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Advanced trauma life support

Advanced Trauma Life Support (ATLS) is a standardized educational program developed and sponsored by the American College of Surgeons (ACS) Committee on Trauma, designed to equip physicians and advanced practice providers with a systematic, concise approach to the early assessment, resuscitation, and stabilization of trauma patients, prioritizing the identification and treatment of life-threatening conditions.^[1] The program emphasizes a reproducible framework that serves as a universal language for trauma teams, enabling efficient care in diverse settings from emergency departments to prehospital environments.^[1] The origins of ATLS trace back to 1976, when orthopedic surgeon Dr. James K. Styner survived a small plane crash in Nebraska, experiencing firsthand the disorganized and inadequate trauma care available at the local hospital; this incident prompted him and colleagues to develop a structured training course to address such deficiencies.^[1] The inaugural ATLS course was conducted in 1978 at the University of Nebraska Medical Center, with formal adoption by the ACS in 1980, leading to its rapid expansion across the United States, Canada, and eventually over 80 countries worldwide.^[1] To date, the program has trained more than one million healthcare professionals, establishing itself as the cornerstone of global trauma education and management protocols.^[1] Central to ATLS is the primary survey, structured around the updated xABCDE algorithm introduced in the 11th edition, which begins with extrication and immediate control of catastrophic external hemorrhage (x), followed by airway maintenance with cervical spine protection (A), breathing and ventilation (B), circulation and hemorrhage control (C), disability assessment (D), and full exposure/environmental control (E) to prevent hypothermia.^[2] This is complemented by the secondary survey—a thorough head-to-toe examination and history-taking using the AMPLE mnemonic (Allergies, Medications, Past history, Last meal, Events)—along with adjuncts like imaging and laboratory tests to identify all injuries.^[2] The curriculum also addresses specific conditions such as shock, thoracic and abdominal trauma, head and spinal injuries, burns, and pediatric/geriatric considerations, all grounded in evidence-based guidelines refined by over 200 international experts.^[2] ATLS courses are delivered in flexible formats to accommodate varying learner needs: the traditional in-person version spans 2–2.5 days with didactic lectures, skills stations, and simulated patient scenarios; the hybrid format combines self-paced online modules for core content with 1.5 days of hands-on training; and refresher courses, required every four years for recertification, last 0.5–1 day focusing on skills renewal.^[3] The 11th edition, launched in 2025, incorporates major enhancements including restructured interactive sessions, over 200 new visual aids in the student manual, expanded topics on team communication, trauma systems, and disaster preparedness, and more than 20 mobile-optimized digital modules for accessible learning.^[2] By standardizing trauma resuscitation practices, ATLS has significantly improved survival rates for injured patients and fostered quality assurance in trauma care delivery, with adaptations for military use and integration into broader systems like verified trauma centers.^[1]

Overview

Definition and Purpose

Advanced Trauma Life Support (ATLS) is a standardized training program and clinical guideline developed by the American College of Surgeons (ACS) for physicians and advanced practice providers involved in the initial management of acute trauma patients.^[1] It provides a systematic, concise approach to assessing and managing multiply injured patients, offering a comprehensive and adaptable framework for trauma care that emphasizes rapid evaluation and intervention.^[1] The primary purpose of ATLS is to equip healthcare providers with a safe, reliable method for immediate assessment, resuscitation, and stabilization of trauma patients during the critical first hour following injury, prioritizing the identification and treatment of life-threatening conditions over definitive diagnosis.^[1] This protocol fosters a universal language for trauma management, enabling coordinated care among multidisciplinary teams and facilitating efficient transfer to specialized facilities when necessary.^[1] Introduced by the ACS in 1980, ATLS has achieved widespread global adoption, with training programs now available in more than 80 countries and over 1 million clinicians educated in its principles.^[1] Studies have linked the implementation of ATLS protocols to substantial improvements in patient outcomes, including a reduction in mortality from 24.2% to 0% in the initial 60 minutes after hospital admission.^[4]

Objectives and Principles

The primary objectives of Advanced Trauma Life Support (ATLS) are to enable healthcare providers to rapidly assess a patient's condition using a standardized algorithm, recognize and prioritize life-threatening injuries, and initiate appropriate management to stabilize the patient.^[5] These goals also encompass determining whether the patient's needs exceed local resources, thereby facilitating timely transfer to definitive care, while promoting effective teamwork, trauma-informed care, clear communication, and injury prevention strategies.^[5] By addressing the greatest threats to life first and preventing secondary injuries such as hypothermia or further hemorrhage, ATLS aims to improve survival rates in the critical early phase of trauma management.^[6] Core principles of ATLS revolve around a systematic, reproducible approach to initial assessment and resuscitation, updated in the 11th edition to incorporate the xABCDE sequence, which prioritizes control of exsanguinating hemorrhage before addressing airway, breathing, circulation, disability, and exposure.^[2] This framework assumes major injury in all trauma patients until proven otherwise, guiding clinicians to err on the side of caution and avoid underestimating occult injuries based solely on initial vital signs.^[6] Integration of team dynamics is emphasized, with defined roles for multidisciplinary teams to enhance communication and efficiency during high-stakes resuscitations.^[2] ATLS prioritizes understanding the patient's physiologic response—such as compensatory mechanisms in early shock—over reliance on vital signs alone, incorporating analysis of injury mechanisms and patterns to anticipate hidden threats like internal bleeding or spinal instability.^[6] A key tenet is damage control resuscitation, which balances limited fluid administration with early use of blood products and definitive hemorrhage control to mitigate coagulopathy, acidosis, and hypothermia in severely injured patients.^[7] This principle supports rapid stabilization and safe inter-facility transfer, ensuring comprehensive care without delaying intervention for the most lethal conditions.^[8]

