Slide 1: 1 Advanced Trauma Life Support
Patrick Cheah, MD
Li-Shin Hospital Emergency Department Slide 2: 2 1. Preparation
3. Primary Survey (ABCDEs)
5. Adjuncts to primary survey & resuscitation
6. Secondary Survey (head to toe evaluation & history)
7. Adjuncts to secondary survey
8. Continued post-resuscitation monitoring & re-evaluation
9. Definite care. Slide 3: 3 1. PREPARATION
A Pre-hospital phase
Receiving hospital is notified first.
Send to the closest, appropriate facility.
B In Hospital Phase
Advanced planning for the trauma pt arrival.
Method to summon extra medical assistance
Transfer agreement with verified trauma center established.
Protect from communicable disease. Slide 4: 4 2. TRIAGE
A Multiple Casualties
no of severity & pt do not exceed the ability of the facility.
B Mass Casualties
no & severity of pt EXCEED the capability of the facility & staff. Slide 5: 5 3. PRIMARY SURVEY
A : Airway with cervical spine protect.
B : Breathing
C : Circulation --control external bleeding.
D : Disability or neurological status
E : Exposure (undress) & Environment (temp control) Slide 6: 6 PRIMARY SURVEY
Priorities for the care of Adult , Pediatrics & Pregnancy women are all the same.
During the primary survey life threatening conditions are identified and management is instituted SIMULTANEOUSLY. Slide 7: 7 A. Airway Maintenance with Cervical Spine Protection.
* GCS score of 8 or less require the placement of definite airway.
*Protection of the spine & spinal cord is the important management principle.
*Neurological exam alone does not exclude a cervical spine injury.
*Always assume a cervical spine injury in any pt with multi-system trauma, especially with an altered level of consciousness or blunt injury above the clavicle. Slide 8: 8 B. Breathing & Ventilation
* Airway patency does not assure adequate ventilation.
C. Circulation with Hemorrhage Control.
1. Blood Volume & Cardiac Output
a. level of consciousness.
b. skin color
*external bleeding is identified & controlled in the
*Tourniquets should not be use. Slide 9: 9 D. Disability ( Neurological Evaluation)
Simple Mnemonic to describe level of consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
Not forget to use also Glascow Coma Scale. Slide 10: 10 E. Exposure / Environmental Control
*It is the pt’s body temp that is most important, not he comfort of the health care provider.
*Intravenous fluid should be warm.
*Warm environment (room tem) should be maintained.
*early control of hemorrhage. Slide 11: 11 4. RESUSCITATION
*definite airway if there is any doubt about the pt’s ability to maintain airway integrity.
B. Breathing /Ventilation/Oxygenation
*every injured pt should received supplement oxygen
*control bleeding by direct pressure or operative intervention
* minimum of two large caliber IV should be established
*pregnancy test for all female of child bearing age.
* Lactated Ringer is preferred & better if warm. Slide 12: 12 5. ADJUNCT TO PRIMARY SURVEY &
A. Electro-cardiographic Monitoring
B. Urinary & Gastric Catheter
1. Urinary catheter.
Urethral injury should be suspected if
*Blood at the penile meatus
*Blood in the scrotum
*High riding or nonpalpable prostate
*Pelvic fracture Slide 13: 13 C. Monitoring
1. Ventilatory rate & ABG
2. Pulse oximetry
does not measure ventilation or partial O2 pressure
3. Blood pressure
poor measure of actual tissue perfusion.
D. X-Ray & Diagnostic Studies
C-spine, CXR, Pelvic film
Essential x-ray should not be avoid in pregnant pt.
*** Consider the need for patient transfer. Slide 14: 14 6 SECONDARY SURVEY
Does not begin until the primary survey (ABCDEs)
is completed, resuscitative effort are well established
& the pt is demonstrating normalization of vital sign.
* Head to Toe evaluation & reassessment of all vital
* A complete neurological exam is performed including
a GCS score.
* Special procedure is order. Slide 15: 15 History
A : Allergies.
M : Medication currently used.
P : Past illness/ Pregnancy.
L : Last Meal
E : Events/Environment related to the injury.
*blunt trauma/penetrating trauma/injuries due to cold & burn/hazardous environment? Slide 16: 16 PHYSICAL EXAMINATION
Hemorrhage of conjunctiva and fundi
Contact lenses(remove before edema occurs)
Dislocation of lens
Ocular movement Slide 17: 17 2. Maxillofacial Injury
no NG tube, definite airway?
