03 • 02 • 2023

Advanced Trauma Life

Support (ATLS)
1
Goals of trauma management
1. Identify and treat threat to life, limbs and then eyesight
2. Prevent worsening of existing injury and occurence of
new ones
3. Return patient to pre-injury level of functioning as
close as possible

Principles of trauma patient management

➔ Treat the greatest threat to life first
➔ Definitive diagnosis is not immediately important.
➔ Time matters (“golden hour” emphasizes urgency).
➔ Do no further harm.
➔ Assess, intervene, reassess
1. Assess basic 2. Assess anatomy
physiology of injuries

BP, RR, GCS

3. Look for evidence of high 4. Assess special

energy impact circumstances
Roles of
Falls > 6 meter in adult and 3m in Pregnancy, Bleeding
scene triage
● ●
children, MVA (ejection from seat, disorder, older age
death in same compartment)
 + Primary Survey
Reordered in trauma to address first life-threatening physiology and then to identify
and correct the anatomic injuries

Airway 1 A 2 Breathing
B
5 Ventilation &
Exposure / oxygenation
Environmental
control E

D 3 Circulation
Disability 4

Brief neurological
exam
 Airway
● Assess patency of airway and look for
obstruction, if present, manage with :
○ Head tilt - chin lift/ Jaw thrust
technique
○ Suctioning of foreign objects
○ Oropharyngeal/ Nasopharyngeal/
Laryngeal mask airway
○ Establish definitive airway ~ Surgery/
Intubation
● Common cause = tongue obstruction
 Breathing
● Ensure adequate ventilation and oxygenation
1. Immobilize head and neck and expose the
chest
2. Assess respiratory rate and depth of breathing
3. Inspect and palpate the chest for chest
movement, tracheal deviation, uses of
accessory muscle
4. Percuss and auscultate the chest
● If low, manage by monitoring the oxygen saturation
with pulse oximetry. Then:
1. Start oxygen therapy, ventilate with bag valve
mask if needed
2. Perform specific procedure (chest drain for
pneumothorax)
 *Haemorrhagic shock is the most common form of
Circulation shock in trauma

Assess for the following:

1. External haemorrhage
● direct manual pressure, tourniquet
2. Tissue perfusion
● CVS : Blood pressure, pulse
● Respiratory system - RR, Sp02
● Skin - color, temperature, CRT<2s
3. Gain vascular access
● 2 16 gauge IV catheters
4. Administer initial fluid - colloid or crystalloids
 Disability
Assess for disability by :
1.Performing a brief neurological examination
- GCS - level of consciousness
- Pupil symmetry & reaction
- Lateralizing signs
2.Ensure airway, breathing and circulation stable
to prevent secondary brain injury
*If there is increased intracranial pressure, consider
- head elevation
- mild hyperventilation to PaCO2 to 35
- mannitol
- neurosurgery consultation
 Exposure/ Environmental

1. Removes the clothes and examine thoroughly

2. Keep pt warm to prevent hypothermia (need to check the pt body
temperature)
3. Notes any useful finding that may help in diagnosing/intervention of pt
condition
Thoracic Trauma
Life Threatening Conditions in Primary Survey
Tracheobronchial
injuries
ATOM TC
Increased suspicion in
-Foreign bodies, SCJ dislocation, injuries/fractures at (facial, mandibular, trachea,
larynx)

Signs
●Silent chest, paradoxical chest movement
●Stridor, respiratory distress
●Cyanosis

Management
●High flow oxygen 15 L/min with non-rebreather mask
●Establish airway patency

Airway Obstruction
 Tension Pneumothorax
A “one-way valve” air leak occurs from the lung
Symptoms & signs
or through the chest wall, and air is forced into
➔ Resp distress, tachypnea,
the thoracic cavity, eventually collapsing the tachycardia, hypotension, chest
affected lung pain, neck vein distension,
hyperresonance, absent breath
sound, tracheal deviation

Management
1.Immediate chest decompression
2.Chest tube insertion
★ Air builds up in Management
pleural cavity
caused by a large
Open 1. Cover defect with sterile
dressing + 3 sides taping
open wound in the Pneumothorax ● Flutter valve effect
chest wall 2. Chest tube insertion at
○ “Sucking chest same side distal from
wound” wound
*Definitive tx: surgical closure

