Summary of Primary Survey ATLS Bahan Ajar

SUMMARY OF
ATLS
dr. Michael John Tedjajuwana, Sp. OT

WHAT WE HAVE TO
PREPARE?
advanced trauma life support, ninth edition
1. PREPARATION
• Pre-hospital
 Notify receiving hospital
 Closest appropriate facility
 Report pertinent information
• In-hospital
 Warmed IV solutions
 Ancillary departments notified
 Equipment made readily available
 Hospital personnel protection
AT HOSPITAL
WHAT IS TRIAGE?
2. TRIAGE PHASE
• Triage : sorting of patients based on their needs for
treatment and the resources available to provide that

treatment.
• Triage situations are categorized as multiple casualties
or mass casualties.
2. TRIAGE PHASE
MULTIPLE CASUALITIES MASS CASUALITIES
• Number and severity of the
• Number of severity do not
patient exceed the capability
exceed the ability of the
of the facility and staff
facility
• Patients having the greatest
• Patients with life- threatening
chance of survival and
problems and those
requiring the least
sustaining multiple-system
expenditure of time,
injuries are treated first.
equipment, supplies,
and personnel, are treated
first.
WHAT SHOULD WE DO
WHEN TRIAGE?
Check Consciousness
How?
Triage
A V P U
Triage
Verbal Pain
Alert Unresponsive
(stimulus) (stimulus)
Triage
Verbal Pain
Alert Unresponsive
(stimulus) (stimulus)
Response : Eye Opening
• Conscious
• Decrease consciousness
• Unconscious
Primary Survey
Step-by-step evaluation :
Assessment
Treatment Maintain
HOW TO CONDUCT PRIMARY
SURVEY IN CONSCIOUS PATIENTS?
Triage
Assess Response : eye opening
Conscious Unconscious/ Decrease consciousness
Primary survey
Can speak
Airway (+)
Breathing (+)
Circulation (+)
Is there any DISTRESS?

Airway : Overview Of Physiology

• How do our voice being produced?
• Voice = Air flow vibrate by the vocal cord

Breathing : Overview Of Physiology

• VOICE = EXPIRATION
• What is the difference between VOICE and
WORDS ?
Circulation : Overview Of Physiology

• MUSCLE needs Perfusion to contracted
HOW DO WE KNOW IF THERE ANY
DISTRESS CONDITION IN
CONSCIOUS PATIENTS?
• Additional Sound (+)  Airway problem
• Short of breath  Breathing problem
• Changing in pulse rate, Hypotension 
Circulation problem
HOW TO CONDUCT PRIMARY
SURVEY IN PATIENTS WITH
DECREASE OF CONSCIOUSNESS
OR UNCONSCIOUS?
3. PRIMARY SURVEY
Goals: Find out if there is any : CARDIAC
ARREST and RESPIRATORY FAILURE
Evaluate:
A = airway + C-spine control
B = breathing + ventilation
C = circulation + bleeding control
D = disability
E = exposure
AIRWAY
Step-by-step evaluation : Airway
Assessment Assessment
Airway Breathing
Treatment Maintain Treatment Maintain
Assessment
Circulation
Treatment Maintain
HOW DO YOU ASSESSING THE
AIRWAY IN PATIENTS WITH
OR UNCONSCIOUS?
Airway : Assessment
Unconscious/decreased consciousness
Look, Listen, Feel ATLS
Look : maxillofacial Listen : Additional sound Feel : tracheal deviation

injury  Snoring : tongue
 Gurgling : fluid
 Stridor : solid
Interpretation : Clear, Partial Obstruction, Total Obstruction

