What are the ATLS (Advanced Trauma Life Support) guidelines for trauma care?

Advanced Trauma Life Support (ATLS) Guidelines for Trauma Care

The Advanced Trauma Life Support (ATLS) guidelines provide a systematic, prioritized approach to trauma management through a primary survey (ABCDE), secondary survey, and definitive care phases to reduce morbidity and mortality in trauma patients. 1

Primary Survey (ABCDE)

A - Airway with Cervical Spine Protection

• Establish and maintain a patent airway while protecting the cervical spine in all trauma patients 1
• Exclude traumatic cervical injury before airway manipulation 1
• Consider oro- or nasopharyngeal airways as temporary measures before definitive airway management 1
• Perform endotracheal intubation for definitive airway protection in severe cases 1

B - Breathing and Ventilation

• Ensure adequate oxygenation and ventilation 1
• Provide initial normoventilation if there are no signs of imminent cerebral herniation 2, 1
• Perform immediate needle decompression for suspected tension pneumothorax with hemodynamic instability 1
• Follow needle decompression with chest tube placement for definitive management 1

C - Circulation with Hemorrhage Control

• Control external hemorrhage immediately 2, 1
• Use tourniquets to stop life-threatening bleeding from open extremity injuries in pre-surgical settings 2, 1
• Leave tourniquets in place until surgical control of bleeding is achieved, but keep this timespan as short as possible 2, 1
• Assess the extent of traumatic hemorrhage using mechanism of injury, patient physiology, anatomical injury pattern, and response to initial resuscitation 2, 1
• Minimize time between injury and surgical intervention for patients needing urgent bleeding control 2, 1

D - Disability (Neurological Evaluation)

• Rapidly assess neurological status using Glasgow Coma Scale 1
• Control seizures if present, especially in cases of traumatic brain injury 1
• Maintain PaCO₂ between 35-40 mmHg after stabilization in patients with traumatic brain injury 1

E - Exposure/Environmental Control

• Completely undress the patient to facilitate thorough examination 1
• Prevent hypothermia by using warming strategies 2, 1
• Implement a warming protocol based on the patient's recorded temperature 2

Secondary Survey

• Perform a comprehensive head-to-toe examination after completing the primary survey 1
• Obtain relevant medical history using the AMPLE approach (Allergies, Medications, Past medical history, Last meal, Events/Environment related to injury) 1
• Reassess vital signs frequently 1
• Perform a complete secondary survey to identify all injuries 2

ATLS Classification of Blood Loss

The ATLS system classifies hemorrhage based on initial presentation:

Class	Blood Loss (%)	Pulse Rate	Blood Pressure	Response to Fluid
I	Up to 15%	<100	Normal	Rapid response
II	15-30%	100-120	Normal	Transient response
III	30-40%	120-140	Decreased	Minimal response
IV	>40%	>140	Decreased	No response

2

Special Considerations

Fluid Resuscitation

• Initiate fluid resuscitation for hypotension 1
• Consider vasopressors if fluid resuscitation is inadequate 1
• Target systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion in patients without TBI 1
• Recognize transient responders (initial response to fluid resuscitation followed by deterioration) as unstable patients requiring immediate surgical intervention 2, 1

Traumatic Brain Injury Management

• Avoid hyperventilation in TBI patients unless signs of imminent cerebral herniation are present 2, 1
• Maintain adequate cerebral perfusion pressure 1

Hypothermia Prevention

• Implement warming strategies based on the severity of hypothermia 2
• For mild hypothermia (32-36°C): Use Level 1 and 2 warming strategies (passive external warming, heating pads, warming blankets, radiant heaters) 2
• For severe hypothermia (<32°C): Consider Level 3 invasive strategies (cavity lavage or extracorporeal circuits) 2

Common Pitfalls to Avoid

• Relying solely on blood pressure as an indicator of hemodynamic stability can be misleading 1
• Failing to recognize transient responders who initially stabilize with fluid resuscitation but later decompensate 1
• Delaying definitive intervention in unstable patients 1
• Neglecting to perform a thorough examination for physical trauma when other conditions (like intoxication) are present 1
• Skipping or incompletely performing primary and secondary survey tasks 2, 3
• Hyperventilating trauma patients, which can worsen outcomes 2

Evidence-Based Implementation

• Using a checklist during trauma resuscitation has been shown to improve ATLS task performance and completion 3
• Standardized management of trauma patients in the emergency room improves outcomes 4, 5
• The ATLS approach should be continually repeated to identify deterioration in the patient's condition and make appropriate interventions 6