Advanced Trauma Life Support (ATLS)

Primary Survey

*Primary survey: Aim: To find and treat life-threatening condition (within 10 minutes)
Mnemonic : DRS ABCDE

DANGER – Assess danger of the surrounding

- Wear proper PPE (goggles, mask, glove and apron) Sign of
airway
obstructio
n
RESPONSE - Tap the shoulder and ask “ Are you ok,sir/madam/miss?” - Stridor
- Cyanosis

SHOUT FOR HELP/ASK TO PREPARE AIRWAY, BREATHING AND CIRCULATION

Airway: ETT, adjunct airway (OPA/NPA), laryngoscope, stylet etc
Breathing: Oxygen, SpO2
Circulation: Insert two large bore branulas and run 1 L of warm NS, send blood for investigation,
vital signs monitoring (blood pressure, heart rate)

AIRWAY & CERVICAL IMMOBILISATION

- Open airway & suction [remove foreign body, blood, secretion, check gag reflex]; no gag
reflex, insert OPA (use appropriate size to avoid blocking the airway)
*always make sure the cervical spine is protected
*open airway via jaw thrust, chin lift (no head tilt in trauma, prevent cervical spine injury)
*jaw thrust: hand at angle of mandible and lift the mandible forward
- Give O2 [ ~ 10-15L / min ] (can give high flow oxygen via ambu bag mask without positive
pressure ventilation)

*you may check for neck swelling, laceration, haematoma & JVP before any immobilization
device in place
- Protect cervical spine by immobilization [manual inline immobilization, apply cervical collar,
head immobilizer at spinal board]
*cervical collar measured from angle of mandible to base of neck

- Check SpO2
*if normal/acceptable range and airway patent: put HFMO2 LETHAL 6
*intubate if presence of inhalation injury or other airway compromise Airway obstruction
Tension pneumothorax
Open pneumothorax
Lethal 6 assessment: Massive haemothorax
1) Airway Obstruction Flail Chest
Cardiac tamponade

Prepared by Leow Zhe Eu Group 4 Year 5

2014/2015
BREATHING AND VENTILATION

INSPECT – Observe breathing, chest movement, Wounds, JVP, Tracheal tug

PALPATE - Tracheal deviation  tension pneumothorax

- Chest spring (anterior, lateral)  rib fracture
*Careful if visible chest wound/flail chest
- Crepitus  emphysema

PERCUSSION – Hyperresonance (pneumothorax) / Dull (haemothorax)

AUSCULTATION - Breath sound. Muffled heart sound in cardiac tamponade with distended
neck vein, hypotension.

Lethal 6 assessment:
Inspection
2) Open pneumothorax
3) Flail chest

Percussion/auscultation
4) Tension pneumothorax
5) Massive hemothorax

Auscultation
6) Cardiac tamponade

Tension pneumothorax Open pneumothorax Massive haemothorax

S : Tracheal deviation
: Reduce chest expansion
: Reduce air entry
: Hyperresonance
: Dyspnoea & tachypnea
: Hypotension
: Mediastinal shift
Mx: Needle thoracocentesis
immediately (temporary
measure)
*2nd ICS, mid-clavicular line
*Green needle and above
: Chest tube (definitive)
2014/2015
S: Bubbling at wound site
: Open wound >2/3 of
trachea size or 2 cm [N=
~3cm]
Mx: 3-sided occlusive
dressing
(temporary)
: Chest tube (definitive)
Prepared by Leow Zhe Eu Group 4 Year 5
S: : Reduce breath sound
: Unequal chest rise
: Dull percussion
Blood drained
: 300ml/h for 2 hours
: 200ml/h for 3 hours
: 600ml / 6 hours
: 600ml / 1 hour
: 1.5L one go
clamp chest tube if more 1L
for tamponade effect, prevent
further blood loss,
decompression acute
pulmonary oedema
*200-300ml  blunt
costophrenic angle in CXR
 Mx: Chest tube insertion
: Refer cardiothoracic

