Initial assessment and management of trauma (ATLS primary and secondary survey)
How an injured patient is assessed and resuscitated in the first hour using the ATLS sequence: preparation, triage, primary survey with resuscitation, adjuncts, secondary survey and reassessment.
UHS PGET syllabus: Trauma (12 MCQs, both groups), Initial assessment and management of traumaUpdated October 2026Share on WhatsApp
In 30 seconds
ATLS runs in a fixed order: prepare, triage, primary survey plus resuscitation, adjuncts, secondary survey, reassess, definitive care; life threats are treated as they are found.
The primary survey is ABCDE (with catastrophic external bleeding controlled first): airway with cervical spine protection, breathing, circulation with haemorrhage control, disability, exposure.
Hypotension after injury is bleeding until proven otherwise: stop the bleeding, give warmed blood products, tranexamic acid within 3 hours, and judge the response to the first fluid bolus.
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Overview
Injury is a leading cause of death in young adults. In Pakistan, road traffic crashes, falls, firearm injuries and blasts fill the emergency rooms every day. The Advanced Trauma Life Support (ATLS) method gives one common language for the first hour of care.
Its core idea is simple: treat the greatest threat to life first, even before you know the exact diagnosis. You do not need a full history or an X-ray to treat an obstructed airway or a tension pneumothorax.
Why people die after injury: the trimodal distribution
Peak
Timing
Typical causes
What helps
First
Seconds to minutes
Severe brain or high cord injury, rupture of the heart or aorta
Prevention only (helmets, seat belts, road safety)
The window of the second peak is called the golden hour. ATLS stresses that this is a period of opportunity, not a fixed 60 minutes.
The ATLS sequence
Preparation: prehospital (pre-alert, short scene time) and hospital (trauma team, warmed fluids, airway kit, standard precautions).
Triage: sorting by need and resources.
Primary survey with resuscitation at the same time.
Adjuncts to the primary survey.
Consider transfer early if your hospital cannot give definitive care.
Secondary survey: history and head-to-toe examination.
Adjuncts to the secondary survey (CT, specialised imaging).
Reassessment and definitive care.
Triage at the hospital door
Situation
Who is treated first
Multiple casualties (resources are enough)
Patients with life-threatening and multisystem injuries
Mass casualties (resources overwhelmed)
Patients with the best chance of survival who need the least time, staff and supplies
High-yield
On reaching a road traffic accident scene, the main job of the trauma team leader is triage, deciding who needs what first. Triage is covered in detail in the disaster surgery chapter.
Primary survey with resuscitation
Bailey & Love writes this as cABCDE: the small "c" means control of catastrophic external haemorrhage before anything else (lesson learnt from war wounds). Use direct pressure and packing first; if a limb wound keeps bleeding, apply a tourniquet above the wound and write down the time it went on.
A: Airway with cervical spine protection
Assess: a patient who answers in a normal voice has a patent airway for now. Look for agitation, stridor, hoarseness, gurgling, blood, vomit, broken teeth and facial or neck injury.
Simple steps first: suction, chin lift or jaw thrust (without extending the neck), then an oropharyngeal or nasopharyngeal airway.
Do not use a nasopharyngeal airway or nasal tube if a cribriform plate (base of skull) fracture is possible.
Cervical spine: restrict movement (manual in-line stabilisation, collar and blocks) in every blunt multisystem injury until injury is excluded.
#### Definitive airway
A definitive airway means a cuffed tube sitting in the trachea, its cuff blown up beneath the vocal cords, attached to oxygen-rich ventilation and tied in place. Indications:
Need
Examples
Protect the airway
GCS 8 or less, risk of aspiration of blood or vomit, severe maxillofacial injury, burns with inhalation injury
Expanding neck haematoma, laryngeal or tracheal injury, stridor
Orotracheal intubation by rapid sequence induction with in-line stabilisation is the usual route. A gum elastic bougie helps when the cords cannot be seen.
Surgical airway is needed when the tube cannot pass the cords: glottic oedema, laryngeal fracture, severe oropharyngeal bleeding.
Surgical cricothyroidotomy is preferred to emergency tracheostomy in adults: quicker, simpler and less bloody.
Exam trap
Surgical cricothyroidotomy is avoided under 12 years because the cricoid is the only complete ring supporting the child's upper trachea. Use needle cricothyroidotomy instead.
