General principles of

management of trauma
and ATLS
By Wegene, MD, Assistant Prof. of Surgery
Introduction
• James K. Styner
• more than nine people die every minute from
injuries or violence,
• 5.8 million people die every year from unintentional
injuries and violence
• Trauma accounts 18% of the world’s total diseases.
• Motor vehicle crashes (RTA) is the leading cause of
death due to injury worldwide.

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Cont’d

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TRIMODAL DEATH DISTRIBUTION

1) The first peak

Within seconds to minutes of injury
Cause of death-apnea due to severe brain or high spinal
cord injury or rupture of the heart, aorta, or other large
blood vessels.
Only prevention can significantly reduce this peak of
trauma-related deaths.
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TRIMODAL DEATH DISTRIBUTION
2) The second peak - within minutes to several hours
Cause of death - subdural and epidural hematomas,
hemopneumothorax, ruptured spleen, lacerations of the liver,
pelvic fractures, and/or multiple other injuries associated with
significant blood loss.
Golden hour  ATLS
3) The third peak - several days to weeks after the initial injury,
due to sepsis and multiple organ system dysfunctions.
What factors affect outcomes?

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Initial Assessment of trauma patient
• Preparation
• Triage
• Primary survey (ABCDEs)
• Adjuncts to the primary survey and resuscitation
• Consideration of the need for patient transfer
• Secondary survey
• Adjuncts to the secondary survey
• Continued post resuscitation monitoring and
revaluation
• Definitive care
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Cont’d

• The primary and secondary surveys are repeated frequently

• ATLS® principles guide the assessment and resuscitation of injured

patients.
•

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Preparation
• Prehospital phase to notify the receiving hospital before personnel
transport the patient from the scene.
• Hospital phase  Critical aspects of hospital preparation
A resuscitation area
Properly functioning airway equipment (e.g., laryngoscopes and
endotracheal tubes)
Warmed intravenous crystalloid solutions
A protocol to summon additional medical assistance is in place,
Transfer agreements

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Triage
• Multiple casualties
• Mass casualties
Who should be treated first?

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• 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.

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PRIMARY SURVEY WITH
SIMULTANEOUS RESUSCITATION
• Patients are assessed, and their treatment priorities are established,
based on their injuries, vital signs, and the injury mechanisms.
• The primary survey encompasses the ABCDEs of trauma care
Airway maintenance with restriction of cervical spine motion
Breathing and ventilation
Circulation with haemorrhage control
Disability(assessment of neurologic status)
Exposure/Environmental control
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 Quick Assessment

What is a quick, simple way

to assess a patient in 10 seconds?

● Identify yourself
● Ask the patient his or her
name
● Ask the patient what
happened

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 Appropriate Response
Confirms

A Patent airway

B Sufficient air reserve to permit

speech

C Sufficient perfusion to permit

cerebration

D Clear sensorium
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AIRWAY MAINTENANCE WITH RESTRICTION
OF CERVICAL SPINE MOTION
• Check airway patency
• Obstruction??
• Restrict cervical spine motion
• Patient is able to communicate verbally???
• TBI pt with GCS ≤8 definitive airway

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 AIRWAY
MANAGEMENT

• Clear mouth
• Chin lift/jaw thrust
• Guedel / Nasopharyngeal airway
• Intubation
• Cervical spine care
• tracheostomy

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19-Jun-21 ATLS 17
Cont’d

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BREATHING AND VENTILATION
Ventilation requires adequate function of the lungs, chest wall, and
diaphragm;
 Assess and ensure adequate oxygenation and ventilation

 Respiratory rate
 Chest movement
 Air entry
 Oxygen saturation

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BREATHING
BEWARE

• Tension pneumothorax
• Massive haemothorax
• Open pneumothorax
• Flail chest
• Lung contusion

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BREATHING
MANAGEMENT

• Oxygen (if available)

• Artificial ventilation
• Decompress pneumothorax
• Drain haemothorax

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Primary survey
CIRCULATION
ASSESSMENT
• Cardiac output

• Blood volume

• External haemorrhage

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 Primary Survey

Circulation
Assess for organ perfusion

● Level of consciousness
● Skin color and temperature
● Pulse rate and character

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 Primary Survey

Circulatory Management

● Control
hemorrhage
● Restore volume Pitfalls
Elderly
● Reassess patient
Children
Athletes
Medications

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CIRCULATION
BEWARE

• Intra-abdominal injury
• Intra-thoracic injury
• Long bone fracture
• Pelvic fracture
• Penetrating injury
• Scalp wounds

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CIRCULATION
MANAGEMENT

• Stop bleeding
• Large bore intravenous access x 2
• Blood for crossmatch and Hb
• Administer IV fluid

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 Primary Survey

Disability

● Baseline neurologic
evaluation
● Glasgow Coma Scale
score
● Pupillary response
Caution
Observe for
neurologic
deterioration

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DISABILITY
• Pupils
• Check awareness
• A Awake
• V Responds to verbal command
• P Responds to pain
• U Unresponsive

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 Primary Survey

Exposure / Environment
Completely undress the patient

Caution
Prevent
hypothermia

Pitfalls
Missed
injuries

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 Resuscitation

● Protect and secure

airway
● Ventilate and
oxygenate
● Stop the bleeding!
● Vigorous shock
therapy
● Protect from
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hypothermia
REASSESSMENT OF ABCDE

If patient is, or becomes, unstable

 Adjuncts to Primary Survey

Vital signs
ECG ABGs

PRIMARY SURVEY
Pulse
Urinary
oximeter
output
and CO2
Urinary / gastric catheters
unless contraindicated

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PRIMARY SURVEY
X-RAYS ( if available)

Cervical spine (lateral)

Chest

Pelvis

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 Adjuncts to Primary
Survey
Diagnostic Tools

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 Adjuncts to Primary
Survey
Diagnostic Tools

● FAST
● DPL

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 Adjuncts to Primary Survey

Consider Early Transfer

● Use time before
transfer for
resuscitation
● Do not delay
transfer for
diagnostic tests

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 What is the secondary
survey?

