21.1 Major Trauma Resuscitation & Initial Assessment

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

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3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

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4 Chapter 4: Lifestyle Counseling & Behavior Change

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5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

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6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

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10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

21.1 Major Trauma Resuscitation & Initial Assessment

Key Takeaways Explain This Topic AI

The ATLS 10th Edition Primary Survey standardizes major trauma stabilization via the ABCDE hierarchy (Airway with cervical spine protection, Breathing and ventilation, Circulation with hemorrhage control, Disability, Exposure/Environmental control); thoracic life threats must be decompressed immediately before moving to circulation.

Tension pneumothorax is a hyper-acute, purely clinical diagnosis requiring immediate needle decompression (large-bore 14- or 16-gauge catheter ≥3.25 inches in the 5th intercostal space anterior axillary line or 2nd intercostal space midclavicular line) or finger thoracostomy followed by tube thoracostomy; delaying decompression for a confirmatory chest radiograph in an unstable patient is fatal.

Damage control resuscitation prioritizes permissive hypotension (target SBP 80–90 mmHg or MAP 50–60 mmHg) until definitive surgical or angiographic hemostasis is achieved to avoid 'popping the clot' and diluting clotting factors; traumatic brain injury (TBI) is the absolute exception, mandating target SBP ≥100–110 mmHg to maintain cerebral perfusion pressure (CPP ≥60 mmHg).

In severe hemorrhagic shock, the Massive Transfusion Protocol (MTP) delivers balanced blood component resuscitation in a 1:1:1 ratio (PRBCs, FFP, platelets); tranexamic acid (TXA: 1 g IV bolus over 10 min followed by 1 g IV infusion over 8 hours) significantly reduces exsanguination mortality when administered within 3 hours of injury, but administration initiated beyond 3 hours increases mortality.

The lethal triad of trauma—hypothermia (<35°C), metabolic lactic acidosis, and severe coagulopathy—drives fatal exsanguination; bedside Extended Focused Assessment with Sonography for Trauma (E-FAST) evaluates 4 peritoneal/pericardial windows plus bilateral anterior thoracic lung sliding, where free fluid in a hemodynamically unstable patient mandates immediate emergent exploratory laparotomy.

Last updated: September 2026

Advanced Trauma Life Support (ATLS 10th Edition) Principles

Trauma remains the leading cause of mortality in individuals under 45 years of age and the fourth leading cause of death overall in North America. The management of major trauma is grounded in the trimodal distribution of trauma mortality , which dictates clinical priorities and resuscitation timing:

First Peak (Immediate Deaths; Seconds to Minutes) : Caused by catastrophic neurological or vascular destruction (brainstem laceration, high cervical cord transection, thoracic aortic dissection/rupture, cardiac rupture). These injuries are rarely salvageable in the hospital setting and are addressed primarily through public health prevention and vehicle safety design.

Second Peak (Early Deaths; Minutes to Several Hours) : The traditional "Golden Hour" of trauma medicine. Fatalities during this window are caused by life-threatening thoracic and abdominal crises (tension pneumothorax, massive hemothorax, cardiac tamponade, subdural or epidural hematomas, ruptured spleen or liver, unstable open-book pelvic ring fractures) and severe exsanguinating hemorrhagic shock. This stage represents the primary target of the ATLS Primary Survey and damage control resuscitation.

Third Peak (Late Deaths; Days to Weeks Post-Injury) : Resulting from severe systemic sepsis, multi-organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and refractory intracranial hypertension. The incidence and severity of third-peak mortality are directly linked to the quality and timeliness of resuscitation delivered during the second peak.

The Primary Survey: The ABCDE Hierarchy

The Primary Survey is executed in a strict, unwavering hierarchical sequence ( A-B-C-D-E ) designed to detect and treat the most immediately lethal physiological derangements first. Resuscitation occurs simultaneously with diagnosis: clinicians must never progress to the next letter in the sequence until the preceding life-threatening condition has been identified and addressed . THE ATLS PRIMARY SURVEY HIERARCHY

