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Emergency Trauma Care: ATLS

Article · January 2011

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 J. Adv Dental Research REVIEW ARTICLE
All Right Res

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@[Link]

Abstract:
Advanced trauma life support orients doctors In developed countries there is a decrease in
to the initial assessment and to provide emergency trauma mortality in recent decades due to a combination of
trauma care for the injured patient. It provides a safe, injury prevention endeavours and improvement in trauma
reliable method and also basic knowledge necessary to, care.(6) The purpose of adequate trauma care is to decrease
1. Assess the patient’s condition rapidly and accurately. this morbidity and mortality, which is expected to be
2. Resuscitate and stabilize according to priority. 3. achieved by fast, systematic, and effective assessment and
Arrange appropriately for the patient’s inter hospital treatment of the injured patient.
transfer (what, who, when and how). 5. Assure that The maxillofacial skeleton is vulnerable to injury,
optimum care is provided. The purpose of advanced and are commonly seen after assault, road traffic accidents,
trauma life support is to decrease morbidity and falls, and sporting injuries. These injuries require
mortality, which is expected to be achieved by fast, immediate first-aid treatment such as the establishment of a
systematic, and effective assessment and treatment of free airway, control of haemorrhage, treatment of shock,
the injured patient. support of the facial structures and positioning of the
patient face-downwards are the essential lifesaving
Key words: Trauma, ATLS, Life support, Emergency measures. Advanced Trauma Life Support (ATLS) includes
care, Trauma care the initial assessment and management of trauma patients
that aims to optimise initial care and reduce mortality and
Introduction morbidity. The ATLS concept is also used in the pre-
The word “Trauma” comes from a Greek word hospital phase of trauma patient care and has been adopted
meaning “a wound”, which implies, any serious injury to for non-trauma medical emergencies and implemented in
the body, often resulting from violence or an accident, or an resuscitation protocols around the world.
event that causes great distress. (1) Trauma is a diverse
disease in which, time, critical decisions and skills affect History of ATLS
patient outcome. For every one patient who dies, there are Importance to the ATLS was established after a
three survivors with serious disabilities. (2, 3) The first tragic plane crash in1976, an airplane with an orthopedic
peak of deaths occurs within minutes of the event from surgeon, J Styner in Nebraska. His wife and children
non-survivable injuries, even with the most advanced crashed in a corn field, the wife died. The surgeon and
medical resources immediately to hand. The second peak three of his four children were seriously injured.
may account for some 30% of deaths, in the first few hours Unfortunately for Dr Styner he found that the subsequent
after injury. Death is most often due to hypoxia and care received in the local hospital was inferior to what he
hypovolaemic shock. (4) This group stands to benefit the was able to provide for 10 hours at the scene of the
most from excellence in trauma care. The third peak, of up accident. And he decided to develop a system to improve
to 20% of trauma deaths, occurs late after the injury, from the care for trauma victims, and thus, ATLS was born. (7)
sepsis, multi-organ failure, and other complications.(5) 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
Serial Listing: Print ISSN(2229-4112) Education Foundation, together with the University of
Online-ISSN (2229-4120) Nebraska founded local courses aiming at teaching
advanced trauma life support skills.(9) After the first
Bibliographic Listing: Index Copernicus. ATLS course in 1978, it was taken up by the American
EBSCO Publishing Database. College of Surgeons Committee on Trauma (ACS COT) in
Proquest. the next year and rapidly spread throughout the North,
Central, and South America. Today ATLS is taught in over
J-Gate. 42 countries and around half a million clinicians have
completed the course. The concept has matured, has been