HOW DO YOU
TREATING THE AIRWAY
PROBLEM?
Airway : Treatment
Clear Partial/Total Obstruction
Treatment
Non-tools Tools
 Finger sweep  Forceps
 Cross finger  Suction
Maintain
Without tools
Oropharyngeal swab
Finger Thrust Finger Sweep
Cross Finger
With tools
• Suction • Magill Forceps
HOW DO YOU
MAINTAIN THE CLEAR
AIRWAY?
Airway : Maintain
Maintain
Non-tools Tools
(Positioning)
 Guedel (OPT)
 Head tilt-chin lift  Laryngeal Mask Airway
 Jaw thrust maneuver  Nasopharyngeal Tube
 Endotracheal Tube
Without tools
Head tilt – chin lift
• Put the patients on supine
position
• Put the palm on the
patients forehead, push
gently backward
• Support patients chin with
index and middle finger,
right in the middle of
arcus mandibular, then
push it upward
• Evaluate ventilation
Without tools
Head tilt – chin lift
chin lift
head tilt
Don’t do
chin lift
neck lift
Head Tilt – Chin Lift
Without tools
Jaw thrust maneuver
• For cervical spine injury suspected
patients.
• Helper use their thumbs to physically
push the posterior (back) aspects of he

mandible upwards (patient with a GCS
< 8).
• When the mandible is displaced

forward, it pulls the tongue forward and
prevents it from occluding (blocking)
the entrance to the trachea, helping to
ensure a patent (secure) airway.
Without tools
Jaw thrust maneuver
• Stand at the top of the casualty’s head.
• Rest your elbows on the surface where casualty is lying
(ground, etc).
• Place one hand on each side of the casualty’s lower jaw
at the angle of the jaw, below the ears.
• Stabilize the casualty’s head with your forearms.
• Use the index fingers to push the angels of the patient’s
lower jaw forward.
• Use the thumb to retract the patient’s lower lip to keep the
casualty’s mouth open, if necessary.
Without tools
Jaw thrust maneuver
With tools
Guedel
Placing the Oropharyngeal Airway
With tools
Laryngeal Mask Airway
With tools
Nasopharyngeal airway/tube
Not to cause the vomiting reflex

Use with caution in patients with suspected basis cranii fracture
Tube diameter for an adult is about 7 mm or can be estimated from his/her small
finger
With tools
Endotracheal tube
• Failure to relieve the
airway from other ways
• Difficulty to deliver
supportive breathing
• High risk of pulmonary
aspiration
• The need to prevent
hypercarbia (head injury)
• GCS 8 or lower
With tools
Endotracheal tube
Airway : Problems
• Every problems on the airway passage which disrupt air
exchange (ventilation) totally or partially.
• E.g :
 Foreign body obstruction
 Base of the tongue obstruction on unconscious patients
 Airway tract edema or spasm
 Airway damage
• How to know that there is airway blockage?

A force pushing back the oxygen given.
Desaturation even after O₂ support
Difficult Airway Problem

OTHER AIRWAY
PROBLEM
Chocking
Signs:
• Universal sign of chocking : hand
at neck, neck slightly flexed
• Unable to speak nor breath
• Swollen face and cyanosis
• Conscious → Unconscious
Chocking Treatment
Heimlich Maneuver/Abdominal Thrust
Combination of Back Blows & Abdominal
Thrusts / Heimlich Maneuver (Five and Five)
Chocking Treatment
Back blow / Back slap
• Embrace the patients from • The other free arm do the back
behind slap/back blow
• Hold patients body with one arm • Back slap/back blow by slap
• Prevent the patients from fall patients back, right between 2
scapula
Chocking Treatment
Back blow/Back slap on the infant
• Put on prone position above one of
rescuers arm, with head lower than
body
• Keep the mouth open with middle finger
• Hold the shoulder with palm and other
finger
• Do back blow/back slap between
scapulas, with base of the other
rescuers palm
• Back slap/back blow five times gentely
Chocking Treatment
Chest thrust
• Put on supine position above
rescuers thigh
• Chest thrust:
• Used index and middle finger
• Placed both finger above the
sternum, right about 1 cm below
imaginary line between two nipples
• Do chest thrust 5 times
• Evaluation
Instead on infant chest thrust was also

indicated for:
Pediatrics, pregnant, and obese victims
BREATHING
Step-by-step evaluation : Breathing
Airway Breathing
Treatment Maintenance Treatment Maintenance
Assessment
Circulation
Treatment Maintenance

