Overview
Definition:
The Advanced Trauma Life Support (ATLS) survey is a systematic approach to the initial assessment and management of critically injured patients
It is divided into two phases: the primary survey (ABCDE approach) to identify and manage immediately life-threatening conditions, and the secondary survey (Head-to-Toe examination and AMPLE history) to obtain further information and identify other injuries.
Epidemiology:
Trauma is a leading cause of death and disability worldwide, particularly in younger populations
The ATLS survey is universally adopted for the initial management of trauma patients, making its understanding critical for all surgical residents preparing for DNB and NEET SS examinations.
Clinical Significance:
Effective application of ATLS protocols ensures rapid identification and stabilization of life-threatening injuries, thereby reducing morbidity and mortality
Understanding the operative implications of findings during these surveys is paramount for timely surgical intervention and improved patient outcomes.
Primary Survey
Airway With Cervical Spine Protection:
Assess for patency
Look for obstructions (blood, vomit, foreign bodies)
Secure airway if compromised (e.g., intubation, cricothyroidotomy)
Maintain cervical spine immobilization until significant injury is ruled out
Operative implication: Emergent airway control is a priority before any definitive surgery
Suspect cervical spine injury in all blunt trauma and penetrating trauma to the neck.
Breathing And Ventilation:
Assess for presence and effectiveness of breathing
Observe chest rise and fall, listen for breath sounds, and assess respiratory rate
Identify and manage conditions like tension pneumothorax, open pneumothorax, flail chest, and hemothorax
Operative implication: Life-threatening chest injuries (e.g., tension pneumothorax requiring immediate chest tube insertion, open pneumothorax requiring a chest seal) may necessitate emergent thoracic procedures.
Circulation And Hemorrhage Control:
Assess for pulse quality and rate, skin color and temperature, and capillary refill
Identify and control sources of external hemorrhage
Evaluate for signs of shock
Operative implication: Hemorrhage is a major cause of preventable death
Aggressive fluid resuscitation and blood product transfusion are crucial
Rapid identification of bleeding sources guides urgent surgical exploration (e.g., laparotomy for intra-abdominal bleeding, thoracotomy for thoracic bleeding).
Disability Neurological Status:
Assess level of consciousness using the AVPU scale (Alert, Verbal, Pain, Unresponsive) or Glasgow Coma Scale (GCS)
Check pupillary size and reactivity
Operative implication: Altered mental status can indicate head injury, hypovolemia, or hypoxia
A low GCS (e.g., <8) is a predictor of need for intubation and may suggest severe intracranial pathology requiring neurosurgical evaluation and intervention.
Exposure And Environmental Control:
Completely expose the patient to allow for a thorough examination, removing all clothing
Prevent hypothermia by covering the patient with warm blankets and using warming devices
Operative implication: Adequate exposure is critical for identifying all injuries
Hypothermia exacerbates coagulopathy and increases mortality, so maintaining normothermia is vital during resuscitation and surgery.
Secondary Survey
History Taking Ample:
Gather information on Allergies, Medications, Past medical history, Last meal, Events/Environment leading to injury
Operative implication: Understanding the patient's baseline health and the circumstances of injury informs anesthetic risk, potential complications, and surgical planning
For example, anticoagulant use influences surgical bleeding risk.
Head To Toe Examination:
Perform a detailed physical examination from head to toe, identifying all injuries
This includes examination of the head, face, neck, chest, abdomen, pelvis, extremities, and back
Operative implication: This systematic review helps identify less obvious but potentially significant injuries that may require surgical intervention, such as occult fractures, soft tissue injuries, or internal injuries not immediately apparent.
Definitive Care And Reassessment:
Once stable, definitive care can proceed, including further investigations and surgical procedures
Continuous reassessment of the patient's condition is essential throughout resuscitation and management
Operative implication: Findings from the secondary survey directly dictate further diagnostic workup (imaging, labs) and inform the decision-making for operative versus non-operative management of specific injuries.
Operative Implications Primary Survey
Airway Management And Surgery:
Airway compromise necessitates immediate intervention
Operative implications include emergent intubation or surgical airway (tracheostomy/cricothyroidotomy) to secure the airway before transfer to OR if critically unstable.
Thoracic Trauma And Surgery:
Tension pneumothorax requiring immediate needle decompression and subsequent chest tube insertion
Hemothorax may require emergent thoracotomy for bleeding control and chest wall repair
Flail chest may necessitate intubation and mechanical ventilation, potentially followed by surgical stabilization.
Hemorrhage Control And Surgery:
Massive external hemorrhage may require direct pressure, tourniquets, or operative exploration
Suspected intra-abdominal or intra-thoracic bleeding mandates rapid transport to the OR for exploratory laparotomy or thoracotomy to control the source of bleeding, often guided by FAST scans or diagnostic imaging.
Neurological Deficit And Surgery:
Decreased GCS or focal neurological deficits may indicate intracranial hemorrhage or significant head injury, requiring urgent neurosurgical consultation and potential craniotomy for decompression or evacuation of hematoma.
Operative Implications Secondary Survey
Abdominal Injuries And Surgery:
Abdominal tenderness, distension, or signs of peritonitis identified during the secondary survey often point to intra-abdominal injury
Exploratory laparotomy is frequently indicated to identify and repair solid organ lacerations, bowel perforations, or vascular injuries.
Pelvic Fractures And Surgery:
Unstable pelvic fractures with signs of hypovolemic shock require rapid fluid resuscitation and potential operative intervention such as pelvic packing, external fixation, or angioembolization to control hemorrhage
Internal fixation may be deferred until the patient is stable.
Extremity Injuries And Surgery:
Open fractures, signs of vascular compromise (e.g., absent pulses, pallor, paresthesia), or compartment syndrome necessitate urgent surgical debridement, irrigation, fracture stabilization (external fixation initially), and potentially vascular repair
Fasciotomy for compartment syndrome is a time-sensitive procedure.
Spinal Cord Injuries And Surgery:
Neurological deficits following spinal injury warrant prompt imaging (CT/MRI) and neurosurgical/orthopedic consultation
Operative indications include spinal instability, spinal cord compression, or penetrating spinal injuries requiring surgical decompression and stabilization.
Key Points
Exam Focus:
The ATLS primary survey (ABCDE) is focused on immediate life threats
The secondary survey (Head-to-Toe, AMPLE history) is more comprehensive
Operative implications link findings from these surveys to urgent surgical decisions.
Clinical Pearls:
Never delay life-saving interventions for complete secondary survey or history
Always reassess ABCDEs after any intervention
Suspect occult injuries in polytrauma patients
Maintain cervical spine precautions until cleared.
Common Mistakes:
Failing to identify critical airway/breathing/circulation issues during primary survey
Inadequate exposure leading to missed injuries
Failure to maintain normothermia
Delaying definitive hemorrhage control
Incorrectly assuming an injury is minor without thorough assessment.