ATLS – Recent

Guidelines

Dr Daivik T Shetty
MBBS, MS Orthopedics
Consultant Orthopedic
Manipal Hospitals, Mangalore
ATLS , ACLS , BLS
JAMES K STYNER
“WHEN I CAN PROVIDE BETTER CARE IN THE FIELD
WITH LIMITED RESOURCES THAN MY CHILDREN AND
I RECEIVED AT THE PRIMARY FACILITY…

THERE IS SOMETHING WRONG WITH THE SYSTEM

AND THE SYSTEM HAS TO BE CHANGED”
REPRESENTS AN ORGANIZED APPROACH FOR
EVALUATION AND MANAGEMENT OF TRAUMA
PATIENTS
Dying from trauma – ”Golden Hour” of
resuscitation
ATLS approach
• Triage
• Primary survey (A[C]BCDE)
• Resuscitation
• Adjuncts to Primary survey
• Secondary survey
• Continue post resuscitation monitoring and re-assessment
• Tertiary survey
• Definitive care
Pre-Hospital Phase
Hospital phase
Trauma team
•Trauma team leader
•ED nurses – 2
•Emergency room physician
•Anesthetist
•Orthopedics
•General surgery
•Radiographer
Critical aspects of hospital preparation

• A resuscitation area is available for trauma patients.

• Properly functioning airway equipment (e.g., laryngoscopes and
endotracheal tubes) is organized, tested, and strategically placed to
be easily accessible.
• Warmed intravenous crystalloid solutions are immediately available for
infusion, as are appropriate monitoring devices.
• A protocol to summon additional medical assistance is in place, as
well to ensure prompt responses by laboratory and radiology
personnel.
• Transfer agreements with verified trauma centers are established and
operational
Triage
• Prioritization or ranking of patients according to their clinical
needs

• Four color code

Red need immediate treatment
Yellow need urgent treatment
Green: stable patient, can be delayed
Black: dead or near dead
Triage (ATLS 10)
MULTIPLE CASUALTIES
• Multiple-casualty incidents are those in which the number of patients and
the severity of their injuries do not exceed the capability of the facility to
render care. In such cases, patients with life-threatening problems and
those sustaining multiple-system injuries are treated first.
MASS CASUALTIES
• In mass-casualty events, the number of patients and the severity of their
injuries does exceed the capability of the facility and staff. In such cases,
patients having the greatest chance of survival and requiring the least
expenditure of time, equipment, supplies, and personnel are treated first
 +
Cervical
 A = Airway
• Approach patient from head side
• Stabilize cervical spine using in
line immobilization

Suction out airway

Jaw thrust/ chin lift

Insertion of oropharyngeal or
nasopharyngeal airway
Definitive airway of choice

•Oral endotracheal intubation with cuffed ET

tube

•Nasotracheal intubation – advantage in

cervical spine trauma
Two assailants beat a 49-year-old man with a wooden bat in
his home during robbery. He is taken to the emergency
department hemodynamically stable with hemoptysis and
cervical subQ emphysema
Which of the following statements is true?
a) Fiber optic assisted intubation should be used

b) Insert gastric tube immediately to prevent aspiration

c) Immediately begin needle decompression

d) Bronchoscopy should be avoided because it may aggravate the

injury
 In suspected tracheobronchial injury
ATLS 10

Extremely difficult airway suspected

Fiber optic intubation with tube placed below the level of

injury

Bronchoscopy can confirm the diagnosis and prevent

worsening the injury by intubating the patient blindly
Maxillofacial, laryngeal and Neck
trauma
Severe Maxillofacial injuries
• Emergency airway of choice : NEEDLE
CRICOTHYROIDOTOMY
High flow oxygen
4-6mm tube inserted
Contraindicated in children <12 years – Subglottic stenosis

• Definitive airway : TRACHEOSTOMY

Laryngeal trauma
Laryngeal trauma is indicated by a triad of
clinical signs:
1. Hoarseness
[Link] emphysema
[Link] fracture
To assess patency : Elicit verbal
response
• Not able to speak

Airway obstruction

Mental status depression

Noisy breathing
Facial trauma
GCS </= 8
Cervical Spine Control
• Protection of spine and spinal cord is key component of
ATLS management
• Neurological exam alone does not exclude cervical spine
injury

