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Revision notes - ADVANCE TRAUMA LIFE SUPPORT (ATLS) - 9th edition - How to assess.


A- Airway maintainance with cervical spine protection
B- Breathing and ventilation
C- Circulation and haemorrhage control
D- Disability (Neurological status)
E- Exposure/enviromental control - completely undress patient but prevent the


1) SpO2 ,pulse and BP monitoring
2) Urinary catherization
3) ABG
4) ECG
5) Chest and pelvic xray
6) FAST scan or DPL(rarely to perform)

Life threatening condition need to suspect in primary survey (summarization)

A- Airway obstruction
T- Tension pneumothorax
O- Open pneumothorax
M- Massive hemothorax
F- Flail chest
C- Cardiac tamponade

A. Airway maintainance with cervical spine protection:

- ascertain patency
- rapidly asscess for airway obstruction

Management - to establish patent airway:

- chin-lift or jaw thrust manuever
- clear the airway from foreign body
- establish definitive airway (if indicated):
-- intubation
-- surgical crycothyroidotomy
- maintain the cervical spine in neutral posotion
- reinstate immobilization of c-spine with appropriate devices after establishing
the airway

B. Breathing and ventilation:

- Expose the neck and chest and ensure immobilization of the head and neck
- determine rate and depth of the respirations
- inspect and palpate for tracheal deviation, chest movements, use of assessory
muscles or any signs of injury
- percuss of presence of any dullness or hyperesonance
- auscultate chest bilaterally

- administer high concentration of O2
- ventilate with bag-mask device (if unble to maintain saturation)
- alleviate tension pneumothorax --> needle thoracocentesis
- seal open pneumothorax
- attach CO2 monitoring device to ETT tube
- attach pulse oxymetry to patient
C. Circulation and Haemorrhage control

- identify source of external, exsanguinating haemorrhage
- identify potential source of external haemorrhage
- assess pulse - quality, rate, regularity and paradox.
- evaluate skin colour
- measure blood pressure if times permits

- apply direct pressure to external bleed
- consider presence of internal Hge and potential need for operative intervention
and obtain surgical consult
- TWO IV large bore branulla
- obtain blood for haematological and chemical analysis
- IV fluid theraphy (preferable 1-2 L of crystalloid) + blood replacement
- prevent hypothermia.

D. Disability:
- Determine the level of concious - GCS scoring
- Check pupil size and reaction
- Assess for laterizing signs and spinal cord injury

E. Exposure/Environmental control
- completely undress patient but prevent hypothermia


1. Obtain AMPLE history

A- Allergies
M- Medications currently used
P - Past ilness/ pregnancy
L- Last meal
E - Events/environment related to injury

2. Head to toe examinations - read further in the protocol.



- spinal xrays
- CT head, thorax or abdomen or spine
- Contrast urography
- Angiography
- Extremity xrays
- Bronchoscopy/Esophagoscopy

For your information, marks will be given for active participation in forum
discussion and also the content of your discussion.

Primary Survey:

After DRS

1. A: Airway Maintenance and Cervical Spine Protection

2. B: Breathing: Ventilation and Oxygenation

3. C: Circulation and Haemorrhage Control

4. D: Disability: Brief Neurologic Examination


- Pupils

- Lateralizing sign and spinal cord injury

5. E: Exposure and Environmental Control

Adjunct to Primary Survey:



- ECG/ Cardiac monitoring

- CBD and Ryle's tube (unless contraindicated), monitor urine output

- AP chest and AP pelvic x-rays


Secondary Survey:

1. AMPLE history and mechanism of injury

2. Head to toe examination

Adjunct to secondary survey:

- Spine x-ray

- CT head, chest, abdomen and/ or spine

- Contrast urography

- Angiography
- Extremities x-ray

- Bronchoscopy

- Oesophagoscopy

Assalamu'alaikum and Hello to Dr Fauzi and all fellow friend.Establishing an airway

is the priority in the management of trauma patient.There is a lot indications for
intubation such as:-

1)Airway obstruction persists despite oropharyngeal airway.

2)Adequate ventilation not possible via bag and mask ventilation.

3)Needs definitive airway protection

4)Unresponsive to pain stimulus

5)Flaccid limbs,decerebrate/decorticate posturing;GCS=8/15 or less

6)Needs prolonged ventilation

7)Respiratory burn injury

Here i want to share about "Rapid Sequence Induction/Intubation".The best mneumonic

to use is "7P".




c)Equipment (M-A-L-E-S)

M-Magill Forcep,Mask,

A-Ambu bag,Airway Guedel(NPA/NPA),Anchor tape

L-Laryngoscope,LMA,Lubricating gel

E-Endotracheal tube,End tidal CO2

S-Syringe,Suction,Stetoscope,Stylet,10cc Syringe,


-3 to 5 minutes of normal tidal volume breathing or 8 vital capacity breath with

100% of oxygen to prevent desaturation during intubation.

3)Pre medication
-IV Fentanyl 2-3 mcg/kg

-IV Lidocaine 100mg

4) (a) Paralysis with induction,given rapid iv push prior to paralysis

-Iv Etomidate 0.3mg/kg

-Iv Midazolam 0.2-0.3mg/kg

-IV Ketamine 1.5mg/kg

(b) Paralytic agent by IV push immedietly after induction agent

-IV Succinylcholine 1.5mg/kg

-IV Rocuronium 1mg/kg


-Perform Sellick Maneuver/Cricoid pressure should be applied as soon as

consciousness lapses and be maintain throughout intubation untill placement of

6)Placement with proof

-Insert ET tube with direct visualization of the vocal chord

-Inflate cuff

-Confirm ET tube is in the trachea using end tidal CO2 if available

-Auscultation on 5 point which is at epigastrium,Bilateral anterior of clavicle

or midclavicular line and bilateral in axillary line/5th intercostal space

-Secure ET tube with tape

-Release Sellick maneuver

7)Post Intubation care


-12 lead ECG

-Cardiac monitoring

-CXR-tip of ET tube tip should be at mid of trachea

-Initiate mechanical ventilation


-NG Tube

-CBD tube

-Close Vital sign monitoring (Every 15 minutes)

-Eye pad

-Cover with blanket to prevent hypothermia

-referral to icu