5.1 ATLS Primary Survey & Trauma Resuscitation

5.1 ATLS Primary Survey & Trauma Resuscitation

Core Clinical Rule: In trauma resuscitation, manage threats to life in strict order of lethality: Airway with cervical spine motion restriction, Breathing with immediate decompression of life-threatening chest injuries, Circulation with aggressive external hemorrhage control and balanced resuscitation, Disability via rapid Glasgow Coma Scale (GCS) scoring, and Exposure with aggressive hypothermia prevention. Never delay life-saving clinical interventions—such as needle decompression for tension pneumothorax or tourniquet placement for arterial exsanguination—to obtain imaging or laboratory tests.

Trauma accounts for a massive burden of morbidity and mortality across Kenyan emergency departments, driven predominantly by road traffic crashes (particularly motorized two- and three-wheelers, matatus, and pedestrian impacts), interpersonal violence, and occupational injuries. The Advanced Trauma Life Support (ATLS 10th Edition) framework provides a standardized, chronological sequence designed to assess and resuscitate the critically injured polytrauma patient during the "Golden Hour"—the critical window in which timely therapeutic intervention halts the fatal progression of hypoxia, hypoperfusion, and the lethal trauma triad.

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1. Airway with Cervical Spine Motion Restriction (A)

The primary priority in any trauma resuscitation is securing a patent airway while preventing secondary spinal cord injury in patients with suspected cervical spine trauma. Any blunt polytrauma mechanism, high-energy impact, or injury above the clavicles mandates the assumption of an unstable cervical spine injury until formally cleared.

Airway Assessment and Basic Maneuvers

• Assess Responsiveness and Vocalization: Ask the patient a direct question (e.g., "What is your name?"). A clear, coherent verbal response confirms that the airway is patent, ventilation is adequate to phonate, and cerebral perfusion is temporarily preserved.
• Signs of Airway Compromise: Gurgling or bubbling (secretions, vomitus, or blood pooling in the pharynx), stridor or crowing (laryngeal edema or foreign body obstruction), hoarseness (laryngeal injury), or paradoxical respiratory efforts ("see-saw" breathing).
• Cervical Spine Motion Restriction: Apply manual in-line stabilization (MILS) immediately with hands placed bilaterally across the mastoid processes and occiput. Do not apply traction; simply maintain the head and neck in a neutral anatomical position. Transition to an appropriately sized rigid cervical collar supplemented with lateral foam head blocks and tape across the forehead on a firm backboard.
• Manual Airway Opening: Perform a jaw thrust or chin lift maneuver. Strictly avoid the head-tilt/chin-lift maneuver in trauma, as cervical spine hyperextension risks severing an injured spinal cord.
• Airway Cleansing: Clear the pharynx under direct visualization using a rigid, wide-bore suction tip (Yankauer catheter). Gently insert an oropharyngeal airway (OPA) in an unconscious patient with no gag reflex (sizing from the corner of the mouth to the angle of the mandible), or a nasopharyngeal airway (NPA) in a conscious or semi-conscious patient with an intact gag reflex (avoid NPA if midface trauma or suspected basilar skull fracture is present due to the risk of intracranial cribriform plate penetration).

Indications for a Definitive Airway

A definitive airway is defined as a cuffed tube placed into the trachea below the vocal cords, secured with tape or a commercial holder, connected to oxygen-enriched ventilation. Indications include:

1. Severe Traumatic Brain Injury: Glasgow Coma Scale (GCS) score $\le 8$.
2. Impending or Actual Airway Obstruction: Stridor, expanding neck hematoma, inhalation injury with mucosal burns or carbonaceous soot, or massive subcutaneous emphysema.
3. Severe Ventilatory Failure or Hypoxia: Persistent tachypnea ($RR > 35$), persistent hypoxemia ($SpO_2 < 90%$ despite high-flow oxygen), or respiratory muscle fatigue.
4. Severe Maxillofacial Skeletal Trauma: Le Fort II/III fractures or massive mandibular fractures disrupting structural airway anatomy.
5. Agitation and Combative Behavior: Severe hypoxia or intoxication preventing essential diagnostic evaluations or therapeutic procedures.

+-----------------------------------------------------------------------------------+
|                SURGICAL AIRWAY: EMERGENCY CRICOTHYROIDOTOMY                       |
+-----------------------------------------------------------------------------------+
| INDICATION: "Cannot intubate, cannot ventilate" scenario following failed         |
| endotracheal intubation, massive facial destruction, or severe glottic edema.     |
|                                                                                   |
| ANATOMICAL LANDMARK: The cricothyroid membrane lies between the thyroid cartilage |
| (superiorly) and the cricoid cartilage (inferiorly) in the anterior midline.      |
|                                                                                   |
| TECHNIQUE (SURGICAL / CRICOTHYROIDOTOMY):                                         |
| 1. Stabilize the thyroid cartilage with the non-dominant hand.                     |
| 2. Make a 2–3 cm vertical skin incision in the midline over the membrane.         |
| 3. Make a transverse incision through the lower half of the cricothyroid membrane.|
| 4. Dilate the tract with the scalpel handle or curved Kelly forceps.              |
| 5. Insert a cuffed endotracheal tube (size 6.0 mm) or tracheostomy tube.          |
| *NOTE: Surgical cricothyroidotomy is contraindicated in children under 12 years;   |
| needle cricothyroidotomy with jet insufflation is preferred to avoid cricoid injury.|
+-----------------------------------------------------------------------------------+

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2. Breathing & Ventilation: Life-Threatening Thoracic Emergencies (B)

During the 'B' phase, expose the chest and neck completely to inspect, palpate, percuss, and auscultate the thorax. Immediately life-threatening thoracic trauma must be diagnosed clinically and treated at the bedside without delay for portable chest radiography.