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disseminated around the world and has become the Assess the patient for airway obstruction:
standard of emergency care in trauma patients. (2) Agitation suggests hypoxia, obtundation suggests
Originally, ATLS was designed for emergency hypercarbia, and cyanosis suggests hypoxemia secondary
situations where only one doctor and one nurse are present. to inadequate oxygenation. Look for evidence of injury to
Nowadays, ATLS is also accepted as the standard of care the larynx and trachea, including crepitus of the soft
for the first (golden) hour in level-1 trauma centres. The tissues. Clinically the patient may have noisy breathing,
priorities of emergency trauma care according to the ATLS snoring, gurgling, or croaking. Hoarseness, subcutaneous
principles are independent of the number of people caring emphysema, and a palpable fracture are suggestive
for the patient. (10) laryngeal fracture. (13)
Apart from the severity of injury, probably the Establish and maintenance of the airway:
single most important factor determining the outcome of a Good suction is essential. The chin should be pulled
trauma patient is the time interval from the moment the forward either through chin lift or jaw thrust procedures.
injuries are received to the provision of definitive care. The jaw thrust and chin lift relieves soft tissue obstruction
Definitive care for the trauma patient implies achieving a by pulling the tongue, anterior neck tissues, and epiglottis
clear airway and effective ventilation, haemorrhage control forward. Remove the debris (broken teeth, dentures) from
and restoration of an adequate blood volume. In managing the mouth with finger sweep technique or Yankauer
emergency trauma, treat the greatest threat to life first. A suction. A Magill‟s forceps may also be used for larger
detailed history is not necessary to begin evaluation and objects. (14)
treatment. Indicated treatment must be applied even when a Airway compromise is uncommon in the
definitive diagnosis is not yet established. conscious patient; however, it may occur in an unconscious
Maxillofacial injuries are commonly seen after patient, particularly those who have sustained bilateral
assault, road traffic accidents, falls, and sporting injuries in parasymphyseal fracture. These patients may require
a ratio mandibular: zygoma: maxillary of 6:2:1.(11) As forward repositioning of the mandible and tongue to
with all traumas, basic advanced trauma life support prevent airway obstruction. A towel clip is useful to pull
principles should be applied to the initial assessment of the the tongue forward.
casualty. This must include a primary and secondary If no foreign body is visible an endotracheal tube
survey. It is only after the secondary survey that definitive should be inserted. Endotracheal intubation with a cuffed
care begins. tube will secure the airway. If the foreign body cannot be
removed quickly or the vocal cords cannot be adequately
Primary survey; visualised or endotracheal intubation is not possible it
In the primary survey, the mnemonic ABCDE is used to should be left and a surgical airway performed. A
remember the order of assessment with the purpose to treat cricothyroidotomy is the preferred way to establish a
first that kills first, surgical airway in the emergency. A recent study of 50
A- Airway and Cervical spine stabilization cricothyoidotomy attempts in trauma patients by
B- Breathing paramedics in Indiana concluded that the procedure was
C- Circulation successful in 47(97%). A 5 or 6 mm tube cuffed
D- Disability and tracheostomy tube should be inserted through the
E- Environment and Exposure(10) cricothyroidotomy incision. A needle cricothyroidotomy is
advised in children less than 12 years of age as there is a
Airway obstruction kills quicker than difficulty of high risk of damaging the cricoid cartilage. As the cricoid
breathing caused by a pneumothorax, and a patient dies cartilage is the only circumferential supporting structure
faster from bleeding from a splenic laceration then from a that maintains patency of the upper trachea.
subdural hematoma. Every patient sustaining significant blunt trauma,
Injuries are diagnosed and treated according to the ABCDE particularly above the clavicles, should be assumed to have
sequence. a cervical spine injury until proved other-wise. These
patients should have the cervical spine immobilized with a
A: Airway semi-rigid cervical collar and bilateral sandbags or block
A recent retrospective study of pre-hospital trauma joined with tape or straps across the forehead. As long as
deaths in North Staffordshire reported that, on the basis of the cervical spine is not cleared by physical examination,
post-mortem evidence, airway obstruction had been present with or without diagnostic imaging, the spine should
in two-thirds of those patients in whom death was judged remain stabilized.
not to have been inevitable. (12)
The main cause of death in severe facial injury is B: Breathing
airway obstruction. This may be because of the tongue Breathing is the second to be evaluated in trauma
falling back and obstructing the hypopharynx in an care. Tension pneumothorax, massive hemothorax, flail
unconscious patient or may be secondary to uncontrolled thorax accompanied by pulmonary contusion, and an open
haemorrhage drowning the airway. The airway is not pneumothorax compromise breathing acutely and can be
compromised when the patient talks normally. A hoarse diagnosed with physical examination alone and should be
voice or audible breathing is suspicious. Patients in a coma treated immediately. Most clinical problems in „B‟ can be
are not capable of keeping their airway patent. treated with relatively simple measures as endotracheal