History and Development

Origins

The origins of Advanced Trauma Life Support (ATLS) trace back to a tragic aviation accident on February 17, 1976, when orthopedic surgeon James K. Styner, MD, piloted a small plane that crashed in a rural cornfield near Hebron, Nebraska, USA. Styner sustained multiple injuries, including a fractured femur and ribs, while all four of his children were injured (with three suffering critical injuries), and his wife, Charlene, was killed instantly. Upon arrival at the local hospital, Styner was dismayed by the disorganized and inadequate trauma care provided, which highlighted significant gaps in standardized training for managing severe injuries, particularly in rural settings without specialized trauma centers. Motivated by this personal experience, Styner founded the ATLS program in 1976 to address these deficiencies and promote a systematic approach to initial trauma resuscitation.^[1] Following Styner's initiative, the American College of Surgeons (ACS) Committee on Trauma (COT) took over development of the program in 1979, recognizing its potential to improve outcomes for trauma patients nationwide. The ACS formalized ATLS as an educational initiative, emphasizing a prioritized, algorithmic method for assessing and stabilizing injured individuals to prevent further deterioration. The first ATLS Student Course Manual was published in 1980, providing the foundational guidelines that outlined the primary survey (airway, breathing, circulation, disability, exposure) and secondary survey processes. This initial focus was specifically on standardizing care in rural and underserved areas, where access to organized trauma systems was limited, enabling non-specialist physicians—such as family practitioners—to deliver effective early interventions.^[1]^[9] Early adoption began with a pilot course in 1978 in Auburn, Nebraska, targeted at local family physicians to test the curriculum's practicality. By 1979, additional pilot programs were conducted across the United States, refining the training format before its national rollout in 1980. International expansion followed in the early 1980s, with Canada adopting ATLS in 1981 and several Latin American countries joining in 1986, marking the program's rapid growth beyond U.S. borders to address global inconsistencies in trauma management.^[1]^[10]

Evolution and Updates

The Advanced Trauma Life Support (ATLS) program, first published in 1980, has undergone ten editions through 2018, each incorporating evidence-based refinements to address evolving trauma care practices. Early editions focused on establishing a standardized systematic approach to initial assessment and management, with subsequent updates emphasizing incremental improvements in areas such as imaging utilization to reduce unnecessary radiation exposure, resuscitation strategies including balanced fluid administration and blood product use, and pediatric trauma considerations like age-specific dosing and anatomical differences. For instance, the 9th edition (2012) integrated advanced imaging protocols and enhanced resuscitation guidelines for hemorrhagic shock, while the 10th edition (2018) introduced drug-assisted intubation, revised needle decompression techniques for tension pneumothorax, and expanded content on massive transfusion protocols with tranexamic acid to manage coagulopathy more effectively. These changes reflected ongoing reviews of clinical literature to prioritize patient-centered outcomes and multidisciplinary team performance.^[1]^[11]^[12] The 11th edition, launched in July 2025, represents a comprehensive overhaul developed by over 200 clinical and educational experts from more than 20 countries, aiming to enhance global applicability and incorporate the latest evidence in trauma management. A key innovation is the introduction of the xABCDE mnemonic, which prioritizes exsanguinating hemorrhage control ("x") before traditional airway, breathing, circulation, disability, and exposure elements, underscoring the need for immediate intervention in life-threatening bleeding. This edition also integrates updated protocols for team communication to improve coordination during resuscitation. Specific revisions include earlier use of hemostatic agents, refined tourniquet application protocols for extremity hemorrhage, and reinforced emphasis on permissive hypotension—maintaining systolic blood pressure at 80-90 mmHg until definitive hemorrhage control is achieved—to minimize re-bleeding risks.^[2]^[2] To broaden accessibility, the 11th edition features tiered pricing for courses based on country income levels: $120 for the US and Canada, $90 for high-income countries, $79 for upper-middle-income, $60 for lower-middle-income, and $0 for low-income settings, alongside adaptations tailored for resource-limited environments. It further expands content on trauma systems development and disaster preparedness, equipping providers with strategies for mass casualty scenarios and regional coordination. These updates build on ATLS's global reach, now taught in over 80 countries to more than 1 million clinicians, ensuring the program remains a cornerstone of international trauma education.^[2]^[5]

Training and Certification

Course Structure

The Advanced Trauma Life Support (ATLS) program offers structured training through various course formats designed to impart systematic trauma care skills to healthcare providers. The traditional initial certification course spans 2 to 2.5 days and is delivered in an in-person, interactive format that combines didactic lectures, interactive discussions, hands-on skill stations, and simulated patient scenarios.^[3] Skill stations focus on practical procedures such as airway intubation and chest decompression, allowing participants to practice under supervision in controlled environments.^[3] The course culminates in a final examination comprising written and practical components to assess proficiency in trauma assessment and management.^[3] For recertification, refresher courses are available every four years and typically last half to one day, emphasizing updates to the curriculum such as the xABCDE sequence introduced in recent editions, which prioritizes exsanguinating hemorrhage control.^[3]^[2] These sessions reinforce core skills through targeted practice rather than full initial training.^[3] Complementing the in-person elements, the ATLS program includes over 20 redesigned, mobile-friendly online learning modules that provide flexible access to core content, supporting self-study and preparation for course activities.^[2] The 11th edition manual, integral to these resources, features more than 200 new tables and images to enhance visual understanding of trauma principles.^[2] A key emphasis across all courses is hands-on application through simulated patient scenarios, where participants conduct primary and secondary surveys in team-based resuscitation exercises to build proficiency in coordinated care and principles of team dynamics.^[3]^[2] This simulation-driven approach ensures learners can integrate knowledge into realistic trauma responses.^[3]

Provider Requirements

Eligibility for the Advanced Trauma Life Support (ATLS) program is open to physicians holding MD or DO degrees, as well as advanced practice providers (APPs) such as nurse practitioners, physician assistants, and certain registered nurses involved in trauma care.^[1] The initial student course does not require prior ATLS certification, allowing new participants to achieve full provider verification upon successful completion.^[3] ATLS certification levels include the student course, which provides full provider verification for delivering trauma care, and instructor courses for those identified with instructor potential, enabling them to teach the program.^[3] Hybrid formats combine online learning modules with in-person skills sessions, offering flexibility especially for international providers.^[2] Physicians can advance to full instructor or course director roles, while APPs, including nurses and PAs, may qualify as associate instructors with supervised teaching responsibilities and a limited skill set as of September 2024.^[13]^[14] Verification status remains current for four years from the completion date of a traditional, hybrid, or refresher course.^[13] Recertification requires completing a refresher course, with a six-month grace period after expiration during which participants can still enroll, though they are not considered verified in the interim.^[13] The 11th edition, launched in 2025, introduces over 20 mobile-friendly online modules and tiered pricing based on World Bank income classifications, reducing costs to zero for low-income countries to promote worldwide adoption.^[2]

