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Trauma & Acute Presentations

Name: Trauma & Acute Presentations
Creator: Veli Bakalov, MD

The ATLS primary survey and the injuries that kill in minutes

Emergency & Critical Care·Trauma & Acute Presentations·5 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Primary survey in strict order: Airway with C-spine protection, Breathing, Circulation, Disability (GCS, pupils), Exposure; GCS ≤8 → intubate, and cricothyroidotomy if you cannot intubate or ventilate.
Hypotension + absent breath sounds + hyperresonance + JVD + trachea deviated away = tension pneumothorax → immediate needle decompression, then chest tube; no x-ray first.
Beck triad (hypotension, JVD, muffled heart sounds) = tamponade → operative decompression (pericardiocentesis only as a bridge); massive hemothorax (>1500 mL initially or >200 mL/h) → thoracotomy.
Hypotension first appears in class III hemorrhage (30–40%, 1500–2000 mL); resuscitate with 1:1:1 blood products, TXA within 3 hours, and permissive hypotension (SBP ~90) except with head injury.
GCS = eye 4 + verbal 5 + motor 6 (range 3–15); decorticate flexion scores 3, decerebrate extension scores 2.
Epidural = middle meningeal artery, lens-shaped, lucid interval, does not cross sutures; subdural = bridging veins, crescent, crosses sutures, elderly, alcoholics, shaken infants.
Cushing triad (hypertension with wide pulse pressure, bradycardia, irregular respirations) = rising ICP → head up 30°, hyperosmolar therapy, brief hyperventilation to PaCO2 30–35; a fixed dilated pupil = uncal herniation.
NEXUS (no midline tenderness, no focal deficit, alert, not intoxicated, no distracting injury) clears the C-spine without imaging; otherwise CT.
Unstable + positive FAST → laparotomy, stable → CT; compartment syndrome = pain on passive stretch with pulses present → fasciotomy if pressure >30 mmHg or delta <30.

Primary survey and airway

ABCDE: fix the killer first. The ATLS primary survey treats life threats in strict order and reassesses after each step before advancing. Obvious exsanguinating external bleeding is controlled at once with direct pressure or a tourniquet. The secondary survey (history and head-to-toe exam) follows only after the primary survey is complete.

AirwayWith cervical spine protection.
BreathingOxygenate; decompress a tension pneumothorax.
CirculationStop hemorrhage; two large-bore IVs; blood products.
DisabilityGCS and pupils.
ExposureUndress fully, then prevent hypothermia.

ATLS primary survey

Airway. Secure a definitive airway (endotracheal intubation by rapid sequence intubation) for GCS ≤8, apnea, or inability to protect the airway, maintaining in-line cervical stabilization. If you cannot intubate and cannot ventilate, perform a surgical cricothyroidotomy (needle cricothyroidotomy in young children).

Immediately lethal chest injuries

Tension pneumothorax is a clinical diagnosis. Hypotension with absent breath sounds, hyperresonance, distended neck veins, and a trachea deviated AWAY from the affected side. Decompress immediately with a needle (4th to 5th intercostal space just anterior to the midaxillary line in adults per ATLS, or 2nd intercostal space, midclavicular line), then place a chest tube. Do NOT wait for an x-ray.

Cardiac tamponade. Beck triad (hypotension, distended neck veins, muffled heart sounds) plus pulsus paradoxus; the FAST pericardial view shows the effusion. In penetrating trauma, operative decompression (pericardial window, sternotomy or thoracotomy) is preferred when a surgeon is available; pericardiocentesis is a bridge when one is not.

Massive hemothorax. More than 1500 mL of initial chest-tube output, or more than 200 mL/h, indicates thoracotomy.

Chest injuries that kill in minutes

Injury	Key findings	Neck veins	Treatment
Tension pneumothorax	Absent breath sounds, hyperresonance, trachea deviated away	Distended	Needle decompression, then chest tube
Cardiac tamponade	Beck triad, pulsus paradoxus	Distended	Operative decompression (window, sternotomy or thoracotomy); pericardiocentesis as a bridge
Massive hemothorax	Absent breath sounds, dullness to percussion, shock	Flat	Chest tube first; thoracotomy if >1500 mL or >200 mL/h

Distended neck veins separate tension pneumothorax and tamponade from hemorrhagic shock, where the neck veins are flat.

Hemorrhagic shock

Blood pressure falls late. Adult blood volume is about 5 L. Compensation holds the pressure until about 30% of volume is lost, so hypotension in a trauma patient means class III hemorrhage or worse.

