Key Facts

ATLS provides the universal framework for initial trauma management. A structured approach saves lives by ensuring life-threatening injuries are identified and treated in order of priority.

Epidemiology

Trauma is the leading cause of death in people aged 1-44 in the UK. ~16,000 major trauma patients/year in England. Road traffic collisions, falls, and assaults are the most common mechanisms. Major trauma networks centralise care to specialist trauma centres.

Aetiology

• Blunt trauma: RTCs (~40%), falls (~30%), assaults, sports injuries
• Penetrating trauma: Stabbings, GSWs (less common in UK than US)
• Blast injuries: Primary (pressure wave), secondary (debris), tertiary (displacement), quaternary (burns/inhalation)
• Polytrauma: Injury Severity Score (ISS) >15 = major trauma

Pathophysiology

• Trimodal death distribution: Immediate (seconds-minutes - massive injury), early (minutes-hours - haemorrhage, airway), late (days-weeks - sepsis, organ failure)

• Damage control resuscitation: Aims to break the lethal triad - permissive hypotension, minimise crystalloid, blood products 1:1:1, prevent hypothermia

Primary Survey (ABCDE)

A - Airway with C-spine control:

• Can the patient talk? → Airway patent
• Stridor, gurgling, snoring → airway compromise
• Jaw thrust, chin lift, suction, oropharyngeal/nasopharyngeal airway
• Definitive airway (intubation) if GCS ≤8 or unable to maintain airway
• In-line C-spine immobilisation until cleared

B - Breathing:

• Life-threatening conditions: Tension pneumothorax, massive haemothorax, open pneumothorax, flail chest
• Assess: RR, chest expansion, tracheal position, percussion, auscultation
• Tension pneumothorax: Needle decompression (2nd ICS MCL or 4th/5th ICS MAL) → chest drain

C - Circulation with haemorrhage control:

• Identify sources of haemorrhage: Chest, abdomen, pelvis, long bones, external ('blood on the floor and four more')
• 2× large bore IV access, IV fluids/blood products
• Pelvic binder if pelvic fracture suspected
• FAST scan (Focused Assessment with Sonography in Trauma)

D - Disability:

• GCS, pupil size and reactivity
• Blood glucose
• Lateralising signs

E - Exposure:

• Full exposure, log roll, prevent hypothermia
• Temperature management

Red Flags (Immediately Life-Threatening)

• Airway obstruction
• Tension pneumothorax
• Massive haemothorax (>1500mL)
• Cardiac tamponade
• Catastrophic external haemorrhage

Bedside

• Primary survey: Clinical assessment
• FAST scan: Free fluid in abdomen/pericardium
• Blood gas (ABG/VBG): pH, lactate, base deficit, Hb
• Point-of-care testing: TEG/ROTEM for coagulopathy

Bloods

• Group and crossmatch: Immediate (O-negative if type not available)
• FBC, coagulation, U&Es, LFTs: Baseline
• Lactate: Marker of tissue perfusion
• Ethanol level, urine drug screen: If indicated

Imaging

• CXR and pelvic X-ray: In primary survey if unstable
• CT traumagram (whole-body CT): Head, C-spine, chest, abdomen/pelvis - gold standard in haemodynamically stable patients
• CT angiography: If vascular injury suspected
• X-rays of long bones: As indicated in secondary survey

Damage Control Resuscitation

• Permissive hypotension: Target SBP ~80-90 mmHg until surgical haemorrhage control (avoid in head injury)
• 1:1:1 ratio: pRBCs:FFP:platelets
• TXA (tranexamic acid): 1g IV within 3 hours of injury (CRASH-2 trial - reduces mortality by ~10%)
• Prevent hypothermia: Warm fluids, forced-air warming, warm environment
• Minimise crystalloid: Avoid dilutional coagulopathy
• Calcium: Replace (citrate in blood products chelates calcium)

Damage Control Surgery

• Abbreviated surgery: Control haemorrhage (packing, ligation), control contamination (staple bowel ends)
• Transfer to ICU for resuscitation (correct lethal triad)
• Return to theatre for definitive surgery at 24-48 hours

Specific Interventions

• Chest drain: Haemo/pneumothorax - triangle of safety (4th/5th ICS, anterior axillary line)
• Thoracotomy: Massive haemothorax (>1500mL initial or >200mL/hr), cardiac tamponade, cardiac arrest in penetrating chest trauma
• Laparotomy: Haemodynamically unstable with positive FAST, peritonism, evisceration
• Pelvic binder: Pelvic fracture with haemodynamic instability

Referral Criteria

• All major trauma (ISS >15) - major trauma centre
• Activation criteria defined by local trauma network

• UK major trauma: Overall mortality ~15-20% (has improved with trauma networks)
• TXA within 3 hours: Reduces all-cause mortality by ~10% (CRASH-2)
• Golden hour: First 60 minutes critical for trauma outcomes
• Damage control resuscitation: Has significantly reduced mortality in massive haemorrhage
• Trauma network implementation: 19% reduction in mortality since 2012 (TARN data)

ATLS Primary Survey Summary

Haemorrhage Classification (ATLS)