ATLS 10th Edition Practice Update: Traditional guidelines recommended needle decompression for tension pneumothorax in the 2nd intercostal space at the midclavicular line. The 10th edition recommends the 4th or 5th intercostal space anterior to the mid-axillary line in adult trauma patients. Clinical and radiological trials demonstrated that standard 5 cm catheters fail to penetrate the muscular chest wall of the 2nd ICS in up to 40% to 50% of adults, whereas the lateral chest wall is significantly thinner, offering superior success rates.

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3. Circulation with Hemorrhage Control (C)

Hemorrhage represents the leading cause of preventable trauma death. The 'C' assessment focuses on immediate external hemorrhage arrest, rapid hemodynamic evaluation, and protocolized volume resuscitation.

External Hemorrhage Control

• Direct Pressure: Apply firm, continuous manual pressure directly over bleeding lacerations with sterile gauze packs. Firm pressure arrests over 90% of external hemorrhage.
• Commercial Arterial Tourniquets: Indicated immediately for catastrophic extremity arterial exsanguination unresponsive to direct pressure or in mass-casualty incidents. Apply the tourniquet 5 to 7 cm proximal to the wound (never over a joint). Tighten until arterial bleeding ceases and distal pulses are obliterated. Document the exact time of application on the tourniquet. A tourniquet can safely remain in place for up to 2 hours before irreversible neuromuscular ischemia occurs.
• Pelvic Binder Application: In high-energy blunt trauma with suspected pelvic ring disruption (e.g., "open-book" anteroposterior compression fracture), pelvic venous plexus and cancellous bone bleeding cause massive retroperitoneal exsanguination. Apply a commercial pelvic binder or folded bed sheet centered firmly over the greater trochanters of the femurs (not the iliac crests) to close pelvic volume and promote clot tamponade.

ATLS Classification of Hemorrhagic Shock

+-------------------------------------------------------------------------------------------------------+
|                                 ATLS CLASSES OF HEMORRHAGIC SHOCK (70 kg ADULT)                       |
+-----------------------------------+-------------------+-------------------+-------------------+-------+
| Parameter                         | Class I           | Class II (Mild)   | Class III (Mod)   | Class |
+-----------------------------------+-------------------+-------------------+-------------------+-------+
| Blood Loss (mL)                   | < 750 mL          | 750–1,500 mL      | 1,500–2,000 mL    | > 2,0 |
| Blood Loss (% Blood Volume)       | < 15%             | 15%–30%           | 30%–40%           | > 40% |
| Heart Rate (bpm)                  | < 100             | 100–120           | 120–140           | > 140 |
| Blood Pressure                    | Normal            | Normal            | Decreased (Hypot.)| Sever |
| Pulse Pressure                    | Normal / Widened  | Decreased (Narrow)| Decreased         | Sever |
| Respiratory Rate (breaths/min)    | 14–20             | 20–30             | 30–40             | > 35  |
| Urine Output (mL/hr)              | > 30 mL/hr        | 20–30 mL/hr       | 5–15 mL/hr        | Negli |
| Mental Status                     | Slightly anxious  | Mildly anxious    | Anxious, confused | Confu |
| Initial Resuscitation Fluid       | Crystalloid       | Crystalloid       | Crystalloid + Blood| Blood |
+-----------------------------------+-------------------+-------------------+-------------------+-------+