Primary Survey

Exsanguinating Hemorrhage Control

In the 11th edition of Advanced Trauma Life Support (ATLS), exsanguinating hemorrhage control is prioritized as the initial "x" step in the revised xABCDE primary survey, recognizing life-threatening bleeding as the leading preventable cause of death in trauma patients and shifting from the traditional ABCDE sequence to address it before airway, breathing, or circulation interventions unless immediate threats to oxygenation exist.^[2] This update reflects evidence from military and civilian studies. Assessment begins with rapid visual inspection to identify external bleeding, such as pulsatile or profuse hemorrhage from wounds, and palpation for signs of internal bleeding, including expanding hematomas in the neck, abdomen, or extremities that indicate ongoing vascular injury.^[15] These findings guide immediate intervention, with the goal of achieving control within minutes to prevent hypovolemic shock. Key techniques for control include applying direct pressure to the wound site using a gloved hand or dressing to compress bleeding vessels, which serves as the first-line method for most external hemorrhages.^[16] For extremity bleeds unresponsive to pressure, tourniquets are recommended, with application targeted within 2-3 minutes of identification to occlude arterial flow proximally, as supported by data demonstrating an 85% reduction in mortality from such injuries when applied early. Wound packing involves stuffing gauze or hemostatic material into deep or irregular wounds to tamponade bleeding, followed by sustained pressure for at least 3 minutes to promote clotting.^[16] Hemostatic agents, such as kaolin-based dressings (e.g., QuikClot), are used to accelerate coagulation by activating the intrinsic pathway when packed into wounds, particularly effective for junctional or non-compressible bleeds.^[16]^[17] The 11th edition integrates these measures with damage control surgery principles, advocating rapid transfer to the operating room for definitive control of internal exsanguination once initial stabilization is achieved, emphasizing a multidisciplinary approach to limit physiological derangements.^[2] To prevent complications, providers are instructed to avoid over-resuscitation with fluids or blood products prior to hemorrhage control, employing permissive hypotension (systolic blood pressure ~90 mmHg) to minimize re-bleeding until surgical hemostasis is secured, as excessive volume can exacerbate coagulopathy and increase mortality.

Airway Management

Airway management constitutes the initial step ("A") in the Advanced Trauma Life Support (ATLS) primary survey, aiming to ensure patency and protect against compromise in trauma patients while simultaneously safeguarding the cervical spine from potential injury. Assessment begins with a rapid evaluation of airway patency using the "look, listen, and feel" approach: visually inspect for cyanosis, facial or neck trauma, or foreign bodies; auscultate for breath sounds and stridor indicating partial obstruction; and palpate for air movement or tracheal deviation. Signs of obstruction include snoring respirations, drooling, paradoxical breathing, or absent breath sounds, which necessitate immediate intervention to prevent hypoxia and aspiration.^[18] Basic interventions prioritize non-invasive maneuvers to open the airway without exacerbating potential cervical injury. The jaw thrust maneuver is preferred over the head-tilt/chin-lift in trauma settings, involving placement of fingers behind the angles of the mandible to lift it forward while maintaining manual in-line stabilization of the cervical spine by a second provider. Adjunctive devices such as oropharyngeal or nasopharyngeal airways can be inserted if tolerated, following suctioning of secretions or debris; however, these are temporary measures. Throughout all procedures, cervical spine protection is paramount, achieved via manual in-line immobilization to minimize axial loading and rotation, often supplemented by a rigid collar once the airway is secured. The 11th edition of ATLS emphasizes this integrated approach to avoid secondary neurological injury.^[18] Definitive airway control via endotracheal intubation is indicated when basic measures fail or in cases of impending compromise, including a Glasgow Coma Scale (GCS) score less than 8, inability to protect the airway (e.g., due to vomiting or reduced reflexes), severe facial or neck trauma, or persistent hypoxia despite supplemental oxygen. Rapid sequence intubation (RSI) is the standard technique, using induction agents and paralytics while maintaining in-line stabilization to limit cervical motion to less than 5 degrees. If intubation fails after two attempts or is contraindicated (e.g., massive facial disruption), a surgical airway such as cricothyroidotomy is performed emergently, involving incision through the cricothyroid membrane for placement of a 6.0 cuffed endotracheal tube. Post-airway securing integrates briefly with breathing assessment to confirm adequate ventilation. These protocols, rooted in ATLS guidelines, have reduced airway-related mortality in trauma by prioritizing early intervention.^[19]^[18]

