The trimoidal desribution of de

1. ATLS
Advanced Trauma Life Support
Supervised by: Prof. Mahmoud Abu-Ebeeleh
Done by: Dr. Faisal Rawagah

2. History
 Dr James Styner, An orthopedic surgeon crashed his plane in February 1976
 “When I can Provide better care in the field with limited resources than what my children and I
received at the primary care facility, there is something wrong with the system, and the system
has to be changed”
-Advanced Trauma Life Support Student Course Manual 10th edition
-Journal of Trauma Nursing April/June 2006, Volume :13 Number 2 , page 41 - 44

3. Do we Need ATLS?
 ATLS Methods is accepted as a standard for the “first hour” of trauma care by
many who provide care for the injured.
 5.8 million people die every year from unintentional injuries and violence.
 Motor vehicle crashes alone case:
 1.3 million deaths annually.
 20 million to 50 million significant injuries.
 Trauma the leading cause of death in persons 1 through 44 years of age in most
developed countries.
-Advanced Trauma Life Support Student Course Manual 10th edition
-https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries

4. The trimodal distribution of deaths
 Classically:
 Immediate (seconds to minutes)
 Severe brain or high spinal cord injury
 Rupture of the heart, aorta, or other large blood
vessels
 Early (minutes to several hours)
 Subdural and epidural hematomas,
 Hemopneumothorax
 Ruptured spleen, lacerations of the liver, pelvic
fractures.
 Late (Several days to weeks)
 sepsis and multiple organ system dysfunctions.
-Advanced Trauma Life Support Student Course Manual 10th edition
-Gunst M, Ghaemmaghami V, Gruszecki A, Urban J, Frankel H, Shafi S. Changing epidemiology of trauma deaths leads
to a bimodal distribution. Proc (Bayl Univ Med Cent). 2010 Oct;23(4):349-54. doi: 10.1080/08998280.2010.11928649.
PMID: 20944754; PMCID: PMC2943446.

5. The “initial assessment”
 Timing is crucial, systematic approach that can be rapidly and accurately applied is essential
 •• Preparation
 •• Triage
 •• Primary survey (ABCDEs) with immediate resuscitation of patients with life-threatening injuries
 •• Adjuncts to the primary survey and resuscitation
 •• Consideration of the need for patient transfer
 •• Secondary survey (head-to-toe evaluation and patient history)
 •• Adjuncts to the secondary survey
 •• Continued postresuscitation monitoring and reevaluation
 •• Definitive care

6. Preparation
 Prehospital Phase
 Airway maintenance, Control of external bleeding and shock.
 Immobilization of the patient, and immediate transport to the closest appropriate facility.
 Obtaining and reporting information needed for triage at the hospital.
 Time of injury events related to the injury, and patient history.
 Hospital Phase
 Resuscitation area.
 Properly functioning airway equipment.
 Warmed intravenous crystalloid solutions (37c-40c) + appropriate monitoring devices.
 Protocol to summon additional medical assistance + laboratory and radiology personnel.
 Transfer agreements with verified trauma centers.
 PPE- standard precautions (face mask, eye protection, water-impervious gown,and gloves)

7. Triage
based on the ABC
 The severity of injury.
 Ability to survive.
 Available resources.
 Multiple-casualty event
 Mass-casualty event
-Advanced Trauma Life Support Student Course Manual 10th edition
-CDC, MMWR, Guidelines for Field Triage of Injured Patients:
Recommendations of the National Expert Panel on Field Triage, 2011

8. Primary Survey with
Simultaneous Resuscitation
 During the primary survey, life-threatening conditions are identified and treated in a
prioritized sequence based on the effects of injuries on the patient’s physiology,
because at first it may not be possible to identify specific anatomic injuries.
 • Airway maintenance with restriction of cervical spine motion.
 • Breathing and ventilation.
 • Circulation with hemorrhage control.
 • Disability(assessment of neurologic status).
 • Exposure/Environmental control.

