What is the initial assessment and management protocol for trauma patients, following Advanced Trauma Life Support (ATLS) guidelines?

Advanced Trauma Life Support (ATLS) Protocol for Initial Assessment and Management of Trauma Patients

The Advanced Trauma Life Support (ATLS) protocol provides a systematic, prioritized approach to trauma patient care, beginning with the primary survey (ABCDE), followed by resuscitation, secondary survey, and definitive care to optimize outcomes and reduce preventable deaths.1

Primary Survey (ABCDE)

A - Airway with Cervical Spine Protection

• Establish and maintain a patent airway while protecting the cervical spine in all trauma patients 1
• Exclude traumatic cervical injury before airway manipulation 1
• Consider oro- or nasopharyngeal airways as temporary measures 1
• Perform endotracheal intubation for definitive airway protection in severe cases 1

B - Breathing and Ventilation

• Ensure adequate oxygenation and ventilation 1
• Provide initial normoventilation if no signs of imminent cerebral herniation are present 2, 1
• Perform immediate needle decompression for suspected tension pneumothorax with hemodynamic instability 1
• Follow needle decompression with chest tube placement for definitive management 1
• Use protective ventilation with low tidal volume and moderate PEEP in bleeding trauma patients at risk of acute lung injury 2, 1

C - Circulation with Hemorrhage Control

• Control life-threatening external hemorrhage immediately 2
• Use tourniquets to stop life-threatening bleeding from open extremity injuries in pre-surgical settings 2, 1
• Leave tourniquets in place until surgical control of bleeding is achieved, but keep this timespan as short as possible (ideally under 2 hours) 2
• Assess the extent of traumatic hemorrhage using mechanism of injury, patient physiology, anatomical injury pattern, and response to initial resuscitation 2, 1
• Classify blood loss severity using ATLS classification (Classes I-IV) to guide resuscitation 2, 1
• Evaluate patient response to initial fluid resuscitation (rapid, transient, or minimal/no response) 2
• Patients presenting with hemorrhagic shock and an identified source of bleeding should undergo immediate bleeding control procedure unless initial resuscitation measures are successful 2

D - Disability (Neurological Status)

• Rapidly assess neurological status using Glasgow Coma Scale 1
• Control seizures if present, especially in cases of traumatic brain injury 1
• Maintain PaCO₂ between 35-40 mmHg after stabilization in patients with traumatic brain injury 1

E - Exposure/Environmental Control

• Completely undress the patient to facilitate thorough examination 1
• Prevent hypothermia by implementing warming strategies 2, 1
• Record core temperature and initiate rewarming during the exposure stage of the primary survey 2

Hemorrhage Classification and Management

ATLS Blood Loss Classification

• Class I: Blood loss up to 750 ml (15% blood volume) 2
• Class II: Blood loss 750-1500 ml (15-30% blood volume) 2
• Class III: Blood loss 1500-2000 ml (30-40% blood volume) 2
• Class IV: Blood loss >2000 ml (>40% blood volume) 2

Response to Initial Fluid Resuscitation

• Rapid Response: Vital signs return to normal and remain stable 2, 3
• Transient Response: Initial improvement followed by deterioration - requires immediate surgical intervention 2, 3
• Minimal or No Response: Ongoing instability despite resuscitation - requires immediate surgical intervention 2, 3

Hypothermia Management in Trauma

Warming Strategy Levels

• Level 1 (Temp >36°C): Passive and active external warming with two warm blankets; monitor temperature every 15 minutes 2
• Level 2 (Temp 32-36°C): Add heating pads, radiant heaters, warming blankets, and humidified gases; monitor temperature every 5 minutes 2
• Level 3 (Temp <32°C): Implement invasive strategies including cavity lavage or extracorporeal circuits 2

Secondary Survey

• Perform a comprehensive head-to-toe examination after completing the primary survey 1
• Obtain relevant medical history using the AMPLE approach:
  • Allergies
  • Medications
  • Past medical history
  • Last meal
  • Events/Environment related to injury 1
• Reassess vital signs frequently 1

Common Pitfalls to Avoid

• Relying solely on blood pressure as an indicator of hemodynamic stability can be misleading, as patients may maintain "normal" blood pressure despite significant ongoing blood loss 3
• Failing to recognize transient responders who initially stabilize with fluid resuscitation but later decompensate 3
• Delaying definitive intervention in unstable patients can lead to poor outcomes 2, 3
• Hyperventilating trauma patients, which increases mortality compared to non-hyperventilated patients 2, 1
• Neglecting to perform a thorough examination for physical trauma when other conditions (like intoxication) are present 1
• Improper or prolonged tourniquet placement leading to complications such as nerve paralysis and limb ischemia 2

Evidence Impact

The implementation of ATLS protocols has been shown to reduce preventable or potentially preventable deaths in trauma patients 4. As the number of ATLS-trained professionals increases in a facility, the rates of potentially preventable or preventable death fall 4. Despite being developed over three decades ago, ATLS remains the most widely accepted method for the initial control and treatment of multiple trauma patients worldwide 5, 6, 7.