Breathing and Ventilation

In the breathing and ventilation phase of the Advanced Trauma Life Support (ATLS) primary survey, evaluation focuses on ensuring adequate oxygenation and ventilation following airway management, assuming the airway is secured with cervical spine protection.^[18] This step identifies immediate life-threatening thoracic injuries by inspecting the chest for symmetric rise and fall, asymmetric excursion, paradoxical movement, or open wounds; auscultating for bilateral breath sounds to detect absent or diminished sounds suggestive of pneumothorax or hemothorax; and palpating for crepitus indicating subcutaneous emphysema or rib fractures.^[18]^[20] Tracheal deviation, jugular venous distension, or hypotension may signal tension pneumothorax, while flail chest is recognized by a segment of the chest wall moving independently due to multiple rib fractures.^[18] Immediate interventions prioritize high-flow supplemental oxygen via non-rebreather mask at 15 L/min for all trauma patients to achieve SpO2 greater than 94%, unless contraindicated.^[18] For tension pneumothorax, a life-threatening condition causing respiratory distress and hemodynamic instability, perform immediate needle decompression in the second intercostal space at the midclavicular line or fifth intercostal space at the anterior axillary line using a 14- to 16-gauge needle, followed by definitive chest tube insertion.^[18] Open pneumothorax, or "sucking chest wound," requires covering the defect with a three-sided occlusive dressing to allow air escape while preventing ingress and potential conversion to tension physiology; avoid fully occlusive dressings.^[18] Massive hemothorax, identified by dullness to percussion and absent breath sounds with significant blood loss, necessitates urgent chest tube placement for drainage, with ongoing monitoring for ongoing hemorrhage requiring thoracotomy if output exceeds 1,500 mL initially or 200-300 mL/hour.^[18] Flail chest with underlying pulmonary contusion and respiratory compromise is managed with positive pressure ventilation to stabilize the chest wall and improve gas exchange, potentially requiring intubation if oxygenation fails.^[18] The 11th edition of ATLS emphasizes normoventilation in intubated patients to maintain end-tidal CO2 (EtCO2) between 35 and 45 mmHg, particularly to avoid hyperventilation in those with traumatic brain injury (TBI), as excessive ventilation can induce cerebral vasoconstriction, reducing cerebral blood flow and exacerbating ischemia.^[21] Prophylactic hyperventilation is discouraged unless signs of herniation are present, with brief hyperventilation to PaCO2 30-35 mmHg only for acute deterioration; continuous capnography guides adjustments to prevent hypocapnia below 35 mmHg.^[21] These targets align with broader neuroprotection strategies in polytrauma, ensuring balanced ventilation without compromising perfusion.^[22]

Circulation Assessment

The circulation assessment in the Advanced Trauma Life Support (ATLS) primary survey focuses on rapidly evaluating and restoring circulatory volume following initial control of exsanguinating hemorrhage, aiming to identify and address hypovolemia or shock.^[18] Clinicians begin by palpating central pulses, such as the carotid or femoral, to assess their presence, rate, and quality; weak or thready pulses suggest significant volume loss.^[18] Skin perfusion is evaluated through color (pale or mottled), temperature (cool and clammy), and capillary refill time, where a refill exceeding 2 seconds indicates inadequate perfusion.^[18] Additionally, the Shock Index, calculated as heart rate divided by systolic blood pressure with a value greater than 1.0 signaling hypovolemia, provides a quick, non-invasive metric to gauge shock severity even in normotensive patients.^[23] Interventions prioritize securing vascular access and volume replacement to maintain organ perfusion. Two large-bore intravenous (IV) lines, preferably 14- to 16-gauge, are established in the upper extremities or, if needed, via intraosseous routes for rapid infusion.^[18] An initial bolus of 1 to 2 liters of warmed crystalloid solution, such as lactated Ringer's or normal saline, is administered to responsive patients, while monitoring for response in vital signs and urine output.^[18] If the patient remains unresponsive or shows signs of ongoing shock, transition promptly to blood products, including packed red blood cells, to avoid dilutional coagulopathy.^[24] The 11th edition of ATLS, released in 2025, refines these strategies with evidence-based updates emphasizing balanced resuscitation. Permissive hypotension is recommended, targeting a systolic blood pressure of 80 to 90 mmHg (or mean arterial pressure of 50 to 60 mmHg) in patients with penetrating torso injuries or prior to surgical hemorrhage control, to minimize clot disruption while awaiting definitive intervention.^[24] For suspected ongoing bleeding, early activation of the massive transfusion protocol (MTP) is advocated to facilitate rapid delivery of blood components in a balanced ratio, improving survival in hemorrhagic shock.^[24] Non-compressible sources of bleeding, such as pelvic fractures or intra-abdominal hemorrhage, require targeted interventions during circulation assessment. Pelvic binding with a sheet or commercial binder is applied to stabilize unstable pelvic rings and reduce volume loss from venous bleeding.^[18] In select cases with access to advanced capabilities, resuscitative endovascular balloon occlusion of the aorta (REBOA) may be deployed in zone 3 (infrarenal) for pelvic hemorrhage control, serving as a bridge to operative management.^[25]

Disability Assessment

The Disability Assessment, or "D" component of the Advanced Trauma Life Support (ATLS) primary survey, provides a rapid neurological evaluation to detect immediate threats to brain or spinal cord function, such as impaired consciousness or focal deficits. This step prioritizes identifying conditions requiring urgent intervention, like severe traumatic brain injury, while integrating seamlessly with prior airway, breathing, and circulation management.^[18] A quick assessment of consciousness uses the AVPU scale: Alert (fully awake and responsive), responsive to Verbal stimuli, responsive only to Painful stimuli, or Unresponsive. For greater precision, the Glasgow Coma Scale (GCS) evaluates eye opening (1-4 points), verbal response (1-5 points), and motor response (1-6 points), yielding a total score from 3 (deep unconsciousness) to 15 (normal). A GCS score of 8 or below signals severe impairment and typically mandates securing the airway to protect against aspiration or hypoventilation.^[18]^[26] Pupillary examination assesses size (normal 2-4 mm), equality, and reactivity to light; unequal or nonreactive pupils may indicate transtentorial herniation or brainstem injury. Motor function is checked in all extremities for purposeful movement, withdrawal to pain, or paralysis, with asymmetry suggesting focal lesions like epidural hematoma.^[18] Key interventions emphasize neuroprotection: ensure oxygenation (PaO2 >60 mmHg) and ventilation to avoid hypoxia-induced secondary injury, maintain normoglycemia (blood glucose 140-180 mg/dL) to prevent exacerbation of cerebral ischemia, and elevate the head of the bed to 30 degrees for patients with GCS <8 to facilitate venous drainage and reduce intracranial pressure, assuming spinal precautions and hemodynamic stability. Sedatives are deferred until stabilization to preserve accurate serial neurological exams.^[27]^[28] The 11th edition of ATLS highlights geriatric considerations, incorporating frailty screening—via tools like the Clinical Frailty Scale—during disability assessment to predict outcomes and guide resuscitation, as frailty correlates more strongly with mortality than chronological age alone; this avoids over-reliance on age-based assumptions.^[2]^[29]