Flail chest Cardiac tamponade Extras

S: > 2 segmental # with > 2
ribs
*may injure lung parenchyma
Mx: Analgesia
(morphine/fentanyl
infusion)
*BP lowfentanyl
*NO NSAIDS > bleeding risk
: Oxygen
: Chest tube if indicated
S : Beck’s triad Intra-pleural pressure
-Hypotension :Inspiration = ~ -8 mmHg
-Elevated JVP :Expiration = ~ -5 mmHg
-Muffled heart sound
Mx: Pericardiocentesis
(ultrasound-guided vs blind)
*withdraw about 50-80ml
A: Left lateral subxiphoid
*gray needle and above or
angiocath
: Aim 45o to tip of left
shoulder
: Advance with continual
aspiration
: if ECG shows ST
changes/artifact,
pull back as needle is
touching myocardium

Pathophysiology
1) Tension pneumothorax
- T.P.  Compress or distort large vessels in the thorax  Decrease Cardiac output 
Hypotension

2) Cardiac tamponade
- Right ventricle affect first due to low pressure system
- Pericardial fluid accumulates and impedes RV  Decrease venous return 
Decrease preloadDecrease CO

CIRCULATION AND HAEMORRHAGE CONTROL

Blood loss
- Insert 2 large bore IV branula and run 1 L of warm NS
# UL  1-2 L
- Check BP and HR # LL  2-3 L
- Blood for investigation # Hip  3-4 L
- Look for source of bleeding – Scalp (check using hand swipe) # pelvic drain all
- Facial fracture blood
- Neck swelling, haematoma, laceration
- Chest (done in breathing)
Prepared by Leow Zhe Eu Group 4 Year 5
2014/2015
 - Abdomen (distended/tender)FASTif massive
intraabdominal bleeding, get GXM 4 pint PC, DIVC regime,
refer surgery
- Genitalia (begin with pelvic spring, blood in external meatus,
perineum)
- Upper limbs Check for #, open bleeding, feel for pulse
- Lower limbs volume and hand swipe for posterior part,
(also check posterior part of trunk during
log roll)
*scalp bleed a lot due to presence of vessels and loose tissue/no tamponade effect
hypovolemic shock  Mx: Hemostatic Suture

- STOP bleeding – Compression [ technique: spiral or figure of 8 ]

- Suture if at scalp
- Torniquet if amputated limb/unsalvageable or 30mins for severe bleed
(* Cx: Damage blood vessels; limb ischaemia, Rhabdomyolysis  Renal
failure)

Priapism: spinal injury  vessels can’t vasoconstrict (symphatetic

disruption)  pooling of blood  priapism
Destot sign: Scrotal/perineal haematoma indicating pelvic #

DISABILITY AND NEUROLOGICAL

- GCS (done in primary survey according to ATLS 7th Edition) GCS≤ 8, prepare for intubation for
cerebral protection during 2 survey if no airway/ventilation problem)
- Pupil
*Constricted: bleeding at pons causing irritation  affect craniosacral outflow (parasympathetic)
 at pons CN III  constriction
*Fixed, dilated: brain death
Bleeding  no blood supply to pons  pons dead  no inhibition from parasympathetic
outflow  Increase in sympathetic activation (thoracolumbar outflow)  fixed, dilated

EXPOSURE AND ENVIRONMENT

- Look and treat for injury
- Log-roll to check posterior – Head/scalp
- Spine (tenderness, stepping sign)
- Laceration wound/ open pneumothorax at back
- Bleeding/ hematoma (may suggest retroperitoneal bleed)
- Muscle tear
- Do Per-rectal – Anal tone, High riding prostate, bleeding
Decrease anal tone  spinal cord injury  loss of anal sphincter  lumbosacral
injury
Prepared
If lax, proceed with bulbocavernous reflex by Leow
[tugging on anZhe Eu Group
indwelling 4 Year 5
Foley
2014/2015
catheter ]
- Maintain temperature – Blanket, give warmer to prevent hypothermia → prevent coagulopathy

ADJUNCT (can be done at any time during primary survey) 2+2+2+2

2 Tubes : Ryle’s tube (via mouth, do not insert via nose in suspected skull/facial bone #)
: CBD (do not insert in suspected urethral injury → refer Uro, may need SPC)

