ATLS study Guide for 2025 Exam Rated A+

ABCDE Mnemonic – A - Airway with cervical spine protection B - Breathing C - Circulation, stop bleeding D - Disability or neurological status E - Exposure (undress) & Environment (temperature control) Breathing & ventilation - injuries that impair ventilation - Severe impairment: * Tension pneumothorax * Flail chest with pulmonary contusion * Massive haemothorax * Open pneumothorax Lesser impairment * Simple pneumothorax / haemothorax * Rib # * Pulmonary contusion Circulation with heamorrhage control - assessing haemodynamic status - LEVEL OF CONSCIOUSNESS Altered level of consciousness may indicate: - ↓ circulating blood volume ∴ ↓ cerebral perfusion SKIN COLOR PULSE * Full, regular pulse = normovolaemia * Rapid, thready pulse ?hypovolaemia Adjuncts to primary survey - ECG - Indicators of blunt cardiac injury: DYSRHYTHMIAS: * Tachycardia * AF * PVC * ST changes PEA can indicate: * Cardiac tamponade * Tension pneumothorax * Hypovolaemia Consider hypoxia & hypo-perfusion if: * Bradycardia * Aberrant conduction * Premature beats Secondary survey - Once primary survey (ABCDE) is complete, resuscitation underway & vital functions normalisation has been demonstrated WHAT IS IT? - Head to toe evaluation - History Secondary survey - AMPLE history - A - Allergies M - Medications P - Past illnesses - Pregnancy L - Last meal E - Events - Environment related to injury Blunt trauma - - Seat belt - Steering wheel deformation - Damage to car + intrusion - Ejection from vehicle Secondary survey - Physical examination - HEAD - SCALP & HEAD: - Lacerations / contusions / fractures EYES: - Visual acuity - Pupillary size - Haemorrhage - conjunctiva / fundus - Penetrating injury - Contact lenses - Lens dislocation - Ocular entrapment - assess eye movements MAXILLOFACIAL STRUCTURES: i) Palpate bony structures ii) Assess occlusion iii) Intraoral examination iv) Assess soft tissues *** Midface fractures may also include cribiform plate fractures *** Secondary survey - Physical examination - CERVICAL SPINE & NECK - *** Presume pts with maxillofacial or head trauma have unstable C-spine injury *** - C-spine tenderness - SC emphysema - Tracheal deviation - Laryngeal # - Carotid arteries - palapate & auscultate ? Seat belt mark *** Do not explore wounds extending through platysma *** Secondary survey - Physical examination - CHEST - - Visual evaluation - Palpation including clavicles / ribs / sternum AUSCULTATION * High anterior ?pneumothorax * Posterior bases ?haemothorax --- Cardiac tamponade: Distant heart sounds & decreased pulse pressure --- Distended neck veins: Tension pneumothorax / cardiac tamponade Laryngeal trauma - Laryngeal fracture is rare - can present with acute airway obstruction INDICATED BY: i) Hoarseness ii) Subcutaneous emphysema iii) Palpable fracture Objective signs of airway obstruction - 1) OBSERVE PATIENT a) Agitation - hypoxia b) Obtundation - hypercarbia c) Cyanosis - hypoxaemia due to inadequate oxygenation - Nail beds & circumoral - Late finding d) Retractions / use of accessory muscles 2) ABNORMAL SOUNDS - Noisy breathing = obstructed breathing i) Snoring / gurgling / crowing (stridor) - partial occlusion of larynx & pharynx ii) Hoarseness (dysphonia) - functional, laryngeal obstruction 3) TRACHEAL POSITION 4) PATIENT BEHAVIOUR - Absuive & belligerent pt maybe due to hypoxia Oxygen delivery methods (BTS guidelines) - RESERVOIR MASK - Delivers 60-90% O2 - 10-15 L/min SIMPLE FACE MASK - Delivers 40-60% O2 - 5-10 L/min - Flows 5 L/min can cause increased resistance to breathing + possible CO2 build up NASAL CANNULAE - Adjustable flow gives wide oxygen dose range (1-6 L/min give FIO2 ~24-50%) Causes of compromised ventilation - i) Airway obstruction ii) Altered ventilatory mechanics - Chest trauma → painful breathing - Prexisting lung disease iii) CNS depression - Intracranial injury → abnormal breathing pattern - C-spinal cord injury → diaphragmatic breathing -Complete c-spinal cord transection (spares phrenic nerve, C3-4) → abdo breathing & intercostal muscle paralysis Objective signs of inadequate ventilation - CHEST WALL MOVEMENT ? Symmetrical chest wall excursion - Asymmetry → splinting of rib cage or flail chest AUSCULTATION - Rapid RR = respiratory distress PULSE OXIMETER - Information about O2 sats & peripheral perfusion Predicting difficult airways - Factors that may predict difficulties with airway maneuvers: i) C-spine injury ii) C-spine arthritis iii) Maxillofacial / mandibular trauma iv) Limited mouth opening v) Obesity vi) Anatomical variations - Receding chin - Overbite - Short, muscular neck LEMON assessment of difficult intubation - L = LOOK EXTERNALLY? Characteristic known to cause difficult intubation / ventilation - Small mouth or jaw / Large overbite / facial trauma EVALUATE 3-3-2 RULE To allow alignment of pharyngeal, laryngeal & oral axes, following relationship must be observed a) 3 fingers breadth distance between incisor teeth b) 3 finger breadth distance between hyoid bone & chin c) 2 finger breadth distance between thyroid notch & floor of mouth M = MALLAMPATI Visualise hypopharynx Mallampati classification - Pt upright or supine - open mouth & protrude tongue CLASSIFICATIONS: Class I Soft palate, uvula, fauces, pillars visible Class II Soft palate, uvula, fauces visible Class III Soft palate, base of uvula visible Class IV Hard palate only visible Anatomy of hypopharynx - FAUCES - Aperture by which mouth communicates with pharynx Boundaries: Superior = soft palate Inferior = dorsum of tongue Lateral = glossopalatine arches PILLARS Anterior pillar = glossopalatine arch Posterior pillar = pharyngopalatine arch PALATINE TONSILS Masses between glossopalatine & pharyngopalatine arches Airway maintenance techniques - 1) Chin-lift 2) Jaw thrust 3) Oropharyngeal airway - Do not use 180° rotation method for insertion in children as it can damage mouth & pharynx 4) Nasopharyngeal airway 5) Extraglottic & supraglottic devices i) LMA / Intubating LMA ii) Laryngeal tube airway iii) Multilumen oesophageal airway Definitive airway - Tube placed in trachea with cuff inflated below the vocal cords 3 types: i) Orotracheal tubes ii) Nasotracheal tubes iii) Surgical airway Indications for definitive airway - NEED FOR AIRWAY PROTECTION 1) Severe maxillofacial fractures 2) Risk of obstruction - Neck haematoma - Laryngeal / tracheal injury - Stridor 3) Risk for aspiration - Bleeding - Vomitng 4) Unconscious NEED FOR VENTILATION 1) Inadequate respiratory effort - Tachypnoea - Hypoxia - Hypercarbia - Cyanosis 2) Massive blood loss & need for volume resusicitation 3) Severe closed head injury + need for hyperventilation if neurological deterioration occurs 4) Apnoea - NM paralysis - Unconscious