ATLS

CO-ASS MARISSA MAHMUD

CHAPTER 1
INITIAL ASSESMENT DAN MANAJEMEN
 Initial assessment of trauma patient
Preparation

Triage

Primary survey (ABCDEs)

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

 Standard
Precautions
Cap
Gown

Mask
Shoe
cover
s
Check safety before start
Goggl primary survey
es
TRIAGE
 A method of quickly identifying victims who have
immediately life- threatening injuries AND who have
the best chance of surviving.

 Red - Immediate (critical)

 Yellow - Delayed (urgent)
 Green - Minor (ambulatory)
 White – those who do not require
treatment
 Black - Deceased

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 Multiple casualties
 No. of patients and the severity of the injuries
do not exceed the ability of the facility to
provide care.

 MASS CASUALTIES
The no. of patients and the severity of their
injuries exceed the ability of the facility to
provide care.

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 Primary
Survey
Airway with c-spine protection

Breathing / ventilation / oxygenation

Circulation with hemorrhage control

Disability

Expose / Environment / body temp.

 SPECIAL GROUPS
PEDIATRIC
 Same Priorities and Approach
 Need for different amounts of
fluids and medications
 Need for equipment of
varying sizes
PREGNANT WOMEN
 Same Priorities and approach
 Anatomic and physiologic s
change
 Potential two patients not one
 “TREAT THE MOTHER TO
TREAT THE FETUS”
 ELDERLY
 Diminished
physiologic reserve
 Comorbidities
– Heart disease, Diabetes, lung
disease
 Multiple medication use
 Increased risk of death for
any given injury compared to
younger patient
Contents
 Golden hour
 ABCDE
 Airway management
 Shock management
 AMPLE history

9
PLATINUM MINUTES

“THE PLATINUM TEN MINUTES”

10
 A Airwa
opened
y clea maintained
r
NASOPHARYNG
OROPHARYNG SUCTION

CLEARING INTUBATE

TRIPLE AIRWAY MANUVER FINGER SWAB ETT SURGICAL AIRWAY

IF EIGHT
INTUBAT
E
 Reasons for airway
obstruction
 Tongue fall
 aspiration of foreign bodies
 regurgitation of stomach contents
 facial, mandibular, tracheal and
laryngeal fractures
 retropharyngeal hematoma resulting
from cervical spine fractures
 Traumatic brain injury

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Sequence of air way
maneuvers
Chin lift&jaw trust

Finger sweep& suction

Airway adjuncts

Oropharyngeal/ orotrachial
tube

LMA

BV

M
14
ADVANCED AIRWAY
 SIZING

•OPAs too large or too small may obstruct the airway.

•NPAs sized incorrectly may enter the esophagus.
•Always check for spontaneous respirations after insertion of either
device.
 AIRWAY MAINTENANCE WITH CERVICAL
SPINE CONTROL
 Suspect cervical spine
injury in all patients unless
other vise proven

 High chance in high speed

impact, and in patients with
altered consciousness

 15% patients with

supraclavicular injuries and
5 % with head injury. 17
injuries to the larynx and
trachea
 neck swelling, dyspnea, voice alteration, or
frothy hemorrhage

 tenderness, and laryngeal or tracheal

crepitus

 Endotracheal intubation / surgical airway

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 Definitive Airway
 defined as an inflated cuffed tube in the trachea.

 Orotracheal
 Naso tracheal
Contra indicated - frontal sinus fractures, base of
skull fractures, and ant cranial fossa fractures

 surgical

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indications

Oral & Maxillofacial trauma – Fonseca Walker 39

STOP MAID
 S: Suction
 T: Tools for intubation (Larhyngoscope blade,
others device )
 O: Oxygen
 P: Positioning
 M: Monitors (electrocardiogram [ECG], O2,
CO2, blood pressure [BP])
 A: Asisstent ; airway Assessment ; Airway
devices .
 I: IV access
 D: Drugs 21
Surgical Airway
 Needle Cricothyroidotomy
 Insertion of a wide-bore needle (or IV
cannula) via the crico-thyroid membrane
into the airway
 Intermittent insufflation (1 second
on and 4 seconds off)
 Maximum 30-45 minutess

 Inadequate ventilation
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24
Surgical Cricothyroidotomy

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26
tracheostomy
 laryngotracheal trauma
 fractures of the thyroid or cricoid
cartilage or hyoid bone
 Prolonged ventilation
 upper airway obstruction
 Thyroid cartilage, cricoid cartilage and
tracheal rings are palpated
 skin incision should be marked while the
patient’s head is in a normal position
 Vertical/horizontal skin incision 27
28
BREATHING
 Assess breathing and
ventilation

 Ventilation is compromised not only by

airway obstruction but also altered
ventilatory mechanics or CNS depression.

