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com/
Polytrauma
Frederick Mars Untalan MD
standard of care
 Advanced Trauma Life Support (ATLS) protocol


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 Airway
 Breathing

 Circulation

 Disability

 Environment
History of the mnemonic
 1957, Peter Safar[4] wrote the book ABC of
Resuscitation which established the basis for mass
training of CPR.

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 1962 training video called "The Pulse of Life" created by
James Jude,[6] Guy Knickerbocker and Peter Safar.
Jude and Knickerbocker, along with William
Kouwenhouen[7] developed the method of external
chest compressions, while Safar worked with
James Elam to prove the effectiveness of artificial
respiration.[8]
 Their combined findings were presented at annual
Maryland Medical Society meeting on September 16,
1960 in Ocean City, and gained rapid and widespread
acceptance over the following decade, helped by the
video and speaking tour the men undertook.
 The ABC system for CPR training was later adopted by
the American Heart Association, which promulgated
standards for CPR in 1973.
First things First
 In the polytrauma patient, a number of injuries
take higher priority than the
craniomaxillofacial ones.

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 life-preserving emergency procedures take
precedence in extensive head or neck injury
 Craniomaxillofacial injuries need to be
diagnosed, a treatment plan established,
and a sequence fitted into the total
treatment plan for the patient at an early
stage.
TEAM (Trauma Evaluation And
Management)
 TEAM introduces the concepts of trauma
assessment and management to medical
students during their clinical years.

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 TEAM Program should satisfy the need for a
standardized introductory course in the
evaluation and management of trauma that
can be taught to all medical students and
multidisciplinary team members.

What is ATLS®?
 a systematic, concise training to the early care
of trauma patients.
 It will provide the participants with a safe,

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reliable method for immediate management
of the injured patient and the basic
knowledge necessary to:
 Assess the patient's condition rapidly and
accurately
 Resuscitate and stabilize the patient according
to priority
 Determine if the patient's needs exceed a
facility's capabilities
 Arrange appropriately for the patient's
interhospital transfer (what, who, when, and
how)
 Assure that optimum care is provided
Advanced Trauma Life Support
 a training program for doctors and Advanced
Practice/Critical Care Paramedics in the management
of acute trauma cases, developed by the
American College of Surgeons. The program has been

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adopted worldwide in over 40 countries,[1] sometimes
under the name of Early Management of Severe
Trauma (EMST), especially outside North America. Its
goal is to teach a simplified and standardized
approach to trauma patients. Originally designed for
emergency situations where only one doctor and one
nurse are present, ATLS is now widely accepted as
the standard of care for initial assessment and
treatment in trauma centers. The premise of the ATLS
program is to treat the greatest threat to life first. It
also advocates that the lack of a definitive diagnosis
and a detailed history should not slow the application
of indicated treatment for life-threatening injury, with
the most time-critical interventions performed early.
However, there is mixed evidence to show that ATLS
Bo uillo n, B., Kanz, K.G., Lac kne r, C.K., Mutsc hle r, W., & 
improves patient outcomes. Sturm, J. The  impo rtanc e  o f Advanc e d Trauma Life  
Suppo rt (ATLS) in the  e me rge nc y ro o m [Artic le  in 
Ge rman]. Unfallc hirurg, 107(10), 844­850.
ABCDE of ENTEmergency


A– Airway & Breathing

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
B– Bleeding & Circulation

C – Call
D – D

E- ENT
Primary Survey
 life-threatening injuries are identified
 simultaneously resuscitation is begun

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

 ABCDE
A Airway Maintenance w/ Cervical Spine
Protection
B Breathing and Ventilation
C Circulation with Hemorrhage Control
D Disability (Neurologic Evaluation)
E Exposure and Environment
Primary Survey
 A - Airway Maintenance with Cervical
Spine Protection

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 assess the airway.

 chin lift or jaw thrust.

 patient's mouth should be cleaned

 cervical spine -immobilised

Simple application for CPR
 A — Airway
 Unconscious patients
 In the unconscious patient, the priority is airway management, to avoid a
preventable cause of hypoxia. Common problems with the airway of