Classes of hemorrhagic shock

Class	Blood loss	Heart rate	Blood pressure	Mental status, urine
I	<15% (<750 mL)	Normal	Normal	Normal
II	15–30%	>100	Normal; narrowed pulse pressure	Anxious
III	30–40% (1500–2000 mL)	>120	Decreased	Confused, oliguric
IV	>40%	>140	Markedly decreased	Lethargic, negligible urine

Give blood 1:1:1, not just saline. Place two large-bore (16–18 gauge) peripheral IVs. A massive transfusion protocol delivers packed RBCs, plasma (FFP), and platelets in a roughly 1:1:1 ratio (PROPPR). Limit crystalloid and allow permissive hypotension (target SBP about 90) until bleeding is controlled; this does not apply to head injury, where cerebral perfusion must be maintained. Tranexamic acid within 3 hours of injury lowers mortality (CRASH-2).

Warm all fluids and blood to avoid the lethal triad: hypothermia, acidosis, and coagulopathy.

Head injury and intracranial pressure

Glasgow Coma Scale. Eye (1–4) + Verbal (1–5) + Motor (1–6), range 3–15; GCS ≤8 defines coma and calls for a secured airway.

Eye: 4 spontaneous, 3 to voice, 2 to pain, 1 none.
Verbal: 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none.
Motor: 6 obeys, 5 localizes, 4 withdraws, 3 flexion (decorticate), 2 extension (decerebrate), 1 none.

Decorticate (flexion) scores higher than decerebrate (extension): de-core-ticate arms pull toward the core.

Who needs a head CT. Noncontrast head CT is first-line for significant head trauma: GCS <15, focal deficit, ≥2 episodes of vomiting, seizure, suspected skull fracture, age ≥65, or coagulopathy (the Canadian CT Head Rule and its exclusions). Basilar skull fracture shows raccoon eyes, Battle sign, hemotympanum, and CSF otorrhea or rhinorrhea.

Epidural vs subdural hematoma

Feature	Epidural	Subdural
Vessel	Middle meningeal ARTERY (temporal bone or pterion fracture)	Bridging VEINS
CT shape	Biconvex (lens)	Crescent
Suture lines	Does not cross	Crosses (but not the midline falx)
Course	Lucid interval, then rapid decline	Acute after major trauma, or chronic with gradual confusion
Typical patient	Young adult with a temporal blow	Elderly, alcoholics, shaken infants (brain atrophy stretches veins)

Cushing triad warns of herniation. Rising ICP produces hypertension (with a widened pulse pressure), bradycardia, and irregular respirations. Manage with head elevation to 30°, sedation, hypertonic saline or mannitol, and brief hyperventilation to PaCO₂ 30–35 as a bridge; hyperventilation lowers ICP fast through cerebral vasoconstriction but risks ischemia if prolonged. Maintain cerebral perfusion pressure (CPP = MAP − ICP) and avoid hypotension and hypoxia. A fixed, dilated pupil signals CN III compression from uncal herniation.

Cervical spine, abdomen, and extremities

NEXUS clears the neck clinically. No imaging is needed if ALL five criteria are met: no posterior midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no distracting injury. Otherwise obtain CT of the cervical spine, and keep the neck immobilized until it is cleared.

FAST. Bedside ultrasound scans four windows for free fluid: perihepatic (Morison pouch), perisplenic, pelvic, and pericardial.

Unstable + positive FAST: exploratory laparotomy; no time for CT.
Stable: CT of the abdomen and pelvis.
Unstable + negative FAST: look for bleeding in the chest, pelvis, long bones, or externally; bind an unstable pelvic fracture.

The spleen is the most commonly injured solid organ in blunt trauma; left shoulder pain from diaphragmatic irritation (Kehr sign) is a clue.

Acute compartment syndrome follows tibial fractures, crush injuries, or reperfusion. The 6 Ps: Pain out of proportion and on passive stretch (earliest and most reliable), Paresthesia, Pallor, Poikilothermia, Paralysis, and Pulselessness (late). A compartment pressure >30 mmHg, or a delta pressure (diastolic BP minus compartment pressure) <30, mandates emergent fasciotomy; watch for rhabdomyolysis afterward.

30 mmHgCompartment pressure (or delta pressure below 30) that mandates fasciotomy

Pulses are usually PRESENT in compartment syndrome; never wait for pulselessness to operate.