• ┌────────────────────────────────────────────────────────────────────────────────────────┐
• │ A: AIRWAY WITH CERVICAL SPINE PROTECTION │
• │ • Manual in-line stabilization or rigid collar • Clear oral cavity • RSI if GCS ≤8 │
• └───────────────────────────────────────────┬────────────────────────────────────────────┘
• │ Patency secured
• ▼
• ┌────────────────────────────────────────────────────────────────────────────────────────┐
• │ B: BREATHING & VENTILATION (ELIMINATE THORACIC LIFE THREATS) │
• │ • Tension Pneumothorax (Decompress) • Massive Hemothorax (Chest tube 28-32 Fr) │
• │ • Open Pneumothorax (3-sided dressing) • Flail Chest (Analgesia, toilet, PPV) │
• └───────────────────────────────────────────┬────────────────────────────────────────────┘
• │ Thoracic life threats eliminated
• ▼
• ┌────────────────────────────────────────────────────────────────────────────────────────┐
• │ C: CIRCULATION & HEMORRHAGE CONTROL │
• │ • Direct pressure & tourniquets • Pelvic binder over greater trochanters │
• │ • Two large-bore 16G IVs or IO • Permissive hypotension (SBP 80-90) │
• │ • 1:1:1 Balanced MTP (PRBC:FFP:Plt) • TXA 1g bolus within 3 hours of injury │
• └───────────────────────────────────────────┬────────────────────────────────────────────┘
• │ Hemorrhage managed & access established
• ▼
• ┌────────────────────────────────────────────────────────────────────────────────────────┐
• │ D: DISABILITY (RAPID NEUROLOGICAL ASSESSMENT) │
• │ • Glasgow Coma Scale (GCS 3-15) • Pupillary symmetry & reactivity • Lateralizing signs │
• └───────────────────────────────────────────┬────────────────────────────────────────────┘
• │ Baseline neurology recorded
• ▼
• ┌────────────────────────────────────────────────────────────────────────────────────────┐
• │ E: EXPOSURE & ENVIRONMENTAL CONTROL │
• │ • Undress completely • Full skin inspection & log roll • Prevent Lethal Triad (Warming)│
• └────────────────────────────────────────────────────────────────────────────────────────┘
• A — Airway with Cervical Spine Protection

Airway compromise kills faster than breathing failure, which kills faster than circulatory exsanguination. Airway assessment begins by asking the patient a simple question (e.g., "What is your name?"). A clear, coherent verbal response confirms airway patency, intact cerebral perfusion, and reasonable ventilatory mechanics. Stridor, gargling, dysphonia, or tachypneic grunting signals impending loss of patency.

Cervical Spine Immobilization

In any blunt trauma mechanism (motor vehicle collision, fall, bicycle crash, direct head impact), the cervical spine must be assumed unstable until cleared clinically or radiographically.

Maintain continuous manual in-line stabilization (MILS) during all airway maneuvers. When using an active rigid cervical collar, the anterior collar piece is detached while an assistant holds the patient's head, mastoid processes, and occiput rigidly neutral without axial traction.

Indications for Definitive Airway (Endotracheal Intubation)

Severe Neurologic Depression : Glasgow Coma Scale (GCS) score ≤ 8 \le 8 ≤ 8 ("GCS of eight, intubate").

Mechanical Airway Obstruction : Expanding neck hematoma, massive maxillofacial smash injuries, retropharyngeal edema, or foreign body aspiration.

Impending Airway Compromise : Inhalation injury with facial burns, singed nasal vibrissae, or laryngeal stridor.

Ventilatory Failure : Severe refractory hypoxemia ( P a O 2 < 60 mmHg PaO_2 < 60\text{ mmHg} P a O 2 ​ < 60 mmHg despite high-flow oxygen), hypercapnic exhaustion, or severe chest wall disruption.

Controlled Resuscitation : Combative, severely agitated trauma patients requiring emergency CT scanning or urgent operative damage control.

Rapid Sequence Intubation (RSI) in Trauma

Pre-oxygenation : Deliver 100 % O 2 100\%\text{ }O_2 100% O 2 ​ via non-rebreather mask or bag-valve-mask (avoiding vigorous positive-pressure bagging to prevent gastric insufflation and passive regurgitation).