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patient with a seriously reduced level of consciousness involve
blockage of the pharynx by the tongue, a foreign body, or vomit.
 At a basic level, opening of the airway is achieved through manual
movement of the head using various techniques, with the most widely
taught and used being the "head tilt — chin lift", although other
methods such as the "modified jaw thrust" can be used, especially
where spinal injury is suspected,[16] although in some countries, its use
is not recommended for lay rescuers for safety reasons.[15]
 Higher level practitioners such as emergency medical service personnel
may use more advanced techniques, from oropharyngeal airways to
intubation, as deemed necessary.[17]
 Conscious patients
 In the conscious patient, other signs of airway obstruction that may be
considered by the rescuer include paradoxical chest movements, use of
accessory muscles for breathing, tracheal deviation, noisy air entry or
exit, and cyanosis.[18]

Primary Survey
 B - Breathing and Ventilation
 chest must be examined

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 tracheal deviation must be identified

 Life-threatening chest injuries tension

 pneumothorax,
 open pneumothorax
 flail chest
 hemothorax
Simple application for CPR
 B — Breathing
 [edit] Unconscious patients
 In the unconscious patient, after the airway is opened the next area to assess is the patient's breathing,[15] primarily to find if the patient is
making normal respiratory efforts. Normal breathing rates are between 12 and 30 breaths per minute,[18] and if a patient is breathing
below the minimum rate, then in current ILCOR basic life support protocols, CPR should be considered, although professional rescuers
may have their own protocols to follow, such as artificial respiration.

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 Rescuers are often warned against mistaking agonal breathing, which is a series of noisy gasps occurring in around 40% of cardiac arrest
victims, for normal breathing.[15]
 If a patient is breathing, then the rescuer will continue with the treatment indicated for an unconscious but breathing patient, which may
include interventions such as the recovery position and summoning an ambulance.[19]
 [edit] Conscious or breathing patients
 In a conscious patient, or where a pulse and breathing are clearly present, the care provider will initially be looking to diagnose
immediately life-threatening conditions such as severe asthma, pulmonary oedema or haemothorax.[18] Depending on skill level of the
rescuer, this may involve steps such as:[18]
 Checking for general respiratory distress, such as use of accessory muscles to breathe, abdominal breathing, position of the patient,
sweating, or cyanosis
 Checking the respiratory rate, depth and rhythm - Normal breathing is between 12 and 20 in a healthy patient, with a regular pattern
and depth. If any of these deviate from normal, this may indicate an underlying problem (such as with Cheyne-Stokes respiration)
 Chest deformity and movement - The chest should rise and fall equally on both sides, and should be free of deformity. Clinicians may be
able to get a working diagnosis from abnormal movement or shape of the chest in cases such as pneumothorax or haemothorax
 Listening to external breath sounds a short distance from the patient can reveal dysfunction such as a rattling noise (indicative of
secretions in the airway) or stridor (which indicates airway obstruction)
 Checking for surgical emphysema which is air in the subcutaneous layer which is suggestive of a pneumothorax
 Auscultation and percussion of the chest by using a stethoscope to listen for normal chest sounds or any abnormalities
 Pulse oximetry may be useful in assessing the amount of oxygen present in the blood, and by inference the effectiveness of the breathing



Primary Survey
 C - Circulation with Hemorrhage Control
 Hemorrhage
 Hypotension

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 Hypotension
 Hypovolemic shock

 crystalloid solution
 type-specific blood, or O-negative if this is not available

 External bleeding is controlled by direct pressure.
 Occult blood loss may be into the chest, abdomen, pelvis or from
the long bones.
 Chest or pelvic bleeding may be identified on X-ray.
 Bleeding into the peritoneum may be diagnosed on ultrasound (
FAST scan),
 CT (if stable) or
 diagnostic peritoneal lavage.

