Developed by the American College of Surgeons Committee on Trauma following a 1976 plane crash that highlighted deficiencies in trauma care, the course is now a global standard used in over 60 countries. The core philosophy involves treating the greatest threat to life first, not allowing a lack of definitive diagnosis to delay treatment, and recognizing that a detailed history is not essential to begin evaluation.

Initial Assessment and Primary Survey The hallmark of ATLS is the primary survey, structured around the ABCDE mnemonic:

• Airway: Assessment of patency while strictly maintaining cervical spine motion restriction. A definitive airway (cuffed tube in the trachea) is required for patients with airway compromise or a Glasgow Coma Scale (GCS) score of 8 or lower.

• Breathing: Identification and immediate management of life-threatening thoracic injuries, such as tension pneumothorax, open pneumothorax, and massive hemothorax.

• Circulation: Recognition of shock, predominately hemorrhagic in trauma. Management focuses on stopping the bleeding and restoring volume. Hypotension is considered hypovolemic until proven otherwise. Fluid resuscitation begins with isotonic crystalloids, moving to blood products for transient or non-responders.

• Disability: A rapid neurologic evaluation using GCS and pupillary response to establish a baseline.

• Exposure: Complete removal of clothing to identify all injuries while preventing hypothermia.

Secondary Survey and Specific Injuries Following the stabilization of vital functions, a detailed head-to-toe secondary survey is performed.

• Head and Spine: The primary goal in traumatic brain injury is preventing secondary brain injury caused by hypotension and hypoxia. Spinal motion is restricted until injury is excluded via clinical rules (NEXUS, Canadian C-Spine) or imaging.

• Abdomen and Pelvis: Unrecognized hemorrhage is a major cause of preventable death. Diagnostic adjuncts include Focused Assessment with Sonography for Trauma (FAST), Diagnostic Peritoneal Lavage (DPL), and CT scans. Unstable pelvic fractures require mechanical stabilization, such as a pelvic binder, to limit hemorrhage.

• Musculoskeletal: Limb-threatening injuries, such as vascular compromise, compartment syndrome, and open fractures, must be identified early. Compartment syndrome is a clinical diagnosis requiring immediate surgical intervention.

• Thermal Injuries: Management involves stopping the burning process and fluid resuscitation. The Parkland formula has been updated to a consensus formula starting at 2 mL/kg/%TBSA for adults to prevent over-resuscitation.

Special Populations and Logistics

• Pediatric: Children have unique anatomical characteristics and physiological reserves. A length-based resuscitation tape (Broselow) helps determine weight-based equipment sizes and drug doses.

• Geriatric: Comorbidities and medications, such as anticoagulants and beta-blockers, alter the physiological response to injury, often masking shock.

• Pregnancy: Treatment involves two patients; optimal fetal outcome depends on aggressive maternal resuscitation. The uterus should be displaced to the left to relieve vena cava compression..

Epidemiology and Unique Characteristics Injury is the leading cause of death and disability in children, surpassing all major diseases. While management priorities (ABCDEs) mirror those of adults, pediatric care requires adjustments for unique anatomy and physiology. Children have a smaller body mass, meaning impact forces are applied per smaller unit of body area, often damaging multiple organs. Their skeletons are incompletely calcified and pliable; consequently, internal organ damage, such as pulmonary contusion, can occur without overlying bone fractures. Additionally, a child's disproportionately large head increases the frequency of blunt brain injuries. The high ratio of body surface area to mass makes children highly susceptible to hypothermia, which can complicate resuscitation.

Airway and Breathing Anatomical differences dictate airway management. The large occiput causes passive flexion of the cervical spine, potentially buckling the airway; therefore, the midface must be maintained parallel to the spine board (neutral position) rather than the "sniffing" position used in adults. Because the infant trachea is short (approx. 5 cm), tube dislodgment and right mainstem intubation are significant risks. Clinicians should use the mnemonic "Don't be a DOPE" (Dislodgment, Obstruction, Pneumothorax, Equipment failure) to troubleshoot deterioration in intubated patients. In breathing assessment, the mobility of mediastinal structures makes children particularly prone to tension pneumothorax.

Circulation and Shock Recognizing shock in children is challenging due to their increased physiologic reserve. A child can maintain a normal systolic blood pressure despite losing up to 30% of their circulating blood volume. Hypotension is a late, ominous sign of decompensated shock involving >45% volume loss. Early signs of hypovolemia include tachycardia, skin mottling, and weakened peripheral pulses rather than blood pressure drops.