• Assume a cervical spine injury in ANY patient with

multisystem trauma especially with an altered level of
consciousness or blunt injury above the clavicle
TRIPLE
IMMOBILISATION-COLLAR-BLOCKS-TAP
E with C-Spine in line and head in Neutral
position
 • A 45-year-old patient presents to the emergency department
following a motor vehicle accident. The patient complains of neck
pain and tenderness. On examination, there is no midline cervical
tenderness, but no focal neurologic deficits or altered level of
consciousness. The patient denies any intoxication and has no
distracting injuries. Based on the ALTS (AANS/CNS Section on
Disorders of the Spine and Peripheral Nerves) Nexus criteria, which of
the following is the most appropriate next step in the management of
this patient?
A) Order cervical spine X-rays
B) Order a CT scan of the cervical spine
C) Proceed with immediate surgical consultation
D) No need for Radiographs, Prescribe analgesics and advise follow-up
in a few days
•Which of the following patients would not require
radiographic evaluation per the Canadian C-spine
Rule?
1. 12 \/o boy who fell from 3 ½ feet
2. 68 y/o man who was ambulatory at the scene
3. 42 y/o woman rear ended by a city bus
4. 35 y/o woman with delayed onset of neck pain who can
actively rotate her neck 45 degrees left and right
5. 23 y/o man with midline cervical spine tenderness
•Which of the following patients would not require
radiographic evaluation per the Canadian C-spine
Rule?
1. 12 \/o boy who fell from 3 ½ feet – high risk factor
2. 68 y/o man who was ambulatory at the scene – high age risk
factor
3. 42 y/o woman rear ended by a city bus – high risk factor
4. 35 y/o woman with delayed onset of neck pain who can
actively rotate her neck 45 degrees left and right
5. 23 y/o man with midline cervical spine tenderness – low risk
factor
Preemptive Intubation
•Burns patients

•Potential inhalational injury

B = BREATHING

•Is the chest moving normally ?

•Rate and depth of respiration ?

•Airway patency does not ensure adequate

ventilation
Ventilation problems :
• Tension Pneumothorax (ATLS 2018)

Wide bore needle

Children – 2nd intercostal in mid clavicular line

Adults – 4th or 5th intercostal middle axillary line

4th or 5th intercostal space anterior to the mid axillary line ABOVE
the rib
Circulation (with hemorrhage control)
C = Circulation with Hemorrhage
control
•Most common cause of Shock in trauma = Bleeding
= Hypovolemic shock

•Vitals –
SBP <100 mm Hg
PR > 100/min
A 20-year-old man fell 20 feet through a rotten plank on an old
wooden bridge to the rocky stream below. He was taken to the
emergency within 30 minutes, complaining of chest pain. On
arrival to ED, he is hypotensive

What are you going to do?

a) Send to OR

b) 2L bolus crystalloid

c) 1L bolus crystalloid

d) Crack the chest

Management
•Two large IV cannula
•Blood – cross match

1L Warm Isotonic Crystalloids

ATLS 10 has reduced 2L to 1L

In children (<40kgs) – 20ml/kg

Mildly hypotensive patient, tachycardic, BP
returns to normal after 1L fluid bolus but then
drops again.
What are you going to do?
a) Begin transfusing blood

b) Transfer to higher level of care

c) Distribute 2L bolus of crystalloid

d) Obtain a CT scan to determine source of bleeding

Non - responding patients
•Manage ongoing bleeding – FAST scan

•Blood transfusion
“Trauma transfusion protocol”

Packed cell : Plasma : Platelets

1:1:1
•Best indicator of tissue perfusion in trauma : Urine
Output

•Best indicator to determine Fluid replacement : CVP

Urine Output
• Adequate volume replacement during resuscitation should
produce a urinary output of approximately

0.5 mL/kg/hr in adults

1 mL/kg/hr is adequate urinary output for paediatric patients
For children under 1 year of age, 2 mL/kg/hr should be
maintained.

The inability to obtain urinary output at these levels or a

decreasing urinary output with an increasing specific gravity
suggests inadequate resuscitation
 Pediatric Mass Transfusion protocol -
2018
• Bolus : 20ml/kg warm, isotonic crystalloids

• Followed by

10-20 ml/kg packed cells

10-20 ml/kg plasma

10-20ml/kg platelets
A 26-year-old woman was hit by a van while walking
across a busy intersection. She has an obvious broken
right femur and 3 broken ribs on the right side. She
requires a blood transfusion.
Which of the following is true:

a) Everyone requiring massive transfusion should receive

calcium supplementation
b) < 12u pRBC in 24hrs would not be considered a massive
transfusion
c) > 4u pRBC in 1hr is considered a massive transfusion
d) The ACS has developed a universal MTP that should be
adopted br all trauma centers
ATLS 10 - Transfusion
• A Massive transfusion is considered to be the
administration of >10 units pRBC in 24 hrs or >4 units pRBC
in 1 hour.