Simple application for CPR
 C — Circulation
 Once oxygen can be delivered to the lungs by a clear airway and efficient breathing, there needs to be a circulation to deliver it to the rest
of the body.
 [edit] Non-breathing patients
 Circulation is the original meaning of the 'C' as laid down by Jude, Knickerbocker & Safar, and was intended to suggest assessing the
presence or absence of circulation, usually by taking a carotid pulse, before taking any further treatment steps.

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 In modern protocols for lay persons, this step is omitted as it has been proven that lay rescuers may have difficulty in accurately
determining the presence or absence of a pulse, and that, in any case, there is less risk of harm by performing chest compressions on
a beating heart than failing to perform them when the heart is not beating.[20] For this reason, lay rescuers proceed directly to
cardiopulmonary resuscitation, starting with chest compressions, which is effectively artificial circulation. In order to simplify the
teaching of this to some groups, especially at a basic first aid level, the C for 'Circulation' is changed for meaning 'CPR' or
'Compressions'.[21][22][23]
 It should be remembered, however, that health care professionals will often still include a pulse check in their ABC check, and may involve
additional steps such as an immediate ECG when cardiac arrest is suspected, in order to assess heart rhythm.
 [edit] Breathing patients
 In patients who are breathing, there is the opportunity to undertake further diagnosis and, depending on the skill level of the attending
rescuer, a number of assessment options are available, including:
 Observation of colour and temperature of hands and fingers where cold, blue, pink, pale, or mottled extremities can be indicative of
poor circulation
 Capillary refill is an assessment of the effective working of the capillaries, and involves applying cutaneous pressure to an area of skin to
force blood from the area, and counting the time until return of blood. This can be performed peripherally, usually on a fingernail bed,
or centrally, usually on the sternum or forehead
 Pulse checks, both centrally and peripherally, assessing rate (normally 60-80 beats per minute in a resting adult), regularity, strength,
and equality between different pulses
 Blood pressure measurements can be taken to assess for signs of shock
 Auscultation of the heart can be undertaken by medical professionals
 Observation for secondary signs of circulatory failure such as oedema or frothing from the mouth (indicative of congestive heart
failure)
 ECG monitoring will allow the healthcare professional to help diagnose underlying heart conditions, including myocardial infarctions


Primary Survey
 D - Disability (Neurologic Evaluation)
 AVPU (alert, verbal stimuli response, painful

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stimuli response, or unresponsive).
 A more detailed and rapid neurological
evaluation is performed at the end of the
primary survey.
 level of consciousness, pupil size and reaction,
lateralizing signs & SCI.
 Glasgow Coma Scale a quick method to
determine the level of consciousness, and is
predictive of patient outcome.
Primary Survey
 E - Exposure / Environmental control
 The patient should be completely undressed

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 Hypothermia in the emergency department.

 Warm Intravenous fluids

 warm environment

 Maintain Patient privacy

Secondary Survey
 head-to-toe evaluation
 complete history and physical examination

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 reassessment of all vital signs.

 Each region of the body must be fully

examined. X-rays indicated by examination


Amal Mattu; Deepi Goyal; Barrett, Jeffrey W.; Joshua Broder; DeAngelis, 
Michael; Peter Deblieux; Gus M. Garmel; Richard Harrigan; David 
Karras; Anita L'Italien; David Manthey (2007). Emergency medicine: 
avoiding the pitfalls and improving the outcomes. Malden, Mass: Blackwell 
Pub./BMJ Books. pp. 60. ISBN 1­4051­4166­2
recovery position
lateral recumbent