Resuscitation Protocols & Hemorrhage Management

1. Vascular Access: Establish two large-bore peripheral intravenous lines (14-gauge or 16-gauge) in the antecubital fossae. If peripheral access is unobtainable within 90 seconds, establish intraosseous (IO) access (proximal tibia or humeral head) or ultrasound-guided femoral/subclavian central venous catheterization.
2. Balanced Crystalloid Resuscitation: Infuse a warmed ($37^\circ\text{C}$ to $40^\circ\text{C}$) balanced salt solution—preferably Ringer's Lactate. Administer an initial bolus of 1,000 mL in adults (or $20\text{ mL/kg}$ in pediatrics). Avoid massive unbuffered $0.9%$ normal saline infusions, which cause hyperchloremic metabolic acidosis and exacerbate coagulopathy.
3. Permissive Hypotension (Damage Control Resuscitation): In penetrating trauma without traumatic brain injury, avoid aggressive fluid overload. Target a systolic blood pressure of 80 to 90 mmHg (Mean Arterial Pressure $\sim 65\text{ mmHg}$) until surgical or angiographic hemostasis is achieved. Excessive fluid administration dislodges newly formed soft clots ("pops the clot"), dilutes clotting factors, and worsens hypothermia.
4. Massive Transfusion Protocol (MTP): Activated when a patient is in Class III or IV shock or demonstrates an Assessment of Blood Consumption (ABC) score $\ge 2$. Transfuse blood products in a 1:1:1 balanced ratio: 1 unit of Packed Red Blood Cells (PRBCs) : 1 unit of Fresh Frozen Plasma (FFP) : 1 unit of Platelets.
5. Tranexamic Acid (TXA): Administer TXA to all adult trauma patients with significant hemorrhage or at risk of hemorrhagic shock within 3 hours of injury (CRASH-2 trial protocol):
   • Loading Dose: $1\text{ g}$ IV over 10 minutes.
   • Maintenance Infusion: $1\text{ g}$ IV infused over the subsequent 8 hours.
   • Caution: Do not initiate TXA if more than 3 hours have elapsed since the traumatic event, as delayed administration is associated with increased mortality due to thrombotic complications.
6. The Lethal Trauma Triad: Hypothermia ($< 35^\circ\text{C}$), acidosis ($pH < 7.20$), and coagulopathy form a vicious, self-propagating cycle. Hypothermia impairs coagulation cascade enzyme function; acidosis halts thrombin generation; coagulopathy amplifies ongoing blood loss.

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4. Disability: Neurological Evaluation (D)

The 'D' assessment establishes baseline central nervous system status and detects expanding intracranial mass lesions. It consists of the Glasgow Coma Scale (GCS) and pupillary examination.

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|                         GLASGOW COMA SCALE (GCS) SCORING                          |
+-----------------------+-----------------------------------------------------------+
| EYE OPENING (E 1–4)   | 4 = Spontaneous opening                                   |
|                       | 3 = Opens to verbal command or sound                      |
|                       | 2 = Opens to pressure / pain stimulus                     |
|                       | 1 = No eye opening                                        |
+-----------------------+-----------------------------------------------------------+
| VERBAL RESPONSE (V 1–5)| 5 = Oriented and converses normally                       |
|                       | 4 = Confused conversation, disoriented                    |
|                       | 3 = Inappropriate words, random speech                    |
|                       | 2 = Incomprehensible sounds, groaning                     |
|                       | 1 = No vocal response (assign 'T' if intubated)           |
+-----------------------+-----------------------------------------------------------+
| MOTOR RESPONSE (M 1–6)| 6 = Obeys verbal commands                                 |
|                       | 5 = Localizes to painful stimulus (moves hand above chin) |
|                       | 4 = Normal flexion / withdrawal to pain                   |
|                       | 3 = Abnormal flexion (decorticate posturing)             |
|                       | 2 = Extension posturing (decerebrate posturing)           |
|                       | 1 = No motor movement (flaccid)                           |
+-----------------------+-----------------------------------------------------------+
| CUMULATIVE GCS SCORE = Eye + Verbal + Motor (Minimum score = 3, Maximum score = 15)|
+-----------------------------------------------------------------------------------+

Traumatic Brain Injury (TBI) Severity Staging

• Mild TBI: GCS score 13 to 15.
• Moderate TBI: GCS score 9 to 12.
• Severe TBI: GCS score 3 to 8 (Mandatory indication for immediate definitive airway management and emergent non-contrast brain CT).

Pupillary Light Reflex Examination

Assess pupils for size, shape, symmetry, and reactivity to light:

• Unilateral Dilated and Sluggish/Fixed Pupil (Anisocoria): Pathognomonic indicator of impending uncal herniation. The medial temporal lobe herniates across the tentorial notch, compressing the ipsilateral oculomotor nerve (Cranial Nerve III) and parasympathetic fibers, followed by compression of the ipsilateral cerebral peduncle (producing contralateral hemiparesis).
• Bilateral Fixed and Dilated Pupils: Severe, catastrophic brainstem herniation, global cerebral ischemia, or brain death.
• Pinpoint Pupils: Pontine injury, severe opiate toxicity, or organophosphate poisoning.

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5. Exposure & Environmental Control (E)

• Complete Undressing: Completely remove all clothing, cutting along seams if necessary, to expose every square centimeter of the patient's body for thorough inspection. Examine the axillae, perineum, groin, and popliteal fossae for hidden penetrating wounds.
• Log-Roll Examination: Perform a coordinated 4-person log-roll while maintaining strict in-line cervical spine stabilization. The team leader maintains head and neck alignment while three providers turn the torso, pelvis, and lower extremities in unison. Inspect the back, spine, and gluteal regions for step-offs, ecchymosis, lacerations, or penetrating foreign bodies. Perform a digital rectal examination if spinal cord trauma or pelvic fracture is suspected to assess sphincter tone, prostate position, and rectal mucosal integrity.
• Hypothermia Prevention: Immediately cover the patient with warm, dry blankets, utilize forced-air warming systems (e.g., Bair Hugger), warm all infused intravenous fluids and blood products to $37^\circ\text{C}$ to $40^\circ\text{C}$, and maintain the resuscitation room ambient temperature at $\ge 28^\circ\text{C}$.