Pediatric Terrorism and Disaster Preparedness: Table 7.3

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Table 7.3. Principles of Advanced Trauma Life Support®

Principle	Description
*Primary Survey and Resuscitation*
Airway/cervical spine	Open: jaw thrust/spinal stabilization
	Clear: suction/remove particulate matter
	Support: oropharyngeal/nasopharyngeal airway
	Establish: orotracheal/nasotracheal intubation^a
	Maintain: primary/secondary confirmation^b
	Bypass: needle/surgical cricothyroidotomy
Breathing/chest wall	Ventilation: chest rise/air entry/effort/rate
	Oxygenation: central color/pulse oximetry
	Support: distress—NRB/failure—BVM^c
	Chest wall: ensure integrity/expand lungs Tension pneumothorax: needle, chest tube^d Open pneumothorax: occlude, chest tube Massive hemothorax: volume, chest tube
Circulation/external bleeding	Stop bleeding: direct pressure, avoid clamps
	Shock evaluation: pulse, skin CRT, LOC^e
	Blood pressure: avoid over/undercorrection Infant/child: low normal = 70 + (age × 2) mmHg Adolescent: low normal = 90 mmHg
	Volume resuscitation: Ringer';s lactate → packed cells Infant/child: 20 mL/kg RL, repeat x 1-2 → 10 mL/PRBC Adolescent: 1-2l, repeat 1-2 × → 1-2 U PRBC
Disability/mental status	Pupils: symmetry, reaction
	LOC: GCS Track and trend as a vital sign Significant change = 2 points Intubate for coma = GCS ≤8
	Motor: strength, symmetry
	Abnormality or deterioration: call neurosurgeon Mild TBI (GCS 14-15): observe, consider CT for history of LOC Moderate TBI (GCS 9-13): admit, obtain CT, repeat CT 12-24 hr Severe TBI (GCS 3-8): intubate, ventilate, obtain CT, repeat CT 12-24 hr
Exposure and environment	Remove clothing
	Logroll: requires four people
	Screening examination: front and back
	Avoid hypothermia: keep patient warm
*Adjuncts*
	Foley catheter unless contraindicated^f
	Gastric tube unless contraindicated^g
*Secondary Survey and Reevaluation*
	History and physical: SAMPLE history, complete examination
	Imaging studies: plain radiographs^h, special studiesⁱ

^a. RSI technique: etomidate then succinylcholine.
^b. Primary: chest rise, air entry; secondary: exhaled CO2 detector, esophageal detector device; watch for DOPE: Dislodgement, Obstruction, Pneumothorax, Equipment failure.
^c. NRB = nonrebreather mask; BVM = bag valve mask.
^d. Do not wait for confirmatory chest x-ray.
^e. CRT = capillary refill time, LOC = level of consciousness; consider obstructive and neurogenic as well as hypovolemic shock: exclude tension pneumothorax, cardiac tamponade, spinal shock.
^f. Meatal blood, scrotal hematoma, high riding prostate.
^g. Cerebrospinal fluid (CSF) oto/rhinorrhea, basilar skull fracture, midface instability.
^h. Chest, pelvis, lateral cervical spine; others as indicated.
^i. FAST, computer tomography (CT) scan as indicated.

Source: Adapted with permission from the American College of Surgeons Committee on Trauma, Advanced Trauma Life Support® for Doctors Student Course Manual.

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