• Air flow vibrate by the vocal cord
• VOICE = EXPIRATION

HOW DO YOU ASSESSING THE
BREATHING IN PATIENTS WITH
OR UNCONSCIOUS?
Breathing : Assessment
Unconscious/decreased consciousness
Look, Listen, Feel ACLS
Look Listen Feel
Chest -
expansion Breath -
sound Breath
flow
• Interpretation : Normal, Respiratory distress, Respiratory failure/arrest
• In ATLS, breathing assessment consist of inspection, palpation, auscultation, and
percussion.
HOW DO YOU TREATING
THE BREATHING
PROBLEMS?
Breathing Failure : Breathing Support

Without tools
Mouth to mouth/nose
Mouth to Mouth Mouth to Nose
With tools
Ambu Bag / Self Inflating Bag
• Elastic rubber bag which
flows amount of air when it
pumped, and will re
expand automatically
• Contain one direction
valve
• Deliver oxygen at 60-80%
concentration
• Oxygen concentration may
rise until 100% by
additional source of
oxygen
With tools
Jackson Rees
• Elastic rubber bag, which
expanded by oxygen
flow at around 10-12
lt/min. flow rate.
• For that reason this
breathing equipment
depend on oxygen flows.
• Contain no breathing
valve
• Deliver oxygen at 100%
concentration
With tools
Ventilators
• Mechanical equipment to
deliver artificial breathing into
the lungs.
• Require electricity and high
pressure gas as it activator.
• Available basic settings:
• Tidal volume (6 ml/kg body
weight)
• Frequency 12-20 times/min.
• Peak inspiratory pressure 40
cmH2O
• Oxygen content 100 %
Breathing : Treatment
How long we should administer breathing support?
Answer : Until spontaneous breathing start again.

If (-) Use ventilator
HOW DO WE KNOW IF THERE IS
ANY DISTRESS BREATHING IN
PATIENTS WITH DECREASE OF
CONSCIOUSNESS OR
UNCONSCIOUS?
Breathing : Assessment
Normal Distress Failure
Life- threatening
condition?
 Tension pneumothorax
 Open pneumothorax
 Flail chest
 Massive hemothorax
 Cardiac tamponade
Managed
Breathing Distress : Life Threatening

Conditions
 Tension
pneumothorax
 Massive haemothorax
 Intercostal disruption /
Flail chest
Tension pneumothorax : Overview

Tension pneumothorax : Overview

• Air trapping in the • Physical exam
pleural space between Absent breath sounds
the lung and chest wall Air hunger
• Sufficient pressure Distended neck veins
builds up and pressure Tracheal shift

to compress the lungs
and shift the • Treatment
mediastinum Needle decompression
Chest Tube (WSD)
Tension pneumothorax : X-ray

Tension pneumothorax : Treatment

 Needle Thoracostomy
- Midclavicular line - Over the 2nd rib
- Rush of air is heard - 14 gauge angiocath

Chest-Tube Insertion
 Insertion site : 5th intercostal
space, Anterior axillary line
1. Sterile prep, anesthesia with
lidocaine
2. 2-3 cm incision along rib margin
with #10 blade
3. Dissect through subcutaneous
tissues to rib margin
4. Puncture the pleura over the rib
5. Advance chest tube with clamp
and direct posteriorly and
apically
6. Observe for fogging of chest
tube, blood output
7. Suture the tube in place


Complications of Chest
Tube Placement
 Injury to intercostal
nerve, artery, vein
 Injury to lung
 Injury to mediastinum
 Infection
 Allergic reaction to
lidocaine
 Inappropriate placement
of chest tube
Open Pneumothorax : Overview

• Sucking Chest Wound
• Large defect of chest
wall
• Leads to rapid
equilibration of
atmospheric and
intrathoracic pressure
• Impairs oxygenation
and ventilation
Open Pneumothorax : X-ray
Pleural cavity pressure

= atmospheric pressure
Open Pneumothorax : Treatment

• Initial Treatment
 Three sided occlusive
dressing
 Provides a flutter valve effect
 Chest tube placement remote
to site of wound
 Avoid complete dressing, will
create a tension
pneumothorax
Massive Haemothorax : Overview

