TRAUMA

ATLS TRIAGE

Dr. Murali. U. M.S; M.B.A

 Learning Outcomes
• Trauma is the commonest cause of death in the Trauma
• Describe the principles & concepts of triage in
management of injured patient based on the
mechanisms of injury

• List the types & phases of triage

• Discuss the principles of primary & secondary surveys

in the assessment & management of trauma
 Introduction
• In all regions of the world, adults over the age of 70
years,particularly females, have significantly higher
fall-related mortality rates than younger people.

• However, children account for the largest morbidity –

almost 50% of the total number of disability adjusted
life-years (DALYs) lost globally to falls occur in children
under 15 years of age. .
 Introduction

• With ever increasing population growth and increased life

expectancy, the injury mortality and morbidity statistics are
likely to be skewed towards the two ends of the age spectrum,
making the pediatric and the elderly very important with
respect to global health care and economics.
 Trauma - Types
• In essence, trauma can be divided into two basic
types:
• Serious and life-threatening injury
• Significant trauma requiring treatment but not
immediately life threatening.
• While it is acknowledged that the two can and often
do overlap.
 InTrauma - Types
* Multiple casualties - Here, the number and severity of injuries
do not exceed the ability of the facility to render care. Priority
is given to the life-threatening injuries followed by those with
polytrauma.

* Mass casualties - The number and severity of the injuries

exceed the capability and facilities available to the staff. In this
situation, those with the greatest chance of survival and the least
expenditure of time, equipment and supplies are prioritised.
 Protocol

• The Advanced Trauma Life Support (ATLS) system was

therefore created initially in the USA and rapidly
taken up globally.
• At present, over 40 countries worldwide are actively
providing the ATLS course to their physicians.
 Mechanism of Trauma
• Blunt Trauma – Direct or indirect blunt injury can occur. Seat belt
reduces the blunt injury in vehicles.
• Penetrating injury – severity depends on the extent of deeper injury.
• Blast injury.
• Crush injury – earthquake, industrial accidents, and train accidents –
causes crush syndrome, compartment syndrome.
• Burn injury.
• Injury in alcohol patients.
 Concepts - Trauma Management
• Concept of “ golden hour “ to treat the trauma patient is important.
• Multidisciplinary approach
• Planning, setting up, organizing, team work.
• Assess respiratory system; circulation; breathing areas – as priority.
• Assess also whether patient is haemodynamically stable or unstable.
• Arrange fluids, blood, catheters, ventilator etc.
• Further definitive therapy depending on severity and site of injury.
TRIAGE
 WHAT IS TRIAGE?
WHY DO WE DO IT?
 PRINCIPLE GOAL OF TRIAGE IS:
TO DETERMINE , WHO SHOULD
BE SEEN FIRST!!!!
 A second major goal

• Not just sort but also stream

• To get the right patients to the right resources
in the right place , and at the right time….
 Definition
a Process of prioritizing patients based on the severity of
their condition.
OR
A medical classification process of priority of emergency
care of simultaneous multiple patients in function of rear
available care resources.
ORIGIN
Term comes from the
French verb
‘trier’,
Means to separate /sort / shift or select.
 In Triage - Phases
• Triage is an important concept in modern health-care
systems & three essential phases have developed:
* pre-hospital triage – in order to despatch
ambulance and prehospital care resources
* at the scene of trauma
* on arrival at the receiving hospital
TRAUMA LIFE SUPPORT

ADVANCE TRAUMA LIFE SUPPORT

Objective

• Identify the correct sequence of priorities for assessment of a

multiple injured pt.

• Apply the principles outlined in primary and secondary

evaluation surveys of ATLS.
ADVANCE

• Apply guidelines and techniques in the initial resuscitative and

definitive care phases of treatment.
 ADVANCE TRAUMA LIFE SUPPORT
TRAUMA LIFE SUPPORT

Initial assessment
Primary survey
Secondary survey
ADVANCE
TRAUMA LIFE SUPPORT ATLS
• Initial assessment of the casualty
• Time interval Initial assessment
• Then proceed to the basic ATLS
procedure i.e. (in short) ABCDE
Primary survey
Secondary survey
ADVANCE
 ATLS
Initial assessment
•Confirmation AIRWAY
TRAUMA LIFE SUPPORT

• If patient Primary survey

talks normally, Breathing
airway not Secondary survey
compromised Circulation f
• Hoarse voice Disability
or audible
breathing, Exposure
suspicious
Assess the patient for airway obstruction (coma)
Agitation--------------- hypoxia
ADVANCE

Cyanosis---------------- hypoxemia, secondary to inadequate oxygenation

Hoarseness,----------- suspected laryngeal fracture
s/c emphysema
& palpable
fracture
 ATLS
Initial assessment
• Established AIRWAY
TRAUMA LIFE SUPPORT

maintenance of Primary survey

airway through Breathing
either of the two Secondary survey
---Head tilt-chin lift Circulation f
---Jaw thrust Disability
JAW THRUST
Exposure
JAW THRUST
•Rescuer fingers are placed behind the
posterior border of the ramus of the
ADVANCE

mandible
•Displace the mandible forward,
dislocating it while tilting the head
backward
•Retract the lower lip with the thump
 ATLS
Initial assessment
• If debris ( broken AIRWAY
TRAUMA LIFE SUPPORT

tooth, dentures) is Primary survey

present, remove it Breathing
by—Finger sweep Secondary survey
technique or Circulation f
--Yankauer suction or Disability
-- Magill’s forceps (for
large object) Exposure

