atls

Advance trauma life

support
Andi Siswandi, MD
Surgeon
Malahayati University, Medicine Faculty

1. Preparation
2. Triage
3. Primary Survey (ABCDEs)
4. Resuscitation
5. Adjuncts to primary survey & resuscitation
6. Secondary Survey (head to toe evaluation &
history)
7. Adjuncts to secondary survey
8. Continued post-resuscitation monitoring &
reevaluation
9. Definite care.

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Preparation and TRIAGE

The used of the following protective devices is
recommended
Goggles
Gloves
Fluid-impervious gowns or aprons
Shoes covers and fluid- impervious leggings
Mask
Head covering

Preparation
A.

Pre-hospital phase
Receiving hospital is notified first.

Send to the closest, appropriate facility.

In Hospital Phase

Advanced planning for the trauma pt arrival.

Method to summon extra medical assistance

Transfer agreement with verified trauma center

established.

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Protect from communicable disease.

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TRIAGE
A Multiple Casualties
no of severity & px do not exceed the ability of
the facility.
B Mass Casualties
no & severity of pt EXCEED the capability of
the facility & staff.

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PRIMARY SURVEY
A : Airway with cervical spine protect.
B : Breathing
C : Circulation --control external bleeding.
D : Disability or neurological status
E : Exposure (undress) & Environment (temp
control)

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PRIMARY SURVEY
Priorities for the care of Adult ,
Pediatrics & Pregnancy women are
all the same.
During the primary survey life
threatening conditions are identified
and management is instituted
SIMULTANEOUSLY.
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A. Airway Maintenance with Cervical Spine

Protection.
GCS score of 8 or less require the placement of

definite airway.
Protection of the spine & spinal cord is the

important management principle.

Neurological exam alone does not exclude a

cervical spine injury.

Always assume a cervical spine injury in any pt

with multi-system trauma, especially with an

altered level of consciousness or blunt injury above
the clavicle.
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B. Breathing & Ventilation

* Airway patency does not assure adequate ventilation.

C. Circulation with Hemorrhage

Control.
1. Blood Volume & Cardiac Output
a. level of consciousness.
b. skin color
c. Pulse.
2. Bleeding
*external bleeding is identified & controlled in the
primary survey.
*Tourniquets should not be use.
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D. Disability ( Neurological
Evaluation)
Simple Mnemonic to describe level of
consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
Do Not forget to use also Glascow Coma
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10
Scale.

E. Exposure / Environmental Control

*It is the pts body temp that is most
important, not he comfort of the health care
provider.
*Intravenous fluid should be warm.
*Warm environment (room tem) should be
maintained.
*early control of hemorrhage.

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RESUSCITATION
A. Airway
*definite airway if there is any doubt about the pts ability to maintain
airway integrity.
B. Breathing /Ventilation/Oxygenation
*every injured pt should received supplement oxygen
C. Circulation
*control bleeding by direct pressure or operative intervention
* minimum of two large caliber IV should be established
*pregnancy test for all female of child bearing age.
* Lactated Ringer is preferred & better if warm.
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Adjunct to Primary Survey &

Resuscitation
A. Electro-cardiographic Monitoring
B. Urinary & Gastric Catheter
Urinary catheter. Urethral injury should be
suspected if
*Blood at the penile meatus
*Perineal ecchymosis
*Blood in the scrotum
*High riding or nonpalpable prostate
*Pelvic fracture
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C. Monitoring
1. Ventilatory rate & ABG
2. Pulse oximetry
does not measure ventilation or partial O2 pressure
3. Blood pressure
poor measure of actual tissue perfusion.
D. X-Ray & Diagnostic Studies

C-spine, CXR, Pelvic film, DPL/FAST

Essential x-ray should not be avoid in pregnant pt.

*** Consider the need for patient transfer

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SECONDARY SURVEY
Does not begin until the primary
survey (ABCDEs) is completed,
resuscitative effort are well
established & the pt is
demonstrating normalization of
vital sign.

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SECONDARY SURVEY
Head to Toe evaluation & reassessment of all

vital signs.
A complete neurological exam is performed

including a GCS score.

Special procedure is order.