Induction Agent : Etomidate ( 0.3 mg/kg 0.3\text{ mg/kg} 0.3 mg/kg IV) is the standard induction agent due to its hemodynamically neutral profile (minimal myocardial depression, no peripheral vasodilation). Ketamine ( 1.5 to 2.0 mg/kg 1.5\text{ to }2.0\text{ mg/kg} 1.5 to 2.0 mg/kg IV) is an excellent alternative in profound hemorrhagic shock, as it preserves sympathetic vascular tone and provides intrinsic bronchodilation.

Neuromuscular Blocker : Succinylcholine ( 1.5 mg/kg 1.5\text{ mg/kg} 1.5 mg/kg IV) delivers rapid paralysis within 45 to 60 seconds with short duration (6–10 min). Caution : Contraindicated in denervating neurological injuries > 48 hours >48\text{ hours} > 48 hours old, major crush injury > 48 hours >48\text{ hours} > 48 hours old, preexisting severe hyperkalemia, or personal/family history of malignant hyperthermia. In these settings, use Rocuronium ( 1.2 mg/kg 1.2\text{ mg/kg} 1.2 mg/kg IV) .

Definitive Surgical Airway (Cricothyroidotomy) : When orotracheal intubation fails in a "cannot intubate, cannot oxygenate" (CICO) scenario, emergency surgical cricothyroidotomy via the scalpel-bougie-tube technique is mandatory through the cricothyroid membrane. Pediatric Rule : In children younger than 8 to 12 years, the cricoid cartilage is the narrowest, most fragile part of the airway; surgical cricothyroidotomy risks permanent subglottic stenosis. Perform needle cricothyroidotomy with trans-tracheal jet insufflation (12- to 14-gauge catheter) as a temporary bridge.

B — Breathing and Ventilation: Immediate Thoracic Life Threats

Once an airway is secured, the clinician exposes the chest, inspects respiratory excursion, palpates for flail segments or subcutaneous crepitus, auscultates breath sounds bilaterally, and percusses the hemithoraces. Four thoracic life threats must be identified and decompressed immediately:

1. Tension Pneumothorax

Pathophysiology : A one-way "ball-valve" laceration in the visceral or parietal pleura permits air entry into the pleural space during inspiration but prevents exit during expiration. Intrapleural pressure escalates above atmospheric and central venous pressures, causing complete collapse of the ipsilateral lung, shifting the mediastinum and trachea away from the affected side, and angulating/compressing the superior and inferior vena cava. Venous return (preload) to the right atrium drops precipitously, producing severe obstructive shock and rapid progression to pulseless electrical activity (PEA) arrest.

Cardinal Signs : Severe dyspnea, tachypnea, extreme cyanosis, profound hypotension, tachycardia, unilaterally absent or diminished breath sounds, hyperresonance to percussion , ipsilateral flattened chest excursion, distended jugular veins (JVD), and contralateral tracheal deviation (a late, pre-terminal sign).

Mandatory Procedural Action :

Tension pneumothorax is a PURELY CLINICAL DIAGNOSIS. Clinicians must NEVER order or await a chest radiograph in an unstable patient with clinical signs of tension pneumothorax.

Immediate Needle Thoracostomy (Needle Decompression) : Insert a large-bore ( 14- or 16-gauge ) angiocatheter with a length of at least 3.25 inches (8 cm) . (Standard 1.75-inch catheters fail to penetrate the thoracic pleural space in > 50 % >50\% > 50% of adults due to chest wall and pectoralis thickness).

Anatomical Sites (ATLS 10th Edition) :

Primary Preferred Site : 5th intercostal space at or just anterior to the anterior axillary line (the safe triangle). This site features thinner chest musculature and a higher procedural success rate than traditional anterior approaches.

Alternative Site : 2nd intercostal space in the midclavicular line , inserting the needle just superior to the 3rd rib to avoid the neurovascular bundle (intercostal vein, artery, and nerve) traveling along the inferior rib border.

Finger Thoracostomy (Mini-Thoracostomy) : In mechanically ventilated or morbidly obese patients, emergency finger thoracostomy at the 5th intercostal space anterior axillary line reliably decompresses tension physiology.

Immediate Follow-Up : Needle or finger decompression must be immediately followed by formal tube thoracostomy (28 to 32 French chest tube) connected to underwater seal suction ( − 20 cm H 2 O -20\text{ cm }H_2O − 20 cm H 2 ​ O ).

