ATLS

1. Dr.Adeel Riaz
PGR General
Surgery
CPTH. Lahore.
Advanced Trauma Life Support
(ATLS)

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. ATLS PROTOCOL
 PRIMARY SURVEY
 RESUSCITATION
 SECONDARY SURVEY
 TERTIARY SURVEY

4. PRIMARY SURVEY
 A : AIRWAY & CERVICAL SPINE
IMMOBILIZATION
 B : BREATHING / VENTILATION
 C : CIRCULATION & HEMORRHAGE CONTROL
 D : DISABILITY ( NEUROLOGICAL
EVALUATION)
 E : EXPOSURE + ENVIRONMENTAL
CONTROL

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. 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. 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. 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. 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. 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. EXPOSURE +ENVIRONMENTAL
CONTROL
 UNDRESS COMPLETELY (USE TRAUMA SCISSORS)
 PREVENT HYPOTHERMIA ( WARM BLANKETS &
WARM FLUIDS)
 EARLY HEMORRHAGE CONTROL
 WARM ROOM TEMPERATURE SHOULD BE
MAINTAINED

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. 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. PHYSICAL EXAMINATION
 HEAD
 MAXILLOFACIAL STRUCTURES
 CERVICAL SPINE & NECK
 CHEST
 ABDOMEN
 PERINEUM,RECTUM & VAGINA
 MUSCULOSKELETAL SYSTEM
 NEUROLOGICAL SYSTEM

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. 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. 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. 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. 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. 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. 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. ATLS OUTLINE
 PRIMARY SURVEY (ABCDE)
 SECONDARY SURVEY 1. HISTORY
2. PHYSICAL
EXAMINATION
3. RELEVANT
INVESTIGATIONS
 RE-EVALUATION
 DEFINATIVE CARE
 TRANSFER