• Most patient requiring transfusion do not need calcium

supplementation

• There is no universal MTP guidelines

Coagulationopathy is a serious risk in
severely injured patient
Which of the following statements is true ?
a) Tranexamic acid should be prescribed within first four hours injury

b) After the initial bolus, tranexamic acid should not be re-dosed

c) To reduce the risk of coagulopathy, keep the patient cool

d) Resuscitation procedures increase the risk of coagulopathy

 CRASH 2 trial – ATLS 10

Tranexamic acid – Hypotensive trauma patients

Decreases mortality in blunt and penetrating trauma

Bolus - 1 gram IV over 10 minutes

Followed by 1 gram IV over 8 hours
Within 3 hours of trauma
Coagulopathy
• Severe injury and hemorrhage result in the consumption of coagulation
factors and early coagulopathy

• Massive fluid resuscitation with the resultant dilution of platelets and

clotting factors contributes to coagulopathy in injured patients.

• Prothrombin time, partial thromboplastin time, and platelet count are

valuable baseline studies to obtain in the first hour

• Thromboelastography (TEG) and rotational thromboelastometry

(ROTEM) can be helpful in determining the clotting deficiency and
appropriate blood components to correct the deficiency
In a patient with hemorrhagic shock, a base
deficit of -4 would indicate what class of shock?
a) Class 1
b) Class 2
c) Class 3
d) Base deficit does not correlate with shock
In a patient with hemorrhagic shock, a base
deficit of -4 would indicate what class of shock?
a) Class 1
b) Class 2
c) Class 3
d) Base deficit does not correlate with shock
Pelvic fractures and Associated
injuries
D = DISABILITY EVALUATION
• CHECK FOR NEUROLOGICAL DEFICITS
• GLASGOW COMA SCALE (GCS) – 2014
EVM = E4 V5 M6

MILD
MODERATE
SEVERE

NT
GCS – P
• GCS - Pupil reactivity score

• Number of nonreactive pupils

Both Pupils nonreactive – 2

One Pupil nonreactive – 1
Neither Pupil nonreactive – 0
GCS PACT
• GCS
• PUPILS
• AGE
• CT FINDINGS
Disability
• Glasgow Coma scale

• Level of consciousness – AVPU (Alert, voice, pain,

unresponsive)

• Neurological status
E = Exposure / Environment Control

• Body temperature of patient is critical

• Warmed IV fluids

• Bair hugger
• Logroll patient to check for posterior injuries
• Expose the patients
• Expose perineum – Pelvic fractures
• Look For Open Fracture
• Rewarm The Patient
Log Roll Technique (4 people)
Ideal number : 5 people

Minimum : 4 people

1 person – Head control

3 people – Supporting body
1 person – Examining
Adjuncts to Primary Survey
• Pulse oximeter
• Cardiac monitoring +/- ECG
• Foley catheter
• NG tube
• CXR/Pelvic X-ray
• Blood glucose
 A 29-year-old man diagnosed with scrotum ecchymosis
after landing hard on his bike while jumping terrain in
the national forest.
Which of the following is appropriate ?
a) A suprapubic catheter should be inserted right away

b) Foley catheter is placed right away

c) First step is Prostate examination, if there is no blood at the urethral

meatus, a foley catheter is placed as precaution

d) Retrograde urethrogram is advised

Retrograde urethrogram is advised
• Prostate exam is no longer used as an indicator of urinary
tract injury in ATLS 10 due to its inaccuracy

• Retrograde urethrogram is performed prior to placement of

Foley’s catheter if there is suspicion of Urethral injury

• Even if there is no blood at the urethral meatus or gross

blood in urine, a retrograde urethrogram should be
performed if there are other signs of urethral injury such as
Scrotal ecchymosis or hematoma
Urinary and Gastric catheters
• Urinary output is a sensitive indicator of the patient’s volume status and
reflects renal perfusion. Monitoring of urinary output is best accomplished
by insertion of an indwelling bladder catheter

• Transurethral bladder catheterization is contraindicated for patients who

may have urethral injury.

• Suspect a urethral injury in the presence of either blood at the urethral

meatus or perineal ecchymosis.

