2016 ATLS guidelines of trauma survey

1. TRAUMA
SURVEY
By
DR. M.V.K.KIRAN

2. OBJECTIVES
• Demonstrate concepts of primary and secondary patient
assessment
• Establish management priorities in trauma situations
• Initiate primary and secondary management as
necessary
• Arrange appropriate disposition

3. ATLS
• Trimodal death distribution
o First peak-- instantly (brain, heart, large vessel injury)
o Second peak-- minutes to several hours (GOLDEN PERIOD)
o Third peak-- days to weeks (sepsis, MSOF)
• ATLS focuses on the second peak…..Deaths from:
 Intra cranial hemorrhages, TBI (Traumatic Brain Injury)
 Basilar skull fractures, orbital fractures
 Penetrating neck injuries, spinal cord syndromes
 Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal
injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary
contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries
…
 Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal
injuries
 Bladder rupture, renal contusion, renal laceration, urethral injury…
 Pelvic fractures, femur fractures, humerus fractures…

4. 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

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

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

7. AIRWAY INTERVENTIONS
• Supplemental oxygen
• Suction
• Chin lift/jaw thrust
• Oral/nasal airways
• Definitive airways
o RSI (Rapid Sequence Intubation)for agitated patients with c-spine immobilization
o ETI (Emergency Tracheal Intubation)for comatose patients (GCS<8)

8. BREATHING & VENTILATION
• Airway patency alone does not ensure adequate ventilation
• Injuries that can impair ventilation in short term are tension
pneumothorax, flail chest with pulmonary contusion, massive
hemothorax & open pneumothorax. These injuries should be
evaluated in primary survey.
• Inspect, palpate, and auscultate
o Deviated trachea, crepitus, flail chest, sucking chest wound, absence of breath sounds
• CXR to evaluate lung fields

9. BREATHING INTERVENTIONS
• Ventilate with 100% oxygen (if not intubated)
• Needle decompression if tension pneumothorax
suspected
• Chest tubes for pneumothorax / hemothorax
• Occlusive dressing to sucking chest wound
• If intubated, evaluate ETT position

10. CIRCULATION
• Hemorrhagic shock should be assumed in any
hypotensive trauma patient
• Rapid assessment of hemodynamic status
o Level of consciousness
o Skin color
o Pulses in four extremities
o Blood pressure and pulse pressure

11. Circulation Interventions
• Cardiac monitor
• Apply pressure to sites of external hemorrhage
• Establish IV access
o 2 large bore IVs
o Central lines if indicated
• Crystalloids should be used
• Volume resuscitation
o Have blood ready if needed
o Level One infusers available
o Foley catheter to monitor resuscitation

12. DISABILITY
• Abbreviated neurological exam
o Level of consciousness
o Pupil size and reactivity
o Motor function
o GCS
• Utilized to determine severity of injury
• Guide for urgency of head CT and ICP monitoring

13. GCS
EYE OPENING
(E)
VERABL
RESPONSE (V)
MOTOR
RESPONSE (M)
SPONTANEOUS 4 NORMAL 5 NORMAL 6
VERBAL 3 CONFUSED 4 LOCALIZES TO PAIN 5
PAIN 2 INCOHERENT 3
WORDS
FLEXION TO PAIN 4
NONE 1 INCOMPREHENSIBLE
SOUNDS 2
DECORTICATE 3
NONE 1 DECEREBRATE 2
NONE 1

14. Disability Interventions
• Spinal cord injury
o High dose steroids if within 8 hours
• ICP monitor- Neurosurgical consultation(ICP monitoring
is done with use of Intraventricular catheter, subdural
screw and epidural sensor )
• Elevated ICP
o Head of bed elevated
o Mannitol
o Hyperventilation
o Emergent decompression

15. EXPOSURE
• Complete disrobing of patient
• Logroll to inspect back
• Rectal temperature
• Warm blankets/external warming device to prevent
hypothermia

16. SECONDARY SURVEY
• The secondary survey does not begin until the primary
survey (ABCDEs) is completed, resuscitative efforts are
underway, and the normalization of vital functions has
been demonstrated.
• The secondary survey is a head to toe evaluation of the
trauma patient that is complete history, physical
examination including reassessment of all vital signs.
• Each region of the body is completely examined as the
potential to miss an injury is high.
• Complete neurologic examination including repeat GCS
and blood investigations, radiographs, ultrasounds
(Fast)and CT scans are obtained.

17. SECONDARY SURVEY
• The AMPLE history is a useful mnemonic for this
purpose:
Allergies
Medications currently used
Past illnesses/Pregnancy
Last meal
Events/Environment related to the injury
• During the secondary survey, physical examination
follows the sequence of head, maxillofacial structures,
cervical spine and neck, chest, abdomen,
perineum/rectum/vagina, musculoskeletal system, and
neurologic system.