2. Massive Hemothorax

Pathophysiology : Accumulation of > 1 , 500 mL >1,500\text{ mL} > 1 , 500 mL of blood (or > 200 mL/hour >200\text{ mL/hour} > 200 mL/hour over 2 to 4 hours) in the pleural space, most commonly from laceration of systemic thoracic arteries (internal mammary or intercostal arteries) or major hilar vessels.

Clinical Presentation : Profound hemorrhagic shock, unilateral absent breath sounds, dullness to percussion on the affected hemithorax, and collapsed/flat neck veins (hypovolemia).

Emergency Management :

Rapid placement of a large-bore chest tube ( 28 to 32 French ) placed at the 5th intercostal space anterior axillary line directed posteriorly and superiorly.

Immediate initiation of balanced component blood resuscitation via Massive Transfusion Protocol (MTP), utilizing an autotransfusion system to re-infuse evacuated shed pleural blood.

Indications for Emergent Operative Thoracotomy :

Immediate initial chest tube drainage of ≥ 1 , 500 mL \ge 1,500\text{ mL} ≥ 1 , 500 mL of blood upon placement;

Ongoing, active chest tube output of ≥ 200 mL/hour \ge 200\text{ mL/hour} ≥ 200 mL/hour for 2 to 4 consecutive hours ;

Persistent, refractory hemodynamic instability despite aggressive balanced blood resuscitation.

3. Open Pneumothorax ("Sucking Chest Wound")

Pathophysiology : A full-thickness traumatic chest wall defect whose diameter exceeds two-thirds the diameter of the trachea. Air preferentially enters the pleural space through the thoracic wall defect (path of least resistance) rather than through the trachea, causing immediate lung collapse and profound ventilatory insufficiency.

Immediate Procedural Action : Apply a sterile occlusive dressing (petrolatum gauze) taped securely on THREE SIDES . This creates a temporary flutter-valve mechanism: during expiration, intrapleural pressure rises and drives air out through the untaped fourth side; during inspiration, negative intrathoracic pressure sucks the dressing flat against the skin, preventing atmospheric air ingress. Never tape all four sides without a chest tube in place , as this converts an open pneumothorax into a fatal tension pneumothorax. Place a formal tube thoracostomy through a separate, remote incision.

4. Flail Chest & Severe Pulmonary Contusion

Pathophysiology : Occurs when ≥ 2 \ge 2 ≥ 2 contiguous ribs are fractured in ≥ 2 \ge 2 ≥ 2 separate locations , creating a free-floating chest wall segment that uncouples from the thoracic cage and displays paradoxical motion (sucked inward during inspiration; pushed outward during expiration). However, the primary cause of life-threatening hypoxemia is not the paradoxical motion itself, but the underlying severe pulmonary contusion (alveolar hemorrhage, microvascular disruption, surfactant loss, and non-cardiogenic consolidation).

Management : Aggressive multimodal analgesia (thoracic epidural analgesia, paravertebral nerve block, patient-controlled IV opioids) to prevent splinting and hypoventilation, dedicated pulmonary toilet, and humidified supplemental oxygen. Judicious fluid administration prevents worsening interstitial contusion edema. Endotracheal intubation with positive-pressure mechanical ventilation is reserved for severe hypoxemia refractory to oxygenation, progressive hypercapnic fatigue, or severe shock.

Diagnostic Differentiation of Thoracic Life Threats

Thoracic Emergency Breath Sounds Percussion Note Tracheal Deviation Jugular Veins Cardinal Immediate Procedure

Tension Pneumothorax Absent unilaterally Hyperresonant Deviated away Distended (JVD) Immediate needle decompression (5th ICS AAL or 2nd ICS MCL) → \rightarrow → Tube thoracostomy

Massive Hemothorax Absent unilaterally Dull / Stony Midline or away Flat / Collapsed Large-bore tube thoracostomy (28–32 Fr) + balanced blood resuscitation → \rightarrow → OR if ≥ 1 , 500 mL \ge 1,500\text{ mL} ≥ 1 , 500 mL

Cardiac Tamponade Clear bilaterally Normal Midline Distended (Beck triad) Bedside E-FAST → \rightarrow → Pericardiocentesis or emergent operating room thoracotomy

Open Pneumothorax Diminished unilaterally Hyperresonant Midline or away Variable Three-sided flutter valve dressing → \rightarrow → Chest tube through separate site

Flail Chest Decreased over segment Normal / Dull Midline Normal / Flat Multimodal analgesia + pulmonary toilet; intubation if refractory hypoxemic failure

C — Circulation with Hemorrhage Control

Hemorrhage is the leading cause of preventable death in major trauma. Resuscitation focuses on rapid external hemostasis, pelvic stabilization, vascular access, and modern damage control resuscitation.