position

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 an airway management technique for assisting people who are
unconscious, or nearly so, but are still breathing. It is
frequently taught alongside CPR in first aid.
 An unconscious person (GCS <8) cannot be trusted to maintain
his or her own breathing. Many fatalities occur where the
original injury or illness which caused unconsciousness is
not inherently fatal, but where the unconscious person
suffocates for one of these reasons. This is a common cause
of death following unconsciousness due to excessive
consumption of alcohol.
 When an unconscious person is lying face upwards, there are two
main risk factors which can lead to suffocation: Fluids,
possibly blood but particularly vomit, can collect in the back
of the throat, causing the person to drown. When a person is
lying face up, the esophagus tilts down slightly from the
stomach toward the throat. This, combined with loss of
muscular control, can lead to the stomach contents flowing
into the throat, called passive regurgitation. Fluid which
collects in the back of the throat can also flow down into the
lungs; stomach acid can attack the inner lining of the lungs
and cause aspiration pneumonia.
 It's possible to achieve limited protection of the airway by tilting
the head back and lifting the jaw. An unconscious person
will not remain in this position unless held constantly, and
crucially it does not safeguard against risks due to fluids. In
the recovery position, the force of gravity will allow any
fluids to drain. The chest is also elevated from the ground,
making breathing easier.


When to use the recovery position
 unconscious person who does not need CPR
 those who are too inebriated to assure their

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own continued breathing
 victims of drowning

 victims of suspected poisoning (who are liable

to become unconscious).

Putting a victim in the recovery
position / lateral recovery position."[
 Checking carotid pulse
 If spinal or neck injuries are possible
 They should be moved to a recovery position only when

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it is necessary to drain vomit from the airway.
 "HAINES modified recovery position" (High Arm IN
Endangered Spine.)
 one of the patient's arms is raised above the head (in full
abduction) to support the head and neck.
 Less neck movement (and less degree of lateral angulation)
than when the lateral recovery position is used, and,
therefore, HAINES use carries less risk of spinal-cord
damage.


 Pregnant victims
 always rest on her left side


 Victims with torso wounds

 wounds closest to the ground to minimize the
possibility of blood affecting both lungs, resulting in
asphyxiation.
Variations
 Nearly all first aid organizations use "ABC" in some
form
 'ABCD' (designed for training lay responders in

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defibrillation)
 'AcBCDEEEFG' (the UK ambulance service version
for patient assessment).

Variations

DR ABC
One of the most widely used adaptations is the
addition of "DR" in front of "ABC", which stands
for Danger and Response

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 “protect yourself before attempting to help others”

 then ascertaining that the patient is unresponsive

before attempting to treat them, using systems
such as AVPU or the Glasgow Coma Score

"The primary survey" St John Ambulance. 
http://www.sja.org.uk/sja/first­aid­advice/lifesaving­
procedures/primary­survey.aspx
Variations

DRsABC
 A modification to DRABC is that when there is no
response from the patient, the rescuer is told to

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Shout for help


"Cardio Pulmonary Resuscitation"Centre for Excellence 
in Teaching and Learning. 
http://www.cetl.org.uk/learning/print/cpr­print.pdf
Variations ABC D
 Defibrillation— The definitive treatment step for
cardiac arrest Cayley, William E, Jr (2006­05­01). "Practice guidelines: 2005 AHA guidelines 
for CPR and Emergency Cardiac Care“.American Family Physician. 
 http://www.aafp.org/afp/20060501/practice.html

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 Disability or Dysfunction[— Disabilities caused by
the injury, not pre-existing conditions
 Primary Trauma Care. Primary Trauma Care Foundation. 2000. ISBN 0­95­39411­08 
http://av.rds.yahoo.com/www.primarytraumacare.org/PTCMain/Training/pfd/PTC_EN
G.pdfRetrieved 2008­12­20.

 Deadly Bleeding
"Emergency First Aid with Level C CPR". Western Canada Fire & First Aid 
 Inc. http://www.wcff.ca/crs­emrgfirstaid.htm. Retrieved 2008­12­20.

 (Differential) Diagnosis
 "Cardiac Arrest associated with Pregnancy“ Circulation 112: 150–153. 2005­11­28. 
http://www.comtf.es/doc/RCP/CIRCULATIONPregnancy.pdf. Retrieved 2008­12­20.
 Decompression
"Resuscitation. Revival should be the first priority". Postgraduation 
Medical Journal 89 (1): 117–20. January 1991. ISSN 0032­5481
Variations ABCD
 Expose and Examine
E Primary Trauma Care. Primary Trauma Care Foundation. 2000. ISBN 
0­95­39411­0­8 
 http//www.primarytraumacare.org/PTCMain/Training/pfd/PTC_EN
G.pdf. Retrieved 2008­12­20

 Environment

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Accident Compensation Corporation (June 2007). Management of burns and 
 scalds in primary care. New Zealand Guidelines Group. 
http://ngc.gov/summary/summary.aspx?view_id=1&doc_id=11509
 Escaping Air — Checking for air escaping, such as
through a sucking chest wound, which could lead
to a collapsed lung.


