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Dr.Adeel Riaz
PGR General
Surgery
CPTH. Lahore.
Advanced Trauma Life Support
(ATLS)
Advanced Trauma Life Support
(ATLS)
Most widely recognised and practiced protocol for the
management of a trauma patient w...
ATLS PROTOCOL
 PRIMARY SURVEY
 RESUSCITATION
 SECONDARY SURVEY
 TERTIARY SURVEY
PRIMARY SURVEY
 A : AIRWAY & CERVICAL SPINE
IMMOBILIZATION
 B : BREATHING / VENTILATION
 C : CIRCULATION & HEMORRHAGE C...
AIRWAY MANAGEMENT & C. SPINE
 SUCTIONING OF NASOPHARYNGEAL AIRWAY
 CHIN LIFT
 JAW THRUST
ADVANCED METHODS:
 ENDOTRACHE...
BREATHING / VENTILATION
 EXPOSE THE CHEST & ACCESS RR & RESP. TYPE.
 GIVE O2 INHALLATION
 CHECK CHEST WALL, LUNGS & DIA...
CIRCULATION
IMPAIRMENT IN CIRCULATION CAN LEAD TO SHOCK
SO LOOK FOR SIGNS OF SHOCK i.e.
 SKIN COLOUR (PALLOR)
 NARROW PU...
CLINICAL CLASSIFICATION OF
SHOCK
CLASS I CLASS II CLASS III CLASS IV
BLOOD LOSS UPTO 750ml 750-1500ml 1500-2000ml >2000ml
...
FLUID REPLACEMENT THERAPY
 DOUBLE I/V LINES SHOULD BE MAINTAINED FOR
FLUID REPLACEMENT
 ADULTS SHOULD BE GIVEN 2 L BOLUS...
DISABILITY ( NEUROLOGICAL
EXAMINATION)
CHECK THE LEVEL OF CONSCIOUSNESS ( AVPU/GCS )
 A: ALERT
 V: RESPONDS TO VOCAL STI...
EXPOSURE +ENVIRONMENTAL
CONTROL
 UNDRESS COMPLETELY (USE TRAUMA SCISSORS)
 PREVENT HYPOTHERMIA ( WARM BLANKETS &
WARM FL...
SECONDARY SURVEY
DOESNOT BEGIN UNTIL THE PRIMARY SURVEY (ABCDEs)
IS COMPLETED, RESUSCITATION EFFORTS ARE WELL
ESTABLISHED ...
COMPLETE HISTORY
 A: ALLERGIES
 M: MEDICATIONS
 P: PAST ILLNESS/ PREGNANCY
 L: LAST MEAL
 E: EVENTS/ ENVIRONMENT/MECH...
PHYSICAL EXAMINATION
 HEAD
 MAXILLOFACIAL STRUCTURES
 CERVICAL SPINE & NECK
 CHEST
 ABDOMEN
 PERINEUM,RECTUM & VAGIN...
HEAD
 VISUAL ACUITY
 PUPPILARY SIZE
 CONJUNCTIVAL HEMORRHAGE
 PENETRATING INJURY
 CONTACT LENSES (REMOVE BEFORE EDEMA...
CERVICAL SPINE AND NECK
 PATIENTS WITH HEAD TRAUMA OR MAXILLOFACIAL
TRAUMA SHOULDE BE PRESUMED TO HAVE
UNSTABLE CERVICAL ...
ABDOMEN
 AFTER INITIAL EXAMINATION, CLOSE OBSERVATION
AND FREQUENT RE-EVALUATION OF THE ABDOMEN
SHOULD BE DONE BY THE SAM...
MUSCULOSKELETAL SYSTEM
 THE EXTREMITIES MUST BE INSPECTED FOR
CONTUSIONS & DEFORMITIES.
 BONES SHOULD BE PALPATED & MOVE...
REASSESSMENT OF VITAL SIGNS
DONE BY:
 CLINICAL REASSESSMENT
 MONITORING OF LOC, PR, BP MONITORING, ABGs &
UOP
 REVIEW O...
