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ITLS

globally recognized program designed to train prehospital providers in the rapid assessment and treatment of trauma patients. Emphasizes a structured, systematic approach to trauma care to improve survival and outcomes. One of the only EMS-specific courses

ITLS key concepts

Systematic approach:•Using the primary and secondary survey to identify life-threatening injuries quickly.⚬Uses ABCDE (Airway, Breathing, Circulation, Disability, Exposure/Environment) as a core framework.

High-Performance Teamwork

•Coordinating effectively with other responders on scene.

Evidence-Based Interventions

 Following best-practice guidelines for airway management, shock treatment, and spinal immobilization

Scene Safety & Triage

•Assessing hazards, prioritizing care, and determining transport urgency.

GOALS OF ITLS

1.Provide rapid and accurate patient assessment in the prehospital setting.

2.Deliver immediate life-saving interventions for trauma patients.

3.Enhance decision-making and critical thinking under stress.

4.Promote team coordination and patient safety during emergency responses.

PRIMARY SURVEY

•Perform scene size-up

•Conduct initial assessment

•Perform rapid trauma survey or focused exam

•Make critical interventions

•Prepare for transport

•Contact OLMC if needed

SECONDARY SURVERY

•Repeat initial assessment

•Repeat vital signs and consider monitors

•Perform neurological exam

•Conduct detailed head-to-toe assessment

REASSESSMENT

•Repeat initial assessment

•Repeat vital signs and monitor

Reassess abdomen, check for injuries and interventions

BLUNT TRAUMA

•Motor Vehicle Collisions (MVC)

•Falls

•Struck by object / impact injuries

PENETRATING TRAUMA

•Stab wounds/knife injuries

•Gunshot wounds/ballistics

•Impaled objects causing injury

•Penetrating objects that breach the skin

OTHER TRAUMA

•Blast injuries / explosions

Understanding MOI

helps predict injury patterns and severity for rapid assessment and intervention.

PRIMARY GOALS

•Minimize injury and reduce preventable death

Prevent secondary insults (e.g., hypoxia, hypotension, hypothermia

ASSESSMENT & INTERVENTION: X-ABC

•X – eXtanguishing injuries (severe bleeding control)

•A – Airway

•B – Breathing

•C – Circulation

TRAUMA TRIAGE DECISIONS

•When in doubt, transport to a trauma center, if it will take a long time to reach a definitive care facility. •Assess need for air transport

PREVENTION & PUBLIC EDUCATION

•Promote injury prevention programs

•Increase public awareness of trauma risks

ITLS patient assessment

Scene Size-Up

•Establish medical command / incident command

•Perform PPE and control hazards

•Request additional resources as needed

•Begin triage in multi-patient events

Initial Assessment & Interventions

•Reposition patient if necessary

•Control bleeding: direct pressure, hemostatic gauze, tourniquet

•Airway management: open airway, assist ventilations, provide oxygen

•Begin CPR if indicated

•Perform rapid extrication if patient safety or access requires

Survey Selection

Deciding Which Survey to Perform

•Base primary survey choice on:

⚬Mechanism of Injury (MOI)

⚬Initial patient assessment

Rapid Trauma Survey (Load & Go Patients)

•Indications: life-threatening injuries

•Critical Actions:

⚬Decompress tension pneumothorax (ALS)

⚬Seal open chest wounds

⚬Apply spinal motion restriction (SMR) if indicated after assessment

Transport & En route

Load & Go (Rapid Transport)

•Rapid transport to trauma center (ground or air)

•Early notification to receiving facility

•Establish IV en route, administer TXA if indicated (ALS)

•Continuous monitoring and reassessment

Not Load & Go (Stable Patient)

•Complete secondary survey

•Establish IV access en route

•Monitor and reassess vital signs

•Perform splinting and wound care as needed

Critical actions critical thinking

Always prioritize life-threatening conditions first, but adapt interventions based on patient stability and transport urgency.