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 life-threatening thoracic
injuries
 A: Airway obstruction
 T: Tension pneumothorax
 O: Open pneumothorax
 M: Massive hemothorax
 F: Flail chest
 C: Cardiac tamponade

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 PRIMARY (Initial Shock)
 SECONDARY (True Shock)

 HEMATOGENIC/HYPOVOLAEMIC/OLIGAM
I C SHOCK
 OBSTRUCTIVE SHOCK / TRAUMATIC
SHOCK
 NEUROGENIC SHOCK
 CARDIOGENIC SHOCK
 SEPTIC SHOCK

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CLINICAL FEATURES

General Clinical Features Of Shock

o Hypotension (Systolic BP<70mmHg)

o Tachycardia (>100/min)
o Cold , Clammy Skin
o Rapid,Shallow Respiration
o Drowsiness,Confusion,Irritability
o Oliguria (Urine Output<30ml/hour)
o Multi-Organ Failure

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STAGES IN SHOCK
3 STAGES
INITIAL SHOCK
PROGRESSIVE SHOCK
IRREVERSIBLE
SHOCK

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  inadequate tissue perfusion and oxygenation
and anaerobic glycolysis results in lactic acid
production

 coagulation factor and platelet dysfunction

combined with coagulation factor
consumption a profound coagulopathy

 Triad of
 Metabolic acidosis
 Hypothermia
 coagulopathy

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 stop hemorrhage
 minimize contamination
 restore near-normal physiology

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36
Management
 Peripheral cannulae – large bore
cannulae  rate of flow proportional to
4th power of radius
 venous cut-down, made 2 cm anterior
and superior to the medial malleolus into
the greater saphenous vein
 central line into the femoral or
subclavian vein

37
Type of fluid Effective plasma duration
volume
expansion/100ml

5% albumin 70 – 130 ml 16 hrs

25% albumin 400 – 500 ml 16 hrs

6% hetastarch 100 – 130 ml 24 hrs

10% pentastarch 150 ml 8 hrs

10% dextran 40 100 – 150 ml 6 hrs

6% dextran 70 80 ml 12 hrs

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Blood transfusion

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Blood transfusion

104
 D: DISABILITY
 Level of consciousness
– Best indicator of central perfusion &
deterioration of patient status
 Pupils
 GCS

 A: Alert
 V: responds to Vocal stimuli
 P: responds to Painful stimuli
 U: Unresponsive to all stimuli
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Jennett and Teasdale in the early 1974

revised in 1976- sixth point -

“withdrawal from painful stimulus

13-15  mild head injury

8-12 moderate
<8  severe

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AVPU/ACDU

 Alert
Confused
 Drowsy
 Unresponsiv
e

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 MAYO HEAD INJURY CLASSIFICATION SYSTEM
FOR TRAUMATIC BRAIN INJURY
 Category A moderate to severe (definite) TBI:
1.Death caused by this TBI
2.LOC of 30 minutes or longer
3. Post-traumatic anterograde amnesia of 24 hours or
longer
4. Worst GCS full score in the first 24 hours less than 13
5.One or more of the following present: EDH, SDH,
Contusion
 Category B
1.Loss of consciousness of momentary to less than 30
minutes
2.Post-traumatic anterograde amnesia of momentary to less
than 24 hours
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3. Depressed, basilar or linear skull fracture
45
 Revised Trauma Score
(RTS)
1981 by Champion et al.

RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR

range 0 to 7.8408 RTS < 4 – severe injury

116
 SECONDARY SURVEY
 complete and comprehensive head to- toe
evaluation
 history and circumstances leading to the
injury
 physical examination of the patient
 reassessment of all vital signs.

 Six potentially lethal injuries that should

be evaluated
 Pulmonary contusion
 aortic disruption
 tracheobronchial disruption 47
 esophageal disruption
 HISTORY
 A: Allergies
 M: Medications currently used
 P: Past illnesses and Pregnancy
 L: Last meal
 E: Events and Environment related to
the injury

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Physical examination
 Scalp
 Lacerations
 Contusions
 hematomas
 bone surface irregularities

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Eyes
 pupillary response - shape, equality, and light
reaction of the pupils
 eye injury - blunt or penetrating
 Direct injury to the optic nerve

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 Neck and Cervical Spine
 unstable cervical spine injury –
unless otherwise proven
 Cervical spine tenderness,
subcutaneous
emphysema
 laryngeal fracture

 Lateral and AP views -seven

cervical vertebrae and the first
thoracic vertebra (C1- C7/T1
junction)
126
Chest
 Pain, dyspnea, and hypoxia
 pneumothorax and
 large flail segments
 Contusions and hematomas occult
pulmonary or cardiac injury
 Distended neck veins  cardiac
tamponade or tension pneumothorax

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Abdomen
 Intra abdominal bleed should be
suspected if there are fractures of the
ribs that overlie the liver and the spleen
 Blunt/penetrating trauma
 Focused assessment with
sonography trauma - FAST

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Perineum, Rectum, and
Vagina
 contusions,hematomas, lacerations, and

urethral bleeding.

 Must before catheterization

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 Musculoskeletal
Assessment
Contusions, lacerations,
deformities
 Peripheral pulses
 Motor and sensory impairement

 Pelvic fractures are suggested by:

 ecchymosis over the iliac wings, pubis, vagina, or
scrotum.
 pain on palpation.
 mobility of the pelvis in response to gentle
anteroposterior pressure in the unconscious patient
 electrical shock–like pain radiating down the spine
or into the limbs nerve root compression
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