Trauma care - ATLS

Primary Survey

The first and key part of the assessment of patients presenting with trauma is called the primary survey. During this time, life-threatening injuries are identified and simultaneously resuscitation is begun. A simple mnemonic, ABCDE, is used as a memory aid for the order in which problems should be addressed.

A Airway Maintenance with Cervical Spine Protection
B Breathing and Ventilation
C Circulation with Hemorrhage Control
D Disability (Neurologic Evaluation)
E Exposure and Environment

A - Airway Maintenance with Cervical Spine Protection

The first stage of the primary survey is to assess the airway. If the patient is able to talk, the airway is likely to be clear. If the patient is unconscious, he/she may not be able to maintain his/her own airway. The airway can be opened using a chin lift or jaw thrust. Airway adjuncts may be required. If the airway is blocked (e.g, by blood or vomit), the fluid must be cleaned out of the patient's mouth by the help of sucking instruments. At the same time, the cervical spine must be maintained in the neutral position to prevent secondary injuries to the spinal cord. The neck should be immobilised using a semi-rigid cervical collar, blocks and tape.

B - Breathing and Ventilation

The chest must be examined by inspection, palpation, percussion and auscultation. Subcutaneous emphysema and tracheal deviation must be identified if present. Life-threatening chest injuries, including tension pneumothorax, open pneumothorax, flail chest and massive haemothorax must be identified and rapidly treated. Flail chest, penetrating injuries and bruising can be recognised by inspection.

C - Circulation with Hemorrhage Control

Hemorrhage is the predominant cause of preventable post-injury deaths. Hypotension following injury must be assumed to be due to blood loss until proven otherwise. Hypovolemic shock is caused by significant blood loss. Two large-bore intravenous lines are established and crystalloid solution given. If the patient does not respond to this, type-specific blood, or O-negative if this is not available, should be given. External bleeding is controlled by direct pressure. Occult blood loss may be into the chest, abdomen, pelvis or from the long bones. Chest or pelvic bleeding may be identified on X-ray. Bleeding into the peritoneum may be diagnosed on ultrasound (FAST scan), CT (if stable) or diagnostic peritoneal lavage.

D - Disability (Neurologic Evaluation)

During the primary survey a basic neurological assessment is made, known by the mnenomic AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive). A more detailed and rapid neurological evaluation is performed at the end of the primary survey. This establishes the patient's level of consciousness, pupil size and reaction, lateralizing signs, and spinal cord injury level.

The Glasgow Coma Scale is a quick method to determine the level of consciousness, and is predictive of patient outcome. If not done in the primary survey, it should be performed as part of the more detailed neurologic examination in the secondary survey. An altered level of consciousness indicates the need for immediate reevaluation of the patient's oxygenation, ventilation, and perfusion status. Hypoglycemia and drugs, including alcohol, may influence the level of consciousness. If these are excluded, changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise.

E - Exposure / Environmental control

The patient should be completely undressed, usually by cutting off the garments. It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient privacy should be maintained.

Secondary Survey

When the primary survey is completed, resuscitation efforts are well established, and the vital signs are normalizing, the secondary survey can begin.

The secondary survey is a head-to-toe evaluation of the trauma patient, including a complete history and physical examination, including the reassessment of all vital signs. Each region of the body must be fully examined. X-rays indicated by examination are obtained.

If at any time during the secondary survey the patient deteriorates, another primary survey is carried out as a potential life threat may be present.

The person should be removed from the hard spine board and placed on a firm mattress as soon as reasonably feasible as the spine board can rapidly cause skin breakdown and pain while a firm mattress provides equivalent stability for potential spinal fractures.[