External Hemorrhage Control & Pelvic Ring Stabilization

Direct External Hemorrhage : Apply firm, continuous manual pressure directly over bleeding lacerations. For catastrophic extremity hemorrhage unresponsive to pressure, apply a commercial extremity tourniquet (Combat Application Tourniquet [CAT]) 2 to 3 inches proximal to the injury site (or "high and tight" on the limb). Tighten the windlass until active arterial bleeding and distal pulses cease. Document the exact application time; tourniquets can remain safely in place for up to 2 hours without irreversible ischemic nerve or muscle damage.

Suspected Pelvic Ring Disruption ("Open-Book" Fracture) : Anteroposterior compression injuries disrupt the pubic symphysis (diastasis > 2.5 cm >2.5\text{ cm} > 2.5 cm ) and tear the posterior sacroiliac venous plexus and internal iliac arterial branches, creating an expandable retroperitoneal space capable of harboring 3 to 4 liters of blood. Clinicians must apply a commercial pelvic binder or tightly folded bedsheet wrapped circumferentially and centered strictly over the GREATER TROCHANTERS of the femurs (NOT over the iliac crests). Clinical Red Flag : Do NOT perform repeated manual "pelvic rocking" or compressive testing of an unstable pelvis, as this shears fragile retroperitoneal venous clots and triggers fatal re-bleeding. PELVIC BINDER PLACEMENT: CRITICAL ANATOMICAL LANDMARK

Incorrect (Iliac Crests): CORRECT (Greater Trochanters):

• ┌────────────────────────┐ ┌────────────────────────┐
• │ [ Iliac Crests ] X │ ◄─ WRONG │ [ Iliac Crests ] │
• │ │ │ (Fails to │ │ │
• │ [ Pelvic Cavity ] │ reduce │ [ Pelvic Cavity ] │
• │ │ │ volume) │ │ │
• │ [ Greater Trochanters] │ │ [Greater Trochanters]◄─┼── ACCURATE (Closes the
• └────────────────────────┘ └────────────────────────┘ pelvic volume & tamponades
• retroperitoneal venous plexus)
• Vascular Access

Rapidly place two large-bore peripheral IV catheters (16- or 14-gauge) in the upper extremities (antecubital veins).

If peripheral venous access cannot be obtained within 90 seconds in a patient with profound shock, immediately establish intraosseous (IO) access . The primary anatomical site is the proximal anteromedial tibia (approximately 2 cm 2\text{ cm} 2 cm distal and 1 to 2 cm 1\text{ to }2\text{ cm} 1 to 2 cm medial to the tibial tuberosity on the flat bony surface). The humeral head is an excellent alternative site in adults, delivering flow rates comparable to central venous lines.

Damage Control Resuscitation (DCR) & Permissive Hypotension

The Pitfall of Crystalloid Over-Resuscitation : Historical protocols infusing 2 to 3 liters of cold normal saline or Ringer's lactate dilute clotting factors, strip the endothelial glycocalyx, produce hypothermia, worsen metabolic acidosis, and mechanically dislodge early fragile platelet plugs.

Permissive Hypotension (Controlled Resuscitation) : In actively bleeding trauma patients without head injury, clinicians deliberately restrict fluid administration, targeting a Systolic Blood Pressure (SBP) of 80 to 90 mmHg (Mean Arterial Pressure [MAP] 50 to 60 mmHg) until definitive surgical or angiographic hemostasis is achieved. This maintains sufficient vital organ perfusion while preventing the catastrophic dislodgement of hemostatic thrombi ("popping the clot").

The Critical Traumatic Brain Injury (TBI) Exception :

In patients with confirmed or suspected TBI ( G C S ≤ 8 GCS \le 8 GCS ≤ 8 or intracranial mass lesion), permissive hypotension is STRICTLY CONTRAINDICATED .

