ATLS primary and secondary survey, systematic approach

Overview and Guiding Principles

• ATLS (Advanced Trauma Life Support) was developed in the late 1970s by the American College of Surgeons Committee on Trauma, based on the premise that appropriate and timely care improves outcomes for injured patients
• ATLS provides a structured, algorithmic approach applicable to any trauma patient, recognising that modifications may be needed for patient-specific variables and practice environments
• Three core concepts underpin all trauma management:
  • Treat the greatest threat to life first
  • A specific diagnosis is NOT required before initiating resuscitation and treatment
  • A systematic approach that can be rapidly and accurately applied is essential
• In the acute setting, life threats are addressed as they are identified, not after a complete assessment
• The framework emphasises high-level team functioning, trauma-informed and humanistic care, empathetic and culturally sensitive communication with patients and families, and attention to injury prevention opportunities

The Initial Assessment Framework

The full initial assessment comprises the following sequential elements:

Zero Survey (Pre-arrival Preparation)

• The Zero Survey formalises prearrival preparation as a critical, named step
• Involves an accurate inventory of local resources before the patient arrives
• Especially critical for triage decisions in multiple casualty incidents
• In hospital, early notification allows the trauma team to assemble in the ED with:
  • Appropriate personal protective equipment donned
  • Team roles clearly assigned
  • Prehospital information communicated to all members
• Crowd and noise control should be maintained throughout the resuscitation

Primary Survey: xABCDE

• The primary survey follows the xABCDE sequence.
• The "x" preceding A represents exsanguinating haemorrhage control, which is addressed first.

x: Control of Exsanguinating Haemorrhage

• Catastrophic external haemorrhage must be identified and controlled before proceeding with airway assessment
• Tourniquet application:
  • Applied 2 to 3 inches (5 to 8 cm) proximal to the bleeding site
  • Must NOT be placed over a joint
  • Applied directly on skin (not over clothing) once clothing is removed at a healthcare facility
  • Tightened sufficiently to overcome systolic blood pressure
  • A pulse should not be palpable distal to the tourniquet after correct application, and bleeding should cease
  • Application is painful when tightened adequately (a sign of correct tension)
  • If bleeding continues, a second tourniquet is placed 2 to 3 inches proximal to the first
  • Time of application must be recorded
  • For "high and tight" tourniquets placed for traumatic amputation: perform tourniquet replacement once shock is improved, and convert to definitive haemorrhage control as soon as clinically appropriate
• Pelvic fracture haemorrhage: application of an external pelvic compression device
• Abdominal haemorrhage: evaluated with peritoneal lavage or FAST (Focused Assessment with Sonography for Trauma)

A: Airway Assessment and Management

• Airway patency must be established and maintained
• Cervical spine protection is simultaneous with airway management in trauma
• Failure to secure the airway is immediately life-threatening; this step takes priority over all other assessments except exsanguination

B: Breathing and Ventilation Assessment and Management

• Assess for life-threatening thoracic injuries impairing ventilation
• Key immediate interventions include:
  • Needle or finger thoracostomy for tension pneumothorax
  • Chest tube insertion for pleural decompression (haemothorax, pneumothorax)
• Pulmonary contusions may not be apparent on initial external examination, particularly in children, and can develop after the primary survey

C: Circulation Assessment and Volume Management

• Identify and control haemorrhage (both external and internal sources)
• Assess haemodynamic status and initiate resuscitation
• Intraosseous access is a recognised adjunct when venous access is not rapidly achievable
• Classify haemodynamic response to resuscitation:

D: Disability (Neurological Assessment)

• Rapid assessment of neurological status
• Glasgow Coma Scale (GCS) is the validated tool for brain injury assessment and must be documented
• Identify pupillary responses and lateralising signs

E: Exposure and Environmental Control

• Remove all clothing to allow full examination
• Prevent hypothermia (especially critical in children due to increased surface area to mass ratio)
• Children are particularly vulnerable to hypothermia and to head trauma (proportionally larger head size)

Adjuncts to the Primary Survey

• FAST examination: abdominal and pericardial free fluid assessment
• Diagnostic peritoneal lavage: alternative to FAST for abdominal haemorrhage detection
• Chest and pelvis radiographs
• Continuous monitoring of vital signs, urine output, and electrocardiography
• Laboratory investigations as clinically indicated

Recognising Transfer Indications

• During the primary survey and resuscitation phase, the treating team must recognise patients who would benefit from transfer to a higher-level facility for definitive management
• This includes patients presenting to Level III centres who require Level I or II capabilities

Secondary Survey

When to Commence

• The secondary survey commences after the primary survey is completed
• In haemodynamically normal patients: begin once the primary survey is done
• In unstable patients: commence only once the patient has responded to resuscitation
• Reevaluation of vital signs is critical at the commencement of the secondary survey

Structure: Head-to-Toe Evaluation

• A complete, systematic head-to-toe physical examination is performed
• All body regions are examined: head, maxillofacial, neck, chest, abdomen, pelvis, perineum, extremities, and back (log roll)
• Positive AND negative findings should be documented; a scribe recording in real time is optimal

History: AMPLE

Humanistic and Trauma-Informed Care During the Secondary Survey

• Respect and preservation of personhood, modesty, and autonomy are paramount throughout
• The clinician must inform the patient about all steps and request permission before examining
• Culturally sensitive communication with patients and families is an explicit component of the ATLS framework

Important Secondary Survey Principles

• Secondary survey findings can reveal injuries not apparent on primary survey
  • Example: pulmonary contusions developing in the absence of rib fractures (particularly in children)
  • Example: bladder injury in the absence of a pelvic fracture
• In infants and toddlers who cannot communicate a history: detailed physical examination, laboratory tests, and imaging studies are essential
• A multidisciplinary approach is necessary for complex trauma patients, particularly children, to address immediate and long-term physical, emotional, and psychiatric needs

Team Dynamics and Communication

• Clear assignment of roles before patient arrival is essential:
  • Team leader
  • Airway provider
  • Circulation/IV access provider
  • Medication preparation and administration nurse
  • Documentation scribe
  • Representatives from anaesthesia, social work, pharmacy as appropriate
• Principles of high-level team functioning must be applied throughout the primary and secondary surveys
• Communication of serious news in the acute trauma setting requires empathy and cultural sensitivity
• Crowd and noise control must be maintained at all times in the resuscitation bay

Special Population: Paediatric Trauma

• The initial assessment in children mirrors the adult xABCDE framework using ATLS principles
• Key unique characteristics:
  • Increased head size relative to body: higher vulnerability to head trauma
  • Increased surface area to mass ratio: higher risk of hypothermia
  • Injuries not apparent on external examination (e.g. pulmonary contusions without rib fractures, bladder injury without pelvic fracture) are more common
  • Infants and toddlers cannot provide a history; physical examination and investigations are correspondingly more important
• In suspected non-accidental injury: initial priority remains patient stabilisation regardless of initial suspicions for abuse
• A full primary and secondary survey per ATLS principles is performed in ALL paediatric trauma patients

Injury Prevention: The "3 Es" Framework

• Clinicians should actively identify opportunities for injury prevention messaging during trauma encounters

Key Clinical Priorities: Summary Table