Dr.

Mohammad Hassan Abbas

MBBS (KE), FCPS (Surgery), FCPSI (Medicine), ATLS, PTC,

Assistant Professor Surgery

ATLS

A Advanced
T Trauma
L Life
S Support
ATLS

• Primary Survey
• Resuscitation
• Secondary Survey
• Definitive Care
 6 Immediate Life Threats

• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
“sucking chest wound”
• Massive hemothorax
• Flail chest
• Cardiac tamponade
6 Potential Life Threats

• Lung contusion
• Heart contusion
• Aorta rupture
• Diaphragm rupture
• Tracheobronchial tree
injury - larynx,
trachea, bronchus
• Esophagus trauma
6 Other Frequent Injuries

• Subcutaneous
emphysema
• Traumatic asphyxia
• Simple pneumothorax
• Hemothorax
• Scapula fracture
• Rib fractures
Airway Obstruction

• Airway obstruction at alveolar level:

assessed and managed during 2o survey
• Upper airway obstruction  immediate
life threat which must be dealt with in
primary survey
• Most common cause: patient’s tongue
Airway Obstruction

• Chin-lift: fingers
under mandible,
lift forward so
chin is anterior
Airway Obstruction
Airway Obstruction

• Jaw thrust: grasp angles of mandible and

bring jaw forward
Airway Obstruction

• Oropharyngeal
airway: insert into
mouth behind tongue
• DO NOT push tongue
further back
Airway Obstruction

• Nasopharyngeal
airway: gently
insert well-
lubricated
“trumpet”
through nostril
Airway Obstruction

Definitive Airway
Management: tube
in trachea through
vocal cords with
balloon inflated
Airway Obstruction

• Orotracheal intubation
• Nasotracheal intubation: in breathing
patient without major facial trauma
• Surgical airways
– jet insufflation
– retrograde
– cricothyrotomy
– tracheostomy
Tension pneumothorax
• Air leak through lung or chest wall
• “One-way” valve  lung collapse
• Mediastinum shifts to opposite side
• Inferior vena cava “kinks” on diaphragm
decreased venous return 
cardiovascular collapse
Inferior vena cava
Tension pneumothorax

• Tension pneumothorax is not an x-

ray diagnosis – it MUST be
recognized clinically
• Treatment is decompression – needle into
2nd intercostal space of mid-clavicular line
- followed by thoracotomy tube
Insert needle here
Open pneumothorax

• “Sucking Chest Wound”

• Normal ventilation requires negative intra-
thoracic pressure
• Large open chest-wall defect 
immediate equilibration of intra-thoracic
and atmospheric pressures
• If hole >2/3 tracheal diameter, air prefers
chest defect
Open pneumothorax
Open pneumothorax

• Initial treatment: seal defect and secure

on three sides (total occlusion may lead to
tension pneumothorax
• Definitive repair of defect in O.R.
Massive hemothorax

• Rapid accumulation of >1500 cc blood in

chest cavity
• Hypovolemia & hypoxemia
• Neck veins may be:
– Flat: from hypovolemia
– Distended: intrathoracic blood
• Absent breath sounds, DULL to percussion
Massive hemothorax: treatment

• Large-bore (32 to 36 F) tube to drain

blood
• If moderate sized (500 to 1500 ml) and
stops bleeding, closed drainage usually
sufficient
• If initial drainage >1500 ml OR
continuous bleeding >200 ml / hr, OPEN
THORACOTOMY indicated
Chest tube
Flail chest

• “Free-floating” chest
segment, usually from
multiple ribs fractures
• Pain and restricted
movement paradoxical
movement” of chest wall
with respiration
Flail chest
Flail treatment (old)
Flail treatment (old)
Flail treatment

• Ventilate well
• Humidify oxygen
• Resuscitate with fluids
• Manage pain (!!)
• Stabilize chest
– Internal  ventilator
– External  sand bags
(rare)
Cardiac tamponade

• Usually from penetrating injuries

• Classic “Beck’s triad”
– elevated venous pressure - neck veins
– decreased arterial pressure - BP
– muffled heart sounds
• Blood in sac
prevents cardiac
activity
Cardiac tamponade

• May find “pulsus paradoxus” - a decrease

of 10 mm Hg or greater in systolic BP
during inspiration
• Systolic to diastolic gradient of less than
30 mm Hg also suggestive
Cardiac tamponade

• Treatment is removal
of small amount of
blood – 15 to 20 ml
may be sufficient –
from pericardial sac
Pericardiocentesis
Stab wound to
right ventricle
pericardium

epicardial fat
The Flock of Birds
behind the heart

Vagoose n.

Azygoose v.

