General Approach
- Assessment + resuscitation at the same time.
- Treat immediate life threats as they are found; keep moving through xABCDE.
- Procedures can happen in parallel while the rest of the team continues the survey.
- After any major intervention or deterioration → repeat xABCDE.
- Goal: find what can kill the patient now, intervene, then move on.
x → A → B → C → D → E
x External Hemorrhage
Assessment
- Rapid external bleeding check.
- Extremities / junctional wounds / obvious active hemorrhage.
External Exsanguination
Critical Action — Control Bleeding
- Direct pressure.
- Wound packing / hemostatic gauze.
- Tourniquet for major extremity hemorrhage as appropriate.
- Control life-threatening external blood loss before moving to A.
A Airway
Assessment
- Patent? Protected? Phonating?
- Blood / vomit / secretions / facial or neck trauma?
- Mental status adequate to maintain airway?
- Cervical spinal motion restriction.
A patient speaking clearly has a patent airway right now; airway protection may still deteriorate with bleeding, swelling, facial trauma, or worsening mental status.
Airway Obstruction / Failure
Critical Action — Secure Airway
- Open airway while limiting cervical motion.
- Suction / remove visible obstruction.
- OPA / NPA as appropriate.
- Bag-mask ventilation if inadequate ventilation.
- Persistent obstruction / inability to protect airway / respiratory failure → intubate.
- Continue the primary survey while airway equipment is being prepared.
B Breathing
Assessment
- Breath sounds / chest rise.
- Respiratory effort.
- Oxygenation.
- Chest wall injury / asymmetric ventilation?
Respiratory Failure / Arrest
Critical Action — Support Breathing
- Oxygen as needed.
- Bag-mask ventilation.
- Intubate as needed.
- Continue xABCDE while definitive airway is being established.
Tension Pneumothorax
Critical Action — Immediate Decompression
- Severe respiratory or hemodynamic compromise + suspected PTX → treat clinically.
- Do not wait for imaging if unstable.
- Finger or needle thoracostomy → chest tube.
- Ultrasound if immediately available and it does not delay decompression.
Related algorithm: Trauma: Blunt Chest
C Circulation
Assessment
- Pulse / blood pressure.
- Skin / mental status / perfusion.
- External bleeding already addressed under x.
- Search for internal hemorrhage:
- Chest.
- Abdomen.
- Pelvis.
- Long bones.
Traumatic Cardiac Arrest
Critical Action — Treat Reversible Causes
- Immediate traumatic-arrest resuscitation.
- Tension PTX / tamponade / hemorrhage / airway-oxygenation problem.
- Resuscitative thoracotomy? → determined by mechanism, signs of life, arrest course, and traumatic-arrest pathway.
Cardiac Tamponade
Assessment
- Hypotension / shock.
- Mechanism compatible with cardiac or pericardial injury.
- FAST / cardiac US → pericardial fluid / hemopericardium.
Classic findings such as muffled heart sounds or JVD may be absent; unstable trauma + traumatic pericardial fluid is the important bedside combination.
Critical Action — Urgent Surgical Decompression
- Unstable → trauma surgery / OR.
- Arrest / peri-arrest → traumatic cardiac arrest pathway / thoracotomy when indicated.
- Pericardiocentesis: bridge only when definitive surgical decompression is not immediately available.
Related algorithm: Trauma: Blunt Chest
Hemorrhagic Shock
Critical Action — Control Hemorrhage + Resuscitate
- Large-bore IV / IO access.
- Early blood / whole blood.
- Activate MTP when indicated.
- Minimize crystalloid.
- Identify and control source:
- Chest → hemothorax?
- Abdomen → FAST / operative or IR pathway?
- Pelvis → binder / hemorrhage-control pathway.
- Long bones → splint / control bleeding.
- Persistent shock despite initial measures → Trauma Resuscitation algorithm (Coming soon).
D Disability
Assessment
- GCS / AVPU.
