Trauma Primary Survey (xABCDE) - ATLS 11

Algorithm Steps

1. ▶

   Start

   Trauma Patient Arrival

   Initiate primary survey using xABCDE approach

   1. ◆

      Decision

      [X] Exsanguinating Hemorrhage?

      Assess for life-threatening external bleeding

      • Massive external hemorrhage?
      • Arterial bleeding from extremity?
      • Traumatic amputation?
      • Junctional hemorrhage (neck, axilla, groin)?
      1. ⚠

         Warning

         IMMEDIATE Hemorrhage Control

         Control bleeding BEFORE airway

         • Direct pressure
         • Tourniquet for extremity (high and tight)
         • Wound packing + pressure for junctional
         • Hemostatic agents if available
         1. ◆

            Decision

            [A] Airway with C-spine Protection

            Assess airway patency and protect cervical spine

            • Is patient talking? (airway patent)
            • Look for obstruction (blood, vomitus, teeth)
            • Listen for stridor, gurgling
            • Maintain manual in-line stabilization
            • Apply cervical collar
            1. ●

               Action

               Secure Airway

               Airway compromised - intervene

               • Chin lift/jaw thrust (avoid head tilt)
               • Suction if needed
               • OPA/NPA if tolerated
               • Intubate if GCS ≤8 or unable to protect
               • Surgical airway if cannot intubate/ventilate
               1. ◆

                  Decision

                  [B] Breathing & Ventilation

                  Assess respiratory function

                  • Expose chest - look for asymmetry
                  • Count respiratory rate
                  • Auscultate bilateral breath sounds
                  • Palpate for crepitus, tracheal deviation
                  • SpO2 monitoring
                  1. ⚠

                     Warning

                     Life-Threatening Chest Injury

                     Immediate intervention required

                     • Tension pneumothorax: Needle decompression → chest tube
                     • Open pneumothorax: 3-sided occlusive dressing
                     • Massive hemothorax: Chest tube + prepare for OR
                     • Flail chest: Consider positive pressure ventilation
                     1. ◆

                        Decision

                        [C] Circulation & Hemorrhage Control

                        Assess perfusion and control bleeding

                        • Assess pulse quality, rate, regularity
                        • Skin color, temperature, capillary refill
                        • Blood pressure (SBP <90 = Class III/IV shock)
                        • Identify sources: chest, abdomen, pelvis, long bones, external
                        • 2 large-bore IV access
                        1. ●

                           Action

                           Hemorrhagic Shock Management

                           Initiate damage control resuscitation

                           • Activate MTP if criteria met
                           • Permissive hypotension (SBP 80-90) until surgical control
                           • TXA 1g IV if <3 hours from injury
                           • Warm blood products
                           • Avoid excessive crystalloid
                           1. ●

                              Action

                              [D] Disability (Neuro Assessment)

                              Rapid neurological evaluation

                              • Glasgow Coma Scale (GCS)
                              • Pupil size and reactivity
                              • Lateralizing signs
                              • GCS ≤8: Protect airway, consider TBI
                              • Check glucose (rule out hypoglycemia)
                              1. ●

                                 Action

                                 [E] Exposure & Environment

                                 Complete exam, prevent hypothermia

                                 • Completely undress patient
                                 • Log-roll for posterior exam
                                 • Prevent hypothermia: warm blankets, warm fluids
                                 • Temperature monitoring
                                 • Cover patient after examination
                                 1. ●

                                    Action

                                    Primary Survey Adjuncts

                                    Monitoring and diagnostics

                                    • ECG monitoring
                                    • Foley catheter (if no contraindication)
                                    • Gastric tube (NG or OG)
                                    • FAST exam or DPL
                                    • Chest and pelvis X-rays
                                    • Labs: Type & Screen, CBC, BMP, Coags, Lactate
                                    1. ✓

                                       Outcome

                                       Proceed to Secondary Survey

                                       Once stabilized, complete head-to-toe evaluation

                           2. ⚠

                              Warning

                              Immediate OR / IR

                              Unstable despite resuscitation

                              • Damage control surgery
                              • Interventional radiology for embolization
                              • REBOA consideration for non-compressible torso hemorrhage