9. Airway maintenance with restriction of cervical
spine motion.
 Asking the patient for his or her name, and asking what happened.
 Inspecting for foreign bodies.
 Identifying facial, mandibular, and/or tracheal/laryngeal fractures and other injuries that
can result in airway obstruction.
 Suctioning to clear accumulated blood or secretions.
 Jaw-thrust or chin-lift.
 Oropharyngeal airway.
 Establish a definitive airway.
 Cervical In-line stabilization.
 Cervical collar.
-Advanced Trauma Life Support Student Course Manual 10th edition
-Austin N, Krishnamoorthy V, Dagal A. Airway management in cervical spine injury. Int J Crit Illn Inj Sci.
2014 Jan;4(1):50-6. doi: 10.4103/2229-5151.128013. PMID: 24741498; PMCID: PMC3982371.

10. Breathing and ventilation
 Expose the patient’s neck and chest
 Assess jugular venous distention.
 Position of the trachea
 Chest wall excursion
 Tension pneumothorax, Massive hemothorax, Open pneumothorax, and tracheal or
bronchial injuries.
 O2 mask-reservoir device.
 Pulse oximeter to monitor.
 Ask but do not stop at; Portable CXR.
 NOT in Primary Survey: Simple pneumothorax, simple hemothorax, fractured ribs, flail
chest, and pulmonary contusion.

11. Circulation with hemorrhage control.
 cABCDE; Catastrophic Haemorrhage Control.
 Blood Volume and Cardiac Output
 If there is no tension pneumothorax then consider that hypotension following injury is
due to blood loss until proven otherwise.
 Evaluation:
 Level of Consciousness
 Skin Perfusion
 Pulse
 BP
 Bleeding
 Blood on the floor and four more

12.  External hemorrhage is identified and controlled during the primary survey.
 Direct manual pressure
 Tourniquet: carry a risk of ischemic injury
 Do NOT do Blind clamping.
 Internal hemorrhage; Four More
 Physical examination and imaging;
 Chest x-ray, Pelvic x-ray, focused assessment with sonography for trauma [FAST], or diagnostic
peritoneal lavage [DPL].
 Chest decompression, and application of a pelvic stabilizing device and/ or extremity splints.
 Definitive management may require surgical or interventional radiologic treatment and pelvic and
long-bone stabilization.
 Definitive bleeding control is essential, along with appropriate replacement of intravascular

13.  Vascular access
 Two large-bore peripheral venous catheters (g16 cannula)
 Send 5 Blood samples
 CBC
 Blood gases and/or lactate level
 Blood Group/ Xmach
 Pt Ptt INR
 Toxicology
 +/- pregnancy test
 Peripheral sites cannot be accessed
 Intraosseous infusion, central venous access(Cordis catheter), or venous cutdown.
-Advanced Trauma Life Support Student Course Manual 10th edition
-Schwartz’s Principles of Surgery Eleventh Edition: chapter 7, page 183- 249

14.  Aggressive and continued volume resuscitation is NOT a substitute for definitive
control of hemorrhage.
 Bolus of 1 L warm (37°C to 40°C) normal saline IV
 Unresponsive; activate massive blood transfusion protocol (1:1:1)
 Your target is permissive hypotension
 Tranexamic acid; best within 1 h of trauma, up to 3 h, followed by 2nd dose infusion
over 8 hours in the hospital.

15. Disability(assessment of neurologic status).
 Patient’s level of consciousness and pupillary size and reaction.
 Identifies the presence of lateralizing signs.
 Determines spinal cord injury level, if present.
 GCS
 Decrease in a patient’s level of consciousness may indicate:
 Decreased cerebral oxygenation and/or perfusion,
 Direct cerebral injury
 Hypoglycemia, alcohol, narcotics, and other drugs
 Call neurosurgeon once a brain injury is recognized
 Your main goal to Prevent secondary brain injury by maintaining adequate oxygenation and
perfusion.