The complete
history and
physical
examination

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 Secondary Survey

When do I start the secondary survey?

After
● Primary survey is completed
● ABCDEs are reassessed
● Vital functions are returning to
normal

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SECONDARY SURVEY

• On completion of primary survey

• When ABC’s are stable
• Aim to find any injury that may threaten life or
limb
• It is a thorough head to toe examination
• Immediately return to ABC’s if any deterioration

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 Secondary Survey

What are the components of the secondary survey?

● History
● Physical exam: Head to toe
● Complete neurologic exam
● Special diagnostic tests
● Reevaluation

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 Secondary Survey

History
Allergies

Medications

Past illnesses
Last meal
Events
/ Environment /
Mechanism

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 Secondary
Survey
Mechanisms of Injury

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SECONDARY SURVEY
HEAD EXAMINATION

• Scalp (bruising, lacerations)

• Skull (tenderness, depression)
• Eyes (pupils, fundi, lens, conjunctva)
• CSF or blood from ear, nose, mouth

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 Secondary Survey

Maxillofacial
● Bony crepitus
● Deformity
● Malocclusion
Pitfalls
Potential airway
obstruction
Cribriform plate fracture
Frequently missed

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 Secondary Survey

Neck (Soft
Tissues)
Mechanism: Blunt vs penetrating
Symptoms: Airway obstruction,
hoarseness
Findings: Crepitus, hematoma, stridor, bruit

Pitfalls
Delayed symptoms and
signs
Progressive airway
obstruction

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Occult injuries 46
 Secondary Survey

Chest
● Inspect
● Palpate
● Percuss
● Auscultate
● X-rays

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 Secondary Survey

Abdomen
● Inspect /
Auscultate
● Palpate / Percuss
● Reevaluate
● Special studies
Pitfalls Hollow viscous injury
Retroperitoneal injury

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 Secondary Survey

Perineum
Contusions, hematomas, lacerations,
urethral blood

Rectum
Sphincter tone, high-riding prostate, pelvic
fracture,
rectal wall integrity, blood
Pitfalls
Urethral injury
Vagina Pregnancy
Blood, lacerations
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 Secondary Survey

Pelvis
● Pain on palpation
● Leg length unequal
● Instability
● X-rays as needed

Pitfalls
Excessive pelvic
manipulation
Underestimating pelvic
blood loss
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 Secondary Survey

Extremities
● Contusion, deformity
● Pain
● Perfusion
● Peripheral
neurovascular status
● X-rays as needed

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 Secondary Survey

Musculoskeletal

Pitfalls
Potential blood loss
Missed fractures
Soft tissue or ligamentous injury
Compartment syndrome (especially
with altered sensorium / hypotension)

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 Secondary
Survey
Neurologic:
● GCS
Brain
● Pupil size and
reaction
● Lateralizing signs
● Frequent
reevaluation
● Prevent secondary
brain injury Early
neurosurgical
consult
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 Secondary Survey

Neurologic: Spinal
Assessment
● Whole spine
● Tenderness and swelling
● Complete motor and sensory exams
● Reflexes
● Imaging studies
Pitfalls
Altered sensorium
Inability to cooperate with
clinical exam

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 Secondary
Survey
Neurologic: Spine and
Cord
Conduct an in-depth evaluation
of the patient’s spine and spinal
cord

Early
neurosurgical /
orthopedic
consult

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 Secondary
Survey
Neurologic

Pitfalls
Incomplete immobilization
Neurologic deterioration

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SECONDARY SURVEY

DON’T FORGET THE BACK!

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SECONDARY SURVEY
LOG ROLL

• Adequate number of personnel ( 4 )

• One giving commands - usually
airway/neck controller
• Clear timing and instructions
• Look for wounds, bruising, tenderness,
deformity of spine, sensation

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 Adjuncts to Secondary
Survey

Special Diagnostic Tests as Indicated

Pitfalls
Patient
deterioration
Delay of
transfer
Deterioration
during transfer
Poor
communication
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SECONDARY SURVEY
X-RAYS

• In secondary survey if not already done

• Chest
• Cervical spine - all 7 vertebrae
• Pelvis
• Others as indicated by examination

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 Pain
Management

● Relief of pain /
anxiety as
appropriate
● Administer
intravenously
● Careful monitoring is
essential

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 Transfer

Which patients do I transfer to

a higher level of care?

Those whose injuries exceed institutional

capabilities:
● Multisystem or complex injuries
● Patients with comorbidity or age extremes

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 Transfer
When should the transfer
occur?

As soon as possible after stabilizing

measures are completed:

● Airway and ventilatory control

● Hemorrhage control (operation)

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 Transfer to Definitive Care

Local facility

Transfer
agreements
Local resources

Trauma Specialty
center facility

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 Summary

Primary Survey
Definitive Care
Adjuncts
Resuscitation
Reevaluation
Reevaluation

Detailed
Secondary
Survey Adjuncts
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References

• ATLS, Advanced Trauma Life Support, 10th Edition

• Schwartz’s Principles of Surgery, 11th Edition

• Internet

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Thank you
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