SPECIFIC PROCEDURES, SPECIFIC
LAB. INVESTIGATIONS
 AFTER HISTORY & EXAMINATION, RELEVANT
INVESTIGATIONS SHOULD BE ADVISED...
DEFINATIVE CARE & TRANSFER
 ACCORING TO CLINICAL AND OTHER DATA PATIENT
IS SHIFTED TO ICU , OT OR OTHERS RESPECTIVELY.
 ...
ATLS OUTLINE
 PRIMARY SURVEY (ABCDE)
 SECONDARY SURVEY 1. HISTORY
2. PHYSICAL
EXAMINATION
3. RELEVANT
INVESTIGATIONS
 R...
Advanced trauma life support (atls)
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Advanced trauma life support (atls)

  1. 1. Dr.Adeel Riaz PGR General Surgery CPTH. Lahore. Advanced Trauma Life Support (ATLS)
  2. 2. Advanced Trauma Life Support (ATLS) Most widely recognised and practiced protocol for the management of a trauma patient worldwide. ATLS PROTOCOL OBJECTIVES:  A standardized approach to all traumatic patients.  A comprehensive assessment and management of patients in emergency situation.  Best utilization of golden hour which lies between life and death after a traumatic event.
  3. 3. ATLS PROTOCOL  PRIMARY SURVEY  RESUSCITATION  SECONDARY SURVEY  TERTIARY SURVEY
  4. 4. PRIMARY SURVEY  A : AIRWAY & CERVICAL SPINE IMMOBILIZATION  B : BREATHING / VENTILATION  C : CIRCULATION & HEMORRHAGE CONTROL  D : DISABILITY ( NEUROLOGICAL EVALUATION)  E : EXPOSURE + ENVIRONMENTAL CONTROL
  5. 5. AIRWAY MANAGEMENT & C. SPINE  SUCTIONING OF NASOPHARYNGEAL AIRWAY  CHIN LIFT  JAW THRUST ADVANCED METHODS:  ENDOTRACHEAL INTUBATION  CRICOTHYROIDOTOMY  TRACHEOSTOMY PREVENTION OF CERVICAL SPINE INJURY:  IMMOBILIZE THE PATIENT  AVOID HYPEREXTENSION OF NECK  APPLY CERVICAL COLLAR
  6. 6. BREATHING / VENTILATION  EXPOSE THE CHEST & ACCESS RR & RESP. TYPE.  GIVE O2 INHALLATION  CHECK CHEST WALL, LUNGS & DIAPHRAGM BY INSPECTION, PALPATION, PERCUSSION & AUSCULTATION.  PULSE OXIMETER  LOOK FOR CONDITIONS THAT IMPAIR VENTILATION  Tension pneumothorax  Massive hemothorax  Flail chest  Rib fractures  Open pneumothorax  Pulmonary contusion
  7. 7. CIRCULATION IMPAIRMENT IN CIRCULATION CAN LEAD TO SHOCK SO LOOK FOR SIGNS OF SHOCK i.e.  SKIN COLOUR (PALLOR)  NARROW PULSE PRESSURE  HYPOTENSION  TACHYCARDIA  LEVEL OF CONSCIOUSNESS  DIMINISHED URINE OUTPUT CONTROL OF HEMORRHAGE :  APPLY DIRECT PRESSURE  PNEUMATIC SPLINTING DEVICES  ACCESS THE NEED FOR SURGICAL INTERVENTION
  8. 8. CLINICAL CLASSIFICATION OF SHOCK CLASS I CLASS II CLASS III CLASS IV BLOOD LOSS UPTO 750ml 750-1500ml 1500-2000ml >2000ml % BLOOD VOLUME UPTO 15% 15-30% 30-40% >40% PULSE RATE (bpm) <100 100-120 120-140 >140 SYSTOLIC B.P. NORMAL NORMAL DECREASED DECREASED PULSE PRESSURE NORMAL OR INCREASED DECREASED DECREASED DECREASED RESPIRATORY RATE 14-20 20-30 30-40 >35 URINE OUTPUT (ml/hr) >30 20-30 5-15 NEGLIGIBLE CNS/MENTAL STATUS SLIGHTLY ANXIOUS MILDLY ANXIOUS ANXIOUS, CONFUSED CONFUSED, LETHARGIC FLUID REPLACEMEN CRYSTALLOI DS CRYSTALLOI DS CRYSTALLOI DS & BLOOD CRYSTALLOI DS & BLOOD
