J.

Adv Dental Research REVIEW ARTICLE

All Right Res

Journal of Advanced Dental Research Vol II : Issue I: January, 2011 www.ispcd.org

Emergency Trauma Care: ATLS

Kiran DN * Anupama Kiran **

*M.D.S, Associate Professor, Department of Oral & Maxillofacial Surgery **M.D.S, Asst
Professor, Department of Conservative & Endodontics, M.M .College of Dental Sciences and
Research, Ambala, India.
Email: kdn30673@gmail.com

Abstract:
Advanced trauma life support orients doctors
to the initial assessment and to provide emergency
trauma care for the injured patient. It provides a safe,
reliable method and also basic knowledge necessary to,
1. Assess the patients condition rapidly and accurately.
2. Resuscitate and stabilize according to priority. 3.
Arrange appropriately for the patients inter hospital
transfer (what, who, when and how). 5. Assure that
optimum care is provided. The purpose of advanced
trauma life support is to decrease morbidity and
mortality, which is expected to be achieved by fast,
systematic, and effective assessment and treatment of
the injured patient.

Key words: Trauma, ATLS, Life support, Emergency
care, Trauma care

Introduction
The word Trauma comes from a Greek word
meaning a wound, which implies, any serious injury to
the body, often resulting from violence or an accident, or an
event that causes great distress. (1) Trauma is a diverse
disease in which, time, critical decisions and skills affect
patient outcome. For every one patient who dies, there are
three survivors with serious disabilities. (2, 3) The first
peak of deaths occurs within minutes of the event from
non-survivable injuries, even with the most advanced
medical resources immediately to hand. The second peak
may account for some 30% of deaths, in the first few hours
after injury. Death is most often due to hypoxia and
hypovolaemic shock. (4) This group stands to benefit the
most from excellence in trauma care. The third peak, of up
to 20% of trauma deaths, occurs late after the injury, from
sepsis, multi-organ failure, and other complications.(5)












In developed countries there is a decrease in
trauma mortality in recent decades due to a combination of
injury prevention endeavours and improvement in trauma
care.(6) The purpose of adequate trauma care is to decrease
this morbidity and mortality, which is expected to be
achieved by fast, systematic, and effective assessment and
treatment of the injured patient.
The maxillofacial skeleton is vulnerable to injury,
and are commonly seen after assault, road traffic accidents,
falls, and sporting injuries. These injuries require
immediate first-aid treatment such as the establishment of a
free airway, control of haemorrhage, treatment of shock,
support of the facial structures and positioning of the
patient face-downwards are the essential lifesaving
measures. Advanced Trauma Life Support (ATLS) includes
the initial assessment and management of trauma patients
that aims to optimise initial care and reduce mortality and
morbidity. The ATLS concept is also used in the pre-
hospital phase of trauma patient care and has been adopted
for non-trauma medical emergencies and implemented in
resuscitation protocols around the world.

History of ATLS
Importance to the ATLS was established after a
tragic plane crash in1976, an airplane with an orthopedic
surgeon, J Styner in Nebraska. His wife and children
crashed in a corn field, the wife died. The surgeon and
three of his four children were seriously injured.
Unfortunately for Dr Styner he found that the subsequent
care received in the local hospital was inferior to what he
was able to provide for 10 hours at the scene of the
accident. And he decided to develop a system to improve
the care for trauma victims, and thus, ATLS was born. (7)
ATLS originally represented a state of the art
training course on the care of major trauma.(8) A group of
local surgeons and physicians, the Lincoln Medical
Education Foundation, together with the University of
Nebraska founded local courses aiming at teaching
advanced trauma life support skills.(9) After the first
ATLS course in 1978, it was taken up by the American
College of Surgeons Committee on Trauma (ACS COT) in
the next year and rapidly spread throughout the North,
Central, and South America. Today ATLS is taught in over
42 countries and around half a million clinicians have
completed the course. The concept has matured, has been
Serial Listing: Print ISSN(2229-4112)
Online-ISSN (2229-4120)
Bibliographic Listing: Index Copernicus.
EBSCO Publishing Database.
Proquest.
J-Gate.
14