3. Cervical Spine & Neck
*Pt with maxillofacial or head trauma should be presumed to have and unstable cervical spine.
*elderly pt are not tolerant of even relatively minor chest injury.
*Children often sustain significant injury to the intrathoracic structure without evidence of thoracic skeletal trauma. Slide 18: 18 5. Abdomen
*excessive manipulation of the pelvic should be avoided.
* Protection of spinal cord is required at all times until a spine injury excluded, especially when the pt is transfer. Slide 19: 19 7. ADJUNCT TO THE SECONDARY SURVEY
include additional x-ray and all other special procedure.
Adult urine output 0.5ml/kg/hr
Pediatric urine output 1mg/kg/hr
*Pain relief -- IM should be avoid.
9. DEFINITE CARE Slide 20: 20 Indication For Definite Airway
* Severe maxillo-facial fracture
* Risk for aspiration : Bleeding/ vomiting
* Risk for obstruction : neck hematoma/laryngeal,tracheal injury/ stridor
* Apnea : Neuromuscular paralysis/unconscious
* Inadequate respiratory effort: tachypnea/hypoxia/hypercapnia/cyanosis
* Severe closed head injury need for hyperventilation Slide 21: 21 Normal Blood Amount:
Normal adult blood volume : 7% of body weight
Normal blood volume for child : 8-9% of body weight
Hemorrhage Classification :
Class I Hemorrhage : up to 15% loss
Class II Hemorrhage : 15-30% loss
Class III Hemorrhage : 30-40% loss
Class IV Hemorrhage : >40% loss Slide 22: 22 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 interstitial & intracellular space Slide 23: 23 Initial Fluid Therapy
Lactated Ringer is preferred
* For adult 1-2 liters bolus
* For child 20ml/kg bolus Slide 24: 24 Intraosseous Puncture/Infusion
Children less than 6 y/o for IV access is impossible due to circulatory collapse or for whom percutaneous peripheral venous cannulation had failed on two attempt. Slide 25: 25 Head Injury Classification:
Mild : GCS 14-15
Moderate : GCS 9-13
Severe : GCS 3-8
Coma = GCS score of 8 or less Slide 26: 26 Diagnostic Peritoneal Lavage Indication
A. Change in sensorium--Head injury/alcohol/drug.
B. Change in sensation--Spinal cord injury.
C. Injury to adjacent structure(indicating abd injury)--lower
D. Equivocal physical examination.
E. Prolong loss of contact with patient anticipated.
*** Positive Test: >100,000 RBC/mm3, >500 WBC/mm3 or Gram Stain with bacteria Slide 27: 27 Determining the level of quadriplegia
a. Raise elbow to level of shoulder -- Deltoid C5
b. Flexes the forearm -- Biceps C6
c. Extend the forearm -- Triceps C7
d. Flexes wrist & finger -- C8
e. Spread finger -- T1 Slide 28: 28 Determine the level of paraplegia
a. Flexes the hip -- Iliopsoas L2
b. Extend knee -- Quadriceps L3
c. Dorsiflexes ankle -- Tibialis anterior L4
d. Plantar flexes ankle -- Gastrocnemius S1 Slide 29: 29 Thoracic Trauma
8 lethal Injury
1. Simple pneumothorax
3. Pulmonary contusion
4. Tracheo-bronchial tree injury
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Mediastinal traversing wounds. Slide 30: 30 Slide 31: 31 Fluid Therapy in 2nd or 3rd Degree Burn
Total amount of first 24 hours:
4 ml of Ringer lactate x BW(kg) x BSA
* give 1/2 in first 8 hrs
* 1/2 in remaining 16 hrs Slide 32: 32 Referral to Burn Center
* 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y/o
* 2nd or 3rd degree burn > 20% BSA in other age group
* 2nd or 3rd degree burn of face/eye/ear/hands/feet/ genitalia/perineum or major joints
* 3rd degree burn >5% in any age group
* Significant electrical/lightning injury
* Significant chemical burn
* Inhalation injury Slide 33: 33 Color Codes Triage Tag
RED : Most critical injury
YELLOW : Less critical injured
GREEN : No life or limb threatened injury
BLACK : Death or obviously fatal injury Slide 34: 34 Priorities with multiple injuries
1. Thoracic trauma or tamponade
2. Abdominal hemorrhage
3. Pelvic Hemorrhage
4. Extremity Hemorrhage
5. Intra-cranial Injury
6. Acute Spinal Cord Injury