16. Exposure/Environmental control
 Cutting off his or her garments
 Examine the anterior surface
 Examine areas that not easy to access; axilla, perineum
 Log rolling maneuver; Examine the back, PR.
 Cover the patient with warm blankets or an external warming device.
 Use only warm IV fluids.
 Hypothermia one of the trauma’s lethal triad.

17. Adjuncts to the Primary Survey with
Resuscitation
 Physiologic parameters such as pulse rate, blood pressure, pulse pressure,
ventilatory rate, ABG levels, body temperature, and urinary output are assessable
measures that reflect the adequacy of resuscitation. Values for these parameters
should be obtained as soon as is practical during or after completing the
primary survey, and reevaluated periodically.
 It is important not to delay transfer to perform an indepth diagnostic evaluation.

18. Special Populations
 Pediatric patients
 Pregnant women
 Older adults
 Obese patients
 Athletes

19. Secondary Survey
 The secondary survey does not begin until the primary survey (ABCDE) is completed,
resuscitative efforts are under way, and improvement of the patient’s vital functions
has been demonstrated.
 History (Allergies, Medications, Past illnesses/Pregnancy, Last meal,
Events/Environment)
 Blunt Trauma
 Penetrating Trauma
 Thermal Injury
 Hazardous Environment

20.  Physical Examination
 Head
 Maxillofacial Structures
 Cervical Spine and Neck
 Chest
 Abdomen and Pelvis
 Perineum, Rectum, and Vagina
 Musculoskeletal System
 Neurological System

21. Blunt Trauma

22. Penetrating and Thermal Trauma

23. HEAD TRAUMA
 Classification of head injuries
 Severity of Injury
 Mild Brain Injury (GCS Score 13–15)
 Moderate Brain Injury (GCS Score 9–12)
 Severe Brain Injury (GCS Score 3–8)
 Morphology
 Skull Fractures
 Intracranial Lesions
 Diffuse Brain Injuries
 Focal Brain Injuries
 Epidural Hematomas
 Subdural Hematomas
 Contusions and Intracerebral Hematomas

25.  Decompressive Craniectomy
 Prophylactic Hypothermia (not Recommended)
 Hyperosmolar Therapy (Hypertonic, Mannitol)
 Cerebrospinal Fluid Drainage (All Severe TBI)
 Ventilation Therapies ((PaCO2) ≤ 25 mmHg is not
recommended)
 Anesthetics, Analgesics, and Sedatives (High-dose barbiturate
administration is recommended)
 Steroids (not recommended)
 Nutrition (Feeding on day 5-7)
 Infection Prophylaxis (Early tracheostomy is recommended)
 Deep Vein Thrombosis Prophylaxis
 Seizure Prophylaxis (Phenytoin is recommended)
 Intracranial Pressure Monitoring (All Severe TBI)
 Cerebral Perfusion Pressure Monitoring (All Severe TBI)
 Advanced Cerebral Monitoring
 Jugular bulb monitoring of arteriovenous oxygen content difference
(AVDO2)
 Blood Pressure Thresholds (SBP >100 -110) (50-69 yr)
 Intracranial Pressure Thresholds (>22 mmHg)
 Cerebral Perfusion Pressure Thresholds (60-70 mmHg)
 Advanced Cerebral Monitoring Thresholds (SJVO2>50%)
-Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N,
Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of
Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi:
10.1227/NEU.0000000000001432. PMID: 27654000.
-Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension N Engl J Med 2016; 375:1119-1130,
DOI: 10.1056/NEJMoa1605215

26. THORACIC TRAUMA
 Primary Survey:
 Airway
 Obstruction
 Tracheobronchial Tree Injury
 Breathing
 Tension Pneumothorax
 Open Pneumothorax
 Massive Hemothorax
 Circulation
 Massive Hemothorax
 Cardiac Tamponade
 Traumatic Circulatory Arrest
 Secondary survey:
 Potentially Life-Threatening Injuries
 Simple Pneumothorax
 Hemothorax
 Flail Chest and Pulmonary Contusion
 Blunt Cardiac Injury
 Traumatic Aortic Disruption
 Traumatic Diaphragmatic Injury
 Blunt Esophageal Rupture