Journal of Advanced Dental Research Vol II : Issue I: January, 2011 www.ispcd.org

disseminated around the world and has become the
standard of emergency care in trauma patients. (2)
Originally, ATLS was designed for emergency
situations where only one doctor and one nurse are present.
Nowadays, ATLS is also accepted as the standard of care
for the first (golden) hour in level-1 trauma centres. The
priorities of emergency trauma care according to the ATLS
principles are independent of the number of people caring
for the patient. (10)
Apart from the severity of injury, probably the
single most important factor determining the outcome of a
trauma patient is the time interval from the moment the
injuries are received to the provision of definitive care.
Definitive care for the trauma patient implies achieving a
clear airway and effective ventilation, haemorrhage control
and restoration of an adequate blood volume. In managing
emergency trauma, treat the greatest threat to life first. A
detailed history is not necessary to begin evaluation and
treatment. Indicated treatment must be applied even when a
definitive diagnosis is not yet established.
Maxillofacial injuries are commonly seen after
assault, road traffic accidents, falls, and sporting injuries in
a ratio mandibular: zygoma: maxillary of 6:2:1.(11) As
with all traumas, basic advanced trauma life support
principles should be applied to the initial assessment of the
casualty. This must include a primary and secondary
survey. It is only after the secondary survey that definitive
care begins.

Primary survey;
In the primary survey, the mnemonic ABCDE is used to
remember the order of assessment with the purpose to treat
first that kills first,
A- Airway and Cervical spine stabilization
B- Breathing
C- Circulation
D- Disability and
E- Environment and Exposure(10)

Airway obstruction kills quicker than difficulty of
breathing caused by a pneumothorax, and a patient dies
faster from bleeding from a splenic laceration then from a
subdural hematoma.
Injuries are diagnosed and treated according to the ABCDE
sequence.

A: Airway
A recent retrospective study of pre-hospital trauma
deaths in North Staffordshire reported that, on the basis of
post-mortem evidence, airway obstruction had been present
in two-thirds of those patients in whom death was judged
not to have been inevitable. (12)
The main cause of death in severe facial injury is
airway obstruction. This may be because of the tongue
falling back and obstructing the hypopharynx in an
unconscious patient or may be secondary to uncontrolled
haemorrhage drowning the airway. The airway is not
compromised when the patient talks normally. A hoarse
voice or audible breathing is suspicious. Patients in a coma
are not capable of keeping their airway patent.
Assess the patient for airway obstruction:
Agitation suggests hypoxia, obtundation suggests
hypercarbia, and cyanosis suggests hypoxemia secondary
to inadequate oxygenation. Look for evidence of injury to
the larynx and trachea, including crepitus of the soft
tissues. Clinically the patient may have noisy breathing,
snoring, gurgling, or croaking. Hoarseness, subcutaneous
emphysema, and a palpable fracture are suggestive
laryngeal fracture. (13)
Establish and maintenance of the airway:
Good suction is essential. The chin should be pulled
forward either through chin lift or jaw thrust procedures.
The jaw thrust and chin lift relieves soft tissue obstruction
by pulling the tongue, anterior neck tissues, and epiglottis
forward. Remove the debris (broken teeth, dentures) from
the mouth with finger sweep technique or Yankauer
suction. A Magills forceps may also be used for larger
objects. (14)
Airway compromise is uncommon in the
conscious patient; however, it may occur in an unconscious
patient, particularly those who have sustained bilateral
parasymphyseal fracture. These patients may require
forward repositioning of the mandible and tongue to
prevent airway obstruction. A towel clip is useful to pull
the tongue forward.
If no foreign body is visible an endotracheal tube
should be inserted. Endotracheal intubation with a cuffed
tube will secure the airway. If the foreign body cannot be
removed quickly or the vocal cords cannot be adequately
visualised or endotracheal intubation is not possible it
should be left and a surgical airway performed. A
cricothyroidotomy is the preferred way to establish a
surgical airway in the emergency. A recent study of 50
cricothyoidotomy attempts in trauma patients by
paramedics in Indiana concluded that the procedure was
successful in 47(97%). A 5 or 6 mm tube cuffed
tracheostomy tube should be inserted through the
cricothyroidotomy incision. A needle cricothyroidotomy is
advised in children less than 12 years of age as there is a
high risk of damaging the cricoid cartilage. As the cricoid
cartilage is the only circumferential supporting structure
that maintains patency of the upper trachea.
Every patient sustaining significant blunt trauma,
particularly above the clavicles, should be assumed to have
a cervical spine injury until proved other-wise. These
patients should have the cervical spine immobilized with a
semi-rigid cervical collar and bilateral sandbags or block
joined with tape or straps across the forehead. As long as
the cervical spine is not cleared by physical examination,
with or without diagnostic imaging, the spine should
remain stabilized.

