Trauma Primary Survey: ATLS Systematic Approach
The x-ABCDE Framework — Updated for ATLS 11th Edition (2025)
- Apply the ATLS x-ABCDE primary survey sequence to systematically identify and treat life-threatening injuries
- Recognize and manage immediately life-threatening airway and breathing emergencies in the trauma bay
- Classify hemorrhagic shock using the ATLS four-class system and initiate appropriate resuscitation
- Describe the principles of damage control resuscitation including permissive hypotension and massive transfusion
- Perform a rapid neurological assessment using the Glasgow Coma Scale and identify signs of raised intracranial pressure
- Outline the transition from primary survey to adjuncts, secondary survey, and definitive care
Trauma Primary Survey
ATLS Systematic Approach — 11th Edition (2025)
Medaptly · Surgery Education Series · 2026
Agenda
Trauma Epidemiology & ATLS Principles
The Foundation of Systematic Trauma Care
Trauma: A Global Health Crisis
The Golden Hour: The first 60 minutes after injury are critical. Approximately 30% of trauma deaths are preventable with timely, systematic assessment and intervention — this is the purpose of ATLS.
ATLS Core Principles
- Treat first what kills first. Airway obstruction kills faster than breathing failure, which kills faster than hemorrhagic shock. Follow the priority sequence.
- Time is critical. Definitive diagnosis is not needed before starting treatment. Do not delay life-saving interventions for history or imaging.
- Continuous reassessment. If a patient deteriorates, return to the beginning of the primary survey (start over from x-A). The survey is cyclical, not linear.
- Team-based, standardized approach. A common language allows parallel assessment and intervention by a coordinated trauma team.
ATLS 11th Edition (2025) Key Updates: x-ABCDE (exsanguinating hemorrhage first), damage control resuscitation integration, permissive hypotension, limited crystalloids, early transfusion, neuroprotective focus, and spine motion restriction replacing rigid immobilization.
The x-ABCDE Primary Survey Sequence
Exsanguinating Hemorrhage
Control massive external bleeding: tourniquet, direct pressure, pelvic binder
Airway + C-Spine
Patent airway with cervical spine motion restriction
Breathing
Ventilation & oxygenation; treat tension PTX, open PTX
Circulation
Hemorrhage control, IV access, resuscitation
Disability & Exposure
GCS, pupils, full exam, prevent hypothermia
Golden Rule: If the patient deteriorates at any point, go back to ‘X’ and start the primary survey again from the beginning. Address the problem before continuing.
Exsanguinating Hemorrhage Control
Stop the Bleeding — The First Priority in ATLS 11th Edition
X — Massive Hemorrhage Control
Direct Pressure
First-line for all compressible hemorrhage. Sustained manual pressure with gauze packing for wound cavities.
Tourniquet
Apply proximal on extremity for life-threatening limb hemorrhage. Tighten until bleeding stops. Note time of application.
Pelvic Binder
At level of greater trochanters for suspected unstable pelvic fracture. Circumferential compression reduces pelvic volume.
Junctional Hemorrhage (groin, axilla, neck): Not amenable to tourniquet. Use hemostatic agents (combat gauze) packed into wound + sustained pressure.
Tourniquet Safety: Complications are rare with <2 hours of use. A tourniquet that saves a life is never the wrong decision. Document application time.
Airway with C-Spine Protection
The First Priority After Hemorrhage Control
A — Airway Assessment
Talk to the Patient
A clear verbal response = patent airway (for now). Ask their name. If they speak clearly, proceed to ‘B’ — but continue to reassess.
Look, Listen, Feel
Look: blood, vomit, foreign bodies, facial fractures, edema. Listen: stridor, gurgling, hoarseness, snoring. Feel: subcutaneous emphysema, tracheal position.
Protect the C-Spine
Assume cervical injury in all blunt trauma above clavicle, altered consciousness, or distracting injury. Manual in-line stabilization (MILS) during all airway maneuvers. Apply cervical collar.
ATLS 11th Ed Update: “Spine motion restriction” replaces “spinal immobilization.” Remove the backboard as soon as feasible. Use collar + firm mattress for ongoing restriction.
Airway Management: Escalation Ladder
Simple Maneuvers
Jaw thrust (preferred in trauma), chin lift, suction, remove visible foreign bodies (Magill forceps)
Airway Adjuncts
OPA (unconscious, no gag) or NPA (semi-conscious; avoid in suspected base-of-skull fracture)
Definitive Airway: Intubation
Cuffed ETT via RSI with MILS. Indications: GCS ≤8, apnea, severe facial trauma, airway burns, anticipated deterioration. Confirm with capnography.
Surgical Airway: Cricothyroidotomy
“Can’t intubate, can’t oxygenate” → Surgical cricothyroidotomy. Incise through cricothyroid membrane. Contraindicated in children <12 (use needle cricothyroidotomy).
