From the Guidelines
Advanced Trauma Life Support (ATLS) should prioritize a systematic approach to trauma care with the primary survey (ABCDE) as its cornerstone, focusing on rapid identification and treatment of life-threatening injuries to improve patient outcomes. The primary survey includes assessing and securing the Airway while maintaining cervical spine protection, evaluating Breathing by assessing respiratory rate, effort, and oxygen saturation, treating life-threatening conditions like tension pneumothorax with needle decompression, and controlling hemorrhage and assessing perfusion for Circulation 1.
Key Components of ATLS
- Assess and secure the Airway while maintaining cervical spine protection
- Evaluate Breathing by assessing respiratory rate, effort, and oxygen saturation
- Control hemorrhage and assess perfusion for Circulation
- Establish two large-bore IVs (16-18 gauge) and administer crystalloid fluids like normal saline or Lactated Ringer's at 1-2 L initially for hypotension
- Assess Disability through the Glasgow Coma Scale and pupillary response
- Perform Exposure by completely undressing the patient while preventing hypothermia
Damage Control Resuscitation Principles
- Permissive hypotension (target systolic BP 80-90 mmHg in penetrating trauma without TBI)
- Balanced blood product administration (1:1:1 ratio of packed red cells:plasma:platelets)
- Limiting crystalloids
- Early use of tranexamic acid (1g IV over 10 minutes followed by 1g over 8 hours) within 3 hours of injury 1
Classification of Blood Loss
The American College of Surgeons Advanced Trauma Life Support (ATLS) classification of blood loss is based on initial patient presentation, including blood loss, pulse rate, blood pressure, pulse pressure, respiratory rate, urine output, and central nervous system/mental status 1.
Recent Guidelines
The European guideline on management of major bleeding and coagulopathy following trauma (sixth edition) recommends a systematic approach to trauma care, including rapid bleeding control and resuscitation with blood products, and emphasizes the importance of early evaluation and correction of trauma-induced coagulopathy 1.
From the Research
Essential Information for Advanced Trauma Life Support
- Severe trauma is a significant global problem, mainly affecting young and healthy adults 2
- Development of a regional trauma system can lead to a 15-50% reduction in mortality 2
- Trauma teams led by senior doctors provide better care, but the involvement of doctors in pre-hospital care lacks clear evidence of benefit 2
Airway Management
- Poor airway management is a common cause of avoidable morbidity and mortality 2
- Rapid sequence induction/intubation is frequently indicated, but the ideal drugs have not been identified 2
- The benefits of cricoid pressure are not clear-cut 2
Fluid Resuscitation
- The choice of fluid for resuscitation is controversial, with both crystalloids and colloids having their advantages and disadvantages 3, 4, 5, 6
- Crystalloids are less efficient than colloids at stabilizing resuscitation endpoints, but may be less likely to cause adverse effects such as renal failure 4
- Colloids can expand plasma volume more effectively, but may impair coagulation and cause anaphylactoid reactions 6
- The ideal initial resuscitation fluid remains unclear, with different studies suggesting different approaches 2, 3, 4, 5, 6
Resuscitation Goals
- Identification of significant hemorrhage can be difficult, and specific early resuscitation goals are not easily definable 2
- A hypotensive approach may limit further bleeding, but could worsen significant brain injury 2
- Early aggressive blood product resuscitation may be beneficial in appropriately selected patients 2