• Blood collecting in the • Physical Exam
pleural space and is Absent or diminished
common after penetrating breath sounds
and blunt chest trauma Dullness to percussion
• Source of bleeding over chest
Lung Hemodynamic
Chest wall (intercostal instability
arteries)
Heart
Great vessels (Aorta)
Diaphragm
Massive Haemothorax : X-ray

Massive Haemothorax : Treatment
Large Caliber Tube

Thoracostomy
 10-20% of cases will
require thoracostomy
for control of bleeding
Cardiac Tamponade: Overview

Cardiac Tamponade: Overview

Clinical sign+sypmtoms Physical examination
Dyspnea • Beck’s triad = acute
Tachycardia compression triad
Tachypnea Increased jugular
Decreased urine output venous pressure
Confusion Hypotension
Cold and clammy Diminished heart
extremities sounds.
Cardiac Tamponade: Pathophysiology

Cardiac Tamponade: X-ray

Cardiac Tamponade: Treatment

Pericardiocentesis
1. Sterilize the subxiphoid area.
2. Insert a pericardiocentesis needle
between the xiphoid and the left costal
margin at a 45 degree angle.
3. Remove the stylet, aim the tip of the
needle towards the patients left shoulder.
4. Slowly advance the needle while
applying negative pressure on the
syringe.
5. Advance the needle until there is return
of fluid.
Flail Chest: Overview

Overview Physical exam
• Direct injury to the chest • Paradoxical movement
resulting in an unstable of chest segment
segment of the chest wall
that moves separately from
remainder of thoracic cage
• Typically results from two or
more fractures on 2 or more
ribs
• Typically accompanied by a
pulmonary contusion
Flail Chest: Overview

Paradoxical movement of chest segment
Flail Chest: X-ray

Flail Chest: Treatment

• Improve abnormalities in gas exchange
• Early intubation for patients with respiratory distress
• Avoidance of overaggressive fluid resuscitation

Breathing : Overview
Normal Distress Failure
Life- threatening Ventilation/Breathing support

condition?
Without tools With tools

 Flail chest Mouth to • Ambu bag
 Massive hemothorax mouth • Jackson-Reese
 Cardiac tamponade • Ventilators
Managed Recovery of spontaneous breathing
Maintain : oxygenation
HOW DO YOU MAINTAIN
THE SPONTANEOUS
AIRWAY?
Breathing : Maintain
• Respiratory Normal breathing : O₂ support
• Respiratory Distressed : increase O₂ support
CIRCULATION
Step-by-step evaluation : Circulation
Airway Breathing
Treatment Maintenance Treatment Maintenance
Assessment
Circulation
Treatment Maintenance
Circulation : Assessment and Treatment

Assessment : carotid artery pulsation?
+ -
Back to breathing Start CPR

evaluation  Push hard, push fast
 Frequency:100x/min
Chest Compression
One helper Two or more helper
• Initial breath support • Start compression with

twice 30:2 ratio
• Start compression with • Until we got the carotid
30:2 ratio pulse again
• Until we got the carotid
pulse again
Circulation : Maintain
• IVFD
Adding preload of heart
Starling’s Law : higher preload will force the
heart to pump harder
Flushing of medicine
• Urine catheterization : to assess output of
the fluid we administer
Disability
Use Glasgow Coma Scale
Environment
• Remove all clothing
Examine for other signs of injury
Injuries cannot be diagnosed until seen by provider
• Logroll the patient to examine patient’s back

Maintain cervical spinal immobilization
Palpate along thoracic and lumbar spine
• Avoid hypothermia
Apply warm blankets after removing clothes
Hypothermia = Coagulopathy (increases risk of hemorrhage)
Trauma Logroll
 One person = Cervical
spine
 Two people = Roll main
body
 One person = Inspect
back and palpate spine
How to make this Position?
Recovery Position
Positioning : recovery position