HISTORY
A : Allergies.
M : Medication currently used.
P : Past illness/ Pregnancy.
L : Last Meal
E : Events/Environment related to the
injury.
*blunt trauma/penetrating
trauma/injuries du e to cold &
burn/hazardous environment?
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PHYSICAL EXAMINATION
Complete neurologic examination
Head and skull
Maxillofacial
Neck
Chest
Abdomen
Perineum/rectum/vagina
Musculoskeletal
Tubes and fingers in every orifice

Neurologic examination

HEAD
Scalp
Fractures
Eyes edema
- Pupil size
- Penetrating injury
Hemorrhage of conjunctivae, fundus
Contact lenses
- Dislocation of lenses
Ocular entrapment Head
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Other Physical
Examination
2. Maxillofacial Injury
airway obstruction , major bleeding
Ex. of mid maxilla beware of NG tube insertion
need frequent reassessment

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Other Physical
Examination
3. Cervical Spine & Neck
Head injury pt. keep in mind of cervical spine
injury
Absence of neurologic deficit does not exclude
spine injury
Inspection , palpation , auscultation , cervical
spine tenderness , subcutaneous
emphysema , tracheal deviation , laryngeal
fracture
Protection of C-spine injury , helmet removing

Other Physical
Examination
4. Chest
Visual evaluation of anterior and posterior
chest
open pneumothorax
flail chest
Pain , dyspnea , hypoxia
Cardiac tamponade , tension pneumothorax
distended neck veins
distant heart sound

Other Physical
Examination
5. Abdomen
excessive manipulation of the pelvic should be

avoided.
6. Perineum/rectum/vagina
contusion , hematoma , laceration , urethral bleeding
rectal examination : blood , high-riding prostate ,
integrity of rectal wall , sphincter tone
female :
Vg exam.: blood , Vg laceration
pregnancy test
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Other Physical
Examination
7. Musculoskeletal
inspection : contusion , deformity
palpation : tenderness , abnormal movement
Pelvic : ecchymosis on iliac wings , pubis ,
labia , scrotum , pain on palpation of pelvic
ring
assessment of peripheral pulses
patients back examination

Adjunct to the Secondary Survey

hemodynamic status
CT scan
Contrast x-ray studies
Extremity x-ray
Endoscopy and USG.

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Re-evaluation
reevaluation for new findings or overlooked
continuous monitoring of vital signs , urinary

output
0.5 ml/kg/hr
1 ml/kg/hr
ABG , EKG , pulse oximetry
effective analgesia

Definitive Care
After identifying the patients injuries

Managing life-threatening problems

Obtaining special studies
Transfer If the patients injuries exceed the
institutions treatment capabilities

Indication For Definite Airway

* Unconscious
* Severe maxillo-facial fracture
* Risk for aspiration : Bleeding/ vomiting
* Risk for obstruction : neck hematoma/laryngeal,tracheal
injury/ stridor
* Apnea : Neuromuscular paralysis/unconscious
* Inadequate respiratory effort:
tachypnea/hypoxia/hypercapnia/cyanosis
* Severe closed head injury need for hyperventilation

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Color Codes Triage Tag

RED : Most critical injury
YELLOW : Less critical injured
GREEN : No life or limb threatened
injury
BLACK : Death or obviously fatal
injury

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Priorities with multiple

injuries
1. Thoracic trauma or tamponade
2. Abdominal hemorrhage
3. Pelvic Hemorrhage
4. Extremity Hemorrhage
5. Intra-cranial Injury
6. Acute Spinal Cord Injury
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Maxillofacial
Trauma

Etiology and Incidence

Multi system injury 20-50%
Nasal and mandibular fractures most common

in community EDs
Midface and zygomatic injuries most common
in Trauma centers
25% of women with facial trauma result of
domestic violence
Incidence of concomitant cervical spine
injuries with facial fractures

Etiology and Incidence

Older age, MVC and TBI-higher incidence
Facial fractures-a distracting injury?
Carotid artery injury
Blindness may occur with facial fractures

Maxillofacial Trauma

Emergency Management and

Resuscitation
Airway
Most urgent complication-Airway compromise
Simple interventions first
No mandible?