• If ---no foreign body is visible, endotracheal tube should be used to secure the
established airway
ADVANCE

--- If the foreign body cannot be removed quickly or the vocal cords cannot be
adequately visualized or endotracheal intubation is not possible, then
cricothyroidotomy is indicated
•
TRAUMA LIFE SUPPORT ATLS

Yankauer
suction
ADVANCE

Magill’s
CRICOTHYROIDOTOMY forceps
 ATLS
Initial assessment
• In patient AIRWAY
TRAUMA LIFE SUPPORT

sustaining Primary survey

significant blunt Breathing
injury, should be Secondary survey
assume to have Circulation f
cervical spine injury, Disability
until prove other-
wise Exposure
•--- such pt. should
have cervical spine
immobilized with semi rigid cervical
ADVANCE

collar and bilateral sand bags or block

joined with tapes or straps across the
forehead
TRAUMA LIFE SUPPORT
ADVANCE ATLS

semi rigid cervical collar

block joined with tapes or straps across the forehead

 ATLS
Initial assessment
•Conditions that Airway
TRAUMA LIFE SUPPORT

acutely compromised Primary survey

breathing are-- BREATHING
• Tension Secondary survey
pneumothorax Circulation f
• Massive Disability
hemothorax
• Flail thorax Exposure
accompanied by
pulmonary contusion
• open pneumothorax compromise breathing
ADVANCE

•Such condition can be diagnosed with physical examination & should be treated
immediately
•It can be treated with endotracheal intubation, mechanical ventilation, needle
thoracocentesis, or tube thoracostomy.
TRAUMA LIFE SUPPORT
ADVANCE ATLS

NEEDLE THORACOCENTESIS TUBE THORACOSTOMY

 ATLS
Initial assessment
•Circulatory problems Airway
TRAUMA LIFE SUPPORT

in trauma patients are Primary survey

usually caused by Breathing
hemorrhage Secondary survey
•First action is to stop CIRCULATION
bleeding Disability
Environment &
•For --- exposure
Intra oral bleeding-----------------bite a cotton swap
Tongue laceration------------------deep suture across the laceration
ADVANCE

Bleeding from fracture-----------manually reducing and brittle wiring of the fracture fragments
mandible end
Mobile maxilla---------------------rubber mouth gags
Soft tissues of head & neck----direct pressure on the bleeding site
Torrential bleeding from--------epistat tube with anterior and posterior balloons
the nasopharynx region
 ATLS
• Assessment of the
Initial assessment
Airway
TRAUMA LIFE SUPPORT

neurological status. Primary survey

The Glasgow coma Breathing
score (GCS) Secondary survey
•Patients who open Circulation f
their eyes
spontaneously, obey DISABILITY
commands, and are Environment &
normally oriented score exposure
a total of 15 points
• worst score is 3 points
ADVANCE

• GCS can be caused by a focal brain injury

• Optimal oxygenation and circulation are important to prevent secondary injury to
the brain
• Impaired consciousness can be caused by hypoxia or hypotension for which ABC
stabilization is essential
 ATLS
Initial assessment
• Represent Airway
TRAUMA LIFE SUPPORT

Hypothermia Primary survey

Burns, and Breathing
Possible exposure Secondary survey
to chemical and CIRCULATION f
radioactive Disability
substance
 Should be EXPOSURE
evaluated and
treated
ADVANCE
 ATLS
• Under this the pt. is examined from head to toe
Initial assessment
TRAUMA LIFE SUPPORT

• Appropriate additional radiographs of the

thoracic and lumbar spine and the extremities
Primary survey
are performed when indicated.
• CT scans, when indicate
Secondary survey
•Secondary survey mnemonics
•Head/skull Has
•Maxillofacial My
•Cervical Spine Critical
•Chest Care
•Abdomen Assessed
•Pelvis Patient's
ADVANCE

•Perineum Priorities
•Orifices Or
•Neurological Next
•Musculoskeletal Management
•Diagnostic tests/ Decision?
Definitive care
 RE-EVALUATION
TRAUMA LIFE SUPPORT

IF, DURING THE SECONDARY SURVEY, THE PATIENT'S CONDITION

DETERIORATES, THE PRIMARY SURVEY SHOULD BE REPEATED
BEGINNING WITH “A”.
ADVANCE
 ADVANCE TRAUMA LIFE SUPPORT
TRAUMA LIFE SUPPORT

Analgesia
Documentation & Legal
Definitive care
ADVANCE
Triage at an accident scene
is performed by a paramedic
or an emergency physician,
using the four-level scale of

Cannot wait
Has to wait
Can wait
No chance of survival
Lost
 category meaning consequences examples

immediate treatment, transport as soon as arterial lesions, internal haemorrhage, major

T1 (I) acute danger for life
possible amputations

constant observation and rapid treatment, minor amputations, flesh wounds, fractures
T2 (II) severe injury
transport as soon as practical and dislocations

treatment when practical, transport and/or

T3 (III) minor injury or no injury minor lacerations, sprains, abrasions
discharge when possible

observation and if possible administration of severe injuries, uncompensated blood loss,

T4 (IV) no or small chance of survival
analgesics negative neurological assessment

collection and guarding of bodies, dead on arrival, downgraded from T1-4, no

T5 (V) deceased
identification when possible spontaneous breathing after clearing of airway
 References
• Bailey & Love’s - Short Practice of Surgery
26th edition.

• Internet websites.