 Elimination
 "Resuscitation. Revival should be the first priority". Postgraduation 
Medical Journal 89 (1): 117–20. January 1991. ISSN 0032­5481
 Evaluate
Variations
 Fundus—
ABCDE
pregnancy
F

 Family (in France) — indicates that rescuers must also
deal with the witnesses and the family, who may be

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able to give precious information about the accident
or the health of the patient, or may present a problem
for the rescuer. "Resuscitation. Revival should be the first priority". Postgraduation 
Medical Journal 89 (1): 117–20. January 1991. ISSN 0032­5481


 Fluids — A check forAccident Compensation Corporation (June 2007). Management of burns and 
obvious fluids (blood, cerebro-
spinal fluid (CSF) etc.)
scalds in primary care. New Zealand Guidelines Group. 
http://ngc.gov/summary/summary.aspx?view_id=1&doc_id=11509

 Fluid resuscitation

 Final Steps — Consulting the nearest definitive care
"Pediatric clinical practice guidelines for nurses in primary care". 
facility Health Canada. http://www.hc­sc.gc.ca/fniah­
spnia/pubs/services/_nursing­infirm/2001_ped_guide/chap_10c­
eng.php. Retrieved 2008­12­21
Variations

ABCDEF G
Go Quickly! — A reminder to ensure all
assessments and on-scene treatments are
completed with speed, in order to get the patient
to hospital within the Golden Hour

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 Glucose — The professional rescuer may choose to
perform a blood glucose test, and this can form
the 'G' or alternately, the 'DEFG' can stand for
"Don't Ever Forget Glucose"
Variations

AcBC
 additional (small) 'c' in between the A and B,
standing for 'cervical spine' or 'consider C-spine'.

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 potential neck injuries to a patient, as opening the
airway may cause further damage unless a
special technique is used.


Occupational First Aid. Level 5. Further Education 
and Training Awards Council. July 2008. 
http://www.safetyireland.com/occupational_first_ai
d_fetac.pdf. Retrieved 2008­12­21
Examination of the
Maxillofacial Region
 Once the patient has been stabilized
and cleared for cervical spinal cord
injuries, the physician can begin to

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evaluate the maxillofacial region.
 If possible, the history of events
surrounding the injury should be
obtained because it can provide clues
to the type of injuries the patient
could have.
 For example, a sharp, penetrating injury
is more likely to injure nerves and
major vessels than is blunt trauma,
Edward Ellis III, DDS
University of Texas Southwestern Medical 
which is more likely to result
Center in
fractures of the facial skeleton.
Emergency Medicine Clinics of North 
America 
Examination of the
Maxillofacial Region
 Do you see " double"?
 binocular diplopia can indicate internal

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or periorbital fractures.
 It should be considered a nonspecific
symptom, however, because it can
also be caused by other things, most
commonly periorbital edema.
 monocular diplopia might indicate an
injury to the globe, for which
ophthalmologic consultation is
necessary. Edward Ellis III, DDS
 University of Texas Southwestern Medical Center
Emergency Medicine Clinics of North America 

Volume 18 • Number 3 • August 2000 
Examination of the
Maxillofacial Region
 Are there any areas of numbness on
your face?

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 Any neurosensory deficit usually
indicates a skeletal fracture has
occurred surrounding the bony
canals/grooves/foramina, through
which the branches of the
trigeminal nerves exit.