B: Breathing
Breathing is the second to be evaluated in trauma
care. Tension pneumothorax, massive hemothorax, flail
thorax accompanied by pulmonary contusion, and an open
pneumothorax compromise breathing acutely and can be
diagnosed with physical examination alone and should be
treated immediately. Most clinical problems in B can be
treated with relatively simple measures as endotracheal
15

Journal of Advanced Dental Research Vol II : Issue I: January, 2011 www.ispcd.org

intubation, mechanical ventilation, needle thoracocentesis,
or tube thoracostomy.
Injuries, like a simple pneumothorax or
hemothorax, rib fractures, and pulmonary contusion, are
often more difficult to appreciate with physical
examination. Because these conditions have less effect on
the clinical condition of the patient, they can be identified
in the secondary survey.

C: Circulation
Circulatory problems in trauma patients are
usually caused by haemorrhage. The first action should be
to stop the bleeding. If there is no evidence of damage to
the major vessels of the neck or middle third of facial
fractures blood loss is usually insufficient to cause
hypovolumic shock problems, but may cause problems
with establishing and maintaining an airway. Bleeding from
the soft tissues of the head and neck may be controlled with
direct pressure on the bleeding site.
If conscious, ask the patient to sit upright as this
allows blood and secretions to drain out of the mouth.
Intra oral bleeding may be controlled by getting the patient
to bite on a swab. Bleeding from a tongue laceration can be
torrential, in such cases deep sutures across the laceration
are advised to achieve haemostasis, as pressure alone will
not stop the bleeding.
Bleeding from fractured mandible ends may be
arrested by manually reducing and brittle wiring of the
fracture fragments. In a patient with a mobile maxilla, the
use of rubber mouth gags is advisable. The mouth gags,
which act as a splint compressing the maxilla between the
skull base and the mandible. In cases where there is also a
mobile mandible fracture a cervical collar may be used as a
temporary form of mandibular splint.
Torrential bleeding from the region of the
nasopharynx can be difficult to control. An epistat tube
with anterior and posterior balloons that can be inflated to
tamponade any bleeding can be very useful in these
situations. Foley catheters may also be used. (14)

D: Disability
This includes assessment of the neurological status. The
Glasgow coma score (GCS) is used to evaluate the severity
of head injury. This score is arrived at by scoring eye
opening, best motor response, and best verbal response.
Patients who open their eyes spontaneously, obey
commands, and are normally oriented score a total of 15
points. The worst score is 3 points. A decreased GCS can
be caused by a focal brain injury, such as an epidural
hematoma, a subdural hematoma, or a cerebral contusion,
and by diffuse brain injuries ranging from a mild contusion
to diffuse axonal injury. To prevent secondary injury to the
brain, optimal oxygenation and circulation are important.
Also, impaired consciousness can be caused or aggravated
by hypoxia or hypotension for which ABC stabilization is
essential.

E: Environment and exposure
Environment and exposure represent hypothermia,
burns, and possible exposure to chemical and radioactive
substances and should be evaluated and treated. At the end
of the primary survey, before continuing with the
secondary survey, the ABCDEs should be re- evaluated and
confirmed.

Secondary survey:
An injury may be missed or its significance may
not be recognised in the trauma resuscitation scenario,
particularly in the unconscious or unstable patient. The
secondary survey starts only after the ABCDE primary
survey is complete and the patient responds to
resuscitation.
The secondary survey can be haphazard, poorly
recorded, and, in the aftermath of a more dramatic initial
resuscitation, may be less thorough. There can be a
substantial delay between the primary and secondary
survey if immediate treatment or surgery is indicated.
During the secondary survey, the patient is
examined from head to toe, and appropriate additional
radiographs of the thoracic and lumbar spine and the
extremities are performed when indicated. CT scans, when
indicated, are also done in the secondary survey.

