Surgery - Advanced Trauma Life Support (ATLS)

Principles of ATLS

Advanced Trauma Life Support (ATLS) provides a systematic and reliable approach to the assessment and initial resuscitation of trauma patients.

The aim is to rapidly identify and immediately treat potentially life-threatening injuries.

Once immediate threats to life have been managed, a more detailed assessment of the entire patient is performed to identify other injuries and establish definitive care.

The ATLS assessment is therefore divided into the primary survey and secondary survey.

Primary Survey

The primary survey is the initial systematic assessment of a trauma patient designed to identify and treat immediately life-threatening injuries.

Assessment and resuscitation occur simultaneously, with problems treated as soon as they are identified.

The primary survey follows the ABCDE approach.

A – Airway with cervical spine protection: Assess and secure the airway while maintaining appropriate cervical spine protection.

B – Breathing: Assess ventilation, oxygenation, and the respiratory system, and immediately treat life-threatening thoracic injuries.

C – Circulation with haemorrhage control: Assess the cardiovascular system, identify shock, and rapidly control significant haemorrhage.

D – Disability: Perform a rapid neurological assessment, including level of consciousness, pupils, and neurological status.

E – Exposure and environmental control: Fully expose the patient to identify injuries while actively preventing hypothermia.

Life-Threatening Injuries in the Primary Survey

The mnemonic ATOMIC can be used to remember important immediately life-threatening injuries.

A – Airway compromise: Airway obstruction may result in inadequate ventilation and oxygenation.

T – Tension pneumothorax: Increasing intrapleural pressure compromises ventilation and venous return and can rapidly cause cardiovascular collapse.

O – Open pneumothorax: A large open chest wall defect allows air to enter the pleural cavity and may severely compromise ventilation.

M – Massive haemothorax: A large accumulation of blood within the pleural cavity causes both respiratory compromise and haemorrhagic shock.

I – Incipient flail chest: Multiple rib fractures can produce an unstable chest wall segment, often associated with significant pulmonary contusion and respiratory compromise.

C – Cardiac tamponade: Accumulation of blood within the pericardial sac restricts cardiac filling and may cause obstructive shock.

Secondary Survey

The secondary survey is a thorough head-to-toe assessment performed after the primary survey and initial resuscitation have addressed immediate life-threatening problems.

Its purpose is to identify other injuries caused by the trauma that may not have been apparent during the primary survey.

It includes a detailed history, complete physical examination, appropriate investigations, and repeated reassessment of the patient.

The findings are then used to formulate a plan for definitive treatment and ongoing care.

If the patient deteriorates at any stage during the secondary survey, assessment should immediately return to the ABCDE primary survey.

Trauma Imaging

Traditionally, the standard trauma radiographic series consisted of cervical spine, chest, and pelvic X-rays.

A chest X-ray (CXR) may rapidly identify important thoracic injuries such as pneumothorax, haemothorax, and other chest pathology.

A pelvic X-ray may identify major pelvic fractures associated with significant haemorrhage.

Dedicated cervical spine X-rays have largely been replaced in many modern major-trauma pathways by CT when cervical spine imaging is indicated.

Imaging should never delay the treatment of an immediately life-threatening injury identified during the primary survey.