ITLS PATIENT ASSESSMENT Key responsibilities

•Delegate interventions to team members during the primary survey

•Do not interrupt the completion of the primary survey except for:

⚬Scene danger or hazards

⚬Exsanguinating hemorrhage

⚬Airway obstruction

⚬Cardiac arrest

Key Point:

•The team leader ensures efficient workflow, patient safety, and situational awareness while allowing the team to complete the primary survey rapidly and effectively.

Portage trauma assessment

SCENE SIZE UP/SCENE SAFETY

Are there any hazards?

•People, odors, pets, live wires, crowds, egress path, fire

How many patients need assistance?

What is the MOI?

Do you need additional resources?

•Law enforcement, additional EMS units (ALS, BLS), air support, fire, hazmat, and an electrical company

What is the environment?

•Weather, safety concerns

Do you have appropriate PPE – Personal Protective Equipment on before approaching the patient?

Are bystanders on scene for additional information?

Is the scene information the same as the information dispatch gave you?

GENERAL IMPRESSION

As you approach the patient, observe:

What is the patient’s age, sex, weight, and height?

What is the patient's position?

•Relaxed

•Sitting, standing, ambulatory

•Supine, recumbent

•Tripod

•Pacing

Observe the Level of activity and/or distress the patient is displaying.

•Work of breathing

•Anxiousness

•Fatigue

•Not moving (unresponsive)

•Patient tracking, you or not aware of your presence

Note the skin color and condition.

Introduce yourself and obtain Consent

C-SPINE/SMR ITLS RECOMENDATIONS

Consider SMR when any of the following are present:

Patient Complaints / Clinical Findings

•Spinal deformity or visible injury

•Pain or tenderness along the spine

Trauma Mechanism / Patient Condition

•Blunt trauma with altered level of consciousness (LOC)

•High-energy mechanism of injury (e.g., MVC, falls > 3m)

•Drug or alcohol impairment affecting mental status

Neurological Considerations

•Focal neurological complaints

•Unable to adequately assess for spinal injury clinically due to altered LOC or distracting injuries

Key Point:

•When in doubt, apply SMR to protect the spine until full assessment can be performed.

INITIAL PATIENT ASSESSMENT

PEARLS – C-A-B-D-E

C – Control Life-Threatening Bleeding

•Direct pressure, hemostatic gauze, tourniquet

A – Airway

•Open airway, assist ventilations, suction if needed

B – Breathing

•Assess respiratory effort, provide oxygen, manage chest injuries

C – Circulation

•Check pulses, control bleeding, monitor perfusion

D – Disability (Neurologic Status)

•Assess level of consciousness, pupils, GCS

E – Exposure & Environment

•Fully expose patient to identify injuries

•Prevent hypothermia, maintain scene safety

idea

Vectors

The average direction and strength of ventricular depolarization.

Axis Deviation

The direction in which the main vector of depolarization points in the frontal plane.

R-Wave Progression

The change in height of the R wave across the precordial leads from V1 to V6.

Ventricular Hypertrophy

Structural thickening of the ventricular myocardium due to chronic pressure or volume overload.

Bundle Branch Block

A blockage of the electrical conduction pathways in the ventricles.

Fascicular Block

A block in one of the divisions of the bundle branches.

Ischemic Mimics

Conditions that can present similarly to ischemia on an ECG.

Diagnostic Pitfalls

Common errors or misunderstandings that may lead to incorrect diagnoses.

ST Elevation

A change in the ECG that indicates that the heart is not receiving enough blood.

J-Point

The point on the ECG where the QRS complex transitions into the ST segment.

Inferior STEMI

Myocardial infarction affecting the inferior wall of the heart.

Anterior STEMI

Myocardial infarction affecting the anterior wall of the heart.

LBBB

Left Bundle Branch Block; a blockage affecting the left side of the heart's conduction system.

Reciprocal Changes

ECG changes that are mirrored in the leads opposite to the leads showing indicative changes.

Hyperkalemia

An elevated level of potassium in the blood, which can affect heart rhythm.

Brugada Syndrome

A genetic condition that can lead to dangerous arrhythmias.

WPW Syndrome

Wolff-Parkinson-White Syndrome; a condition where an additional electrical pathway in the heart can lead to rapid heart rates.