OUTLINE OF EMERGENCY PATIENT MANAGEMENT

Patient come in Triage
AVPU
Conscious Consciousness Unconscious
Primary survey
No Respiratory+Cardiac arrest Respiratory + Cardiac arrest
No Respiratory Resuscitation room

Respiratory +cardiac
+cardiac Clear
distress
distress CPR
Adjunct
 Vital signs Life- threatening condition
 ECG Secondary survey
 X-ray
 Urine output Head-to-toe
+ -

Resuscitation
Respiratory + cardiac arrest room
CPR
Respiratory spontaneous Respiratory failure Dead

Cardiac spontaneous Cardiac spontaneous
Adjunct
 Vital signs
 ECG
 X-ray
Secondary survey  Urine output
Head-to-toe
HCU ICU : ventilator


Respiratory + cardiac distress Surgical/ non
surgical room
Life- threatening condition
- +
Managed  Open pneumothorax
 Flail chest
 Massive hemothorax
Adjunct
 Vital signs
Secondary survey  ECG
Head-to-toe  X-ray
 Urine output
•Thank you
SECONDARY SURVEY
4. SECONDARY SURVEY
• Start right after primary survey completed
Stabilized patient
Vital sign stable
• Head to toe examination:
• Check from Cranial to Caudal & Anterior to
Posterior
4. SECONDARY SURVEY
History
 A Allergies
 M Medications
 P Past illnesses
 L Last meal
 E Events related to injury
1.Blunt
2.Penetrating
3.Burns
4.Hazardous Environment
4. SECONDARY SURVEY
• Head to toe examination
HEENT (Head, Eyes, Ears, Nose, Throat)
Neck
Chest
Abdomen
Pelvis
Genitourinary
Extremities
Neurologic
HEENT
Evaluate Pitfalls
• Head • Hyphemia
• Eyes • Optic nerve injury
• Ears • Lens dislocation
• Nose • Head injury
• Throat • Posterior scalp laceration
HEENT
Battle Sign Raccoon's Eyes
Maxillofacial
Evaluate Pitfalls
• Midline facial fractures • Pending airway obstruction
• Bite occlusion • Changes in airway status
• Bleeding • Cervical spine injury
• Fracture : repair can wait • Exsanguinating midface
fracture
• Lacrimal duct lacerations
• Facial nerve injuries
Midface Fracture :La-Fort

C-spine and neck

Evaluate Pitfalls
• Must be immobilized • C-spine injury
• Inspection • Esophageal injury
• Palpation • Tracheal or laryngeal
• Auscultation (carotids) injury
• Carotid injury (blunt or
penetrating
Chest
Evaluate Pitfalls
• Visual evaluation (ant & • Open chest wound
post) • Aortic rupture (widened
• Palpate rib cage mediastinum)
• Sternal pressure
• Auscultation (heart &
lungs)
• Chest xray
Abdomen
Evaluate Pitfalls
• Frequently repeated • Liver or splenic flexure
exams • Deceleration injuries :
• Inspection Hollow viscus, Lumbar spine
• Palpation • Pancreatic injury
• Normal initial exam does • Major intraabdominal
not rule out injury vascular injury
• Peritoneal lavage v.s. CT • Renal injury
scan v.s. U/S (FAST) • Pelvic fractures
Abdomen
Cullen’s Sign Grey-Turner’s Sign

Abdomen
Seatbelt Sign
Perineum/Rectum/Vagina
Evaluate Pitfalls
• Contusions, hematomas, • Urethral injury
lacerations • Rectal injury
• Urethral bleeding • Bladder injury
• Rectal blood • Vaginal injury
• High riding prostate
• Sphincter tone
• Vaginal vault injuries
(pelvic fractures)
Musculoskeletal
Evaluate Pitfalls
• Contusion • SPINE FRACTURES
• Deformity • Fractures with vascular
• Palpation compromise
• Pelvic pressure and • Pelvic fractures
compression • Digital fractures
• Vascular exam
• Neurologic exam
Neurologic
Evaluate Pitfalls
 Immobilization of entire • Increased intracranial
patient pressure
 Reevaluate GCS
 Cranial nerve exam
• Subdural hematoma
 Motor exam • Epidural hematoma
 Sensory exam • Depressed skull fracture
 Monitor frequently for
changes in neuro status
• Spine injury
 Assess O2 delivery if • Beware of unconscious
changes noted patient
 Early neurosurgical
consultation
Subdural Hematoma
Epidural Hematoma
4. SECONDARY SURVEY : ADJUNCT