Injured brain parenchyma loses auto-regulatory vascular tone; cerebral blood flow becomes directly dependent on Mean Arterial Pressure ( C P P = M A P − I C P CPP = MAP - ICP CPP = M A P − I CP ). Even a single transient episode of hypotension ( S B P < 90 mmHg SBP < 90\text{ mmHg} SBP < 90 mmHg ) doubles mortality in severe TBI.

Target Hemodynamics in TBI : Maintain S B P ≥ 100 mmHg SBP \ge 100\text{ mmHg} SBP ≥ 100 mmHg (in patients aged 50–69 years) or ≥ 110 mmHg \ge 110\text{ mmHg} ≥ 110 mmHg (in patients aged 15–49 or ≥ 70 \ge 70 ≥ 70 years) to preserve a Cerebral Perfusion Pressure (CPP) of at least 60 to 70 mmHg .

Massive Transfusion Protocol (MTP): The PROPPR Trial

When a trauma patient presents with severe hemorrhagic shock (Assessment of Blood Consumption [ABC] score ≥ 2 \ge 2 ≥ 2 : penetrating mechanism, positive FAST, S B P ≤ 90 mmHg SBP \le 90\text{ mmHg} SBP ≤ 90 mmHg , H R ≥ 120 bpm HR \ge 120\text{ bpm} H R ≥ 120 bpm ), activate the Massive Transfusion Protocol immediately:

Balanced Component Ratio (1:1:1) : Deliver uncrossed blood components in a strict 1:1:1 ratio : 1 unit of Packed Red Blood Cells (PRBCs) : 1 unit of Fresh Frozen Plasma (FFP) : 1 unit of Platelets (typically dispensed as 6 units PRBCs, 6 units FFP, and 1 apheresis platelet pack).

Evidence (PROPPR Trial) : The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial demonstrated that resuscitation with a 1:1:1 ratio significantly reduced 24-hour exsanguination mortality and achieved anatomical hemostasis faster than an unbalanced 1:1:2 ratio.

Adjunctive Hemostatic Targets :

Fibrinogen Replacement : Cryoprecipitate (10 to 20 units) or fibrinogen concentrate, targeting a serum fibrinogen level > 150 to 200 mg/dL > 150\text{ to }200\text{ mg/dL} > 150 to 200 mg/dL .

Ionized Calcium : Citrate preservative in stored blood products chelates free calcium, impairing cardiac contractility and clotting cascade complexes. Monitor ionized calcium ( i C a iCa i C a ) frequently and administer 1 to 2 g 1\text{ to }2\text{ g} 1 to 2 g IV Calcium Gluconate (or Calcium Chloride) for every 4 units of blood products, maintaining i C a > 1.0 mmol/L iCa > 1.0\text{ mmol/L} i C a > 1.0 mmol/L .

Tranexamic Acid (TXA): The CRASH-2 Trial

Mechanism : Synthetic lysine analog that competitively inhibits plasminogen activation to plasmin, halting fibrin clot breakdown and stabilizing newly formed hemostatic seals.

Dosing Protocol : 1 g 1\text{ g} 1 g IV bolus administered over 10 minutes , followed immediately by an intravenous infusion of 1 g 1\text{ g} 1 g over the subsequent 8 hours .

The Strict 3-Hour Window (CRASH-2 Mandate) :

TXA MUST BE ADMINISTERED WITHIN 3 HOURS OF INJURY .

When given within 1 hour, TXA reduces all-cause trauma mortality by > 30 % >30\% > 30% ; between 1 and 3 hours, it delivers significant survival benefit.

administration beyond 3 hours post-injury Paradoxically INCREASES mortality (due to late hypercoagulability, microvascular thrombosis, and inflammatory shut-off) and is strictly contraindicated.

The Lethal Triad of Trauma

The primary physiological endpoint of modern damage control resuscitation is disrupting the self-propagating "Lethal Triad" :

Hypothermia ( < 35.0 ∘ C < 35.0^\circ\text{C} < 35. 0 ∘ C ) : Dramatically inhibits the enzymatic reaction kinetics of the coagulation cascade; clotting factor activity decreases by ∼ 10 % \sim 10\% ∼ 10% for every 1.0 ∘ C 1.0^\circ\text{C} 1. 0 ∘ C drop in core body temperature.