PE

Pulmonary Embolism; a blockage in one of the pulmonary arteries in the lungs.

LVH

Left Ventricular Hypertrophy; thickening of the heart's left ventricle.

Ventricular Paced Rhythms

ECG rhythms resulting from an artificial pacemaker.

Electrical Axis

The net direction of electrical activity during ventricular depolarization.

Hexaxial Reference System

A method to determine the electrical axis of the heart using the six frontal limb leads.

Left Axis Deviation (LAD)

A change in the direction of the heart's electrical axis towards the left.

Right Axis Deviation (RAD)

A change in the direction of the heart's electrical axis towards the right.

Extreme Axis Deviation

An axis deviation that occurs between -90° and -180° or 90° and 180°.

Classic STEMI Criteria

Defined by specific ST elevation patterns in contiguous leads on an ECG.

De Winter Pattern

Up-sloping ST depression at the J-point in V1-V6 with tall, symmetric T waves, indicating LAD occlusion.

Wellens' Syndrome

A warning pattern indicating critical proximal LAD stenosis.

Pneumonic for STEMI Locations

A memory aid to remember the anatomical regions affected by ST elevation.

Height Measurement for LVH

The criteria used to assess the voltage changes that indicate left ventricular hypertrophy.

Sokolow-Lyon Criteria

A measure used to screen for left ventricular hypertrophy by combining R and S wave measurements.

Poor R-Wave Progression

Decreased size of R waves from V1 to V6; often signifies anterior MI or LVH.

Causes of Poor R-Wave Progression

Includes conditions such as left bundle branch block, anterior MI, tension (LVH), and emphysema.

Common Questions - Cardiac Axis

Questions typically asked regarding interpretation and implications of axis deviations.

Acute Coronary Syndrome

A range of conditions associated with sudden reduced blood flow to the heart.

Dysrhythmia

An irregularity in the rhythm of the heartbeat.

Electrolyte Imbalance

An abnormal level of electrolytes in the body, which can affect heart function.

ST Segment Morphologies

The various shapes of the ST segment that can indicate different cardiac conditions.

ECG Lead Placement

The correct positioning of leads on the body to accurately record the electrical activity of the heart.

T Wave

The part of the ECG that represents ventricular repolarization.

Troponin

A protein released during heart muscle damage; often checked to diagnose myocardial infarction.

Strain Pattern

Changes on the ECG that indicate stress on the heart muscle usually seen in VT or RVH.

Rise in myocardial oxygen demand

The need for increased oxygen by the heart muscle during stress or activity.

Electrophysiological Changes

Alterations in the electrical activity of heart tissue caused by various conditions.

ECG Interpretation

The process of analyzing an electrocardiogram to assess heart function.

Reciprocal ST Depression

ST segment depression observed in leads opposite to those showing ST elevation.

Cardiac Myocyte

A muscle cell of the heart, responsible for its contraction.

Echocardiogram

An ultrasound of the heart used to visualize heart structures and function.

Cardiac Compliance

The ability of the heart to expand and fill with blood.

Atrial Fibrillation

An irregular, often rapid heart rate that can increase the risk of strokes.

Septal Infarction

An infarction that affects the septum (the wall between ventricles) of the heart.

ST Segment Depression

A downward deviation of the ST segment from the baseline, often indicating ischemia.

Critical Lesion

A blockage in a coronary artery that significantly impairs blood flow to the heart.

Pulmonary Hypertension

Increased blood pressure in the pulmonary arteries, which can lead to RVH.

Cor Pulmonale

Right heart failure due to lung disease.

Heart Failure

A condition in which the heart is unable to pump sufficiently to maintain blood flow.

Diagnosis

The identification of the nature of an illness or condition.

Cardiac Monitoring

Continuous observation of heart activity using electrocardiography.

Rescue Intervention

Emergency procedures performed to restore normal heart function.

Electrocardiographic Changes

Alterations in the ECG patterns that can indicate various cardiac conditions.

Lateral Wall Infarction

Infarction affecting the lateral wall of the heart, typically seen in V5 and V6.