Table 1 Secondary survey mnemonic (15)

Mnemonic Secondary survey
Has Head/skull
My Maxillofacial
Critical Cervical Spine
Care Chest
Assessed Abdomen
Patients Pelvis
Priorities Perineum
Or Orifices (PR/PV)*
Next Neurological
Management Musculoskeletal
Decision? Diagnostic tests/ definitive care

*Tubes and fingers in every orifice. Include AMPLE
history.

If, during the secondary survey, the patients condition
deteriorates, the primary survey should be repeated
beginning with A.

Conclusion:

Trauma continues to be the most common cause of
death in first four decades of life. In that, Maxillo-facial
injuries require immediate first-aid for the establishment of
a free airway, control of hemorrhage, and treatment of
shock. The facial structures must always be supported and
the patient kept in a face-downward position. From its
tragic origin ATLS has become an icon in medical
education. There is no doubt that ATLS is at a crossroads in
its development. To do nothing runs the risk of a schism
developing. Alternatively it could adapt to become a truly
international course. Either option will require trauma
16

Journal of Advanced Dental Research Vol II : Issue I: January, 2011 www.ispcd.org

enthusiasts wishing to develop a more effective course for
patients. ATLS is a systematic approach for the assessment
of trauma patients. In multidisciplinary trauma care, it is
beneficial and, maybe, even mandatory for effective
communication that all members of the trauma team, speak
the same ATLS language, so that the mortality will be
reduced.

References:

1. Rowe Norman Lester. History of maxillofacial trauma.
Annals of Royal College of surgery. 1971; 49: 329
349.
2. American College of Surgeons Committee on Trauma
Advanced trauma life support program for doctors, 7th
edn. American College of Surgeons, 2004.
3. World Health Organization (2007) Detailed data files
of WHO mortalitydatabase, 2003. WHO, the
Netherlands.
http://www.who.int/whosis/database/mort/table1.cfm.
Cited May 10, 2007
4. Alexander RH, Proctor HJ, eds. Committee on trauma:
resource document 1: trauma prevention. In Advanced
trauma life support. American College of Surgeons,
1993.
5. Jon Clasper. David Rew. Trauma life support in
conflict. British Medical Journal. 2003;327:11789
6. Roudasri Bahman S., Nathens Avery B. Emergency
Medical Service (EMS) systems in developed and
developing countries Injury, Int. J. Care Injured. 2007;
38: 1001 1013.
7. P Driscoll, J Wardrope. ATLS: past, present, and
future - Emerg Med J 2005; 22:2-3
8. Nolan JP. Advanced trauma life support in the United
Kingdom: time to move on. Emerg Med J. 2005; 22:3
4.
9. M R Carmont. The Advanced Trauma Life Support
course: a history of its development and review of
related literature. Postgrad Med J 2005; 81:8791.
10. Digna R. Kool & Johan G. Blickman Advanced
Trauma Life Support. ABCDE from a radiological
point of view Emerg Radiol (2007) 14:135141
11. Jacobson LE, Gomez GA, Sobieray RJ, Rodman GH,
Soltkin KC, Misinski ME, Surgical
crichothyroidotomy in trauma patient: analysis of its
use by paramedics in the field. Journal of Trauma
1996; 41: 15-20.
12. Haug RH, Prather J, Indresano AT. An epidemiologic
survey of facial fractures and concomitant injuries. J
Oral Maxillofac Surg 1990; 48:926.
13. Hussain LM. Redmond AD. Are pre-hospital deaths
from accidental injury preventable? British Medical
Journal 1994; 308: 1077-1080.
14. P O Ceallaigh, K Ekanaykaee, C J Beirne, D W
Patton Diagnosis and management of common
maxillofacial injuries in the emergency department.
Part 1: advanced trauma life support. Emerg Med J
2006; 23:796797.
15. S C A Hughes Letters. Emerg Med J 2006; 23:661
663.






Source of Support: Nil
Conflict of Interest: Not Declared

Received: November 2010
Accepted: December 2010