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intubation, mechanical ventilation, needle thoracocentesis, substances and should be evaluated and treated. At the end
or tube thoracostomy. of the primary survey, before continuing with the
Injuries, like a simple pneumothorax or secondary survey, the ABCDEs should be re- evaluated and
hemothorax, rib fractures, and pulmonary contusion, are confirmed.
often more difficult to appreciate with physical
examination. Because these conditions have less effect on Secondary survey:
the clinical condition of the patient, they can be identified An injury may be missed or its significance may
in the secondary survey. not be recognised in the trauma resuscitation scenario,
particularly in the unconscious or unstable patient. The
C: Circulation secondary survey starts only after the ABCDE primary
Circulatory problems in trauma patients are survey is complete and the patient responds to
usually caused by haemorrhage. The first action should be resuscitation.
to stop the bleeding. If there is no evidence of damage to The secondary survey can be haphazard, poorly
the major vessels of the neck or middle third of facial recorded, and, in the aftermath of a more dramatic initial
fractures blood loss is usually insufficient to cause resuscitation, may be less thorough. There can be a
hypovolumic shock problems, but may cause problems substantial delay between the primary and secondary
with establishing and maintaining an airway. Bleeding from survey if immediate treatment or surgery is indicated.
the soft tissues of the head and neck may be controlled with During the secondary survey, the patient is
direct pressure on the bleeding site. examined from head to toe, and appropriate additional
If conscious, ask the patient to sit upright as this radiographs of the thoracic and lumbar spine and the
allows blood and secretions to drain out of the mouth. extremities are performed when indicated. CT scans, when
Intra oral bleeding may be controlled by getting the patient indicated, are also done in the secondary survey.
to bite on a swab. Bleeding from a tongue laceration can be
torrential, in such cases deep sutures across the laceration Table 1 Secondary survey mnemonic (15)
are advised to achieve haemostasis, as pressure alone will
not stop the bleeding. Mnemonic Secondary survey
Bleeding from fractured mandible ends may be Has Head/skull
arrested by manually reducing and brittle wiring of the
My Maxillofacial
fracture fragments. In a patient with a mobile maxilla, the
use of rubber mouth gags is advisable. The mouth gags, Critical Cervical Spine
which act as a splint compressing the maxilla between the Care Chest
skull base and the mandible. In cases where there is also a Assessed Abdomen
mobile mandible fracture a cervical collar may be used as a Patient‟s Pelvis
temporary form of mandibular splint.
Priorities Perineum
Torrential bleeding from the region of the
nasopharynx can be difficult to control. An epistat tube Or Orifices (PR/PV)*
with anterior and posterior balloons that can be inflated to Next Neurological
tamponade any bleeding can be very useful in these Management Musculoskeletal
situations. Foley catheters may also be used. (14) Decision? Diagnostic tests/ definitive care
D: Disability *Tubes and fingers in every orifice. Include „„AMPLE‟‟
This includes assessment of the neurological status. The history.
Glasgow coma score (GCS) is used to evaluate the severity
of head injury. This score is arrived at by scoring eye If, during the secondary survey, the patient‟s condition
opening, best motor response, and best verbal response. deteriorates, the primary survey should be repeated
Patients who open their eyes spontaneously, obey beginning with „A.‟
commands, and are normally oriented score a total of 15
points. The worst score is 3 points. A decreased GCS can Conclusion:
be caused by a focal brain injury, such as an epidural
hematoma, a subdural hematoma, or a cerebral contusion, Trauma continues to be the most common cause of
and by diffuse brain injuries ranging from a mild contusion death in first four decades of life. In that, Maxillo-facial
to diffuse axonal injury. To prevent secondary injury to the injuries require immediate first-aid for the establishment of
brain, optimal oxygenation and circulation are important. a free airway, control of hemorrhage, and treatment of
Also, impaired consciousness can be caused or aggravated shock. The facial structures must always be supported and
by hypoxia or hypotension for which ABC stabilization is the patient kept in a face-downward position. From its
essential. tragic origin ATLS has become an icon in medical
education. There is no doubt that ATLS is at a crossroads in
E: Environment and exposure its development. To do nothing runs the risk of a schism
Environment and exposure represent hypothermia, developing. Alternatively it could adapt to become a truly
burns, and possible exposure to chemical and radioactive international course. Either option will require trauma

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