ADVANCED TRAUMA LIFE SUPPORT

1. ADVANCE TRAUMA LIFE
SUPPORT(ATLS)
PRESENTER: DR RAVI BHUSHAN
MODERATOR : DR NEERAJ DHAMEEJA
SIR GANGARAM HOSPITAL NEW DELHI

2.  This focus on urgent problems is first captured by the
“Golden hour” catch phrase and is one of the most
important lessons of ATLS

3. Objectives:
 To identify – the sequence of priorities in the early assessment of the
injured patient
 To learn – the principle of triage in immediate management of the
injured patient
 To apply- the principles of primary and secondary surveys in the
assessment and management of trauma
 Techniques for the initial resuscitative and definitive care aspects of
trauma
 To recognize-patients whose managements should differ from the
normal

5. Basics of Trauma Assessment
Preparation
– Team Assembly
– Equipment Check
Triage
Primary Survey
Resuscitation
Secondary Survey
Monitoring and Evaluation, Secondary adjuncts
Transfer to Definitive Care

6. The steps in the ATLS principles:
Primary survey with simultaneous resuscitation : identify
and treat what is killing the patient
Secondary survey: proceed to identify all other injuries
Definitive care: develop a definitive management plan

7. TRIAGE
The process of categorizing victims of mass casualties
based on their need for treatment and the resources
available
MAIN GOALS :
Prevent avoidable deaths.
Ensure proper initial treatment with a
minimal time frame.
Avoid misusing assests on hopeless cases

8. TRIAGE

9.  Multiple Casualties Vs Mass Casualties

10. PRIMARY SURVEY
 What is the quick ,simple way to assess
the trauma patient in 10 seconds?
 1. Airway is patent.
2. Breathing intact.
3. Good cerebral circulation

11. PRIMARY SURVEY
Airway and Protection of Spinal Cord
Breathing and Ventilation
Circulation
Disability
Exposure and Control of the Environment

12. PRIMARY SURVEY
Airway and Protection of Spinal Cord
Why first in the algorithm?
– Loss of airway can result in death in < 3 minutes
– Prolonged hypoxia = Inadequate perfusion, End-organ damage
Airway Assessment
– Vital Signs = RR, O2 sat
– Mental Status = Agitation, Coma
– Airway Patency = Secretions, Stridor, Obstruction
– Ventilation Status = Accessory muscle use, Retractions, Wheezing

13. PRIMARY SURVEY
 Clinical
– Patients who are speaking normally generally do not have a need
for immediate airway management
– Hoarse or weak voice may indicate a subtle tracheal or laryngeal
injury
– Noisy respirations frequently indicates an obstructed respiratory
pattern

14. AIRWAY MANAGEMNT
Maintenance of Airway
Patency
–Suction of Secretions
–Chin Lift/Jaw thrust
–Nasopharyngeal Airway
–Definitive Airway

15. AIRWAY MANAGEMNT
 Airway Support
– Oxygen
– Bag Valve Mask
 Definitive Airway
– Endotracheal Intubation
 In-line cervical stabilization
– Surgical Crichothyroidotomy

16. AIRWAY MANAGEMNT
Needle-
Cricothyroidotomy
• Insertion of a needle
through the
cricothyroid
membrane or Into the
trachea
• provide temporary,
supplemental
oxygenation so that
intubation can be
accomplished on an
urgent rather than an
emergent basis.

17. Surgical-
Cricothyroidotomy
Palpate the thyroid notch, cricothyroid
interval, and the sternal notch for
orientation.
Make a transverse skin incision over
the cricothyroid membrane and
carefully incise through the membrane
transversely.
Insert hemostat or tracheal spreader
into the incision and rotate it 90
degrees to
open the airway.
Insert a proper-size, cuffed
endotracheal tube or tracheostomy
tube into the cricothyroid membrane
incision, directing the tube distally into
the
trachea.

18. Breathing and Ventilation
General Inspection (Look)
 Absence of spontaneous breathing Paradoxical chest wall movement
Auscultation
 to assess for gas exchange Diminished or Absent breath sounds
Palpation (FEEL)
 Deviated Trachea Broken ribs
 Injuries to chest wall

19. Breathing and Ventilation
 100% Oxygen administration to all trauma patients at high flow
 Identify and manage life threatening problems first
 Tension pneumothorax – needs immediate decompression with needle insertion
or chest tube insertion
 Cardiac temponade – Pericardiocentesis
 Massive hemothorax(>1.5L of blood)
-insertion of chest drain tube
Open pneumothorax
Flail chest with pulmonary contusion

20. Breathing and Ventilation
Needle Thoracostomy
– Midclavicular line
– 14 gauge angiocath
– Over the 2nd rib
– Rush of air is heard

21. Breathing and Ventilation

22. Chest Tube Insertion
STEP1. Determine the insertion site, usually at the
nipple level (fifth intercostal space), just anterior to the
midaxillary line on the affected
side. A second chest tube may be used for a
hemothorax.
STEP2. Surgically prepare and drape the chest at
the predetermined site of the tube insertion.
STEP3. Locally anesthetize the skin and rib
periosteum.
STEP4. Make a 2- to 3-cm transverse (horizontal)
incision at the predetermined site and
bluntly dissect through the subcutaneous
tissues, just over the top of the rib.

23. Chest Tube Insertion

STEP5. Puncture the parietal pleura with the tip
of a clamp and put a gloved finger into the
incision to avoid injury to other organs and
to clear any adhesions, clots, and so on.
Once the tube in the proper place, remove
the clamp from the tube.
STEP6. Clamp the proximal end of the thoracostomy tube and advance it into the
pleural space to the desired length.
The tube should
be directed posteriorly along the inside of
the chest wall.

24. Chest Tube Insertion
 STEP7. Look for “fogging” of the chest tube with
expiration or listen for air movement.
STEP8. Connect the end of the thoracostomy tube
to an underwater-seal apparatus.
STEP9. Suture the tube in place.
STEP10. Apply an occlusive dressing and tape the
tube to the chest.
STEP11. Obtain a chest x-ray film.
STEP12. Obtain arterial blood gas values and/or
institute pulse oximetry monitoring as
necessary.

25. Circulation
Shock
The first step in the initial management of shock in trauma patients is to recognize its
presence
?Is the patient in
?
“Any injured patient who is cool and has tachycardia is considered to be in shock until
proven otherwise”

26. Circulation
Clinical Signs of Shock
Altered mental status
 Tachycardia (HR > 100)
 Most common sign
Arterial Hypotension (SBP < 90)
Inadequate Tissue Perfusion
 Pale skin color , Cool clammy skin ,Delayed cap refill (> 3 seconds) , LOC
, Decreased Urine Output
 (UOP < 0.5 ml/kg/hr)
 Reliance solely on systolic blood pressure as an indicator of shock can
result in delayed recognition of the shock state.

27. Circulation
 The second step in the initial management of shock
is to identify the probable cause of the shock state.
What is the cause of shock?
Hemorrhagic Shock
Nonhemorrhagic Shock
 Cardiogenic Shock NeurogenicShock

28.  Most injured patients in shock
have hypovolemia, but they may suffer from cardiogenic, obstructive, neurogenic,
and, rarely, septic shock
 Hemorrhage is the most common cause of shock in the
injured patient

29. THANK YOU