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 Massive Haemothorax
Rapid accumulation of > 1500 mL of blood in the chest cavity Management
➢ Hemorrhagic shock: pallor, tachycardia, hypotension, cool 1. Fluid resuscitation (rapid
extremities crystalloid/blood transfusion)
➢ Ipsilateral chest movement reduced, dullness + reduce breath - Massive transfusion protocol
sound if needed
➢ Persistent blood loss following chest tube 2. Chest tube insertion
- Reexpanding lung may
compress bleeding vessels
3. Thoracotomy
- Continue blood loss >200
mL/H
Flail Chest
Occurs when multiple adjacent rib fractures
cause a segment of the chest wall to
separate from the rest of the rib cage
➔ Respiratory compromise exacerbated
by pain
➔ Respiratory distress
➔ Bony crepitus
Management
➔ Paradoxical chest movement
1.Adequate oxygenation
2.Analgesia (to improve ventilation)
3.Respiratory monitoring and support
4.Intubation/mechanical ventilation if needed

This is supposed to be in secondary survey

 Dr asked about landmark for pericardiocentesis

Bleeding/fluid in pericardial sac impairing

Cardiac Tamponade cardiac output due to compression
❖ Beck’s Triad: Hypotension, Raised
JVP, muffled heart sounds
❖ Pulsus paradoxus: >10 mmHg fall in
pressure during inspiration
❖ Kussmaul’s Sign: raised JVP on
inspiration

Management
1.High flow O2 15 L/min non rebreather mask to help reduce
workload on the heart
2.Needle pericardiocentesis to quickly drain fluid
3.Definitive: Pericardiectomy (remove part of pericardium)
4.Emergency thoracotomy in cardiac arrest
Corrections
1. Must include secondary survey
2. Flail chest has been exchanged with
Tracheobronchial injuries (Primary vs
Secondary)
3. Hidden Six
4. Include fast scan, bedside ultrasound
Advanced
Cardiovascular Life
Support (ACLS)

2
Poh Jason 197112
 Contents

Survey Algorithm
Cardiac Arrest
Primary vs. Secondary
Algorithm

Causes Rate
Reversible causes in Tachycardia vs.
Cardiac Arrest Bradycardia
Survey
1
Primary vs Secondary
 Primary Survey
1 (Begin BLS algorithm)
*Remember DRS!

Airway Circulation
Check pulse; Chest
Look, Listen, Feel
Compressions

Breathing Defibrillation
Provide defibrillator
Provide 2 slow breaths
shocks in safe manner
2 Secondary Survey

Airway Circulation
Intubation for compromised IV line, fluids, monitor,
airway rhythm appropriate drugs

Breathing Differential Diagnosis

Confirm and secure
Search, find, treat
tube placement,
reversible cause
assess oxygenation
and ventilation
Awesome Words
Cardiac Arrest
Algorithm
2
“To shock or not to shock.”
 ? Why early defibrillate?

Statistics 1 4 Treatment
Most frequent initial Treatment for VF is
rhythm in outside hospital defibrillation
witnessed sudden
cardiac arrest (SCA) is VF

Time 2 3 Deterioration
Probability of VF tends to
successful deteriorate to
defibrillation asystole over time
diminishes rapidly
over time
? Shockable or Non-shockable?

Shockable Non-Shockable
Ventricular Fibrillation (VF), Asystole, Pulseless
Ventricular Tachycardia (VT) Electrical Activity (PEA)
Causes
3
Reversible causes of cardiac arrest: H’s and T’s
Rate
4
Tachycardia and Bradycardia
1 Tachycardia

Definition Pathophysiology Signs and Causes

symptoms
High HR > reduced - Dehydration
HR >100 bpm - Hypotension
CO& arrhythmias - Hypoxia
- Altered mental
status - Infection
- Shock - Sepsis
- Ischemic - Shock
chest pain
- Acute heart
failure
2 Bradycardia

A B C

Definition Signs and symptoms Causes

HR >50 bpm - Chest discomfort/pain
- SOB
- Decreased consciousness
- Weakness/fatigue
- Lightheadedness/dizziness
- Presyncope/syncope
- MI
- Electrolyte imbalance
- Intoxication
- Infection
- Hypoglycaemia
- Hypothyroidism
 References

● Advanced Life Support training manual, MOH 2012.

● ACLS Provider Manual Supplementary Material,
American Heart Association 2016.