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 Contraindications to nasotracheal intubation - Fractures - facial / frontal sinus / basilar skull / cribiform plate Signs: i) Nasal fracture ii) Raccoon eyes (bilateral periorbital ecchymosis) iii) Battle's sign (post-auricular ecchymosis) iv) Rhinorrhoea / otorrhoea (CSF leakage) Suxamethonium / succinylcholine - caution - Depolarising NM blocker CAUTION i) Hyperkalaemia - Caution with severe crush injuries / burns / electrical injuries ii) Malignant hyperthermia → uncontrolled skeletal muscle oxidative metabolism Surgical airway - Surgical airway required when airway obstructed by: - Oedema of glottis - Laryngeal fracture - Oropharyngeal haemorrhage Surgical cricothyroidotomy preferred to tracheostomy: i) Easier to perform ii) Less bleeding iii) Requires less time to perform Needle cricothyroidotomy - a) Plastic cannula through cricothyroid membrane b) Connected to 15L O2 c) Jet insufflation - 1sec ON / 4 sec OFF ** Inadequate exhalation ∴ CO2 accumulates ** Can be used for 30-45 mins Assessing adequate oxygenation - PULSE OXIMETRY - Measures O2 sats of arterial blood - Does not measure PaO2 ** Sats ≥95% suggests adequate peripheral arterial oxygentaion (PaO2 70mmHg or 9.3kPa) NOTE: i) Requires intact peripheral perfusion ii) Cannot distinguish oxyhaemoglobin from carboxyhaemoglobin / metheamoglobin LIMITED USEFULNESS IN: a) Vasoconstriction b) CO poisoning c) Profound anaemia (Hb 5g/dL) d) Hypothermia (30°) When is pulse oximetry unreliable? - i) Poor peripheral perfusion ii) Severe anaemia iii) High levels of carboxyhaemoglobin or methaemoglobin iv) High levels of circulating dye (e.g. indocyanine green / methylene blue) v) Excessive pt movement vi) Intense ambient light Oxygen dissociation curve - * Describes relationship between pO2 (x) & O2 sats (y) * Hb binds 4 O2 molecules reversibly * Binding of first molecule is difficult but facilitates binding of subsequent molecules FACTORS AFFECTING CURVE RIGHT SHIFT = Hb has decreased affinity for oxygen - Difficult for Hb to bind O2 / easier to release - Increases pO2 in tissues (e.g. during exercise / shock) LEFT SHIFT = Hb has increased affinity for O2 - Binds O2 more easily / releases it less easily Factors affecting oxygen dissociation curve - MNEMONIC for causes of right shift: 'CADET, face right' C = CO2 A = Acid D = 2,3-DPG E = Exercise T = Temperature (Increases in these causes right shift) Complications of needle cricothyroidotomy - i) Inadequate ventilation → hypoxia / death ii) Aspiration (blood) iii) Oesophageal laceration iv) Perforation of posterior tracheal wall v) Haematoma vi) Subcutaneous / mediastinal emphysema vii) Thyroid perforation viii) Pneumothorax Complications of surgical cricothyroidotomy - i) Aspiration (blood) ii) Creation of false passage into tissues iii) Subglottic stenosis / oedema iv) Haemorrhage / haematoma formation v) Oesophageal / tracheal laceration vi) Mediastinal emphysema vii) Vocal cord paralysis, hoarseness Definition of shock - Abnormality of the circulatory system that results in inadequate tissue perfusion & oxygenation Basic cardiac physiology - cardiac output - CARDIAC OUTPUT Volume of blood pumped by the heart per minute HR x SV (mL/beat) = CO (L/min) Basic cardiac physiology - stroke volume - STROKE VOLUME (amount of blood pumped with each cardiac contraction) - Determined by: a) Preload b) Myocardial contractility c) Afterload Basic cardiac physiology - Preload 1 - PRELOAD (volume of venous return to heart) - Determined by: a) Venous capacitance b) Volume status c) Difference between mean venous systemic pressure & right atrial pressure * Pressure differential determines venous flow * Basic cardiac physiology - Preload 2 - Venous system like a reservoir / capacitance system Volume of blood divided into 2 components: i) Volume of blood remaining in system if pressure in system was zero - Does not contribute to mean systemic venous pressure ii) Venous volume that contributes to mean systemic venous pressure * Pressure gradient drives venous flow * Basic cardiac physiology - myocardial contractility - Volume of venous return determines myocardial muscle fibre length after ventricular filling at the end of diastole - Muscle fibre length relates to muscle contractility according to Starling's law Frank-Starling law of the heart - Stroke volume increases in response to increase in volume of blood filling the heart (end diastolic volume) when all other factors remain constant Basic cardiac physiology - Aferload - Resistance to forward flow of the heart Blood loss pathophysiology - CIRCULATORY RESPONSES TO BLOOD LOSS Compensation: - Vasoconstriction of cutaneous / muscle / visceral circulation - Preserves blood flow to kidneys / heart / brain → TACHYCARDIA = earliest sign ↑ PERIPHERAL VASCULAR RESISTANCE - ↑ DBP & ↓ PULSE PRESSURE Recognition of shock - Signs of shock: i) Tachycardia ii) Cutaneous vasoconstriction iii) ↓ pulse pressure iv) ↑ RR v) ↓SBP Neurogenic shock - * Isolated intracranial injuries do not cause shock * - Cervical / upper thoracic spinal cord injury → hypotension due to loss of sympathetic tone Haemorrhagic shock - Haemorrhage = acute loss of circulating blood volume * Normal adult blood volume ~ 7% of body weight * Class I haemorrhage (≤ 15 blood volume loss) - MINIMAL CLINIC SYMPTOMS i) Possibly minimal tachycardia No changes in BP / PP / RR - For healthy patients, no replacement required ∵ cap. refill & other compensatory mechanisms wiil restore blood volume within 24 hrs Class II haemorrhage (15-30% blood volume loss) - ~ 750-1500mL blood loss (70kg man) i) Tachycardia (100bpm) ii) Tachypnoea iii) ↓ pulse pressure iv) Subtle CNS changes - anxiety / fright / hostility v) UO only mildly affected (20-30 mL/hr) Most pts stabilised with crystalloid replacement Class III haemorrhage (30-40% blood loss) - ~ mL (70kg man) Classic signs of inadequate perfusion: i) Tachycardia ii) Tachypnoea iii) Changes in mental status iv) ↓ SBP - Require transfusion Class IV haemorrhage (40% blood loss) - Immediately life-threatening i) Tachycardia ii) ↓ SBP iii) Very narrow pulse pressure iv) Negligible UO v) Depressed mental status vi) Cold, pale skin Contraindication for transurethral catheterisation (male) - i) Blood at urethral meatus ii) High-riding, mobile or non-palpable prostate Need radiographic confirmation of intact urethra Vascular access - 2 large-bore cannula * Rate of flow is: a) Proportional to fourth power of radius of cannula b) Inversely proportional to length ∴ wide, short cannulas are preferred for rapid infusion of large volumes of fluid Composition of commonly used IV fluids - Evaluation of fluid resuscitation & organ perfusion - Acid-base balance - Early hypovolaemic shock: - Tachypnoea → respiratory alkalosis - Followed by mild metabolic acidosis Long-standing / severe shock: - Severe metabolic acidosis - Inadequate tissue perfusion → anaerobic metabolism → lactic acid production Response to initial fluid resuscitation - Pattern of response to initial fluid administration, 3 groups: i) Rapid response ii) Transient response iii) Minimal / no response Response to initial fluid resuscitation - rapid response - - Respond to initial fluid bolus - Remain haemodynamically normal - Minimal blood loss (20%) - Keep G&S & crossmatched blood available Response to initial fluid resuscitation - transient response - - Respond to initial fluid bolus - Deterioration of perfusion indices: ? Ongoing blood loss / inadequate resuscitation - Blood loss = 20-40% - Transfusion of blood products indicated - Requires operative / angiographic haemorrhage control Response to initial fluid resuscitation - minimal or no response - - Failure to respond → immediate definitive intervention (operation / angioembolization) May be due to pump failure: a) Blunt cardiac trauma b) Cardiac tamponade c) Tension pneumothorax Special consideration in diagnosis / treatment of shock - Mistaken equation of BP with CO - 1) Mistaken equation of BP with CO - Treating shock requires correcting inadequate tissue perfusion by increasing organ blood flow & tissue oxygenation - Increasing blood flow requires ↑CO Ohm's law: V = I x R BP (V) proportional to CO (I) and SVR (R) a) ↑ BP does not necessarily mean ↑ CO. b) Could be due to ↑ SVR , e.g. with vasopressors BUT tissue perfusion is not improved Special consideration in diagnosis / treatment of shock - Advanced age - 2) Advanced age i) ↓ sympathetic activity - ↓ catecholamine response & ↓ cardiac compliance ∴ unable to compensate ii) Atherosclerosis → organs sensitive to ↓ blood flow iii) Pre-exisiting volume depletion - Diuretics - Subtle malnutrition iv) Respiratory system - ↓ Pulmonary compliance - ↓ Diffusion capacity - Weakness of respiratory muscles → Unable to meet ↑ gas exchange demands Special consideration in diagnosis / treatment of shock - Athletes - Altered CV dynamics: i) ↑ blood volume 15-20% ii) ↑ CO iii) ↑ SV iv) Bradycardia Special consideration in diagnosis / treatment of shock - Pregnancy - Maternal hypovolaemia ∴ greater blood loss until perfusion abnormalities Special consideration in diagnosis / treatment of shock - Medications - a) β-blockers / Ca-channel blockers - Alters haemodynamic response b) Insulin OD - ? Hypoglycaemia c) Diuretics - ? Hypokalaemia d) NSAIDs - altered platelet function Femoral venepuncture - locating femoral vein - Femoral vein lies medial to femoral artery Mnemonic NAVEL: N - Nerve A - Artery V - Vein E - Empty space L - Lymphatic Complications of femoral venous access - i) DVT ii) Arterial / neurologic injury iii) Infection iv) AV fistula Complications of central venous puncture - i) Pneumothorax / haemothorax ii) Venous thrombosis iii) Arterial or neurological injury iv) AV fistula v) Chylothorax vi) Infection vii) Air embolism Complication of intraosseous puncture - i) Infection ii) Through & through bone penetration iii) Subcutaneous & subperiosteal infiltration iv) Skin pressure necrosis v) Physeal plate injury vi) Haematoma Venous cutdown - Sites for venous cutdown: 1) Greater saphenous vein (medial ankle) - 2cm anterior & superior to medial malleolus 2) Antecubital medial basilic vein - 2.5cm lateral to medial epicondyle of humerus at flexion crease of elbow Complications of peripheral venous cutdown - i) Cellulitis ii) Haematoma iii) Phlebitis iv) Perforation of posterior vein wall v) Venous thrombosis vi) Nerve transection vii) Arterial transection Beck's triad - 3 medical signs associated with cardiac tamponade: i) Elevated venous pressure - ↓ diastolic filling of RV due to expanding pericardial sac → ↑CVP & distended neck veins ii) Low arterial BP - Pericardial fluid accumulation impairs ventricular stretch & SV iii) Muffled heart sounds Kussmaul's sign - Paradoxical rise in JVP on inspiration - indicates limited RV filling due to right heart failure PATHOPHYSIOLOGY Normally: JVP falls on inspiration - ↓ pressure as thorax expands & ↑ RV expansion during diastole Kussmaul sign: RV filling impaired due to: i) Pericardial fluid ii) Poor compliance of myocardium / pericardium - Impaired filling → reduced venous return & jugular venous distension Haemothorax - guideline for operative exploration - i) 1500mL blood obtained immediately from chest tube ii) 200mL/hr for 2-4 hrs is drained iii) Blood transfusion required Complications of needle thoracocentesis - i) Local haematoma ii) Pneumothorax iii) Lung laceration Complications of chest tube insertion - i) Laceration / puncture of thoracic / abdominal organs ii) Pleural infection iii) Damage to neurovascular bundle iv) Incorrect tube position v) Chest tube occlusion, kinking vi) Persistent penumothorax - leak vii) Subcutaneous emphysema viii) Recurrence of pneumothorax ix) Lung fails to expand - plugged bronchus x) Anaphylactic / allergic reaction to surgical preparation / anaesthetic Complications of pericardiocentesis - i) Aspiration of ventricular blood instead of pericardial blood ii) Laceration of ventricular epicardium / myocardium iii) Coronary artery / vein laceration iv) New haemopericardium - secondary to laceration of cardiac structure v) VF vi) Pneumothorax vii) Great vessel puncture → worsening pericardial tamponade viii) Oesophageal puncture → mediastinitis ix) Peritoneal puncture → peritonitis / false positive aspirate Anatomy of abdomen - ANTERIOR ABDOMEN (boundaries) Superior - between costal margins Inferior - Inguinal ligaments & symphysis pubis THORACO-ABDOMEN (boundaries) Area inferior to: i) Trans-nipple line anteriorly ii) Infra-scapular line posteriorly + Superior to costal margins FLANK Area between ANTERIOR & POSTERIOR AXILLARY LINES from SIXTH ICS to the ILIAC CREST BACK - Posterior to posterior axillary line - Tip of scapulae to iliac crests Truncal & cervical injuries from restraint devices - Lap Seat Belt: - Compression - Hyperflexion - - Tear / avulsion of mesentery (Bucket Handle) - Rupture of small bowel / colon - Thrombosis if iliac artery or abdominal aorta - Chance failure of lumbar vertebrae - Pancreatic / duodenal injury Truncal & cervical injuries from restraint devices - Shoulder Harness: - Sliding under seat belt (submarining) - Compression - - Intimal tear / thrombosis in innominate, carotid, subclavian or vertebral arteries - Fracture / dislocation of cervial spine - Pulmonary contusion - Rupture of upper abdominal viscera Truncal & cervical injuries from restraint devices - Air Bag: - Contact - Contact / deceleration - Flexion (unrestrained) - Hyperextension (unrestrained) - - Corneal abrasions - Face, neck, chest abrasions - Cardiac rupture