Fluid resuscitation is weight-based. If weight is unknown, a length-based resuscitation tape (e.g., Broselow) is essential for estimating medication doses and equipment sizes. Venous access can be difficult; if peripheral attempts fail, intraosseous (IO) infusion is the preferred alternative. Current protocols suggest an initial bolus of 20 mL/kg of warmed isotonic crystalloid. However, strategies are shifting toward "damage control resuscitation" using balanced blood products early for those with severe hemorrhagic shock.

Head, Spine, and Abdomen Children are susceptible to secondary brain injury caused by hypovolemia and hypoxia. However, because of the long-term cancer risks associated with ionizing radiation, CT scans should be used selectively, guided by clinical decision rules like PECARN, rather than routinely. Regarding the spine, "SCIWORA" (Spinal Cord Injury Without Radiographic Abnormalities) is common; a normal x-ray does not rule out spinal cord injury. In abdominal trauma, gastric decompression is critical as swallowed air can mimic distension. Most hemodynamically normal children with solid organ injuries are managed non-operatively.

Maltreatment Non-accidental trauma is a leading cause of infant homicide. Clinicians must identify red flags, such as history inconsistent with the injury, delays in seeking care, retinal hemorrhages, or fractures in children too young to walk.

Analogy: Think of a child's cardiovascular system like a modern lithium-ion battery, while an adult's is like an old flashlight battery. An old flashlight battery dims gradually as it loses power (adults show dropping blood pressure as they lose blood). A lithium battery provides consistent, strong output until it is nearly empty, then shuts down abruptly and completely.

Effective management of trauma in pregnancy requires a dual focus on two patients: the mother and the fetus. However, the sources emphasize that the best initial treatment for the fetus is the optimal resuscitation of the mother. To provide effective care, clinicians must navigate significant anatomical and physiological changes that alter injury patterns and responses to shock.

Physiological Adaptations and Hemodynamics Pregnancy induces hypervolemia, with plasma volume increasing steadily until 34 weeks. This allows a healthy pregnant patient to lose 1,200 to 1,500 mL of blood before exhibiting typical signs of hypovolemia, such as tachycardia or hypotension. Consequently, maternal vital signs may appear stable even when the fetus is in distress due to compromised uterine perfusion. The fetal heart rate is a sensitive indicator of maternal blood volume status and must be monitored; rates outside the normal 120–160 beats per minute range suggest decompensation.

A critical procedural adaptation involves patient positioning. In the supine position, the enlarged uterus compresses the inferior vena cava, potentially reducing cardiac output by 30%. To counteract this, patients requiring spinal motion restriction should be logrolled 15–30 degrees to the left to displace the uterus and maintain venous return.

Respiratory and Anatomical Changes Oxygen consumption increases during pregnancy, making the maintenance of adequate arterial oxygenation essential. Hormonal and mechanical changes lead to increased minute ventilation and a baseline state of hypocapnia (PaCO2 of 30 mm Hg). Therefore, a PaCO2 of 35 to 40 mm Hg, which is normal in nonpregnant patients, may indicate impending respiratory failure in a pregnant trauma patient. Anatomically, as the uterus rises out of the pelvis, it pushes the bowel upward. This affords the bowel some protection from blunt trauma but makes the uterus and placenta more vulnerable.

Specific Injuries and Management The leading cause of fetal death is maternal shock/death, followed by abruptio placentae (placental separation). Abruption may present with vaginal bleeding, uterine tenderness, and tetany, though vaginal bleeding is absent in 30% of cases. Uterine rupture is rare but catastrophic, marked by shock and palpable fetal parts outside the uterus.

Standard trauma diagnostics, including x-rays and CT scans, should not be withheld due to fetal radiation concerns if they are necessary for maternal evaluation. However, if diagnostic peritoneal lavage is used, the open technique above the umbilicus is required. All Rh-negative pregnant trauma patients should receive Rh immunoglobulin within 72 hours to prevent isoimmunization. In cases of maternal cardiac arrest, perimortem cesarean section may be attempted, with the best chance of success if performed within 4 to 5 minutes of arrest.