• When urethral injury is suspected, confirm urethral integrity by performing a

retrograde urethrogram before the catheter is inserted.
After Primary Survey
• Re-assess with changes made

• Obtain imaging – CXR/ Pelvis/ CT trauma

Secondary Survey
• Head to toe examination
• Thorough systematic review and history from the patient
• Manage nonlife threatening problems and missed injuries
• Open fracture management – BOAST 4 guidelines
• Consider closing soft tissue injuries
• Determine how stable patient is – DCO vs ETC ?
AMPLE history
•Allergies
•Medications
•Past illness / Pregnancy
•Last meal
•Events related to injury
Tertiary Survey
• Comprehensive evaluation after initial resuscitation (after
24 hours)

❑ Thorough physical examination

❑ Targeted radiographic imaging

Revaluation
•For adult patients, maintenance of urinary output at
0.5 mL/kg/h is desirable.

•In paediatric patients who are older than 1 year, an

output of 1 mL/kg/h is typically adequate.
ATLS with musculoskeletal trauma
Management of Significant Vascular
Injury
• A stepwise approach to controlling arterial bleeding begins with
manual pressure to the wound.
• A pressure dressing is then applied, using a stack of gauze held in
place by a circumferential elastic bandage to concentrate pressure
over the injury.
• If bleeding persists, apply manual pressure to the artery proximal to
the injury. If bleeding continues, consider applying a manual
tourniquet (such as a windlass device) or a pneumatic tourniquet
applied directly to the skin
• A pneumatic tourniquet may require a pressure as high as 250 mm Hg
in an upper extremity and 400 mm Hg in a lower extremity
Transfer of trauma patients
“ABC-SBAR”

Airway, Breathing and Circulation problems identified, and

interventions performed

Situation – pt name, age, referring details, IV access site

Background – event history, AMPLE, Blood products,
medications, imaging
Assessment – vitals, physical exam findings
Recommendation
ATLS in Pediatric Trauma
Airway
• Orotracheal intubation is the most reliable means of establishing an airway and
administering ventilation to a child. The smallest area of a young child’s airway is at
the cricoid ring, which forms a natural seal around an uncuffed ETT, a device that is
commonly used in infants because of their anatomic features

• Before attempting to mechanically establish an airway, fully preoxygenate the child.

• Surgical cricothyroidotomy is rarely indicated for infants or small children. It can be

performed in older children in whom the cricothyroid membrane is easily palpable
(usually by the age of 12 years).
Breathing
• Use of a paediatric bag-mask is recommended for children under 30
kg.

• Hypoxia is the most common cause of paediatric cardiac arrest

• In case of tension pneumothorax in Children - needle decompression

just over the top of the third rib in the midclavicular line

• 14–18-gauge needle
Circulation
• The goal of fluid resuscitation is to rapidly replace the
circulating volume.
An infant’s blood volume can be estimated at 80 mL/kg
and a child aged 1-3 years at 75 mL/kg
and children over age 3 years at 70 mL/kg.
Intraosseous
insertion
Old ATLS protocol
• Intravenous administration of warmed isotonic crystalloid solution as
an initial 20 mL/kg bolus, followed by one or two additional 20 mL/kg
isotonic crystalloid boluses pending the child’s physiologic response.
If the child demonstrates evidence of ongoing bleeding after the
second or third crystalloid bolus, 10 mL/kg of packed red blood cells
may be given.
ATLS 10
• initial 20 mL/ kg bolus of isotonic crystalloid followed by
weight- based blood product resuscitation with 10-20
mL/kg of packed red blood cells and 10-20 mL/kg of fresh
frozen plasma and platelets, typically as part of a paediatric
mass transfusion protocol
Urine Output
• The output goal for infants is 1-2 mL/kg/hr
• For children over age one up to adolescence the goal is 1-1.5 mL/kg/hr
• 0.5 mL/kg/hr for teenagers.
ATLS for Pregnant woman
ATLS for Pregnant woman
• If the patient requires spinal motion restriction in the supine
position, logroll her to the left 15–30 degrees (i.e., elevate
the right side 4–6 inches), and support with a bolstering
device, thus maintaining spinal motion restriction and
decompressing the vena cava

• Initial fetal heart tones can be auscultated with Doppler

ultrasound by 10 weeks of gestation. Perform continuous
fetal monitoring with a tocodynamometer beyond 20 to 24
weeks of gestation
Fetus
• Fetal heart rate is a sensitive indicator of both maternal
blood volume

• Perform any indicated radiographic studies because the

benefits certainly outweigh the potential risk to the fetus.
Thank you