Intubation
Avoid nasotracheal intubation
May not want RSI
Benzodiazepines
Ketamine
Etomidate
Be Prepared and Be Creative

Emergency Management and

Resuscitation
Airway Management Options
Awake intubation
Laryngeal Mask Airway
Fiberoptic intubation
Lateral or semi-prone position
Percutaneous transtracheal jet ventilation
Retrograde intubation
Cricothyroidotomy

Emergency Management and

Resuscitation
Hemorrhage Control
Rarely develop shock from facial bleeding alone
Direct Pressure
LeFort Fractures
Nasal hemorrhage may require A&P packing
History
Vision
Teeth alignment
Abuse

Maxillofacial Trauma-Physical Exam

Inspection
Facial elongation
High grade LeFort Fracture
Asymmetry
Deformities

and cranial nerve injury

Palpation
Tenderness
Step offs
Facial stability

Crepitus
Subcutaneous air
Cutaneous anesthesia

Maxillofacial Trauma-Physical Exam

Periorbital and

Orbital Exam
Perform early

Professional Lid
Retractor

Maxillofacial Trauma-Physical Exam

Periorbital and Orbital Exam
Look for exophthalmos or enophthalmos
Pupil shape
Hyphema
Visual acuity
Entrapment signs
Raccoon sign

Bimanual Palpation Test

Maxillofacial Trauma-Physical Exam

Penetrating Injuries
Occult globe penetration
Eyelid lacerations
Nose
Septal hematoma
CSF Rhinorrhea
Ears
Subperichondral hematoma
Hemotympanum
Battle sign

Maxillofacial Trauma-Physical Exam

Oral and Mandibular Exam
Mandible deviation
Teeth malocclusion
Paresthesia
Tongue Blade Test
95% Sensitive
65% Specific

Maxillofacial TraumaImaging
Head, chest and abdominal trauma takes

precedence
PE detects up to 90% of fractures
Plain Films
CT
Orbital fractures
3D images available

Maxillofacial Trauma-Specific
Fractures
Frontal Sinus/Bone Fractures
Direct blow
Frequent intracranial injuries
Mucopyoceles
Consult with NS for treatment, disposition and
antibiotics
Nasoethmoidal-Orbital Injuries
Lacrimal apparatus disruption
Bimanual palpation if medial canthus pain
CT face

Maxillofacial Trauma-Specific
Fractures
Orbital Fractures
Usually through
floor or medial wall
Enophthalmos
Anesthesia
Diplopia
Infraorbital stepoff
deformity
Subcutaneous
emphysema

Maxillofacial Trauma-Specific
Fractures
Orbital Fissure Syndrome
Fracture of the orbital canal
Extraocular motor palsies and blindness
If significant retrobulbar hemorrhage, may
need cantholysis to save vision

Zygomatic Fractures
Tripod fracture
Most serious
Arch fracture
Lateral subconjunctival hemorrhage
Most common
Need ORIF
Outpatient repair

Tripod Fracture

Maxillofacial Trauma-Specific
Fractures
Maxillary Fractures
High-energy injury
100x gravity
Malocclusion
Facial lengthening
CSF rhinorrhea
Periorbital ecchymosis

LeFort Fractures

Maxillofacial Trauma-Specific Facial

Fractures
Mandibular Fractures
Second most common facial

fracture
Often multiple
Plain films
Malocclusion
Panorex
Intraoral lacerations CT
Sublingual ecchymosis
Nerve injury
Open Fractures
Pen

G or Cleocin

Body

30-40 %

Angle

25-30 %

Condyle

15-17 %

Symphysis

7-15 %

Ramus

3-9 %

Alveolar

2-4 %

Coronoid
Process

1-2 %

Lecture Questions
1. What portion of the mandible is most

commonly fractured?
Ramus
b. Coronoid process
c. Body
d. Angle
e. Symphysis
a.

2. Orbital fractures can cause all of the following

except:
Blindness
b. Motor palsies
c. Facial anesthesia
d. Enophthalmos
e. Hyphema
a.

3. Which of the following is/are true regarding

maxillary fractures?
Only minimal force necessary
b. Rarely cause CSF rhinorrhea
c. May cause facial lengthening
d. Usually the only sustained injury
e. All of the above are true
a.

4. The best modality for diagnosing an orbital

or facial fractures is
Plain films
b. MRI
c. CT
d. Ultrasound
e. Osteopathic palpation
a.

5. Which statement below is correct?

a. Midface fractures usually have minimal
morbidity
b. The tongue blade test is quite sensitive in
assessing need for mandibular xrays
c. The bimanual nasal exam is crucial in possible
medial orbital wall fracture
d. Midface fracture is an indication for
nasotracheal intubation and RSI is often needed
in these patients
c, e, c, c, b

THANK YOU