Capnography: Use end-tidal CO2 (capnography) to confirm AND continuously monitor ETT placement. This is the gold standard — more reliable than auscultation alone.
Breathing & Ventilation
Life-Threatening Thoracic Injuries in the Primary Survey
Breathing: Assessment & Immediate Threats
Rapid Chest Assessment
- Inspect: RR, symmetry, wounds, flail, accessory muscles
- Palpate: Tenderness, crepitus, tracheal position
- Percuss: Hyperresonant = PTX; Dull = hemothorax
- Auscultate: Absent/diminished breath sounds
- Monitor: SpO2, high-flow O2 for all trauma patients
1. Tension pneumothorax
2. Open (sucking) pneumothorax
3. Massive hemothorax
4. Flail chest + pulmonary contusion
Tension Pneumothorax is a CLINICAL diagnosis. Do NOT wait for CXR. Needle decompression (2nd ICS MCL or 4th/5th ICS AAL) followed by chest tube.
Life-Threatening Thoracic Injuries
| Condition | Key Findings | Immediate Treatment |
|---|---|---|
| Tension PTX | Hypotension, JVD, absent breath sounds, tracheal deviation, hyperresonance | Needle decompression → chest tube |
| Open PTX | Sucking chest wound >2/3 trachea diameter, air through wound | 3-sided occlusive dressing → chest tube (remote from wound) |
| Massive Hemothorax | Hypotension, flat neck veins, absent breath sounds, dull percussion | Chest tube (36–40 Fr) + volume resuscitation ± thoracotomy |
| Flail Chest | Paradoxical movement, crepitus, hypoxia from pulmonary contusion | O2, analgesia, ventilatory support PRN, fluid restriction |
Circulation & Hemorrhage Control
Hemorrhagic Shock Assessment and Damage Control Resuscitation
C — Circulation Assessment
Perfusion Indicators
- Consciousness: Earliest indicator of hypoperfusion
- Skin: Cool, pale, diaphoretic = shock
- HR: Tachycardia often first measurable sign
- BP & Pulse Pressure: Narrowed PP = early shock
- Capillary refill: >2 seconds = reduced perfusion
1. Chest (hemothorax)
2. Abdomen (solid organ injury)
3. Pelvis (pelvic fracture)
4. Retroperitoneum
5. Long bones (femur fractures)
IV Access: Two large-bore (16G+) peripheral IVs. If unable within 90 seconds → intraosseous (IO) access. Central venous access is NOT first-line in acute trauma resuscitation.
ATLS Hemorrhage Classification
| Parameter | Class I | Class II | Class III | Class IV |
|---|---|---|---|---|
| Blood Loss (mL) | Up to 750 | 750–1,500 | 1,500–2,000 | >2,000 |
| Blood Loss (%) | Up to 15% | 15–30% | 30–40% | >40% |
| Heart Rate | <100 | 100–120 | 120–140 | >140 |
| Blood Pressure | Normal | Normal | Decreased | Decreased |
| Mental Status | Slightly anxious | Mildly anxious | Anxious, confused | Confused, lethargic |
| Initial Fluid | Crystalloid | Crystalloid | Crystalloid + blood | MTP activation |
Damage Control Resuscitation (DCR)
Permissive Hypotension
Target SBP 80–90 mmHg in penetrating torso trauma until surgical control. NOT in TBI.
Limit Crystalloids
Avoid large-volume crystalloid. Maximum 1–2 L, then switch to blood products. Crystalloid dilutes clotting factors.
Balanced Transfusion 1:1:1
pRBC : FFP : Platelets in 1:1:1 ratio. Activate massive transfusion protocol (MTP) early for Class III/IV hemorrhage.
Tranexamic Acid (TXA)
1 g IV within 3 hrs of injury + 1 g over 8 hrs. CRASH-2: reduces mortality. DO NOT give after 3 hours.
The Lethal Triad: Hypothermia + Acidosis + Coagulopathy. Each worsens the others. DCR targets all three simultaneously. Prevent hypothermia aggressively (warm fluids, warming devices, warm environment).
Disability & Exposure
Neurological Assessment and Complete Patient Evaluation
D — Disability: GCS & Neurological Assessment
| Component | Response | Score |
|---|---|---|
| Eye Opening | Spontaneous | 4 |
| To voice | 3 | |
| To pain | 2 | |
| None | 1 | |
| Motor (best) | Obeys commands | 6 |
| Localizes pain | 5 | |
| Flexion / Extension / None | 4–1 |
GCS ≤8 = Severe TBI → Intubate for airway protection. Maintain SBP >90 mmHg, SpO2 >90%, PaCO2 35–40 mmHg.
Pupils: Unilateral fixed dilated pupil = uncal herniation (ipsilateral CN III compression). Urgent CT + neurosurgery consult. Mannitol or hypertonic saline as bridge.