- Pupils.
- Gross motor function.
- Gross sensation.
- Focal / lateralizing deficits.
If feasible, document a quick neurologic exam before sedation/paralysis; never delay a necessary airway.
Brain / Spinal Cord Injury
Critical Action — Assess / Protect
- Prevent hypoxia.
- Prevent hypotension.
- Continue cervical spinal motion restriction when indicated.
- Treat immediate neurologic threats.
- CT after stabilization and when safe to leave the resuscitation area.
- Suspected spinal cord injury → focused neuro exam + spine pathway.
Cervical Spine Imaging
- Low-risk patient meeting validated clearance criteria → may not need imaging.
- Imaging indicated → CT C-spine without contrast preferred over plain radiographs in adults.
E Exposure / Environment
Assessment
- Fully expose patient.
- Inspect entire body, including back when appropriate.
- Look for missed wounds / deformity / abdominal or pelvic injury / soft-tissue injury.
Missed Injury / Hypothermia
Critical Action — Inspect / Keep Warm
- Warm room.
- Warm blankets.
- Warmed blood / fluids.
- Re-cover patient after examination.
- Avoid iatrogenic heat loss.
Hypothermia worsens coagulopathy; exposure should find injuries without leaving the patient cold.
Adjuncts to the Primary Survey
These occur during xABCDE when useful; not a separate rigid step.
FAST / eFAST
- Pericardial fluid.
- Intraperitoneal free fluid.
- Pneumothorax / hemothorax when using eFAST.
- Most useful when the answer changes an immediate decision.
- Negative FAST does not exclude all important injury.
Urinary Catheter
- Useful for urine output / resuscitation monitoring in selected significant trauma.
- Blood at urethral meatus / concern for urethral injury → do not blindly pass Foley; evaluate urethra first.
Analgesia
- Treat pain early once immediate life threats are addressed.
- Avoid withholding appropriate analgesia solely to “preserve the exam.”
Team / Family / EMS Information
- EMS, witnesses, family, friends → history while xABCDE continues.
- Do not delay resuscitation waiting for a complete history.
AMPLE History
- A — Allergies
- M — Medications
- Anticoagulants / antiplatelets especially important.
- P — Past medical history / Pregnancy
- L — Last meal
- E — Events / environment surrounding trauma
Secondary Survey + Targeted Workup
Begin after immediate life threats are identified and initial resuscitation is underway.
Head-to-Toe Exam
- Scalp / face / neck.
- Chest.
- Abdomen / flanks / back.
- Pelvis / perineum.
- Extremities.
- Neurovascular status.
- Reassess wounds, deformity, compartments.
- Repeat xABCDE if anything changes.
Imaging
- Imaging driven by physiology + mechanism + suspected injury.
- eFAST / portable chest X-ray / pelvis imaging when they answer an immediate trauma-bay question.
- Stable enough for CT → targeted CT / whole-body trauma CT as clinically appropriate.
- C-spine imaging indicated → CT, not routine plain films.
Labs
Common in significant trauma
- CBC.
- Chemistry.
- Coagulation studies.
- Type and screen / crossmatch.
- Lactate / base deficit as useful for perfusion and resuscitation.
- Pregnancy test when relevant.
Selective
- Troponin → suspected blunt cardiac injury.
- EtOH / toxicology → clinically relevant.
- UA → suspected GU injury.
- ABG / VBG → respiratory or metabolic question.
Cases
References
- American College of Surgeons — ATLS 11
- ACS — Trauma Care Gets Major Upgrade with ATLS 11 / xABCDE
- ACS — ATLS 11 Course / Skills Objectives
- EAST — Screening for Blunt Cardiac Injury
- EAST — Blunt Aortic Injury: Evaluation and Management
- Western Trauma Association — Traumatic Pneumothorax Algorithm
- ACR — Acute Spinal Trauma
- AUA — Urotrauma Guideline