Exposure and Environmental Control

The exposure phase of the primary survey in Advanced Trauma Life Support (ATLS) involves fully undressing the patient to enable a comprehensive visual inspection for occult injuries, ensuring no life-threatening conditions are overlooked. This step requires cutting away clothing if necessary to avoid disrupting ongoing resuscitation or spinal precautions, followed by a log-roll maneuver performed by a coordinated team to examine the posterior body surfaces, including the back, flanks, and buttocks, while maintaining inline cervical spine stabilization.^[18]^[30] Immediately after exposure, environmental control measures are instituted to mitigate the risk of hypothermia, a common iatrogenic complication in trauma patients that can exacerbate coagulopathy and increase mortality. The patient should be covered with warmed blankets, the ambient room temperature raised, intravenous fluids administered via in-line warmers, and forced-air warming devices applied as available, with the target core body temperature maintained above 35°C to preserve hemostatic function.^[18]^[31] The 11th edition of ATLS, released in 2025, places heightened emphasis on rapid re-warming protocols immediately post-exposure to counteract thermal threats and integrates environmental control into team handovers for seamless continuity during transitions of care.^[32] Prolonged exposure risks secondary injuries such as hypothermia-induced impairment in platelet function and enzymatic coagulation, necessitating a balanced approach that prioritizes exposure duration alongside simultaneous airway, breathing, and circulatory interventions.^[31] Hypothermia below 35°C may also contribute to neurologic changes, including altered level of consciousness, underscoring the need for vigilant temperature monitoring.^[18]

Adjuncts to Primary and Secondary Surveys

Initial Diagnostic Imaging

Initial diagnostic imaging in Advanced Trauma Life Support (ATLS) protocols serves as a critical adjunct to the primary survey, enabling rapid identification and confirmation of life-threatening injuries such as hemorrhage, pneumothorax, and pericardial effusion without compromising ongoing resuscitation efforts. These modalities are prioritized for their speed and availability at the bedside, particularly in unstable patients where transport to advanced imaging suites could exacerbate instability.^[18] The Extended Focused Assessment with Sonography for Trauma (E-FAST) is a cornerstone bedside ultrasound examination recommended for all patients with major blunt or penetrating thoracic and abdominal trauma as part of the primary survey. It systematically evaluates for pericardial effusion via the subxiphoid or parasternal view, hemoperitoneum through right upper quadrant, left upper quadrant, and pelvic views, and pneumothorax using lung sliding assessment in bilateral anterior chest views. E-FAST demonstrates high diagnostic performance, with pooled sensitivity of 80-95% and specificity exceeding 95% for detecting free intraperitoneal fluid indicative of hemoperitoneum; for pneumothorax, sensitivity is approximately 69% with specificity of 99%; and for pericardial effusion, sensitivity reaches 91% with specificity of 94%. These metrics underscore its utility as a non-invasive, radiation-free tool to guide immediate interventions like pericardiocentesis or operative exploration.^[33]^[34]^[35] Portable radiographs, including supine anteroposterior chest and pelvis X-rays, are obtained promptly in unstable major trauma patients to detect hemothorax, pneumothorax, rib fractures, and pelvic disruptions that may signal ongoing bleeding. The chest X-ray is indicated when thoracic injury is suspected but not fully clarified clinically, revealing abnormalities such as widened mediastinum or opacified hemithorax; similarly, the pelvic X-ray identifies fractures or instability requiring immediate stabilization, such as with a pelvic binder. These imaging studies are performed at the bedside to minimize delays, with evidence supporting their routine use in the initial evaluation of polytrauma to inform resuscitation priorities.^[18]^[36] The 11th edition of ATLS emphasizes enhanced integration of advanced imaging, recommending whole-body computed tomography (CT) for hemodynamically stable patients (typically systolic blood pressure >90 mmHg after initial resuscitation) where no immediate operative intervention is needed, as the diagnostic yield justifies potential risks like radiation exposure. Emerging evidence supports a lower threshold for such imaging in select patients responding to resuscitation with systolic blood pressure ≥60 mmHg and no immediate surgical needs. In contrast, for unstable patients, such imaging is deferred to avoid resuscitation delays, prioritizing clinical assessment and adjuncts like E-FAST. This approach reflects updated evidence favoring timely whole-body CT protocols in severe injuries to reduce missed diagnoses.^[36]

Monitoring and Laboratory Tests

In the primary and secondary surveys of Advanced Trauma Life Support (ATLS), continuous physiologic monitoring is essential to assess and guide resuscitation efforts, allowing for early detection of deterioration in trauma patients.^[2] Key modalities include continuous electrocardiography (ECG) to detect arrhythmias and ischemia, pulse oximetry to evaluate oxygenation status, and non-invasive or invasive (arterial line) blood pressure monitoring to track hemodynamic stability.^[37] Capnography is also employed to confirm endotracheal tube placement and monitor ventilation adequacy, particularly in intubated patients.^[37] These tools provide real-time data to inform interventions during the acute phase. Laboratory tests are initiated early to support clinical assessments and resuscitation decisions, with samples drawn alongside intravenous access.^[38] Essential evaluations include type and crossmatch to prepare for potential blood transfusion in hemorrhagic shock, hemoglobin and hematocrit levels to quantify blood loss, serum lactate to gauge tissue hypoperfusion and shock severity (elevated levels >4 mmol/L indicating class III or IV shock), and arterial blood gas analysis to assess acid-base balance, oxygenation, and ventilation.^[38]^[39] These tests help prioritize fluid and blood product administration while avoiding over-resuscitation. The 11th edition of ATLS emphasizes advanced monitoring techniques for targeted therapy, including pulse pressure variability derived from arterial waveform analysis to predict fluid responsiveness in mechanically ventilated patients, where variations >13% suggest potential benefit from volume loading.^[40] Early use of thromboelastography (TEG) is recommended to identify trauma-induced coagulopathy, guiding component-specific therapy such as fibrinogen replacement or platelet transfusion based on clot formation kinetics.^[41] Monitoring frequency is intensified during initial resuscitation, with vital signs reassessed every 15 to 30 minutes to capture trends rather than isolated snapshots, enabling adjustments to ongoing care and correlation with imaging findings if abnormalities arise.^[42] This dynamic approach ensures comprehensive evaluation of the patient's response to interventions throughout the surveys.