Intimate Partner Violence (IPV) Trauma frequently results from IPV, which affects 17% of injured pregnant patients. Clinicians must maintain a high index of suspicion, looking for indicators such as injuries inconsistent with the history, delayed care seeking, or a partner who dominates the interview. Screening questions regarding safety and fear should be asked when the partner is not present

Demographics and Physiology The global population is aging rapidly, with older adults comprising the fastest-growing segment in the United States. As mobility and active lifestyles increase among the elderly, injury has become the fifth leading cause of death in this demographic. Geriatric trauma presents unique challenges; data shows that older adults face higher mortality rates than younger patients with similar injury severity,. This vulnerability is largely due to "decreased physiologic reserve," characterized by declining cellular function and impaired homeostatic mechanisms that reduce the body's ability to tolerate the stress of injury,. Furthermore, preexisting conditions (PECs) such as cirrhosis, coagulopathy, COPD, ischemic heart disease, and diabetes significantly increase the likelihood of mortality.

Mechanisms of Injury Falls are the most common cause of fatal injury and traumatic brain injury (TBI) in the elderly. Risk factors include physical impairments, medication use, dementia, and environmental hazards like loose rugs,. Motor vehicle crashes are another significant cause, often occurring during the day due to issues like slower reaction times, vision loss, and cognitive impairment,. Burns are particularly devastating in older adults; due to a paucity of hair follicles and aging organ systems, even small burns carry high mortality rates,. Penetrating injuries are less common but often fatal, with many gunshot wounds related to suicide.

Clinical Assessment and Management Trauma care follows the standard ABCDE survey but requires age-specific modifications.

• Airway: Management is complicated by loss of protective reflexes, dentures, and arthritic changes that make intubation difficult,. Drug dosages for rapid sequence intubation should be reduced to avoid cardiovascular depression.

• Breathing: Aging lungs have decreased compliance and a suppressed heart rate response to hypoxia, making respiratory failure a high risk.

• Circulation: Traditional vital signs can be misleading. Because older patients often have preexisting hypertension, a systolic blood pressure of 110 mm Hg should be utilized as the threshold for hypotension. Fixed heart rates or beta-blocker use can mask shock, necessitating the use of markers like lactate and base deficit to assess tissue hypoperfusion,.

• Disability: Cerebral atrophy and the high prevalence of anticoagulant use place the elderly at high risk for intracranial hemorrhage, even with minor trauma.

• Exposure: Older patients are highly susceptible to hypothermia and pressure injuries caused by immobilization on spine boards,.

Specific Injuries Rib fractures carry a high risk of pneumonia (up to 30%), making pain control and pulmonary hygiene critical, though narcotics must be used with extreme caution to avoid delirium,. TBIs are associated with high mortality, often due to the patient's inability to recover, requiring aggressive reversal of anticoagulants,. Pelvic fractures, usually resulting from ground-level falls in osteoporotic patients, result in high transfusion needs and frequently lead to a permanent loss of independence,.

Special Considerations Clinicians must be vigilant for elder maltreatment, including physical abuse and neglect, especially when physical findings conflict with the patient's history,. Given that trauma accounts for nearly 30% of deaths in patients over 65, establishing goals of care and consulting palliative services early is essential to patient-centered treatment

Effective management of thermal injuries prioritizes airway control, stopping the burning process, and hemodynamic resuscitation to minimize morbidity and mortality. The primary survey begins by completely removing the patient's clothing to stop burning, brushing away dry chemicals, and covering the patient with warm linens to prevent hypothermia. Airway obstruction may be insidious due to progressive edema, particularly in patients with burns to the face, burns inside the mouth, or those involving more than 40% to 50% of the total body surface area (TBSA). Inhalation injury is a major concern in enclosed-space fires, requiring immediate administration of 100% oxygen to treat potential carbon monoxide poisoning, as standard pulse oximetry does not distinguish between oxyhemoglobin and carboxyhemoglobin.

Burn shock differs from hemorrhagic shock as it results from capillary leak due to inflammation, necessitating fluid resuscitation for deep partial and full-thickness burns larger than 20% TBSA. The American Burn Association consensus formula recommends starting lactated Ringer’s solution at 2 mL/kg/%TBSA for adults and 3 mL/kg/%TBSA for children. Half of the calculated total volume is administered in the first eight hours post-injury, with the remainder given over the subsequent 16 hours. However, these formulas are merely starting points; fluid rates must be titrated hourly to maintain a urine output of 0.5 mL/kg/hr in adults and 1 mL/kg/hr in children weighing less than 30 kg. Over-resuscitation should be avoided to prevent complications such as compartment syndrome.

