CLOSE OBSERVATION
AND FREQUENT RE-EVALUATION OF THE ABDOMEN
SHOULD BE DONE BY THE SAME OBSERVER TO
NOTE ANY INTRAABDOMINAL INJURY AND IT
SHOULD BE DEALT AGGRESSIVELY.
PERINEUM, RECTUM & VAGINA
ď PERINEUM SHOULD BE EXAMINED FOR
CONTUSIONS,LACERATIONS,HEMATOMA &
URETHRAL BLEEDING
ď RECTUM MUST BE EXAMINED FOR BLOOD IN
BOWEL LUMEN, PELVIC FRACTURES OR HIGH
RIDING PROSTATE.
ď VAGINAL EXAMINATION SHOULD BE DONE IN
18. MUSCULOSKELETAL SYSTEM
ď THE EXTREMITIES MUST BE INSPECTED FOR
CONTUSIONS & DEFORMITIES.
ď BONES SHOULD BE PALPATED & MOVEMENTS AT
THE JOINTS SHOULD BE CHECKED.
ď ASSESSMENT OF PERIPHERAL PULSES SHOULD BE
DONE FOR VASCULAR INJURIES.
19. REASSESSMENT OF VITAL SIGNS
DONE BY:
ď CLINICAL REASSESSMENT
ď MONITORING OF LOC, PR, BP MONITORING, ABGs &
UOP
ď REVIEW OF DIAGNOSTIC RESULTS
ď USE OF ANALGESIA
COMPLETE NEUROLOGICAL
EXAMINATION
ď LOC/GCS
ď CNs EXAMINATION
ď DETERIORATION/IMPROVEMENT IN LOC/GCS
20. SPECIFIC PROCEDURES, SPECIFIC
LAB. INVESTIGATIONS
ď AFTER HISTORY & EXAMINATION, RELEVANT
INVESTIGATIONS SHOULD BE ADVISED e.g.
ď FOR SUSPECTED CERVICAL SPINE INJURY X-RAYS
SHOULD BE DONE AS:
1. LATERAL VIEW: OCCIPUT TO TOP OF T1
2. ANTERO-POSTERIOR VIEW: SPINOUS PROCESSES
C2-C7
⢠Additional X-rays Extremities, Spine
⢠CT-SCAN
⢠Contrast X-rays, Urography, Angiography
⢠Endoscopy
21. DEFINATIVE CARE & TRANSFER
ď ACCORING TO CLINICAL AND OTHER DATA PATIENT
IS SHIFTED TO ICU , OT OR OTHERS RESPECTIVELY.
ď OR TRANSFRRED TO OTHER FACILITY ACCORDING
TO PATIENTâS NEED OR INSTITUTIONâS CAPABILITY.
TERTIARY SURVEY
ď DEFINED AS PATIENTâS EVALUATION THAT
IDENTIFIES AND CATALOGUES ALL INJURIES AFTR
INITIAL RESUSSITATION AND OPERATIVE
INTERVENTIONS
ď PATIENT IS MORE AWAKE
ď MORE INFORMATION ABOUT MODE OF INJURY BY
PATIENT IS GATHERED
22. ATLS OUTLINE
ď PRIMARY SURVEY (ABCDE)
ď SECONDARY SURVEY 1. HISTORY
2. PHYSICAL
EXAMINATION
3. RELEVANT
INVESTIGATIONS
ď RE-EVALUATION
ď DEFINATIVE CARE
ď TRANSFER