• Radiology
Standard emergent films (C-spine, CXR, Pelvis)
Focused Abdominal Sonography in Trauma (FAST)
Additional films
Cat scan imaging
Angiography
• Foley Catheter
Blood at urethral meatus = No Foley catheter
• Pain Control
• Tetanus Status
• Antibiotics for open fractures

Focused Abdominal Sonography in Trauma
• Bedside ultrasound looking for blood collection in an
unstable patient.
• If the patient is unstable and a blood collection is found,
proceed to the operating theater.

• 4 views of the abdomen to look for fluid.
• RUQ/Morrison’s pouch
• Sub-xiphoid – view of heart
• LUQ – view of spleen-renal junction
• Bladder – view of pelvis
FAST – Subxiphoid view
Normal view (+) Pericardial effusion

FAST – RUQ view

FAST – LUQ view
• View between the spleen

and kidney
• Another dependent place
that fluid collects
• Also see diaphragm in this
view
FAST – Bladder view
• Evaluates for fluid in the

pouch of Douglas
• Posterior to bladder
• Dependent potential space
5. AFTERCARE
• Continuous adjunct re-evaluation
 Vital signs
 ECG
 X-ray
 Urine output
• Definitive care : ward/ HCU/ ICU

•Thank you

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SUMMARY OF

dr. Michael John Tedjajuwana, Sp. OT

treatment and the resources available to provide that

Response : Eye Opening

Conscious Unconscious/ Decrease consciousness

Is there any DISTRESS?

Airway : Overview Of Physiology

• Voice = Air flow vibrate by the vocal cord

Breathing : Overview Of Physiology

Circulation : Overview Of Physiology

Treatment Maintain Treatment Maintain

Look, Listen, Feel ATLS

Look : maxillofacial Listen : Additional sound Feel : tracheal deviation

Interpretation : Clear, Partial Obstruction, Total Obstruction

• Helper use their thumbs to physically

push the posterior (back) aspects of he

• When the mandible is displaced

Not to cause the vomiting reflex

• How to know that there is airway blockage?

Difficult Airway Problem

Instead on infant chest thrust was also

Treatment Maintenance Treatment Maintenance

Breathing : Overview Of Physiology

Breathing : Overview Of Physiology

Look, Listen, Feel ACLS

Look Listen Feel

• Interpretation : Normal, Respiratory distress, Respiratory failure/arrest

• In ATLS, breathing assessment consist of inspection, palpation, auscultation, and

Breathing Failure : Breathing Support

Answer : Until spontaneous breathing start again.

Breathing Distress : Life Threatening

Tension pneumothorax : Overview

Tension pneumothorax : Overview

builds up and pressure Tracheal shift

Tension pneumothorax : X-ray

Tension pneumothorax : Treatment

Tension pneumothorax : Treatment

Tension pneumothorax : Treatment

Tension pneumothorax : Treatment

Open Pneumothorax : Overview

Open Pneumothorax : X-ray

Pleural cavity pressure

Open Pneumothorax : Treatment

Massive Haemothorax : Overview

Massive Haemothorax : X-ray

Massive Haemothorax : Treatment

Large Caliber Tube

Cardiac Tamponade: Overview

Cardiac Tamponade: Overview

Cardiac Tamponade: Pathophysiology

Cardiac Tamponade: X-ray

Cardiac Tamponade: Treatment

Flail Chest: Overview

Flail Chest: Overview

Flail Chest: X-ray

Flail Chest: Treatment

• Early intubation for patients with respiratory distress

• Avoidance of overaggressive fluid resuscitation

Life- threatening Ventilation/Breathing support