Secondary Survey

Patient History

The patient history is a key component of the secondary survey in Advanced Trauma Life Support (ATLS), undertaken only after the primary survey has stabilized the patient's airway, breathing, circulation, disability, and exposure.^[43] This history gathering helps identify factors that influence management decisions, such as comorbidities or injury patterns, without delaying resuscitation.^[43] The AMPLE mnemonic provides a structured framework for obtaining this history efficiently.^[43] Allergies refer to any known sensitivities to medications, foods, or environmental agents that could affect treatment choices.^[43] Medications encompass current prescriptions, over-the-counter drugs, and supplements, which are particularly relevant in older adults due to polypharmacy risks.^[43] Past medical history includes chronic conditions, prior surgeries, pregnancies (in females of childbearing age), or events like tetanus immunization status.^[43] Last meal documents the time and content of the patient's most recent intake to assess aspiration or anesthesia risks.^[43] Events or environment details the mechanism of injury, such as the speed and type of motor vehicle collision (MVC), to gauge energy transfer—for instance, high-speed collisions indicate high-energy trauma likely associated with multisystem injuries.^[44] History is elicited from the patient when possible, supplemented by witnesses, emergency medical services (EMS) reports, or bystanders to fill gaps in recollection.^[43] Emphasis is placed on the mechanism of injury to anticipate occult injuries, such as those from deceleration forces in high-speed impacts.^[44] In geriatric patients, considerations include frailty assessment (e.g., via tools evaluating mobility, cognition, and nutrition) to predict poorer outcomes and tailor care.^[29] Frailty screening in elderly patients identifies vulnerability to decompensation from even low-energy trauma.^[29] Overall, the patient history directs subsequent focused examinations and interventions by highlighting risks, such as bleeding potential from anticoagulants in the medication review or abdominal injuries from blunt mechanisms in the events description.^[43]

Physical Examination

The physical examination in the secondary survey of Advanced Trauma Life Support (ATLS) constitutes a comprehensive, systematic head-to-toe evaluation conducted after the primary survey and initial resuscitation to detect all potential injuries, ensuring no significant trauma is overlooked.^[43] This detailed assessment complements the patient history by providing tactile and visual confirmation of injuries, guiding further diagnostic and therapeutic interventions.^[45] The examination emphasizes preventing secondary brain injury through vigilant monitoring of oxygenation, ventilation, and cerebral perfusion, particularly in patients with suspected head trauma.^[43] The examination follows a standardized sequence beginning with the head and progressing caudally to include the neck, chest, abdomen, pelvis, extremities, and back. For the head, clinicians inspect and palpate the scalp for lacerations, hematomas, or depressions, while checking for signs of basilar skull fracture such as battle's sign (postauricular ecchymosis) or raccoon eyes (periorbital ecchymosis); the face and ears are assessed for deformities, hemotympanum, or cerebrospinal fluid leaks.^[43] The neck is examined while maintaining cervical spine immobilization, involving inspection for swelling, tracheal deviation, or jugular venous distension, followed by gentle palpation for tenderness, crepitus, or subcutaneous emphysema.^[45] Moving to the chest, inspection reveals asymmetry, paradoxical movement, or seatbelt signs, with palpation identifying rib fractures via crepitus or tenderness, and auscultation confirming breath and heart sounds.^[43] The abdominal assessment includes inspection for distension, bruising (e.g., Cullen's or Grey Turner's signs), and palpation across all quadrants for tenderness, guarding, or rebound, often prompting integration with focused assessment with sonography for trauma (FAST) imaging.^[45] Pelvic stability is evaluated by gentle compression to detect instability or tenderness, avoiding excessive manipulation to prevent worsening hemorrhage.^[43] For the extremities and perineum, inspection identifies open wounds, deformities, or ecchymosis, while palpation checks for fractures or compartment syndrome; neurovascular status is systematically assessed in each limb, including pulses, capillary refill, motor function, and sensation to rule out vascular compromise or nerve injury.^[45] The back and posterior body are examined via log-roll maneuver under spinal precautions, palpating the spine for step-offs, tenderness, or deformities.^[43] Key techniques employed throughout include thorough inspection for external signs of injury, palpation to elicit tenderness or instability, and percussion or auscultation where appropriate to enhance detection.^[2] Findings suggestive of intracranial pathology—such as altered mental status or focal deficits—prompt immediate neuroimaging, such as non-contrast CT of the head, to facilitate early neurosurgical consultation and mitigate secondary brain injury from hypoxia or hypotension.^[2] Similarly, extremity injuries like open fractures necessitate orthopedic referral, with imaging such as X-rays integrated based on exam results.^[43] Adjunctive measures, such as analgesia to facilitate the examination and tetanus prophylaxis based on history, are administered as needed.^[43] Documentation of the physical examination is meticulous and systematic, recording all findings, including normal variants, vital signs at key intervals, and neurovascular status to support interdisciplinary consultations and track changes over time.^[45] This detailed record ensures continuity of care and informs the tertiary survey for re-evaluation.^[43]

Tertiary Survey

Re-evaluation Process

The re-evaluation process, integral to the tertiary survey in Advanced Trauma Life Support (ATLS), involves a systematic reassessment of the trauma patient following initial stabilization to detect any overlooked or evolving injuries. This process typically occurs 12 to 24 hours after admission or after significant interventions such as surgery, allowing time for the patient to stabilize while minimizing delays in identifying issues.^[46]^[47] Key components include repeating the AMPLE history (Allergies, Medications, Past medical history, Last meal, Events of injury) and conducting a thorough head-to-toe physical examination, building on the baseline from the secondary survey. The team reviews all accumulated data, including laboratory results, imaging reports, and vital sign trends, to identify discrepancies or new developments. Multidisciplinary input from relevant specialists is essential to ensure comprehensive evaluation and prompt addressing of findings.^[48]^[46]^[47] The process emphasizes team-based elements such as debriefings to enhance coordination and communication among providers, alongside regular updates to family members for holistic patient care. Special attention is directed to high-risk areas prone to missed injuries, including the spine, through targeted re-examination. Standardized checklists are recommended to structure the assessment, reducing variability and promoting consistency across teams.^[46]