  9. 9. FLUID REPLACEMENT THERAPY  DOUBLE I/V LINES SHOULD BE MAINTAINED FOR FLUID REPLACEMENT  ADULTS SHOULD BE GIVEN 2 L BOLUS FLUID (PREFFERED FLUID IS RINGER LACTATE BETTER IF WARM)  CHILDREN SHOULD BE GIVEN @ 20ml/Kg BOLUS FLUID 3 FOR 1 RULE : A rough guideline for the total amount of crystalloid volume acutely is to replace each ML of blood loss with 3 ML of crystalloid fluid, thus allowing for restitution of plasma volume lost into the
  10. 10. DISABILITY ( NEUROLOGICAL EXAMINATION) CHECK THE LEVEL OF CONSCIOUSNESS ( AVPU/GCS )  A: ALERT  V: RESPONDS TO VOCAL STIMULI  P: RESPONDS TO PAINFUL STIMULI  U: UNRESPONSIVE TO ALL STIMULI CHECK PUPIL SIZE & LIGHT REACTION CHECK THE LEVEL OF SPINAL CORD INJURY LEVEL
  11. 11. EXPOSURE +ENVIRONMENTAL CONTROL  UNDRESS COMPLETELY (USE TRAUMA SCISSORS)  PREVENT HYPOTHERMIA ( WARM BLANKETS & WARM FLUIDS)  EARLY HEMORRHAGE CONTROL  WARM ROOM TEMPERATURE SHOULD BE MAINTAINED
  12. 12. SECONDARY SURVEY DOESNOT BEGIN UNTIL THE PRIMARY SURVEY (ABCDEs) IS COMPLETED, RESUSCITATION EFFORTS ARE WELL ESTABLISHED & THE PATIENT IS HAVING NORMALIZATION OF VITAL SIGNS.IT INCLUDES:  COMPLETE HISTORY  COMPLETE HEAD TO TOE EXAMINATION  REASSESSMENT OF VITAL SIGNS  COMPLETE NEUROLOGICAL EXAMINATION (GCS)  SPECIFIC PROCEDURES, SPECIFIC LAB. INVESTIGATIONS
  13. 13. COMPLETE HISTORY  A: ALLERGIES  M: MEDICATIONS  P: PAST ILLNESS/ PREGNANCY  L: LAST MEAL  E: EVENTS/ ENVIRONMENT/MECHANISM OF INJURY: BLUNT TRAUMA: AUTOMOBILE COLLISIONS PENETRATING TRAUMA: FIREARMS/STABBING THERMAL INJURIES: BURNS/EXPLOSIONS HAZARDOUS INJURIES: CHEMICALS/TOXINS/
  14. 14. PHYSICAL EXAMINATION  HEAD  MAXILLOFACIAL STRUCTURES  CERVICAL SPINE & NECK  CHEST  ABDOMEN  PERINEUM,RECTUM & VAGINA  MUSCULOSKELETAL SYSTEM  NEUROLOGICAL SYSTEM
  15. 15. HEAD  VISUAL ACUITY  PUPPILARY SIZE  CONJUNCTIVAL HEMORRHAGE  PENETRATING INJURY  CONTACT LENSES (REMOVE BEFORE EDEMA DEVELOPS)  DISLOCATION OF THE LENS  OCULAR ENTRAPMENT MAXILLOFACIAL STRUCTURES  PALPATE ALL BONY STRUCTURES  INTRAORAL EXAMINATION  ASSESSMENT OF SOFT TISSUES  TRAUMA NOT RELATED TO AIRWAY OR BLEDDING CAN BE DELAYED
  16. 16. CERVICAL SPINE AND NECK  PATIENTS WITH HEAD TRAUMA OR MAXILLOFACIAL TRAUMA SHOULDE BE PRESUMED TO HAVE UNSTABLE CERVICAL INJURY (FRACTURE/LIGAMENT INJURY), NECK SHOULD BE IMMOBILIZED IMMEDIATELY, UNTIL INVESTIGATED.  CERVICAL SPINE TENDERNESS, SUBCUTANEOUS EMPHYSEMA, TRACHEAL DEVITATION & LARYNGEAL FRACTURES OR PENETRATING INJURIES SHOULD BE SEEN DURING EXAMINATION OF NECK. CHEST  A THOROUGH EXAMINATION OF CHEST WALL SHOULD BE DONE TO RULE OUT OPEN OT TENSION PNEUMOTHORAX, HEMOTHORAX, FLIAL CHEST OR CONTUSIONS.
