ATLS protocol

Advanced Trauma Life Support (ATLS) for MBBS Students

History of ATLS

The James Styner Story

The Advanced Trauma Life Support program emerged from a tragic yet transformative event in 1976. Dr. James Styner, an orthopedic surgeon from Nebraska, was piloting his family on a trip when their small aircraft crashed in a cornfield in Nebraska. The crash resulted in:

  • Death of his wife
  • Serious injuries to his four children
  • Dr. Styner himself sustained critical injuries

When they reached the local hospital, Dr. Styner was shocked by the inadequate trauma care. The emergency physician lacked proper trauma training, and there were no established protocols for managing multiple trauma victims. This experience made Dr. Styner realize that trauma patients in rural and even urban hospitals were receiving suboptimal care due to lack of standardized training.

Development into a Worldwide Course

Following his recovery, Dr. Styner collaborated with the American College of Surgeons (ACS) to develop what would become ATLS:

  1. 1978 – First ATLS course conducted in Auburn, Nebraska
  2. 1980 – ACS officially adopted ATLS as a national program
  3. 1980s – Rapid expansion across the United States
  4. 1990s – International expansion began
  5. Present – ATLS is taught in over 60 countries worldwide

Key Milestones:

  • Over 1 million healthcare providers trained globally
  • Regular updates every 4 years based on evidence-based medicine
  • Currently in its 11th edition (2025)
  • Recognized as the gold standard for initial trauma management
 

  • ATLS Approach to Patient Management

    Core Philosophy

    ATLS follows a systematic, prioritized approach based on the principle that “the greatest threat to life is addressed first.”

    What is killing patient?

    The xABCDE Approach( ATLS 11th edition)

    1. x- eXsanguinating eXternal hemorrhage
    2. A – Airway (with cervical spine protection)
    3. B – Breathing (ventilation and oxygenation)
    4. C – Circulation (with hemorrhage control)
    5. D – Disability (neurological assessment)
    6. E – Exposure/Environment (complete examination and temperature control)

    Identify life threatening & then limb/organ threatening conditions as soon as possible and do necessary interventions without waiting for investigations. e.g in case of absent breath sounds on hemithorax, tachypnea, tracheal shifting to other side ,Do needle thoracostomy/ICD without waiting for X-ray Chest

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Pre-hospital Care Guidelines

Scene Safety and Assessment

  • Ensure scene safety for responders
  • Rapid scene survey and mechanism of injury assessment
  • Call for appropriate resources (air ambulance, specialized teams)

Pre-hospital ABCDE Management

Airway:

  • Open airway using jaw thrust (not head tilt-chin lift if C-spine injury suspected)
  • Clear visible debris
  • Consider basic airway adjuncts (oropharyngeal/nasopharyngeal airways)
  • Advanced airway only if trained and necessary

Breathing:

  • High-flow oxygen for all trauma patients
  • Identify and treat tension pneumothorax
  • Seal open chest wounds

Circulation:

  • Control external bleeding with direct pressure
  • Establish IV access if possible
  • Fluid resuscitation (limited in penetrating trauma)
  • Pelvic binder for suspected pelvic fractures

Disability:

  • Rapid neurological assessment (GCS)
  • Maintain spinal immobilization

Exposure:

  • Prevent hypothermia
  • Rapid trauma survey

Transport Decisions

  • Load and Go situations:
    • Airway compromise
    • Hemodynamic instability
    • Altered mental status
    • Significant mechanism of injury

Management at Tertiary Care Center

Preparation Phase

  • Pre-arrival notification from EMS
  • Activate trauma team
  • Prepare resuscitation bay
  • Ensure equipment readiness

Primary Survey (First 2-5 minutes)

A – Airway Assessment:

  • Speak to patient (if responsive, airway is patent)
  • Look for obstruction, facial fractures, neck hematoma
  • Management: Jaw thrust, suctioning, definitive airway if needed
  • Always maintain C-spine immobilization

B – Breathing Assessment:

  • Look: chest movement, respiratory distress, cyanosis
  • Listen: breath sounds bilaterally
  • Feel: chest wall integrity, subcutaneous emphysema
  • Immediate life threats to identify:
    • Tension pneumothorax → Needle decompression/ICD
    • Open pneumothorax → Occlusive dressing
    • Massive hemothorax → Chest tube

C – Circulation Assessment:

  • Pulse quality and rate
  • Blood pressure
  • Capillary refill
  • Skin color and temperature
  • Hemorrhage control:
    • Direct pressure
    • Tourniquet for extremity bleeding
    • Pelvic binder
    • Identify need for blood products

D – Disability Assessment:

  • Glasgow Coma Scale
  • Pupillary response
  • Gross motor and sensory function
  • Blood glucose level

E – Exposure:

  • Complete undressing
  • Log roll for back examination
  • Prevent hypothermia with warming measures
 

Secondary Survey

Only after primary survey is complete and patient is stable

  1. History (AMPLE):
    • Allergies
    • Medications
    • Past medical history
    • Last meal
    • Events leading to injury
  2. Head-to-toe examination:
    • Systematic examination of all body regions
    • Neurological assessment
    • Appropriate imaging studies

Key ATLS Guidelines and Principles

Resuscitation Guidelines

Fluid Resuscitation:

  • Initial bolus: 20 mL/kg crystalloid (pediatric), 1-2L (adult)
  • Blood transfusion if no response initial crystalloid
  • Massive transfusion protocol when indicated

Blood Product Ratios (Massive Transfusion):

  • PRBC : FFP : Platelets = 1:1:1 ratio
  • Goal: damage control resuscitation

Imaging Guidelines

Primary Survey Imaging:

  • Chest X-ray
  • Pelvic X-ray
  • C-spine imaging 
  • e-FAST (extended-Focused assessment with sonography for Trauma)

Secondary Survey Imaging:

  • CT scan (when patient is stable)

Definitive Care Priorities

  1. Damage Control Surgery (if indicated)
  2. Transfer criteria to higher level of care
  3. Disposition planning

Special Considerations

Pediatric Modifications

  • Weight-based medication dosing
  • Different normal vital signs
  • Consider non-accidental trauma

Elderly Patients

  • Comorbidities affect response
  • Medications (anticoagulants)
  • Lower physiological reserve

Pregnancy

  • Maternal stabilization is priority
  • Left lateral positioning
  • Early obstetric consultation
 

  • Conclusion

    ATLS represents a paradigm shift in trauma care, transforming it from an unorganized response to a systematic, evidence-based approach. The program’s success lies in its:

    • Standardized methodology
    • Global applicability
    • Regular updates based on evidence
    • Emphasis on teamwork and communication

    As future physicians, mastering ATLS principles is crucial for providing optimal trauma care and potentially saving lives in critical situations.

    Remember: “The first hour after injury is the most critical – what you do or fail to do during this time can determine whether the patient lives or dies.”

Birth of ATLS

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