Identification of Missed Injuries

In trauma care, the tertiary survey plays a crucial role in identifying injuries overlooked during initial assessments, with common misses including occult fractures such as scaphoid fractures in the wrist, which are frequently undetected due to subtle initial presentations in hand and wrist evaluations.^[49] Diaphragmatic ruptures, often resulting from blunt abdominal trauma, are another prevalent missed injury, as they may not manifest immediately and can lead to delayed herniation of abdominal contents into the thorax.^[50] Spinal injuries, including unstable fractures and ligamentous disruptions, are also commonly overlooked, with studies indicating miss rates of around 4-5% in the absence of systematic re-evaluation, particularly in polytrauma cases where multiple injuries distract from thorough spinal assessment.^[51] These injuries typically account for a significant portion of delayed diagnoses, with fractures and ligament tears comprising over 80% of such cases in severe trauma patients.^[52] Several risk factors increase the likelihood of missed injuries during trauma management. Intoxication and altered mental status impair patient cooperation and clinical examination accuracy, contributing to diagnostic oversights.^[53] Multiple distracting injuries, often indicated by higher Injury Severity Scores (ISS), further complicate prioritization and lead to incomplete evaluations.^[54] Elderly patients face elevated risks due to comorbidities, reduced physiological reserve, and atypical injury presentations, which can mask underlying pathology.^[29] Prevention strategies emphasize structured protocols within the tertiary survey to mitigate these risks. Implementation of a standardized tertiary checklist, combined with serial physical examinations and targeted repeat imaging such as CT scans or X-rays for suspected areas, significantly enhances detection rates.^[46] Adherence to Advanced Trauma Life Support (ATLS) protocols has been associated with reduced missed injury rates through improved compliance, with studies showing detection improvements from 2% to 9% following protocol introduction.^[46] Early re-evaluation within 24 hours identifies up to 23.5% of delayed diagnoses, underscoring the value of timely, protocol-driven assessments.^[52] Missed injuries substantially impact patient outcomes, contributing to significant late morbidity through complications like chronic pain, infection, or neurological deficits.^[55] Clinically significant misses, occurring in 15-22.3% of affected patients, often prolong hospital stays and increase overall trauma care costs, highlighting the importance of vigilant re-evaluation for optimal recovery.^[55]

Specific Management Strategies

Shock Classification and Resuscitation

In trauma patients, shock is most commonly hypovolemic due to hemorrhage, but other types include distributive shock from neurogenic causes such as spinal cord injury and cardiogenic shock from blunt cardiac injury.^[56] The Advanced Trauma Life Support (ATLS) protocol classifies hypovolemic shock into four classes based on estimated blood loss as a percentage of total blood volume (approximately 5 L in adults) and associated vital sign changes, aiding in rapid recognition and management.^[57] Class I hypovolemic shock involves up to 15% blood loss (up to 750 mL), with minimal or no changes in heart rate, blood pressure, pulse pressure, or respiratory rate, often presenting asymptomatically.^[57] Class II features 15-30% loss (750-1500 mL), tachycardia (heart rate 100-120 bpm), decreased pulse pressure, and mildly increased respiratory rate (20-24 breaths/min), with normal systolic blood pressure.^[57] Class III indicates 30-40% loss (1500-2000 mL), marked tachycardia (heart rate ≥120 bpm), hypotension, further decreased pulse pressure, and respiratory rate >24 breaths/min, signifying significant tissue hypoperfusion.^[57] Class IV represents >40% loss (>2000 mL), with heart rate >120 bpm, profound hypotension (systolic <90 mm Hg), and pulse pressure ≤25 mm Hg, requiring immediate intervention to prevent death.^[57] Resuscitation in ATLS emphasizes damage control principles to minimize coagulopathy and acidosis, particularly in the 11th edition, which prioritizes early hemostatic resuscitation over large-volume crystalloids.^[32] For patients requiring massive transfusion protocol (MTP) activation, a balanced 1:1:1 ratio of packed red blood cells, plasma, and platelets is recommended to approximate whole blood and improve survival in severe hemorrhage. If available, whole blood is preferred for its comprehensive hemostatic benefits in resource-equipped settings.^[58] Tranexamic acid (TXA), an antifibrinolytic, should be administered intravenously (1 g over 10 minutes, followed by 1 g infusion over 8 hours) within 3 hours of injury in patients with significant bleeding to reduce mortality from hemorrhage. Ongoing monitoring during resuscitation uses base deficit and lactate levels as key endpoints to assess adequacy of perfusion and guide therapy.^[59] Base deficit categorizes shock severity (mild: -3 to -5 mEq/L; moderate: -6 to -9 mEq/L; severe: ≥-10 mEq/L), with serial measurements tracking response to interventions.^[60] Lactate clearance, targeting levels below 2 mmol/L, indicates resolution of anaerobic metabolism and improved outcomes, with persistent elevation signaling inadequate resuscitation.^[61]