  17. 17. ABDOMEN  AFTER INITIAL EXAMINATION, CLOSE OBSERVATION AND FREQUENT RE-EVALUATION OF THE ABDOMEN SHOULD BE DONE BY THE SAME OBSERVER TO NOTE ANY INTRAABDOMINAL INJURY AND IT SHOULD BE DEALT AGGRESSIVELY. PERINEUM, RECTUM & VAGINA  PERINEUM SHOULD BE EXAMINED FOR CONTUSIONS,LACERATIONS,HEMATOMA & URETHRAL BLEEDING  RECTUM MUST BE EXAMINED FOR BLOOD IN BOWEL LUMEN, PELVIC FRACTURES OR HIGH RIDING PROSTATE.  VAGINAL EXAMINATION SHOULD BE DONE IN
  18. 18. MUSCULOSKELETAL SYSTEM  THE EXTREMITIES MUST BE INSPECTED FOR CONTUSIONS & DEFORMITIES.  BONES SHOULD BE PALPATED & MOVEMENTS AT THE JOINTS SHOULD BE CHECKED.  ASSESSMENT OF PERIPHERAL PULSES SHOULD BE DONE FOR VASCULAR INJURIES.
  19. 19. REASSESSMENT OF VITAL SIGNS DONE BY:  CLINICAL REASSESSMENT  MONITORING OF LOC, PR, BP MONITORING, ABGs & UOP  REVIEW OF DIAGNOSTIC RESULTS  USE OF ANALGESIA COMPLETE NEUROLOGICAL EXAMINATION  LOC/GCS  CNs EXAMINATION  DETERIORATION/IMPROVEMENT IN LOC/GCS
  20. 20. SPECIFIC PROCEDURES, SPECIFIC LAB. INVESTIGATIONS  AFTER HISTORY & EXAMINATION, RELEVANT INVESTIGATIONS SHOULD BE ADVISED e.g.  FOR SUSPECTED CERVICAL SPINE INJURY X-RAYS SHOULD BE DONE AS: 1. LATERAL VIEW: OCCIPUT TO TOP OF T1 2. ANTERO-POSTERIOR VIEW: SPINOUS PROCESSES C2-C7 • Additional X-rays Extremities, Spine • CT-SCAN • Contrast X-rays, Urography, Angiography • Endoscopy
  21. 21. DEFINATIVE CARE & TRANSFER  ACCORING TO CLINICAL AND OTHER DATA PATIENT IS SHIFTED TO ICU , OT OR OTHERS RESPECTIVELY.  OR TRANSFRRED TO OTHER FACILITY ACCORDING TO PATIENT’S NEED OR INSTITUTION’S CAPABILITY. TERTIARY SURVEY  DEFINED AS PATIENT’S EVALUATION THAT IDENTIFIES AND CATALOGUES ALL INJURIES AFTR INITIAL RESUSSITATION AND OPERATIVE INTERVENTIONS  PATIENT IS MORE AWAKE  MORE INFORMATION ABOUT MODE OF INJURY BY PATIENT IS GATHERED
  22. 22. ATLS OUTLINE  PRIMARY SURVEY (ABCDE)  SECONDARY SURVEY 1. HISTORY 2. PHYSICAL EXAMINATION 3. RELEVANT INVESTIGATIONS  RE-EVALUATION  DEFINATIVE CARE  TRANSFER
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