In the Emergency Department (ED), according to Advanced Trauma Life Support (ATLS), should we complete the primary survey before addressing specific problems in a trauma patient?

ATLS Approach to Trauma Management in the ED

According to ATLS protocol, you must identify and immediately treat life-threatening problems during the primary survey before moving on to the next step—you do NOT complete the entire survey before addressing critical issues. 1, 2, 3

The "Treat as You Go" Principle

The ATLS methodology follows a systematic ABCDE approach where life-threatening conditions are managed as soon as they are identified, not after completing the full assessment. 2, 3, 4 This means:

• Airway problems (obstruction, need for definitive airway) are addressed immediately when discovered 1, 3
• Breathing emergencies (tension pneumothorax, massive hemothorax) require immediate intervention—for example, needle decompression for tension pneumothorax with hemodynamic instability must be performed right away 3
• Circulation issues (life-threatening hemorrhage) demand immediate control through tourniquets, direct pressure, or surgical intervention 1, 3
• Each problem is fixed before proceeding to the next letter in the ABCDE sequence 2, 4

Why This Matters

The American College of Surgeons emphasizes that the primary survey is designed to rapidly identify AND address life-threatening conditions simultaneously. 2 Research demonstrates that ATLS training significantly reduces mortality in the first 60 minutes after admission (24.2% pre-ATLS vs 0.0% post-ATLS, p=0.002), specifically because critical interventions happen immediately rather than being delayed. 5

The Complete Sequence

1. Primary Survey (ABCDE): Identify and treat life-threatening problems as encountered 2, 3, 6

   • Airway with C-spine protection
   • Breathing and ventilation
   • Circulation with hemorrhage control
   • Disability (neurological status)
   • Exposure with temperature control

2. Resuscitation occurs simultaneously with the primary survey, not after it 4

3. Secondary Survey: Only performed after the patient is relatively stable following primary survey interventions 2, 3

   • Comprehensive head-to-toe examination 2, 3
   • Detailed history using SAMPLE/AMPLE approach 2, 3
   • Appropriate imaging and laboratory studies 2

4. Continuous reassessment: The primary and secondary surveys must be continually repeated to identify any deterioration 6, 4

Critical Pitfalls to Avoid

• Never delay intervention to complete the survey—transient responders and non-responders to initial resuscitation require immediate surgical bleeding control 7, 3
• Skipping components of the primary survey leads to incomplete resuscitation and missed life-threatening injuries 7, 2
• Conducting the secondary survey before stabilization results in missed critical conditions 2
• Studies show that even trained professionals frequently skip or incompletely perform ATLS tasks, particularly during overnight shifts and with certain injury mechanisms (burns, penetrating trauma) 7, 8

The evidence is clear: ATLS is a prioritized, systematic approach where immediate threats to life are treated the moment they are discovered, not after completing an assessment checklist. 6, 4