Assessment of burn severity relies on estimating the surface area using the Rule of Nines or the patient's palm (representing 1% TBSA) and evaluating burn depth. Partial-thickness burns are painful and blistered, while full-thickness burns appear leathery, dry, and painless. Circumferential burns to the extremities or chest can lead to compartment syndrome by restricting circulation or ventilation; this may require escharotomy if compartment pressures exceed 30 mm Hg or clinical signs of compromise appear. Pain management should utilize small, frequent doses of intravenous narcotics, as intramuscular absorption is unreliable, and prophylactic antibiotics are not indicated.

Unique injury types require specialized care. Chemical burns necessitate immediate, copious irrigation with water for 20 to 30 minutes, especially for alkali exposures which penetrate deeply. Electrical injuries often involve deep tissue damage not visible on the surface and can cause rhabdomyolysis; resuscitation for these patients starts at 4 mL/kg/%TBSA to maintain higher urine output and clear hemochromogens. Tar burns are treated by cooling and using mineral oil to dissolve the tar. Clinicians must also remain vigilant for burn patterns indicating abuse, such as circular burns or those with clear immersion lines.

Cold injuries, such as frostbite, are managed by rapid rewarming in circulating water at 40°C (104°F) only when there is no risk of refreezing. Massage is contraindicated, and injured tissue should be protected from pressure. Patients meeting specific criteria, including partial-thickness burns >10% TBSA, burns to functional areas like hands or face, inhalation injuries, or electrical/chemical burns, should be stabilized and transferred to a burn center.

Life-Threatening Injuries The primary survey must identify life-threatening conditions, specifically major arterial hemorrhage, bilateral femur fractures, and crush syndrome. Hemorrhage control is critical, utilizing direct pressure and pressure dressings. Tourniquets are indicated for life-threatening hemorrhage but carry risks if left in place for prolonged periods; they should ideally be used when lethal bleeding cannot be controlled otherwise. Bilateral femur fractures signify that the patient was subjected to significant force and are associated with higher risks of mortality and pulmonary complications compared to unilateral fractures. Crush syndrome, caused by the release of myoglobin from compressed muscle, can lead to acute renal failure and requires early, aggressive intravenous fluid therapy.

Limb-Threatening Injuries The secondary survey focuses on limb-threatening conditions, including open fractures, vascular injuries, compartment syndrome, and neurologic damage. Open fractures communicate with the external environment, carrying a high risk of infection; management requires immediate administration of weight-based antibiotics and surgical debridement. Vascular injuries leading to ischemia necessitate rapid revascularization, as muscle necrosis begins after six hours of anoxia. Simple realignment and splinting of a deformed fracture can often restore blood flow if an artery is kinked. Compartment syndrome, characterized by increased pressure within a fascial space, is a clinical diagnosis often signaled by pain out of proportion to the injury and pain on passive stretch. The definitive treatment is fasciotomy, and delays can result in myoglobinuria and amputation.

Assessment and Diagnosis Accurate assessment relies heavily on obtaining a detailed history of the mechanism of injury, such as the position of a patient in a car crash or the distance of a fall, to predict injury patterns. Physical examination involves a "Look, Ask, Feel" approach: inspecting for deformity and color, assessing voluntary motor function, and palpating for tenderness and pulses. The Ankle/Brachial Index (ABI) is a useful tool; a value less than 0.9 indicates abnormal arterial flow. X-ray examination confirms fractures but should not delay the reduction of a dislocation if vascular compromise is present.

Management and Pitfalls Effective management includes proper immobilization to realign extremities, control pain, and enhance the tamponade effect to reduce bleeding. Pain control is essential but must be balanced with the need to monitor for compartment syndrome and respiratory depression. Clinicians must be vigilant against pitfalls such as failing to recognize occult injuries, delaying antibiotics for open fractures, or missing compartment syndrome in patients with altered mental status. Teamwork is emphasized as crucial, particularly when managing multiple tasks simultaneously, such as applying traction splints while maintaining resuscitation efforts.

To view this system metaphorically, musculoskeletal trauma management operates like a structural engineer stabilizing a building after an earthquake: one must first secure the critical supports to prevent total collapse (life threats), then systematically repair the internal wiring and plumbing (vascular and neuro) to ensure the structure remains functional (limb survival), all while monitoring for hidden stress fractures (occult injuries) that could cause failure later.

