ATLS Notes for Ward-Leaving Viva

1. Overview

ATLS (Advanced Trauma Life Support) follows ABCD: Airway → Breathing → Circulation → Disability

Field setting (accidents) → cABCD (c = Control of exsanguinating hemorrhage) — control massive bleeding before airway
BLS (Basic Life Support) → CAB — used for cardiac arrest/collapse (compressions first)

ATLS Guidelines - 3 Surveys

Survey	Description
Primary survey	ABCD + identify life-threatening injuries (Red category)
Secondary survey	Detailed head-to-toe survey for injuries
Tertiary survey	Done post-extubation of an intubated patient

Whole body CT vs Secondary survey:

Pros: quick assessment
Cons: ↑ radiation dose; only feasible in hemodynamically stable patients

2. Primary Survey

A0 - Cervical Spine

C-spine examination must be done before airway management
NEXUS Criteria (National Emergency X-Radiography Utilisation Study) - if ALL negative, no imaging needed; if ANY positive → Philadelphia collar + C-spine imaging:
- N – Neuro deficit
- E – Ethanol/alcohol intoxication
- X – eXtreme distracting injury
- U – Unable to give history (altered consciousness)
- S – Spinal (midline) tenderness

A - Airway

Ask the patient to speak - easiest bedside method of airway assessment
Signs of compromised airway (= indications for intubation):
1. Unable to speak
2. GCS ≤ 8
3. Unexplained confusion
4. Coma

Securing a definitive airway:

ETT possible	ETT NOT possible
Orotracheal (most common) or Nasotracheal (contraindicated in skull base fracture)	Emergency: Needle cricothyroidotomy → Definitive: Tracheostomy

Needle cricothyroidotomy:

High-flow O2 via Y-connector: 1 sec ON, 4 sec OFF
Can sustain oxygenation for 15-30 minutes, after which CO2 retention occurs

B - Breathing

Chest exam with auscultation
Adjuncts: pulse oximetry; imaging (chest AP, pelvis, cervical X-ray); eFAST (Extended Focused Assessment with Sonography in Trauma)

C - Circulation

Minimum two 18G IV lines → give 1 litre fluid bolus
If IV access not possible:
- Emergency: Intraosseous infusion (site: tibial tuberosity, just below it) or venous cut-down (great saphenous vein at medial malleolus)
- Definitive: Central line (in trauma, most common site = internal jugular vein)

Key updates:

ATLS 10th edition: 1 litre fluid bolus (revised down from 2 litres - "more judicious")
CRASH-2 trial: If SBP < 90 mmHg and/or HR > 110/min → give Tranexamic acid to reduce mortality: 1 g IV over 10 min, followed by 1 g over 8 hours

D - Disability (GCS - Glasgow Coma Scale)

Behaviour	Response	Score
Eye opening (E)	Spontaneous / To speech / To pain / None	4/3/2/1
Verbal (V)	Oriented / Confused / Inappropriate words / Incomprehensible sounds / None	5/4/3/2/1
Motor (M) - single best criteria	Obeys commands / Localizes pain / Withdraws from pain / Abnormal flexion (decorticate) / Abnormal extension (decerebrate) / None	6/5/4/3/2/1

Total = E + V + M
Interpretation: Mild 13-15, Moderate 9-12, Severe ≤8
GCS must be measured serially
Updates: If E or M not testable → E_NT / M_NT; if intubated, V → V_NT (not V_T)
GCS(P) score = GCS - PRS (Pupil Reactivity Score)

Pupils unreactive to light	PRS
Both	2
One	1
Neither	0

3. Log Roll

Done to examine the patient's back
Requires 4 people (5 if there's a limb fracture)
Minimal/avoid role in: pelvic fracture (may dislodge clot → rebleeding), abdominal trauma
- Exception: penetrating abdominal injury - log roll to check if the wound tract has gone all the way through

4. Pelvic Binder

Used when pelvic fracture is suspected
Keep in place until fracture is ruled out
If unavailable: tie a long cloth/sheet around the hips

5. Severity Scores

Score	Basis
ISS (Injury Severity Score)	AIS (Abbreviated Injury Score) of top 3 injuries, each squared and summed
RTS (Revised Trauma Score)	GCS + Systolic BP + Respiratory Rate
TRISS (Trauma Score & Injury Severity Score)	RTS + ISS + Mechanism of injury + Age → predicts survival probability
MESS (Mangled Extremity Severity Score)	Type of injury + Ischemia group + Shock group + Age group

MESS Interpretation: ≤6 = salvageable limb; ≥7 → amputation is the likely outcome

6. Metabolic Response to Trauma (Ebb and Flow - Cuthbertson/Moore)

Phase	Duration	Role	Physiological changes	Hormones
Ebb	<24 hrs	Maintain blood volume	↓BMR, ↓temp, ↓O2 consumption, vasoconstriction, ↑CO/HR, ↑acute phase proteins	Catecholamines, Cortisol, Aldosterone
Catabolic	3-10 days	Maintenance of energy	↑BMR, ↑temp, ↑O2 consumption, negative N2 balance	↑Insulin, glucagon, cortisol, catecholamines (insulin resistance present)
Anabolic (Moore)	10-60 days	Replace lost tissue	Positive N2 balance	Growth hormone, IGF

Adequate resuscitation can ↓ duration/extent of ebb phase
Catabolic phase patients need ↑ protein intake

Viva Questions (Ward-Leaving) - With Quick Answers

Basics/Approach

What is the full form of ATLS and what does the primary survey follow? → Advanced Trauma Life Support; follows ABCD (+ life-threatening injury identification).
What's the difference between ABCD, cABCD, and CAB - when is each used? → ABCD = ATLS in-hospital; cABCD = field/accident setting (control hemorrhage first); CAB = BLS for cardiac arrest.
What are the three surveys in trauma management and when is each done? → Primary (immediate, ABCD+life threats), Secondary (detailed after primary), Tertiary (post-extubation).
Whole-body CT vs secondary survey - pros/cons? → CT is quick but only for stable patients and gives more radiation.

