ATLS initial management Dr. Khalid Abdulwahid CABS, FRCS(England)

initial management
Dr. Khalid Abdulwahid
CABS, FRCS(England)
Al Bashir teaching hospital
Tri model death distribution
• First peak: within seconds to minutes of injury, result
of apnea(brain or high spinal cord), rupture heartaorta-large vessel
• Second peak: within minutes to several hours, result
of subdural-epidural hematomas,
hemopneumthorax, rupture spleen, liver laceration,
fracture pelvic.
• Third peak: several days to weeks after injury, result
of sepsis and multi organ dysfunction
Initial assessment
• Treatment of seriously injured patient requires rapid
assessment of injury and institution of life preserving
therapy. Because time is of the essence, a systemic
approach includes:
1- Preparation
2- Triage
2-Primary survey (ABCDE) and resuscitation
3- adjunct to primary survey and resuscitation
4-secondary survey and resuscitation
5-definitive care
• Pre hospital phase: pre hospital agency and
personnel, maintain airway, control bleeding,
immobilization, transport contact. Record of injury:
time, events related to injury, patient history,
mechanism of injury
• Hospital phase: hospital informed, equipment ready;
airway, tubes, warmed IVF, protection (mask, gloves,
aprons, glasses)
• Sorting of patients based on there need for treatment
and resources available to provide that treatment. Two
types present:
• 1- multiple casuality: No. of patients and severity don not
exceed the ability of the facility to render care. Patient
with life threatening problems and mutiple system
injuries treated first.
• 2- mass casuality: No. of patients and severity of their
injury exceeds the capability of the facility and staff.
Patient with greatest chance of survival, least
expenditure of time , equipment and personnel treated
Primary survey
1- Airway and cervical spine
2- Breathing and ventilation
3- Circulation and hemorrhage control
4- Disability: neurologic status
5- Exposure/ Environment control: completely
undress the patient but prevent hypothermia
• During primary survey life threatening conditions
identified and managed simultaneously.
Primary survey
Airway and cervical spine protection:
 inspection F.B, facial- mandibular-tracheal
fractures, do chin lift jaw thrust to open airway.
 prevent excessive movement of cervical spine, use
cervical collar.
Primary survey
• Breathing and ventilation
 Assess chest wall excursion and auscultation
 visual inspection, palpation and percussion looking
for; tension pneumothorax, flail chest, pulmonary
contusion, massive hemothorax or open
Primary survey
• Circulation and hemorrhage control
 Look for hypotension, tachycardia, altered level of
consciousness, pale cold skin.
 External bleeding identified and controlled during
primary survey.
• Disability: neurologic status
 Level of consciousness, pupillary size and reaction,
lateralizing signs and spinal cord injury level.
Primary survey
• Exposure/ Environment control:
 Undress , complete assessment, cover with warm
blankets, warm IVF,
• Airway : protect airway; jaw thrust or chin lift, oral
airway, definitive airway( tube, tracheotomy)
• Breathing : treatment of hemo or pneumothorax
• Circulation : IVF, blood,2 large peripheral( or central
line or cut down) IV cannula fixed with infusion of 12 liters of warmed crystalloid solution(37-40 c).
control of external or internal bleeding by pressure,
suture ligation, cautery, operation,
angioembolization, fracture fixation…etc
Adjunct to primary survey
• ECG monitoring: tachycardia, dysrhythmia, pulseless
electrical activity: cardiac temponade, tension
• Urinary and gastric catheter
• Ventilatory rate and ABG
• Pulse oximetry
• Blood pressure
• X ray and diagnostic tests: FAST and DPL, but not CT.
• Consider transport
Secondary survey
AMPLE history
A: allergies
M: medications
P: past illness/ pregnancy
L: last meal
E : events/ environment related to the injury
Secondary survey
• Adjunct to secondary survey:
 Spinal X-ray
 CT head, chest, abdomen, and or spine
 Contrast urography
 Angiography
 Extremity X-ray
 Transesophageal US
 Bronchoscopy
 esophagoscopy
• Definitive care?
A 22-year-old man is hypotensive and tachycardic after a shotgun wound
to the left shoulder. His blood pressure is initially 80/40 mm Hg. After 2
liters of crystalloid solution his blood pressure increases to 122/84 mm Hg.
His heart rate is now 100 beats per minute and his respiratory rate is 28
breaths per minute. His breath sounds are decreased in the left
hemithorax, and after initial IV fluid resuscitation, a closed tube
thoracostomy is performed for decreased left breath sounds with the
return of a small amount of blood and no air leak. After chest tube
insertion, the most appropriate next step is
A) reexamine the chest.
B) perform an aortogram.
C) obtain a CT scan of the chest.
D) obtain arterial blood gas analyses
E) perform transesophageal echocardiography
• In managing the head-injured patient, the
most important initial step is to
• A) secure the airway.
• B) obtain c-spine film.
• C) support the circulation
• D) control scalp hemorrhage.
• E) determine the GCS Score.
• A 7-year-old boy is brought to the emergency
department by his parents several minutes after he
fell through a window. He is bleeding profusely from
a 6-cm wound of his medial right thigh. Immediate
management of the wound should consist of
A) application of a tourniquet.
B) direct pressure on the wound.
C) packing the wound with gauze.
D) direct pressure on the femoral artery at the groin.
E) debridement of devitalized tissue.
Which one of the following findings in an adult
should prompt immediate management during the
primary survey?
A) Distended abdomen.
B) Glasgow Coma Scale Score of 11.
C) Temperature of 36.5°‫آ‬C (97.8°‫آ‬F).
D) Heart rate of 120 beats per minute.
E) Respiratory rate of 40 breaths per minute.
Thank you
The most important, immediate step in the
management of an open pneumothorax is
A) endotracheal intubation.
B) operation to close the wound.
C) placing a chest tube through the chest wound.
D) placement of an occlusive dressing over the
E) initiation of 2, large-caliber IVs with crystalloid