Esophagoose

Thoracic duck
6 Potential Life Threats

• Pulmonary contusion
• Myocardial contusion
• Traumatic aortic rupture (TAR)
• Traumatic diaphragmatic rupture
• Tracheobronchial tree injury: larynx,
trachea, bronchus
• Esophageal trauma
Pulmonary contusion

• Potentially life-threatening condition with

insidious onset
• Parenchymal injury without laceration
• More than 50% will develop pneumonia,
even with treatment
• Up to 50% have only hemoptysis as
presenting symptom
Pulmonary contusion

• Patients with pre-existing conditions

(emphysema, renal failure) need early
intubation
• Treatment needs
to occur over time
as symptoms develop
Myocardial contusion

• Blunt precordial chest

trauma
• Difficult to diagnose
• Risk for dysrhythmia,
sudden death,
tamponade,
pericarditis,
ventricular aneurysm
Myocardial contusion
Myocardial contusion

Also may see:

• myocardial concussion  “stunned”
myocardium with no cell death
• coronary artery laceration
Diagnosis by:
• trans-esophageal echocardiogram (TEE)
• serial cardiac enzymes / markers
Myocardial contusion

• Question: Does it matter?

• New nomenclature: Anterior Chest Wall
Syndrome
Traumatic aortic rupture

• 90% or more dead at scene

• 90% mortality each undiagnosed day
• Must have high index of suspicion
• Disruption occurs at ligamentum
arteriosum (ductus arteriosus)
• Contained hematoma of 500 to 1000 ml
of blood
Traumatic aortic rupture

Radiographic signs • Elevated mainstem

• Wide mediastinum bronchus with shift to
(>8cm) right
• Fractured 1st & 2nd rib • Obliterated “aortic
• Obliterated aortic window”
knob • Esophagus shifted to
• Trachea deviated to right (NG at T4)
right • Depressed left
• Pleural cap mainstem bronchus
dye leakage
Traumatic aortic rupture

• CT becoming imaging of choice

• Must know site!
• NPV of normal chest x-ray (good quality,
upright): 98% (CT will find mediastinal
hemorrhage in 3%, TAR in 0.4%)
• 78% of patients with post-traumatic “wide
mediastinum” on chest film have normal
CT
Traumatic aortic rupture

• Treatment -
SURGICAL REPAIR
Traumatic diaphragmatic rupture

• Blunt trauma: tears leading to immediate

herniation
• Penetrating trauma: small tears which
may take years to develop herniation
• Usually on left side
Traumatic diaphragmatic rupture

• Treatment: surgical repair

Tracheobronchial tree injury

Larynx - rare
• Hoarseness
• Subcutaneous emphysema
• Palpable crepitus
Intubation may be difficult: tracheostomy
(not cricothyroidotomy) is treatment of
choice
Tracheobronchial tree injury

Trachea
• Blunt or penetrating
• Esophagus, carotid
artery and jugular
vein may be involved
• Noisy breathing 
partial airway
obstruction
Tracheobronchial tree injury

Bronchus
• 1.5% blunt chest
trauma
• 80% due to
BLUNT trauma
within one inch of
carina (tethered)
Esophageal trauma

• Penetrating > blunt

• Lethal if not recognized
High suspicion if…
…left pneumothorax and hemothorax
without rib fracture
…shock out of proportion to apparent blunt
chest trauma
…particulate matter in chest tube
Esophageal trauma
Esophageal trauma

Blunt trauma,
most tears
superior
If low esophagus
 leakage of
stomach contents
into mediastinum
6 Other Frequent Injuries

• Subcutaneous emphysema
• Traumatic asphyxia
• Simple pneumothorax
• Hemothorax
• Scapula fracture
• Rib fractures
Subcutaneous emphysema

• “Rice Krispies”
• May result from
– airway injury
– lung injury
– blast injury
• No treatment
required  address underlying problem
Traumatic asphyxia

• Purple face from

extravasation of blood
(“Masque
ecchymotique”)
• Major damage is to
underlying structures
• Purple face fades over
time in survivors
Simple pneumothorax

• Air enters potential space between

visceral and parietal pleura
• Breath sounds down on affected side
• Percussion  hyper-resonance
• Treatment: chest tube in 4th or 5th
intercostal space anterior to mid-axillary
line
 Medial
pneumothorax
Pocket shooter
Hemothorax

• Lacerated lung OR disrupted intercostal

artery or internal mammary artery
• Most are self-limiting
• Surgical consultation if…
…initial drainage of >20 cc/kg (~1500 cc)
…continued flow of >200 cc/hr
Scapula fractures

Fractured scapula
or 1st & 2nd ribs
indicates major
mechanism of
injury; consider
underlying
damage
Rib fractures

• Most frequent thoracic cage injury

• Most commonly injured: 4th  9th
• If 10th / 11th / 12th  suspect liver or
spleen injury
• If 1st / 2nd / 3rd worry about injury to head,
neck, spinal cords, lungs, great vessels
Rib fractures – treatment

• Intercostal blocks
• Epidural anesthesia
• Systemic analgesics
Do not use…
…taping
…rib belts
…external splints
Rib fractures

Ribs x-rays…
…are expensive
…are inaccurate for diagnosis (~50%
sensitivity)
…add nothing to treatment
…require painful positioning of the patient
…are, in general, not useful
In conclusion...

• Chest trauma is common in the

multiply-injured patient
• Most conditions can be treated by the
evaluating physician and do not
require emergent thoracotomy
• Airway management and a
judiciously placed needle can save
many lives