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Initial assessment of the trauma patient (ATLS primary survey)
The primary survey treats what kills first, in order — catastrophic external bleeding, the airway while guarding the neck, breathing, circulation, neurological status and exposure — and fixes each problem as soon as it is found, before moving on.
Why it matters in the exam
Trauma questions in the exam are almost always questions of priority: what to do first in a patient who arrives after a crash with several injuries at once. The correct answer is the step that treats the immediate threat in ABCDE order, not the most sophisticated test: airway before a chest X-ray, needle decompression for suspected tension pneumothorax before any imaging, and haemorrhage control before CT. Current trauma practice places control of catastrophic external bleeding (tourniquet, direct pressure) before all of these.
Candidates are also asked about the adjuncts to the primary survey — FAST, chest and pelvic X-rays, urinary catheter and gastric tube — and their limits: no urinary catheter when there is blood at the urethral meatus, and no nasal gastric tube when a skull-base fracture is suspected. A recurring topic is the decision on a definitive airway (GCS of 8 or less, inability to protect the airway, airway burns), and the difference between the primary survey and the secondary survey — a focused history and a head-to-toe examination that begin only once the patient is stable.
Key points
- The order: x (external bleeding) → A → B → C → D → E; fix each problem as you find it.
- GCS 8 or less — definitive airway.
- Tension pneumothorax — immediate needle decompression then a drain, no X-ray.
- Shock in trauma is bleeding until proven otherwise; FAST, chest X-ray and pelvic X-ray find the source.
- Tranexamic acid within 3 hours of injury; warm the patient and prevent hypothermia.
Summary table
| Step | What to look for | Immediate action |
|---|---|---|
| x — catastrophic external bleeding | Arterial bleeding from a wound | Direct pressure, tourniquet |
| A — airway with cervical spine protection | Speech, stridor, foreign body, facial and neck injury | Jaw thrust, suction, intubation when GCS 8 or less; cricothyroidotomy when there is no other way |
| B — breathing | Tension pneumothorax, open pneumothorax, massive haemothorax, flail chest | Needle decompression then a chest drain; three-sided dressing; chest drain |
| C — circulation | Shock, internal bleeding (chest, abdomen, pelvis, long bones), FAST | Two large-bore cannulas, early blood, pelvic binder, tranexamic acid within 3 hours |
| D — disability | GCS, pupils, lateralising signs | Prevent hypoxia and hypotension; head CT once stable |
| E — exposure and environment | Hidden injuries, hypothermia | Full exposure then warming — blankets and warmed fluids |
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Sources
- ATLS Advanced Trauma Life Support, Student Course Manual (American College of Surgeons), 10th edition (2018) — Initial Assessment and Management
- Sabiston Textbook of Surgery, 21st edition (2022) — Management of Acute Trauma
- European guideline on management of major bleeding and coagulopathy following trauma, 6th edition (2023) — Initial resuscitation and prevention of further bleeding
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.