What are the initial steps in Advance Trauma Life Support (ATLS) for a trauma patient?

Advanced Trauma Life Support (ATLS) Initial Steps

The initial management of a trauma patient follows the ABCDE approach, where (catastrophic/critical bleeding) now precedes the traditional ABCDE sequence, emphasizing immediate hemorrhage control before airway management. 1

- Catastrophic Bleeding (First Priority)

Control life-threatening external hemorrhage immediately before proceeding to airway assessment. 2, 3

• Apply tourniquets directly to stop life-threatening bleeding from open extremity injuries, keeping them in place until surgical control is achieved but ideally under 2 hours to prevent complications like nerve paralysis and limb ischemia 2, 3
• Use direct manual pressure for all other bleeding wounds as the most effective initial intervention 4
• Minimize time between injury and surgical intervention for patients requiring urgent bleeding control 2

A - Airway (with Cervical Spine Protection)

Establish and maintain a patent airway while simultaneously protecting the cervical spine in every trauma patient. 2, 3

• Exclude traumatic cervical injury before any airway manipulation 2, 3
• Consider oro- or nasopharyngeal airways as temporary measures before definitive management 2, 3
• Perform endotracheal intubation for definitive airway protection in severe cases 2, 3

B - Breathing and Ventilation

Ensure adequate oxygenation and provide initial normoventilation if no signs of imminent cerebral herniation are present. 2, 3

• Perform immediate needle decompression for suspected tension pneumothorax with hemodynamic instability (defined as systolic BP <90 mmHg, heart rate >120 bpm, cool/clammy skin, altered consciousness, and/or shortness of breath) 2, 3
• Follow needle decompression with chest tube placement for definitive management 2, 3
• Use protective ventilation with low tidal volume (<6 ml/kg) and moderate PEEP in bleeding trauma patients at risk of acute lung injury 1, 3
• Avoid hyperventilation, as it increases mortality compared to normoventilation 3, 4
• Maintain PaCO₂ between 35-40 mmHg after stabilization in patients with traumatic brain injury 2, 3

C - Circulation and Hemorrhage Control

Assess the extent of traumatic hemorrhage using mechanism of injury (e.g., falls >6 meters, high-energy deceleration, high-velocity gunshot wounds), patient physiology, anatomical injury pattern, and response to initial resuscitation. 1, 2, 3

ATLS Classification of Blood Loss:

• Class I: Up to 750 ml (15% blood volume) 3
• Class II: 750-1500 ml (15-30% blood volume) 3
• Class III: 1500-2000 ml (30-40% blood volume) - requires immediate surgical intervention 3
• Class IV: >2000 ml (>40% blood volume) - imminent death without immediate hemorrhage control 3, 4

Response to Initial Fluid Resuscitation:

• Rapid Response: Vital signs return to normal and remain stable - continue monitoring 3
• Transient Response: Initial improvement followed by deterioration - requires immediate surgical intervention 1, 3
• Minimal or No Response: Ongoing instability despite resuscitation - requires immediate surgical intervention 1, 3

Use Shock Index (heart rate divided by systolic blood pressure) to assess degree of hypovolemic shock, with SI ≥0.9-1.0 associated with increased need for massive transfusion and operative intervention 1

D - Disability (Neurological Assessment)

Rapidly assess neurological status using Glasgow Coma Scale. 2, 3

• Control seizures if present, especially in traumatic brain injury 2, 3
• Recognize that secondary brain injury from hemorrhage-induced hypotension and coagulopathy creates a "vicious circle" that worsens outcomes 4

E - Exposure and Environmental Control

Completely undress the patient to facilitate thorough examination. 2, 3

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

Secondary Survey (Only After Primary Survey Completion)

Perform a comprehensive head-to-toe examination after completing and stabilizing the primary survey. 2, 3

• Obtain relevant medical history using AMPLE: Allergies, Medications, Past medical history, Last meal, Events/Environment related to injury 2, 3
• Reassess vital signs frequently 2, 3

Critical Pitfalls to Avoid

• Do not rely solely on blood pressure as an indicator of hemodynamic stability, as patients may maintain "normal" blood pressure despite significant ongoing blood loss 2, 3
• Do not fail to recognize transient responders who initially stabilize with fluid resuscitation but later decompensate - these patients require immediate surgical intervention 2, 3
• Do not delay definitive intervention in unstable patients, as every additional minute increases mortality risk (1% per minute of scene time, 2% per minute of response time in penetrating trauma) 4
• Do not hyperventilate trauma patients, as this significantly increases mortality 3, 4
• Do not leave tourniquets in place longer than necessary, as prolonged placement leads to nerve paralysis and limb ischemia 2, 3