Metabolic Lactic Acidosis ( p H < 7.20 pH < 7.20 p H < 7.20 , Base Deficit > − 6 mEq/L > -6\text{ mEq/L} > − 6 mEq/L ) : Caused by anaerobic cellular metabolism during tissue hypoperfusion; directly suppresses myocardial contractility, impairs vascular catecholamine responsiveness, and halts factor complex assembly.

Severe Coagulopathy : Triggered by consumption of clotting factors, hypothermia, acidemic enzyme inhibition, and hyperfibrinolysis.

Extended Focused Assessment with Sonography for Trauma (E-FAST)

The E-FAST is a bedside point-of-care ultrasound (POCUS) examination performed during the Primary Survey to rapidly identify pathologic fluid collections (hemoperitoneum, hemothorax, hemopericardium) and pneumothorax in under 3 minutes.

The Six Sonographic Windows

Right Upper Quadrant (Morison's Pouch / Hepatorenal Recess) :

Probe placed at the 8th to 11th intercostal space, mid-to-posterior axillary line.

The most sensitive dependent abdominal space for free intraperitoneal blood in the supine patient. Pathologic fluid collects as an anechoic (black) stripe between the liver and right kidney, or along the inferior liver tip.

Left Upper Quadrant (Splenorenal Recess & Subphrenic Space) :

Probe placed at the 6th to 9th intercostal space, posterior axillary line.

Identifies free fluid between the spleen and left kidney, or in the subphrenic space above the spleen.

Pelvic Window (Suprapubic / Rectovesical or Rectouterine Pouch) :

Transverse and sagittal views angled postero-inferiorly behind the pubic symphysis.

Evaluates the rectovesical pouch in males and the rectouterine pouch of Douglas in females. (An empty or catheterized bladder limits acoustic visualization).

Pericardial Window (Subxiphoid / Subcostal View) :

Transducer placed flat in the subxiphoid region, pointing toward the left shoulder, using the left lobe of the liver as an acoustic window.

Identifies anechoic fluid separating the fibrous pericardium from the myocardium. Demonstrates right ventricular diastolic collapse in cardiac tamponade .

& 6. Bilateral Anterior Thoracic Windows (Pleural / Lung Evaluation) :

High-frequency linear probe placed longitudinally across the 2nd to 4th intercostal spaces at the midclavicular lines.

Normal Lung : Displays shimmering, glistening horizontal "lung sliding" ("ants marching on a log") where visceral pleura glides over parietal pleura during respiration, accompanied by vertical reverberation comet-tail artifacts ( B-lines ). On M-mode, normal lung creates the "Seashore Sign" (linear motionless chest wall above; granular beach-like lung below).

Pneumothorax : Shows complete absence of lung sliding and absence of B-lines (presence of B-lines 100% excludes pneumothorax at that probe position). On M-mode, absent sliding displays the "Stratosphere / Barcode Sign" (uniform parallel horizontal lines across the entire display).

The Lung Point : The pathognomonic transition point where normal sliding lung intermittently alternates with absent sliding; possesses 100 % 100\% 100% specificity for pneumothorax, defining its exact anatomical boundary. THE E-FAST CLINICAL TRIAGE DECISION TREE

• Blunt Trauma Patient in Bay
• │
• Perform E-FAST
• │
• ┌──────────────────────┴──────────────────────┐
• ▼ ▼
• HEMODYNAMICALLY UNSTABLE HEMODYNAMICALLY STABLE
• (SBP <90 mmHg) (SBP ≥90 mmHg)
• │ │
• ┌──────────┴──────────┐ ┌──────────┴──────────┐
• ▼ ▼ ▼ ▼
• POSITIVE FAST NEGATIVE FAST POSITIVE FAST NEGATIVE FAST
• (Free fluid RUQ/ (No peritoneal (Free fluid seen, (No fluid or PTX)
• LUQ / Pelvis) fluid seen) patient stable) │
• │ │ │ ▼
• ▼ ▼ ▼ Selective Imaging /
• IMMEDIATE TO Search for extra- CONTRAST-ENHANCED Serial Abdominal
• OPERATING ROOM abdominal bleeding: CT ABDOMEN/PELVIS Exams in Bay
• FOR EXPLORATORY • Unstable Pelvis? (Grade solid organ
• LAPAROTOMY (Apply binder) injury, extravasation)

• Thoracic Hemorrhage?