Needle cricothyroidotomy (jet insufflation: roughly one second of oxygen, then four seconds to let gas out) oxygenates for only about 30–45 minutes, because carbon dioxide accumulates. It is a bridge, not a definitive airway.
High-yield
Laryngeal fracture shows a triad of hoarseness, subcutaneous emphysema and a palpable fracture.
B: Breathing and ventilation
Give high-flow oxygen to every major trauma patient.
Expose the chest, look, feel, percuss and listen.
Find and treat at once: tension pneumothorax, open pneumothorax and massive haemothorax (and in Bailey & Love's list, flail chest). Details are in the chest trauma chapter.
Exam trap
Tension pneumothorax is a clinical diagnosis. Decompress first; never send the patient for a chest X-ray to confirm it.
C: Circulation with haemorrhage control
Hypotension after injury is due to bleeding until proven otherwise. Look for blood "on the floor and four more": external, chest, abdomen (and retroperitoneum), pelvis and long bones.
Two large-bore cannulas; if veins fail, use intraosseous access.
Send blood for group and cross-match, blood gas and lactate, and a pregnancy test in women of childbearing age.
Apply a pelvic binder over the greater trochanters (not the iliac crests) in an unstable patient after blunt injury; keep it on until a pelvic fracture is excluded.
Never "spring" the pelvis repeatedly; it disturbs clot.
#### Classes of haemorrhagic shock (adult)
Adult blood volume is about 7% of body weight (about 5 L in a 70 kg man).
Class
I
II
III
IV
Volume lost
<15%
15–30%
31–40%
>40%
Pulse
Normal
Normal or raised
Raised
Markedly raised
Systolic BP
Normal
Normal
Normal or falling
Low
Pulse pressure
Normal
Narrowed
Narrowed
Narrowed
Urine output
Normal
Normal
Reduced
Minimal
Mental state (GCS)
Normal
Normal
Reduced
Reduced
Base deficit
0 to −2
−2 to −6
−6 to −10
−10 or worse
Blood needed
Monitor
Possibly
Yes
Massive transfusion protocol
High-yield
In class II the narrow pulse pressure comes from a rise in diastolic pressure (catecholamine vasoconstriction). The systolic pressure usually starts to fall in class III.
Exam trap
Young fit adults, athletes and patients on beta-blockers may show little tachycardia; the elderly may be "hypotensive" at a systolic of 110. Do not rely on one sign.
Worked example: estimating blood loss
70 kg man, blood volume ≈ 7% of 70 kg = 4.9 L Class II starts at 15% → 0.15 × 4.9 L ≈ 0.74 L Class III starts above 30% → 0.30 × 4.9 L ≈ 1.47 L Class IV is over 40% → 0.40 × 4.9 L ≈ 1.96 L
#### Fluids, blood and the response to the first bolus
First give a warmed isotonic bolus: 1 L in adults, 20 mL/kg in children under 40 kg (this counts fluid already given before arrival).
Early blood and blood products are better than large volumes of crystalloid, which dilute clotting factors and worsen acidosis, hypothermia and lung injury.
A massive transfusion protocol gives red cells, plasma and platelets in a balanced ratio (Bailey & Love: 1:1:1).
Permissive (balanced) hypotension: until bleeding is controlled, aim for a systolic of about 70–90 mmHg (a palpable radial pulse), but keep it above 90 mmHg if a head injury is suspected. This is a short bridge to surgery, not a treatment.
Tranexamic acid:1 g IV over 10 minutes, then 1 g over 8 hours, given within 3 hours of injury to patients with significant bleeding.
Do not give sodium bicarbonate for the acidosis of hypovolaemic shock; restore perfusion instead.
Response to first bolus
Vital signs
Likely loss
Meaning
Rapid response
Return to normal and stay normal
<15%
Bleeding has stopped; keep cross-matched blood ready; surgeon still involved
Transient response
Improve, then worsen again
15–40%, ongoing
Still bleeding: give blood, plan operation or angioembolisation
Minimal or no response
Stay abnormal
>40%
Immediate surgery and massive transfusion; also think of non-haemorrhagic shock (tension, tamponade)
Memory hook
"One on the floor and four more": external, chest, abdomen, pelvis, long bones.
D: Disability
Glasgow Coma Scale, pupil size and reaction, and movement of all four limbs.
A low GCS may be due to poor oxygenation or perfusion, so correct A, B and C first, then reassess.
Remove all clothing to find every injury, then cover the patient at once.