E — Exposure & Environmental Control
Complete Exposure
- Fully undress patient to find all injuries
- Log-roll to examine back, spine, buttocks
- Check axillae, perineum, scalp for occult injuries
- Remove from backboard ASAP (skin breakdown)
Prevent Hypothermia
- Warm IV fluids and blood products
- Forced-air warming blankets (Bair Hugger)
- Increase ambient room temperature
- Remove wet clothing immediately
- Monitor core temperature continuously
Hypothermia kills. Core temp <35°C impairs coagulation and worsens the lethal triad. Cover the patient after examination. Warm everything that goes into the patient.
Adjuncts, Secondary Survey & Takeaways
Completing the Assessment and Transitioning to Definitive Care
Adjuncts to the Primary Survey
4 views for free fluid:
1. RUQ (Morrison pouch) — most sensitive
2. LUQ (splenorenal recess)
3. Suprapubic (pelvis)
4. Subxiphoid (pericardium)
eFAST adds: bilateral anterior chest for PTX
AP Chest X-ray: Hemothorax, PTX, mediastinal widening, rib fractures
AP Pelvic X-ray: Pelvic fracture (guides binder placement)
CT (if stable): Head, C-spine, chest, abdomen/pelvis — the ‘pan-scan’ after stabilization
FAST(+) + Unstable = OR. Do not delay for CT. Immediate surgical exploration.
Secondary Survey & AMPLE History
Head-to-Toe Examination
- Scalp: lacerations, hematomas, skull fractures
- Face & eyes: Le Fort fractures, globe injury
- Neck: JVD, subcutaneous emphysema, trachea
- Chest: auscultate, palpate all ribs
- Abdomen: tenderness, distension, guarding
A — Allergies
M — Medications (anticoagulants critical)
P — Past medical/surgical history
L — Last meal (for anesthesia)
E — Events/environment of injury
Tertiary Survey (24–48 hrs): Repeat head-to-toe exam to catch missed injuries. Missed injury rate is ~10% in major trauma. Essential for intubated/altered patients.
Non-Hemorrhagic Causes of Shock in Trauma
| Type | Mechanism | Key Features | Treatment |
|---|---|---|---|
| Tension PTX | Obstructive | JVD, absent breath sounds, tracheal deviation, hypotension | Needle decompression → chest tube |
| Cardiac Tamponade | Obstructive | Beck triad (hypotension, JVD, muffled hearts); FAST(+) pericardial fluid | Pericardiocentesis or ED thoracotomy |
| Neurogenic | Distributive (loss of sympathetic tone) | Hypotension + bradycardia; warm, dry extremities; spinal cord injury | Fluids + vasopressors (phenylephrine) |
| Cardiogenic | Pump failure | Blunt cardiac injury (contusion); arrhythmias; high-energy chest trauma | Echo, inotropes, monitor ECG |
Rule: Assume hemorrhagic shock until proven otherwise. If a trauma patient doesn’t respond to volume — reassess for obstructive causes (tension PTX, tamponade) before considering non-hemorrhagic etiologies.
Key Takeaways
- XStop the bleeding first: Tourniquet for extremity hemorrhage, direct pressure, pelvic binder. x-ABCDE is the new standard (ATLS 11th Ed).
- AAirway is life: A talking patient = patent airway (for now). GCS ≤8 = intubate. Surgical airway when you can’t intubate, can’t oxygenate. Always protect the C-spine.
- BTension PTX is a clinical diagnosis: Do NOT wait for imaging. Needle decompress immediately if suspected with hemodynamic compromise.
- CDamage control resuscitation: Limit crystalloids, early 1:1:1 transfusion, TXA within 3 hrs, permissive hypotension (not in TBI). FAST(+) + unstable = OR.
- DPrevent secondary brain injury: Maintain SBP >90, SpO2 >90%, PaCO2 35–40. Avoid hypoxia and hypotension in TBI at all costs.
References (1 of 2)
- American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS®): Student Course Manual, 11th Edition. Chicago (IL): ACS; 2025.
- Abubakar S. Advanced trauma life support 2025: A brief review of updates. Injury. 2026;57(4):112176. DOI
- Kostiuk M, Burns B. Trauma Assessment. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Link
- CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2). Lancet. 2010;376(9734):23–32. DOI
- Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio (PROPPR trial). JAMA. 2015;313(5):471–482. DOI
References (2 of 2)
- Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, 4th edition. Neurosurgery. 2017;80(1):6–15. DOI
- Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2(7872):81–84. DOI
- Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: 6th edition. Crit Care. 2023;27(1):80. DOI
- Pape HC, Lefering R, Butcher N, et al. The definition of polytrauma revisited. J Trauma Acute Care Surg. 2014;77(5):780–786. DOI
- Gallaher JR, Charles A. Acute cholecystitis: a review. JAMA. 2022;327(10):965–975. DOI
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