28. Traumatic Circulatory
Arrest

29. -Resuscitative endovascular balloon occlusion of the aorta: current evidence Open Access Emerg Med. 2019; 11: 29–38. Published online 2019 Jan 14. doi: 10.2147/OAEM.S166087
-Sridhar, Srikanth MD*; Gumbert, Sam D. MD*; Stephens, Christopher MD*; Moore, Laura J. MD†; Pivalizza, Evan G. MBChB, FFASA* Resuscitative Endovascular Balloon Occlusion of the Aorta: Principles, Initial Clinical Experience, and Considerations for
the Anesthesiologist, Anesthesia & Analgesia: September 2017 - Volume 125 - Issue 3 - p 884-890 doi: 10.1213/ANE.0000000000002150
Resuscitative endovascular
balloon occlusion of the
aorta (REBOA)

30. ABDOMINAL AND PELVIC TRAUMA
 Blunt
 Spleen (40% to 55%)
 Liver (35% to 45%)
 Small bowel (5% to 10%)
 Retroperitoneal hematoma
 Pelvic Fractures
 Penetrating
 Stab wounds
 Liver (40%), Small bowel (30%),
Diaphragm (20%), colon (15%)
 High-energy low-energy
gunshot wounds
 small bowel (50%), colon (40%),
liver (30%), and abdominal
vascular structures (25%).

31. FAST

33. References
 Advanced Trauma Life Support Student Course Manual 10th edition
 Journal of Trauma Nursing April/June 2006, Volume:13 Number 2 , page 41-44
 https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries
 Gunst M, Ghaemmaghami V, Gruszecki A, Urban J, Frankel H, Shafi S. Changing epidemiology of trauma deaths leads to a bimodal distribution. Proc
(Bayl Univ Med Cent). 2010 Oct;23(4):349-54. doi: 10.1080/08998280.2010.11928649. PMID: 20944754; PMCID: PMC2943446.
 CDC, MMWR, Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage, 2011
 Austin N, Krishnamoorthy V, Dagal A. Airway management in cervical spine injury. Int J Crit Illn Inj Sci. 2014 Jan;4(1):50-6. doi: 10.4103/2229-5151.128013.
PMID: 24741498; PMCID: PMC3982371.
 Schwartz’s Principles of Surgery Eleventh Edition: chapter 7, page 183- 249
 Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC,
Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan
1;80(1):6-15. doi: 10.1227/NEU.0000000000001432. PMID: 27654000.
 Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension N Engl J Med 2016; 375:1119-1130, DOI: 10.1056/NEJMoa1605215
 https://www.grepmed.com/images/2422/echocardiogram-tamponade-clinical-cardiac-pocus
 Resuscitative endovascular balloon occlusion of the aorta: current evidence Open Access Emerg Med. 2019; 11: 29–38. Published online 2019 Jan
14. doi: 10.2147/OAEM.S166087
 Sridhar, Srikanth MD*; Gumbert, Sam D. MD*; Stephens, Christopher MD*; Moore, Laura J. MD†; Pivalizza, Evan G. MBChB, FFASA* Resuscitative
Endovascular Balloon Occlusion of the Aorta: Principles, Initial Clinical Experience, and Considerations for the Anesthesiologist, Anesthesia & Analgesia:
September 2017 - Volume 125 - Issue 3 - p 884-890 doi: 10.1213/ANE.0000000000002150

34. Thank you
Supervised by:
Prof. Mahmoud Abu-Ebeeleh
Cardiothoracic surgery consultant
Done by:
Dr. Faisal Rawagah
Critical Care Fellow
Jordan University Hospital 17.03.2022