Considerations for Special Populations

Advanced Trauma Life Support (ATLS) protocols require adaptations for special populations to account for physiological differences that affect trauma assessment and management. These groups, including pediatric, geriatric, and pregnant patients, exhibit unique responses to injury, necessitating tailored approaches to ensure optimal outcomes. The 11th edition of ATLS integrates special population considerations throughout, with dedicated emphasis on standardized vital signs and equipment for pediatrics, and early trauma team activation for patients aged over 55 years to address age-related vulnerabilities.^[62]^[29] In pediatric patients, weight-based dosing is critical due to variability in size and development, with tools like the Broselow tape providing color-coded estimates for medication, fluid, and equipment sizing to facilitate rapid resuscitation. Shock thresholds are higher in this group; for instance, a heart rate exceeding 160 beats per minute in infants signals compensated shock, reflecting their greater reliance on tachycardia to maintain cardiac output before hypotension develops. Additionally, the pediatric version of the Glasgow Coma Scale (GCS) modifies scoring for verbal and motor responses to better assess neurological status in children under 5 years, improving accuracy in disability evaluation.^[63]^[56] Geriatric patients demand frailty index assessment, such as the Trauma-Specific Frailty Index, which evaluates comorbidities, functionality, and nutrition to predict adverse outcomes and guide resource allocation, as frailty scores of 0.25 or higher correlate with increased mortality independent of age. Hypotension thresholds are lowered to a systolic blood pressure below 110 mmHg, given their blunted compensatory mechanisms and higher baseline blood pressures, prompting earlier intervention to prevent occult hypoperfusion. These patients also face elevated miss rates for occult injuries, up to 20-30% higher than younger adults, due to atypical presentations and comorbidities, underscoring the need for comprehensive imaging and repeated evaluations.^[29]^[64]^[65] For pregnant patients, particularly beyond 20 weeks gestation, the left lateral tilt position at 25-30 degrees alleviates aortocaval compression by the gravid uterus, enhancing venous return and cardiac output during resuscitation. In cases of maternal cardiac arrest, perimortem cesarean delivery is indicated if return of spontaneous circulation is not achieved within 4 minutes, performed at the site of arrest to optimize maternal hemodynamics regardless of fetal viability, with delivery ideally within 5 minutes to improve survival rates.^[66]^[67]

Evidence and Alternatives

Clinical Evidence Supporting ATLS

Advanced Trauma Life Support (ATLS) has been evaluated through various studies demonstrating its role in improving trauma care outcomes, particularly in reducing errors and mortality. A key study by Ali et al. (2001) highlighted the attrition of ATLS-acquired skills over time, underscoring the need for ongoing training to maintain error reduction benefits. In low-resource settings, implementation of ATLS protocols has led to significant mortality drops; for instance, a 2024 study in resource-limited environments reported a reduction in 30-day mortality from 17% to 6% among severely injured patients following ATLS training.^[68] Similarly, World Health Organization-supported initiatives in such contexts have documented decreased trauma-related deaths through ATLS adoption, emphasizing its adaptability for global use. Evidence supporting specific ATLS components, such as the updated xABCDE approach in the 11th edition, links to enhanced hemorrhage control. The xABCDE prioritizes exsanguinating hemorrhage before traditional ABCDE steps, with clinical observations from implementation trials showing improved control of life-threatening bleeding in simulated and real-world scenarios. Overall, centers implementing ATLS have reported mortality reductions of 15-25%, attributed to systematic primary survey adherence and timely resuscitation. For example, a 2016 study (PubMed ID: 27598587) found that introducing ATLS guidelines alongside trauma teams positively impacted mortality within the first 24 hours post-admission, both in shock rooms and overall.^[69] A 2025 mixed-methods cohort study quantified ATLS training's efficacy, showing significant reductions in preventable and potentially preventable deaths—from 30% to 15% for preventable cases and 40% to 25% for potentially preventable ones—across diverse settings.^[70] This confirmed enhanced clinical decision-making and lower mortality through ATLS adherence. Despite these benefits, the evidence base relies predominantly on observational studies, which limit causal inferences due to confounding factors like varying trauma volumes and provider experience. Multiple systematic reviews stress the need for randomized controlled trials (RCTs) to rigorously evaluate ATLS updates and long-term impacts, as no large-scale RCTs currently demonstrate definitive patient outcome improvements.

Comparisons with Other Protocols

Advanced Trauma Life Support (ATLS) shares foundational principles with the Early Management of Severe Trauma (EMST) course, which is the Australasian adaptation developed through a long-standing memorandum of understanding with the American College of Surgeons. Both protocols employ the systematic ABCDE approach to initial trauma assessment and management, emphasizing airway, breathing, circulation, disability, and exposure. However, EMST places comparatively less emphasis on the emergent control of exsanguinating hemorrhage (the "x" in the updated xABCDE sequence introduced in ATLS's 11th edition), reflecting its alignment with earlier ATLS iterations, and features a shorter course duration of approximately 2.5 days versus ATLS's typical 3-day format.^[71]^[72]^[2] In Singapore, trauma management protocols, such as the CHOP (Check Haemorrhage, Open Abdomen, Pack, Proceed to Interventional Radiology or Operating Theatre) system implemented at institutions like Khoo Teck Puat Hospital, integrate elements of ATLS's primary survey but incorporate a stronger focus on rapid definitive interventions for exsanguinating patients and disaster preparedness within the national trauma registry framework. This regional approach prioritizes multidisciplinary team activation for severe hemorrhage and penetrating injuries, contrasting with ATLS's broader global standardization that facilitates consistent application across diverse healthcare settings without heavy reliance on specialized second-tier activations. Studies indicate ATLS's standardized framework yields more uniform outcomes in international contexts compared to such localized protocols, which may vary in scalability during mass casualty events.^[73]^[74]^[75] Prehospital protocols like Prehospital Trauma Life Support (PHTLS) complement rather than compete with ATLS, as PHTLS adapts ATLS principles for field-based care by emergency medical technicians and paramedics, stressing rapid scene assessment, packaging, and transport to definitive care. In contrast to ATLS's hospital-centric focus on in-depth resuscitation and secondary surveys, PHTLS emphasizes logistical challenges in austere environments and has been adopted in over 80 countries to bridge the gap between prehospital stabilization and hospital handover. Similarly, International Trauma Life Support (ITLS) offers a practical, team-oriented alternative for prehospital providers, with a flexible structure that includes 1-day courses for first responders and a global emphasis on high-threat scenarios, differing from ATLS by prioritizing immediate life-saving interventions over comprehensive diagnostic evaluations.^[76]^[77]^[78] The 11th edition of ATLS, launched in 2025, enhances its adaptability over earlier U.S.-centric versions through contributions from more than 200 experts across over 20 countries, incorporating diverse perspectives on trauma systems, disaster response, and resource-limited settings to reduce outcome variances globally. Early feedback from 2025 pilot courses highlights improved training efficacy and hands-on skills.^[2]^[32] This international input refines protocols like the xABCDE algorithm for broader applicability, with evidence suggesting improved standardization and reduced mortality in adapted implementations compared to region-specific guidelines that lack such collaborative revisions.

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