Step 2 CK · Surgery

Trauma & ATLS

Name: Trauma & ATLS
Creator: Veli Bakalov, MD

The primary survey, the clinical emergencies, and the numbers that save lives

Surgery·Trauma·5 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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ATLS primary survey (11th edition) is xABCDE in order: control of exsanguinating external hemorrhage first (tourniquet, packing, pressure), then airway with cervical spine protection, breathing, circulation with hemorrhage control, disability (GCS, pupils), exposure; secure a definitive airway for GCS ≤8.
Tension pneumothorax (tracheal deviation away, absent breath sounds, hyperresonance, JVD, hypotension) is clinical → immediate needle decompression, then chest tube; never wait for a chest x-ray.
Cardiac tamponade: Beck triad (hypotension, JVD, muffled heart sounds) plus pulsus paradoxus → pericardiocentesis or thoracotomy; breath sounds are equal, unlike tension pneumothorax.
Hemorrhagic shock: class I <15%, II 15–30% (tachycardia, narrow pulse pressure), III 30–40% (hypotension, confusion), IV >40% (lethargy, negligible urine); BP often normal until class III.
Resuscitate with limited crystalloid then early blood (massive transfusion 1:1:1), permissive hypotension, and TXA within 3 hours (CRASH-2); avoid the lethal triad of hypothermia, acidosis, coagulopathy.
Blood hides on the floor and in four more sites: chest, abdomen, pelvis/retroperitoneum, and long bones; bind an unstable pelvis to tamponade retroperitoneal bleeding.
Positive FAST (perihepatic, perisplenic, pelvic, pericardial) in an unstable patient → laparotomy; stable → CT; the spleen is the most commonly injured organ in blunt trauma, then the liver.
Epidural = middle meningeal artery, biconvex, lucid interval, temporal fracture; subdural = bridging veins, crescent that crosses sutures, elderly and alcoholics.
Cushing reflex (hypertension, bradycardia, irregular respirations) signals rising intracranial pressure and impending herniation.

The primary survey

xABCDE, in that order. The ATLS primary survey (11th edition) treats life threats in the order they kill: control of eXsanguinating external hemorrhage (tourniquet, wound packing, direct pressure), then Airway with cervical spine protection, Breathing, Circulation with hemorrhage control, Disability (GCS and pupils), and Exposure/environment. Each threat is fixed before moving on, and the survey restarts whenever the patient deteriorates.

x: Exsanguinating hemorrhageTourniquet, packing, or pressure before the airway.
A: AirwayJaw thrust with in-line cervical spine immobilization.
B: BreathingTension pneumothorax, hemothorax.
C: CirculationHemorrhage control, two large-bore IVs.
D: DisabilityGCS, pupils.
E: ExposureUndress fully, prevent hypothermia.

ATLS primary survey

GCS 8, intubate. Secure a definitive airway for a Glasgow Coma Scale of 8 or less (the patient cannot protect the airway), severe facial or airway trauma, or impending obstruction. If intubation fails, perform a surgical cricothyroidotomy. The GCS runs from 3 to 15 (eye 4, verbal 5, motor 6).

Adjuncts and secondary survey. Chest and pelvic films and FAST accompany the primary survey. Do not place a urinary catheter when there is blood at the urethral meatus (retrograde urethrogram first), and avoid a nasogastric tube with a suspected basilar skull fracture. The head-to-toe secondary survey and AMPLE history (Allergies, Medications, Past history, Last meal, Events) come only after stabilization.

Thoracic life threats

Treat before imaging. Tension pneumothorax and cardiac tamponade are clinical diagnoses; do not wait for a chest x-ray.

Tension pneumothorax causes tracheal deviation away from the affected side, absent breath sounds, hyperresonance, distended neck veins, and hypotension. Treat with immediate needle decompression (in adults, the 4th to 5th intercostal space just anterior to the midaxillary line is preferred because the 2nd intercostal space at the midclavicular line often fails; the 2nd intercostal space midclavicular line is used in children), then a chest tube.

Cardiac tamponade, often from penetrating chest trauma, gives the Beck triad (hypotension, distended neck veins, muffled heart sounds) plus pulsus paradoxus; the FAST pericardial window shows the effusion. Treat with pericardiocentesis or emergency thoracotomy.