18. HEAD
• The entire scalp and head should be examined for
lacerations, contusions and evidence of fractures. Because
edema around the eyes can later preclude an in-depth
examination, the eyes should be reevaluated for Visual acuity,
Pupillary size, Hemorrhage of the conjunctiva and/or fundi,
Penetrating injury, Contact lenses (remove before edema
occurs), Dislocation of the lens, Ocular entrapment
• A quick visual-acuity examination of both eyes can be
performed by asking the patient to read printed material such
as a hand held Snellen chart, or words on an IV container or
dressing package. Ocular mobility should be evaluated to
exclude entrapment of extraocular muscles due to orbital
fractures.

19. MAXILLO FACIAL STRUCTURES
• Examination of the face should include palpation of all
bony structures, assessment of occlusion, intraoral
examination and assessment of soft tissues.
• Maxillofacial trauma that is not associated with airway
obstruction or major bleeding should be treated only
after the patient is stabilized completely and life-
threatening injuries have been managed.

20. CERVICAL SPINE & NECK
• Patients with maxillofacial or head trauma should be
presumed to have an unstable cervical spine injury
(e.g., fracture and/or ligament injury), and the neck
should be immobilized until all aspects of the
cervical spine have been adequately studied and an
injury has been excluded.
• The absence of neurologic deficit does not exclude injury
to the cervical spine, and such injury should be
presumed until a complete cervical spine radiographic
series and CT

21. CHEST
• A complete evaluation of the chest wall requires palpation of
the entire chest cage, including the clavicles, ribs, and
sternum. Sternal pressure can be painful if the sternum is
fractured or costochondral separation
• Significant chest injury can manifest with pain, dyspnea, and
hypoxia. Evaluation includes auscultation of the chest and a
chest x-rays exist.
• Auscultation is conducted high on the anterior chest wall for
pneumothorax and at the posterior bases for hemothorax.
• Distant heart sounds and decreased pulse pressure can
indicate cardiac tamponade. In addition, cardiac tamponade
and tension pneumothorax are suggested by the presence of
distended neck veins

22. ABDOMEN
• Abdominal injuries must be identified and treated
aggressively. The specific diagnosis is not as important
as recognizing that an injury exists that requires surgical
intervention.
• Spleen is the most common organ injured in blunt
trauma and liver being the second are often associated
with other abdominal injuries.
• Patients with unexplained hypotension, neurologic injury,
impaired sensorium secondary to alcohol and/or other
drugs and equivocal abdominal findings should be
considered candidates for peritoneal lavage, abdominal
ultrasonography or if hemodynamic findings are normal,
CT of the abdomen.

23. FAST
• FOCUSED ASSESSMENT SONOGRAPHY in TRAUMA.
• It is a bedside ultrasound highly preferred in trauma
patients.
• The four classic areas examined for free fluid are
Perihepatic space (Morison’s pouch), Perisplenic space,
Pericardium and Pelvis.
• The newer version- eFAST (Extended FAST) which
includes examination of both lungs (b/l anterior thoracic
sonography). This allows for the detection of
pneumothorax.

24. PERINEUM/ RECTUM/ VAGINA
• The perineum should be examined for contusions,
hematomas, lacerations, and urethral bleeding.
• Pregnancy tests should be performed on all females of
childbearing age.

25. MUSCULOSKELETAL SYSTEM
• The extremities should be inspected for contusions and
deformities. Palpation of the bones and examination for
tenderness and abnormal movement aids in the identification
of occult fractures.
• Pelvic fractures can be suspected by the identification of
ecchymosis over the iliac wings, pubis, labia or scrotum.
Assessment of peripheral pulses can identify vascular injuries.
• Ligament ruptures produce joint instability. Muscle-tendon unit
injuries interfere with active motion of the affected structures.
Impaired sensation and/or loss of voluntary muscle
contraction strength can be caused by nerve injury or
ischemia, including that due to compartment syndrome.

26. NEUROLOGIC EXAM
• A comprehensive neurologic examination includes not
only motor and sensory evaluation of the extremities, but
reevaluation of the patient’s level of consciousness and
pupillary size and response.
• Patients should be monitored frequently for deterioration
in level of consciousness and changes in the neurologic
examination, as these findings can reflect worsening of
the intracranial injury.
• If a patient with a head injury deteriorates neurologically,
oxygenation and perfusion of the brain and adequacy of
ventilation (i.e., the ABCDEs) must be reassessed.
Intracranial surgical intervention or measures for
reducing intracranial pressure may be necessary.

27. SUMMARY
• Trauma Survey includes
 Primary survey : ABCDE’s
 Secondary survey: AMPLE history with head to toe evaluation
• ECG’s, ABG’s, FAST, blood investigations, X-ray’s and CT
scans are also important in excluding the injuries.
• Reevaluation: Trauma patients must be reevaluated
constantly to ensure that new findings are not overlooked and
to discover deterioration in previously noted findings.
• Continuous monitoring of vital signs and urinary output is
essential.
• The relief of severe pain is an important part of
• the treatment of trauma patients.

28. THANK YOU