2 Imaging : Chest
: Pelvic
: *Cervical if suspected (AP, lateral (swimmer’s view)

2 Investigations : ECG
: FAST (Focused Assessment with Sonography of Trauma)

2 Drugs : Anti-tetanus toxoid (2 drugs not included in primary survey but still important)
: Analgesia

LETHAL TRIAD OF TRAUMA

ACIDOSIS – cause decrease myocardial contractility

- Hypoxia/tissue hypoperfusion is the No. 1 cause of acidosis

HYPOTHERMIA - Disrupt cellular metabolism (<36.2ºC), causing coagulopathy

- usually iatrogenic (cold ER, saline)

COAGULOPATHY - Transfuse blood/packed cell if massive bleeding

- DIVC Regime
: 4 Fresh frozen plasma (all coagulation factors)
: 4 platelet concentrates (some center only give if platelet <50)
: 6 cryoprecipitates (contain labile factors eg F 5,8,13)
-give IV Tranexamic acid 1g if no contraindication

Prepared by Leow Zhe Eu Group 4 Year 5

2014/2015
 Secondary Survey: Examine from head to toe

also look for HIDDEN 6 (PATMET)

PULMONARY CONTUSION

Mechanism Blunt trauma direct impact or # ribs(flail chest) haemorrhage into

lung parenchyma  HYPOXEMIA ( worsen over 24-48 hours )
Signs - Haemoptysis
- Blood in ET tube
Investigations - Chest Xray  findings delayed (can take up to 5 hours post injury)
- Contrast-enhanced CT scan
Management Mild : Oxygen
: Analgesia
: Aggressive pulmonary toilet
Severe : Mechanical ventilation
: Prevent fluid overload  pulmonary edema/ARDS

AORTIC DISRUPTION

Mechanism - Automobile collision

- Fall from great height
Signs - BP discrepancy between left and right arm/ UL & LL
- Widened pulse pressure
- Chest wall contusion
Investigations - Erect Chest X-ray – widened mediastinum
Management - Immediate open operative intervention
- Conservation(for physiologically unstable patient eg trauma elsewhere)
- Control systolic pressure > 100 mmHg

TRACHEOBRONCHIAL DISRUPTION

Mechanism Severe subcutaneous emphysema with respiratory compromise

Signs - Large air leak at chest tube
- Collapse lung fail to re-expand
Investigations Diagnostic bronchoscopy
Management Intubation of unaffected bronchus  operative repair

Prepared by Leow Zhe Eu Group 4 Year 5

2014/2015
MYOCARDIAL CONTUSION

Mechanism Blunt cardiac injury

Signs - Chest pain
- Palpitation
- Hypotension/ hypoxia
Investigations - 12-lead ECG – to monitor for 24 hrs for dysrhythmias
- ECHO
- Cardiac markers
Management Haemodynamic stabilisations

ESOPHAGEAL TRAUMA

Mechanism Penetrating injuries

Signs - Odynophagia
- Subcutaneous/mediastinal emphysema
- Pleural effusion
- Retro-esophageal air
- Unexplained fever in 24 hours
Investigations Esophagram in decubitus position + esophagoscopy
Management Operative

TRAUMATIC DIAPHRAGMATIC RUPTURE

Mechanism - Stab wound below nipple line

- Blunt diaphragm rupture – often miss due to associated injuries
*normal expiration diaphragm rise up to 5th ICS
Signs - Difficulty in breathing
- Tracheal deviation
- Asymmetrical chest expansion
- Absence of breath sound dt lung displacement
- Bowel sound during auscultation over chest
Investigations - CXR after NG tube insertion
- CT scan
Management Operative repair

CREDITS
I would like to express our gratitude and appreciation to Dr Ariff Arithra and Dr Junainah
Nor for their guidance and teachings throughout resuscitation week for Year 5 2014/2015.
Special thanks to Tan Chung Yung from Group 5 for his assistance in preparing these
notes. Thanks to all who had assisted directly and indirectly.
Prepared by Leow Zhe Eu Group 4 Year 5
2014/2015
 Prepared by Leow Zhe Eu Group 4 Year 5
2014/2015