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Dr Md Munzur Rahman. FCPS (Ort

Consultant, Department of Orthopaedic Surgery, Rajshahi Medical College Hospi

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Article of the website Dr Md Munzur Rahman, created on: 4/2/2011 8:42:10 PM

By: Dr. Md. Munzur Rahman | Created: 02/04/2011 20:43 |

Advanced Trauma Life Support (ATLS)


Trauma is the leading cause of death in people under 40 years old. Death from trauma has a trimodal distribution :


1.    First peak (Immediate) death (30%)  Those occurring immediately or within few minutes of injury, often before the  patient arrives at hospital usually due to brain or upper spinal cord, the head or major vessels injuries.

2.    Second peak (Early) death (30%)   Occurring between 1st and 4 hours after injury. Cause hyphoxia or hypovolumia. This period also called Golden Hour.

3.    Third peak (late) death (20%)  Occurring days or weeks after injury, generally due to sepsis or multiple organ failure.


Patient who have sustained trauma will often multiple injuries, so it is important to use an organised  and systematic method of examination and treatment to ensure that injuries are not missed. Advance trauma life support is one such system and is routinely used in many accident and emergency departments.


For most severe injuries management proceed in several well-defined stages :


  1. Emergency treatment at the scene of accident & during transit to hospital.
  2. Management in hospital
  3. Finally long term rehabilitation of the patient.



Management at the scene of an accident :


The aims of first aid at the scene are to preserve life, prevent the condition worsening, promote recovery & relieve pain.


The treatment of the individual patient begins at once. The usual process is :


a)    Obtain access

b)    Establish an airway but protect the cervical spine

c)    Ensure ventilation

d)    Arrest haemorhage and combat shock

e)    Give analgesia

f)     Extricate

g)    Splint fracture

h)    Transport





Management in hospital :


 Patient who arrive in hospital after a major accident are at risk of falling into second mortality peak with death from either hyphoxia or hypovolaemic shock. They are also at risk of further damage to their cervical spine, thoraco-lumber spine and brain. This is the Golden Hour during which effective resuscitation  can save lives.


ATLS, consisting of 4 inter-related stages :

  • A rapid primary survey with simultaneous resuscitation.
  • A detailed secondary survey
  • Constant re-evaluation
  • Initiation of definitive care.



Primary Survey : A simple pnemonic for remembering the element of the primary survey is based on the first five letters of the alphabet

A = Airway maintenance with control of cervical spine.

B =  Breathing and oxygenation

C = Circulation and control of bleeding

D = Disability

E = Exposure and avoidance of hypothermia



Airway and cervical spine control


A clear airway must be established as an absolute priority. With control of cervical spine by manual support in natural position or immobilisation by sandbags, forehead tape or collar until the attendant has satisfies him or herself that the airway is secure and there is no cervical injury. A systemic sequence is followed : Chin lift jaw thrust finger sweep suction oropharyngeal tube orotracheal tube and if necessary , surgical  cricothyroidotomy.


Breathing and oxygenation


Even if airway is clear, the peripheral tissues will not be adequately oxygenated unless the patient can breathe. This is due to some life threatening chest injuries such as tension pneumothorax, sucking chest wound, massive haemothorax and  flail chest must be considered. Most chest injuries can be managed with a canula or chest tube.







Circulation and control of bleeding


Circulation is assess by 1) state of consciousness 2) skin color, 3) pulse and 4) BP. Bleeding is controlled by pressure.




A rapid neurological evaluation is performed at the end of the primary survey. This neurologic evaluation assess by AVPU and pupillary size and reaction

A = Alert

V = Responds to vocal stimuli

P = Responds to painful stimuli

U = Unresponsive


Exposure and avoidance of hypothermia


The patient should be completely undressed to facilitate through examination and assessment. The environment must be considered.


Constant re-examination


The patient must be re-evaluated frequently to assess the response to resuscitation and detect any deterioration at the earliest moment.



Secondary survey:


This stage comprises a head to toe examination of undressed and stable patient. This includes

  1. Head and GCS (Glasgow coma scale)
  2. Maxillofecial trauma
  3. Cervical spine & neck
  4. Chest
  5. Abdomen
  6. Rectum
  7. Fractures
  8. Investigation includes ;

a)    CXR

b)    X-ray pelvis

c)    X-ray cervical /spine

d)    CT

e)    USG

f)     MRI




Definite Treatment


This is decided by the finding during the primary and 2ndary surveys. Other specialist assistant may be required and the patient may betransfer.


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By: Dr. Md. Munzur Rahman | Created: 02/04/2011 20:40 |