Prevent hypothermia: warm room, warm blankets, fluid warmers (crystalloid warmed to about 39°C). Never warm blood products in a microwave.
Log-roll to inspect the back (Bailey & Love advises delaying a formal log roll in blunt trauma with a suspected pelvic fracture, but always look at the back in penetrating trauma).
High-yield
The lethal (deadly) triad is hypothermia, acidosis and coagulopathy. Each worsens the others; avoiding them is a key aim of resuscitation.
Adjuncts to the primary survey
Adjunct
Point to remember
ECG monitoring
Unexplained tachycardia or arrhythmia suggests blunt cardiac injury; PEA suggests tamponade, tension pneumothorax or profound hypovolaemia
Pulse oximetry, end-tidal CO2, ABG
Base deficit and lactate show the depth of shock and the response to treatment
Urinary catheter
Urine output is a sensitive guide to perfusion. Do not insert if there is blood at the meatus or perineal bruising: do a retrograde urethrogram first
Gastric tube
Decompresses the stomach and reduces aspiration. Pass it orally if a cribriform plate fracture is suspected
X-rays
AP chest and AP pelvis in blunt multisystem injury
FAST / eFAST, DPL
Rapid search for blood in the abdomen, pericardium and pleura (see torso chapter)
High-yield
Adequate resuscitation gives a urine output of about 0.5 mL/kg/h in adults, 1 mL/kg/h in children and 2 mL/kg/h in infants under 1 year. Hourly urine output is a reliable bedside guide.
Secondary survey
Starts only when the primary survey is complete and vital signs are improving.
AMPLE history:Allergies, Medications, Past illness or Pregnancy, Last meal, Events and environment of the injury.
Head-to-toe examination: scalp, eyes (before swelling closes them), face, neck, chest, abdomen, perineum, rectum and vagina when indicated, musculoskeletal system and full neurological examination.
Adjuncts: CT of head, spine, chest, abdomen and pelvis; angiography; contrast studies; endoscopy.
Bailey & Love describes whole-body CT (head to pelvis with contrast) as the gold standard for the severely injured patient who is stable enough to be scanned. An unstable patient goes to the operating theatre, not the scanner.
Exam trap
Patients who were intubated or confused need a tertiary survey once awake, to catch "minor" injuries missed earlier (for example a scaphoid fracture).
Reassessment, transfer and records
Reassess constantly. Any deterioration means go back to A.
Transfer early if the hospital cannot provide definitive care; do not delay transfer for tests that will not change management.
Record everything with times. In a life-threatening emergency, treat first and obtain consent later.
Short operation: stop bleeding, control contamination, temporary closure; ICU resuscitation; definitive repair later
Early total care
Patient responds well and physiology normal
Definitive fixation and repair early
Bailey & Love uses venous lactate as a guide: below 2 mmol/L suits early total care, 2–3 look at the trend, above 3 suggests under-resuscitation, and above 5 points to damage control.
Exam focus
Expect: the first priority at the scene or in the emergency room (airway with cervical spine protection after catastrophic bleeding, or triage when many patients arrive), the definition and indications of a definitive airway, why surgical cricothyroidotomy is avoided in children, classes of haemorrhage and which class first lowers the systolic pressure, response to the first fluid bolus, the best bedside index of resuscitation (urine output), contraindications to urinary and nasogastric tubes, tranexamic acid timing, AMPLE, GCS calculation and the trimodal death distribution.
Blood at meatus: urethrogram before catheter. Skull base fracture: orogastric tube.
AMPLE history; tertiary survey for the intubated patient.
Written by The House Job from standard references (ATLS Student Course Manual, 10th edition; Bailey & Love's Short Practice of Surgery, 27th edition).
FAQ
What is the first thing to do for a multiply injured patient?
Stop any catastrophic external bleeding and secure the airway while protecting the cervical spine; then move through breathing, circulation, disability and exposure.
Why is urine output used to judge resuscitation?
It reflects kidney perfusion and responds within hours, so a steady output of about 0.5 mL/kg/h in an adult shows that organs are being perfused.
What does a transient responder need?
Blood and blood products and an early decision on surgery or angioembolisation, because the temporary improvement shows that bleeding is continuing.
When should tranexamic acid be given?
As early as possible and within 3 hours of injury in a patient with significant bleeding; giving it later offers no benefit.
What is a tertiary survey?
A repeat full examination once a previously intubated or confused patient is awake, done to find injuries missed in the first hours.