Edward Ellis III, DDS
University of Texas Southwestern Medical Center
Emergency Medicine Clinics of North America 

Volume 18 • Number 3 • August 2000 
Examination of the
Maxillofacial Region
 Does your bite feel " normal"?
 Most mandibular and/or maxillary

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fractures are associated with the
subjective feeling that the bite is
not "normal."
 The location of premature contact of
the teeth can help to direct the
clinician to the site of fracture.

Edward Ellis III, DDS
University of Texas Southwestern Medical Center
Emergency Medicine Clinics of North America 

Volume 18 • Number 3 • August 2000 
Examination of the
Maxillofacial Region
 Which areas on your face hurt?
Although this question seems basic,

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one could find a patient who points
to a location that is not swollen or
bruised, such as the preauricular
area, in the case of a condylar
process fracture of the mandible.


Edward Ellis III, DDS
University of Texas Southwestern Medical Center
Emergency Medicine Clinics of North America 

Volume 18 • Number 3 • August 2000 
Examination of the
Maxillofacial Region
 Does it hurt when you open your mouth? Where?
 The presence of pain when one attempts functional
movements of the mandible can indicate that

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skeletal fractures have occurred, although
contusions of the temporomandibular joint can also
produce pain in the absence of skeletal fractures.
 If pain is present, however, its location helps to
determine underlying fractures.
 For instance, preauricular tenderness with
mandibular movement could indicate a condylar
process fracture.
 Pain at the angle of the mandible could indicate a
fracture in that location.
 Pain in the cheek region when one attempts to open
the mouth could signify a zygomaticomaxillary
complex fracture Edward Ellis III, DDS
 University of Texas Southwestern Medical Center
Emergency Medicine Clinics of North America 

Volume 18 • Number 3 • August 2000 
 The clinical evaluation of the maxillofacial
region must be organized and sequential
and should be performed prior to ordering

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radiographs and other images. The head and
neck examination must be methodical, or
significant injuries can be missed. The
maxillofacial examination must include the
following components:
 Soft tissues

 Nerves

 Skeleton

 Dentition Edward Ellis III, DDS
University of Texas Southwestern Medical Center
Emergency Medicine Clinics of North America 

 
Volume 18 • Number 3 • August 2000
"inside out and bottom up."
 One approach organizes the examination from
"inside out and bottom up."

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 Following this recommendation, the oral cavity is
inspected first for lacerations or penetrating
injuries. The tongue is frequently lacerated and
can produce profuse bleeding.
 Soft tissue injuries should be explored for tooth
fragments and other foreign bodies.
 Areas of soft tissue swelling and ecchymosis are
noted because they can indicate underlying
skeletal fractures.
 Lacerations of the attached gingiva around the
teeth or palate also can indicate an underlying
Edward Ellis III, DDS
University of Texas Southwestern Medical Center
fracture. Emergency Medicine Clinics of North America 

 
Volume 18 • Number 3 • August 2000

 An examination of the maxillofacial skeleton involves
inspection and palpation.
 Injuries in the maxillofacial area can be associated with

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massive edema, which makes evaluation of the
underlying skeleton difficult; however, bony contours
should be palpated for irregularities and tenderness
(discussed in their specific regions).
 One should always inspect carefully any fluid exiting
the nose in case it could be cerebrospinal fluid (CSF).
 The presence of CSF rhinorrhea indicates disruption of
the anterior cranial base, most commonly at the
cribriform plate of the ethmoid bone associated with
naso-orbitoethmoid fractures, or from disruption of
the posterior wall of the frontal sinus.
 Areas of "numbness" on the face should make one
suspect disruption of the sensory branch of the
trigeminal nerve from skeletal fractures
Edward Ellis III, DDS
University of Texas Southwestern Medical Center
Emergency Medicine Clinics of North America 

Volume 18 • Number 3 • August 2000 
 Star of Life
Preserve Life
Prevent Further Injury

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Promote Recovery.
6 stages of high quality 
pre­hospital care:

Early Detection
Early Reporting
Early Response  
Good On Scene Care
Care in Transit
Transfer to Definitive Care[
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Polytrauma
Frederick Mars Untalan MD
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