Hypotension after chest trauma

Feature	Tension pneumothorax	Cardiac tamponade	Massive hemothorax
Neck veins	Distended	Distended	Flat (hypovolemia)
Breath sounds	Absent on one side	Equal bilaterally	Decreased on one side
Other clues	Hyperresonance, tracheal deviation	Muffled heart sounds, pulsus paradoxus	Dullness to percussion
Treatment	Needle decompression, then chest tube	Pericardiocentesis or thoracotomy	Chest tube; thoracotomy for >1500 mL initially or >200 mL/h for 2 to 4 hours

Tension and tamponade share hypotension and distended neck veins; breath sounds (absent) vs heart sounds (muffled) tell them apart.

Other breathing problems. An open ("sucking") chest wound gets an occlusive dressing taped on three sides, then a chest tube. Flail chest signals an underlying pulmonary contusion and needs analgesia and ventilatory support.

Circulation and hemorrhagic shock

Blood on the floor and four more. Control external hemorrhage with direct pressure and place two large-bore IVs (intraosseous access if veins fail). Major internal blood loss hides in the chest, abdomen, pelvis/retroperitoneum, and long bones (thighs). Hemorrhage is the leading cause of preventable trauma death, so hypotension after trauma is bleeding until proven otherwise.

Classes of hemorrhagic shock

Class	Blood loss	Findings
I	<15%	Normal vitals
II	15–30%	Tachycardia, narrowed pulse pressure, anxiety
III	30–40%	Hypotension, marked tachycardia, confusion
IV	>40%	Lethargy, negligible urine output

Blood pressure often stays normal until class III; tachycardia and a narrow pulse pressure come first.

Crystalloid, then blood, plus TXA. Give a limited crystalloid bolus, then early blood products. Permissive hypotension avoids dislodging clots before surgical control, except in traumatic brain injury, where cerebral perfusion must be maintained. Give tranexamic acid within 3 hours of injury to reduce mortality (CRASH-2 trial): 1 g over 10 minutes, then 1 g over 8 hours.

Massive transfusion is 1:1:1 packed red cells, fresh frozen plasma, and platelets; low-titer group O whole blood is an alternative where available. Citrate in stored blood chelates calcium, so watch for hypocalcemia, along with hyperkalemia and hypothermia.

Avoid the lethal triad of hypothermia, acidosis, and coagulopathy: warm the patient and fluids, and limit crystalloid.

Abdomen, pelvis, and damage control

FAST finds free fluid fast. The Focused Assessment with Sonography for Trauma checks four windows for free fluid: perihepatic (Morison pouch), perisplenic, pelvic, and pericardial. A positive FAST in a hemodynamically unstable patient means laparotomy; stable patients get CT.

Blunt abdominal trauma. The spleen is the most commonly injured organ, followed by the liver. Left lower rib fractures and referred left shoulder pain (Kehr sign) raise suspicion for splenic injury. Stable patients are imaged with CT, and many solid-organ injuries are managed nonoperatively, with angioembolization when needed. After splenectomy, vaccinate against pneumococcus, meningococcus (MenACWY with boosters every 5 years, plus MenB), and H. influenzae type b, ideally 14 days or more after surgery, or before discharge if follow-up is uncertain.

Penetrating abdominal trauma. Instability, peritonitis, or evisceration mandates laparotomy; stable stab wounds may be evaluated with CT or serial exams.

Bind the pelvis. An unstable pelvic fracture can bleed massively into the retroperitoneum; a pelvic binder at the level of the greater trochanters tamponades the bleeding, followed by angioembolization or pelvic packing if hemorrhage persists.

Abbreviated operationRapidly control hemorrhage and contamination.
Temporary closureLeave the abdomen open or temporarily closed.
ICUResuscitate, rewarm, correct coagulopathy.
ReturnDefinitive repair once physiology recovers.

Damage control surgery for the crashing patient

Head trauma

Epidural hematoma: tear of the middle meningeal artery (arterial) with a temporal bone fracture; biconvex, lens-shaped, and does not cross suture lines; classic lucid interval, then rapid deterioration.
Subdural hematoma: torn bridging veins (venous); crescent-shaped and crosses suture lines; slower, and common in the elderly and alcoholics because of brain atrophy.

Rising intracranial pressure. The Cushing reflex (hypertension, bradycardia, irregular respirations) signals rising intracranial pressure and herniation; a unilateral blown pupil points to uncal herniation on that side. Elevate the head of the bed, give hyperosmolar therapy (mannitol or hypertonic saline), use hyperventilation only briefly as a bridge, and evacuate an expanding hematoma by emergent craniotomy.