Structured approach of the primary survey:
The ABCDE method in ATLS is designed to identify and manage life-threatening conditions in order of priority. Each step should be assessed and treated before moving to the next to avoid missing critical injuries. Trauma patients can deteriorate quickly, so reassessment is important. If a patient worsens at any stage, the sequence should be restarted from Airway (A) to ensure no life-threatening issue has been overlooked.
Cervical spine precautions
Rigid cervical collars remain the mainstay of initial cervical spine immobilisation, but they have limitations and should be used as part of a multimodal approach rather than in isolation. While a hard collar helps limit gross movement, it does not fully prevent micromovements of the cervical spine, particularly in high cervical injuries. Additionally, prolonged use can contribute to raised intracranial pressure (ICP), pressure ulcers, and impaired venous return, particularly in patients with traumatic brain injury (TBI) or prolonged pre-hospital times.
For optimal immobilisation, a hard collar should be combined with manual in-line stabilisation (MILS) and supportive blocks with tape or straps when the patient is on a spinal board. This approach minimises both flexion-extension movement and lateral rotation, providing better stabilisation than a collar alone. The collar should be removed as soon as cervical spine injury is excluded using clinical assessment and imaging to prevent complications. In alert, cooperative patients, allowing voluntary motion restriction rather than prolonged collar use may be preferable once major instability is ruled out.
Airway management
Airway management is the highest priority in ATLS, as hypoxia can cause irreversible brain injury within 4-6 minutes and cardiac arrest within 10 minutes. Signs of airway compromise include stridor, hoarseness, gurgling, paradoxical chest and abdominal movements, or silent obstruction, all of which indicate the need for immediate intervention. Patients with GCS ≤ 8 are at high risk of aspiration and airway obstruction, requiring definitive airway management. Suction should be used to clear blood, vomit, or secretions, and Magill forceps may be required to remove foreign bodies. If initial airway support is needed, a nasopharyngeal or oropharyngeal airway can help maintain patency in patients with a partial obstruction. However, in suspected base of skull fractures, nasopharyngeal airways should be avoided due to the risk of intracranial placement.
For patients requiring temporary airway support, a supraglottic airway (iGel or LMA) can be used, with iGel preferred for its superior seal and ease of insertion. If definitive airway management is required, rapid sequence induction (RSI) and video laryngoscopy is preferred as the method of intubation. All intubations must be confirmed with capnography (gold standard), auscultation, and visual chest rise, as oesophageal intubation can rapidly cause deterioration. In patients with severe facial trauma, airway burns, or significant swelling, fibreoptic intubation may be required.
Rapid sequence induction (RSI) is the preferred method of securing the airway in trauma patients who require intubation. It is designed to minimise the risk of aspiration and avoid prolonged manual ventilation, which can worsen gastric insufflation and increase the risk of regurgitation. RSI involves the simultaneous administration of a fast-acting sedative (induction agent) and a neuromuscular blocking agent (paralytic) to facilitate intubation without bag-mask ventilation.
If intubation fails, or the patient enters a cannot intubate, cannot oxygenate (CICO) scenario, an emergency front-of-neck airway may be required to establish a secure airway. The preferred emergency surgical airway in trauma is a cricothyroidotomy, as it is faster and safer than a formal tracheostomy in the acute setting.
Cricothyroidotomy involves making an incision through the cricothyroid membrane, located between the thyroid and cricoid cartilages. It can be performed using a scalpel-bougie-tube technique (preferred in adults) or a needle cricothyroidotomy with jet ventilation (used in children under 12, as a formal cricothyroidotomy risks subglottic stenosis). Cricothyroidotomy provides rapid oxygenation, but it is a temporary airway and should be converted to a tracheostomy if prolonged airway support is needed.
Cricothyroidotomy is preferred over tracheostomy in acute trauma as it is faster and safer. However, in children under 12 years, a needle cricothyroidotomy with jet ventilation is preferred due to the risk of subglottic stenosis with a formal surgical airway. Patients with major airway trauma or prolonged mechanical ventilation may later require a tracheostomy as a more definitive airway.
Paediatric airway considerations are particularly important, as children have a proportionally larger tongue and more flexible airway structures, increasing the risk of obstruction. In all cases, early recognition and intervention are key, as delays in securing the airway can lead to hypoxic brain injury and cardiac arrest.
Breathing assessment
Breathing assessment in trauma focuses on oxygenation, ventilation, and the identification of life-threatening thoracic injuries. A look, listen, feel, monitor, and image approach is used. The chest should be inspected for rise and fall, paradoxical movements, tracheal deviation, and external trauma. Bilateral breath sounds should be assessed to detect conditions such as pneumothorax, haemothorax, or bronchial injury. Palpation can help identify subcutaneous emphysema, tracheal deviation, and chest wall tenderness, which may indicate underlying pathology. Oxygen saturation and respiratory rate should be closely monitored, as persistent hypoxia despite oxygen therapy suggests the need for urgent intervention. If time allows, an eFAST ultrasound can assess for pneumothorax, haemothorax, and cardiac tamponade.