Patient Handling and Logrolling To safely manage a patient with potential spinal injuries, the team leader must determine the appropriate time to perform a logroll maneuver to examine the back and remove the backboard. This procedure requires strict coordination to maintain spinal alignment. One individual is assigned specifically to restrict head and neck motion, while others positioned on one side of the torso manually prevent the chest or abdomen from sagging, bending laterally, flexing, extending, or undergoing segmental rotation. Additional personnel are responsible for moving the legs and physically removing the backboard.

Fluid Resuscitation and Shock Management When active hemorrhage is not evident, clinicians must distinguish between hypovolemic shock (typically presenting with tachycardia) and neurogenic shock (classically presenting with bradycardia) in patients with persistent hypotension. Treatment begins with a fluid challenge; however, if hypotension persists without occult hemorrhage, the judicious use of vasopressors—such as norepinephrine, dopamine, or phenylephrine hydrochloride—is recommended.

It is critical to avoid overzealous fluid administration, as this can precipitate pulmonary edema in patients with neurogenic shock. If the patient's volume status remains uncertain, invasive monitoring or ultrasound estimation is advised. Furthermore, a urinary catheter should be inserted to prevent bladder distention and monitor output.

Medication and Transfer Protocols Regarding pharmacological treatment, the source material notes there is insufficient evidence to support the use of steroids in spinal cord injury.

Patients with neurological deficits or spine fractures should be transferred to a facility capable of providing definitive care, ideally following consultation with a spine specialist or the accepting trauma team leader. Before transfer, the patient must be stabilized with a semirigid cervical collar, backboard, and necessary splints. Special attention must be paid to airway management, as cervical spine injuries above C6 can result in the loss of respiratory function. If there is any concern regarding the adequacy of ventilation, clinicians should intubate the patient prior to transfer and strictly avoid unnecessary delays

Surgical Management of Hematoma When addressing cranial hematomas, the sources emphasize that simple drill holes (burr holes) are frequently ineffective. Even when performed by experienced hands, they are easily placed incorrectly and rarely drain enough of the hematoma to make a clinical difference. Instead, a bone flap craniotomy is identified as the definitive, lifesaving procedure required to effectively decompress the brain. Trauma teams are urged to ensure this procedure is performed in a timely fashion by a practitioner who is specifically trained and experienced in it.

Prognosis and Pediatric Considerations The protocols dictate that all patients should receive aggressive treatment while awaiting neurosurgical consultation. This is particularly critical for children, as they possess a remarkable capacity to recover from injuries that might otherwise appear devastating. Because of this potential for recovery, practitioners must carefully consider the diagnosis of brain death in pediatric patients.

Diagnosing Brain Death A diagnosis of brain death confirms that there is no possibility for the recovery of brain function. Most experts agree that the following criteria must be met to make this diagnosis:

• A Glasgow Coma Scale score of 3.

• Nonreactive pupils and absent brainstem reflexes, such as corneal, oculocephalic, and gag reflexes.

• No spontaneous ventilatory effort during formal apnea testing.

• The absence of confounding factors, specifically hypothermia or intoxication by alcohol or drugs.

Ancillary Studies and Verification To confirm a diagnosis, medical teams may utilize ancillary studies, including Electroencephalography (EEG) showing no activity at high gain, cerebral angiography, or Cerebral Blood Flow (CBF) studies (such as Doppler or xenon studies) demonstrating no flow.

It is vital to distinguish true brain death from reversible conditions that mimic it, such as barbiturate coma or hypothermia. Therefore, a diagnosis should only be considered after physiological parameters are normalized and CNS function is not potentially suppressed by medication. If there is any doubt—especially in children—clinicians should utilize multiple serial exams spaced several hours apart to verify the initial impression.

Organ Procurement Protocols Finally, the protocols require that local organ procurement agencies be notified regarding any patient with a confirmed or impending diagnosis of brain death prior to the discontinuation of artificial life support measures.

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Analogy Diagnosing brain death is comparable to determining if a computer has suffered a total hardware failure versus a system freeze; before declaring the computer broken, a technician must first ensure it isn't simply in "sleep mode" due to power settings (hypothermia) or software conflicts (drugs), checking the internal components (ancillary studies) to confirm the machine is truly incapable of rebooting.