C-spine / Airway 5. When should you image the cervical spine? State the NEXUS criteria. → If any of Neuro deficit, Ethanol intoxication, eXtreme distracting injury, Unable to give history, Spinal midline tenderness is positive → collar + imaging. 6. What is the easiest bedside test of airway patency? → Ask the patient to speak. 7. List indications for intubation in a trauma patient. → Unable to speak, GCS ≤8, unexplained confusion, coma. 8. Orotracheal vs nasotracheal intubation - which is contraindicated in what setting? → Nasotracheal is contraindicated in skull base fractures; orotracheal is most common. 9. What do you do if endotracheal intubation is not possible? → Emergency needle cricothyroidotomy, definitive management is tracheostomy. 10. Describe needle cricothyroidotomy technique and its time limit. → High-flow O2 via Y-connector, 1 sec on/4 sec off; effective for 15-30 min before CO2 retention.

Breathing/Circulation 11. What are the adjuncts used in the "Breathing" assessment? → Pulse oximetry, chest/pelvis/C-spine X-rays, eFAST scan. 12. What is eFAST and why is it used in trauma? → Extended Focused Assessment with Sonography in Trauma - detects hemoperitoneum, hemothorax, pneumothorax, pericardial effusion at bedside. 13. What is the minimum IV access requirement in trauma resuscitation, and what fluid bolus is given? → Two 18G cannulas; 1 litre fluid bolus (per ATLS 10th ed, revised down from 2 L). 14. If peripheral IV access fails, what are your emergency and definitive options? → Emergency: intraosseous infusion (tibial tuberosity) or venous cut-down (great saphenous vein at medial malleolus); Definitive: central line (IJV most common in trauma). 15. What is the CRASH-2 trial and its significance? → Showed tranexamic acid reduces mortality in trauma with SBP <90 or HR >110; dose 1g over 10 min then 1g over 8 hrs.

Disability/GCS 16. What does GCS stand for and what are its components? → Glasgow Coma Scale = Eye opening + Verbal response + Motor response. 17. What is the "single best criteria" component of GCS and why? → Motor response - most reliable/reproducible indicator of neurological status. 18. Classify head injury severity by GCS. → Mild 13-15, Moderate 9-12, Severe ≤8. 19. What are E_NT, M_NT, V_NT? → Notations used when Eye/Motor components aren't testable (NT = Not Testable), and V_NT is used instead of V_T when the patient is intubated (can't assess verbal response). 20. What is GCS(P) and how is it calculated? → GCS(P) = GCS - Pupil Reactivity Score (PRS); PRS = 2 if both pupils unreactive, 1 if one, 0 if neither. 21. Why must GCS be measured serially? → To detect trends/deterioration in neurological status over time.

Log Roll / Pelvic Binder 22. How many people are needed for a log roll, and why is it done? → 4 people (5 if limb fracture present); done to examine the patient's back. 23. In which situations should log roll be avoided or minimized? → Suspected pelvic fracture (risk of clot dislodgement/rebleed) and abdominal trauma - except penetrating abdominal injury (to check if the wound has traversed through). 24. When is a pelvic binder applied and how long should it stay on? → Applied for suspected pelvic fracture; kept on until fracture is definitively ruled out. 25. What can you use if a pelvic binder is unavailable? → A long cloth/sheet tied around the hips.

Severity Scores 26. What is ISS and how is it calculated? → Injury Severity Score - AIS of the top 3 injured body regions, each squared and summed. 27. What parameters make up the Revised Trauma Score (RTS)? → GCS, systolic BP, respiratory rate. 28. What is TRISS used for and what parameters does it include? → Predicts survival probability of a trauma patient; uses RTS, ISS, mechanism of injury, and age. 29. What is MESS and what does a score ≥7 indicate? → Mangled Extremity Severity Score (type of injury, ischemia, shock, age); score ≥7 predicts eventual amputation, ≤6 suggests a salvageable limb.

Metabolic Response 30. Describe the phases of the metabolic response to trauma (Ebb and Flow / Moore's classification). → Ebb (<24h, maintain blood volume, catecholamines/cortisol/aldosterone) → Catabolic (3-10 days, energy maintenance, negative N2 balance, insulin resistance) → Anabolic (10-60 days, tissue repair, positive N2 balance, GH/IGF). 31. How does adequate resuscitation affect the ebb phase? → It shortens the duration and reduces the severity of the ebb phase. 32. What nutritional consideration applies during the catabolic phase? → Increased protein intake is required due to negative nitrogen balance.

Quick oral drill tip for viva: examiners commonly rapid-fire in this sequence - ABCD → NEXUS criteria → intubation indications → cricothyroidotomy technique → fluid resuscitation/CRASH-2 → GCS scoring → log roll exceptions → MESS/pelvic binder. Rehearse that exact order out loud once; it mirrors how these questions are typically strung together on rounds.

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