• Retroperitoneal CT
• D — Disability (Neurological Evaluation)

Glasgow Coma Scale (GCS) : Standardized quantification of neurologic function:

Eye Opening (1 to 4) : 4 = Spontaneous; 3 = To verbal command; 2 = To pain; 1 = None.

Verbal Response (1 to 5) : 5 = Oriented; 4 = Confused; 3 = Inappropriate words; 2 = Incomprehensible sounds; 1 = None.

Motor Response (1 to 6) : 6 = Obeys commands; 5 = Localizes pain; 4 = Withdraws from pain; 3 = Abnormal flexion (decorticate); 2 = Abnormal extension (decerebrate); 1 = None.

Severity Stratification : Severe TBI = GCS 3–8; Moderate TBI = GCS 9–12; Mild TBI = GCS 13–15.

Pupillary Examination : Inspect baseline pupil size, symmetry, and light response. An acute unilateral dilated, non-reactive pupil ("blown pupil") indicates transtentorial uncal herniation compressing the ipsilateral oculomotor nerve (CN III), demanding immediate neurosurgical decompression and hyperosmolar therapy (hypertonic saline 3 % 3\% 3% or mannitol).

E — Exposure & Environmental Control

Complete Exposure : Remove all clothing with shears to visualize every square centimeter of the body. Missed posterior puncture wounds, axillary stab lacerations, perineal tears, and open extremity fractures occur when clothing is left partially attached.

Log Roll & Spine Palpation : With the cervical spine rigidly maintained in neutral alignment by a designated team member at the head of the bed, a 4-person coordinated log roll is executed. Palpate the entire length of the spinous processes for step-offs, focal midline tenderness, or boggy hematomas. Inspect the gluteal fold, perineum, and back.

Aggressive Hypothermia Prevention : Once exposure is complete, immediately apply pre-warmed blankets and forced-air warming devices (Bair Hugger), warm all infused intravenous fluids and blood components to 39.0 ∘ C to 42.0 ∘ C 39.0^\circ\text{C to }42.0^\circ\text{C} 39. 0 ∘ C to 42. 0 ∘ C via high-flow fluid warmers, and keep the trauma bay ambient temperature elevated ( ≥ 26.0 ∘ C \ge 26.0^\circ\text{C} ≥ 26. 0 ∘ C ).

The Secondary Survey & Radiographic Trauma Series

The Secondary Survey is initiated ONLY AFTER the Primary Survey has been fully executed, ABCDE life threats eliminated, and hemodynamic resuscitation actively established .

• The AMPLE History
• A : Allergies
• M : Medications (especially anticoagulants: DOACs, warfarin, antiplatelet agents)

P : Past medical history & Pregnancy status (all reproductive-age females require rapid urine/serum β \beta β -hCG)

• L : Last meal (time of last oral intake)
• E : Events & Environment preceding the traumatic injury
• Physical Examination & Trauma Series Imaging

Systematic Head-to-Toe Examination : Scalp lacerations, hemotympanum, Battle sign (mastoid ecchymosis), raccoon eyes (periorbital ecchymosis), facial bone stability, stability of the pelvis and all four extremities, distal pulses, and rectal exam (assessing rectal sphincter tone, mucosal integrity, and gross blood).

Essential Plain Radiographs in Trauma Bay :

Portable Anteroposterior (AP) Chest Radiograph : Screen for pneumothorax, hemothorax, mediastinal widening, and endotracheal tube depth.

Portable AP Pelvis Radiograph : Detects pelvic ring disruptions, sacroiliac joint widening, and acetabular fractures.

Definitive Diagnostic Imaging (Pan-Scan CT) : In stable patients, high-resolution contrast-enhanced computed tomography (Non-contrast Head CT, Cervical Spine CT with sagittal/coronal reformats, and IV Contrast-Enhanced Chest, Abdomen, and Pelvis CT) represents the gold standard diagnostic series.

Loading diagram... ATLS Major Trauma Resuscitation & Damage Control Algorithm