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Orthopaedic Emergencies

ATLS / Major Trauma — Introduction

The origins of ATLS
The story behind ATLS
Origin of ATLS
Why ATLS exists

ATLS was created to standardise the first hour of trauma care — so any clinician, in any hospital, can deliver a safe, structured approach to immediately life-threatening problems.

Key timeline
  • February 1976: Dr James K. Styner crashed his plane in rural Nebraska. Noticing a worrying lack of emergency trauma training at the local hospital, he highlighted major variability and gaps in trauma care.
  • 1978: The first prototype ATLS course was delivered locally, turning the "what should we do first?" problem into a teachable system.
  • 1980: The American College of Surgeons (ACS) adopted and began wider dissemination of ATLS.
Take-home: ATLS is a shared language — prioritise threats, intervene early, reassess repeatedly.
🎯 Learning objectives
By the end of this module, you should be able to:
  • Explain the purpose and philosophy of ATLS.
  • Describe the primary survey using the ABCDE approach.
  • Recognise life-threatening injuries.
  • Understand the difference between primary and secondary survey.
  • Appreciate the importance of team roles and communication.
  • Apply ATLS principles to a trauma case.
⚠️ This module is not a substitute for the formal ATLS course delivered by the Royal College of Surgeons of England. It is designed as a brief overview and supplementary learning resource.
⚙️
ATLS · Major Trauma

Trauma Call Workflow at WSH

What happens from alert to primary survey
Alertive

Alertive critical alert

1. Trauma Alert Activated
A critical alert is sent on Alertive for adult or paediatric trauma call.
↓
2. Trauma Team Assembles
Team members attend the designated resus bay, introduce themselves, and prepare for arrival.
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3. Sign-in
Team members sign the trauma call booklet to confirm attendance.
↓
4. Patient Arrival & Handover
Patient transferred to resus trolley; paramedics deliver a structured handover.
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5. Primary Survey Begins
Trauma assessment proceeds immediately to the ABCDE primary survey.

The complete trauma assessment has 10 stages. Click each to expand:

1PreparationSet up team and environment before patient arrives.Expand ▾
Team readiness: roles allocated, PPE, resus bay prepared, airway/IV/monitoring equipment checked, trauma call activated.
2TriagePrioritise based on physiology, mechanism and severity.Expand ▾
Rapid prioritisation based on physiology, mechanism, and suspected severity to ensure the sickest patients are managed first.
3Primary SurveyIdentify and treat life-threatening problems (ABCDE).Expand ▾
Airway with C-spine, Breathing, Circulation/haemorrhage control, Disability, Exposure/temperature — identify and treat immediately life-threatening problems.
4ResuscitationTreat life threats while you assess.Expand ▾
Simultaneous treatment: oxygenation/ventilation, haemorrhage control, IV access, fluids/blood, warming, urgent interventions.
5Adjuncts to Primary SurveyTools that support diagnosis during ABCDE.Expand ▾
Monitoring, ECG, blood gas/lactate, bedside ultrasound (FAST/eFAST), portable imaging.
6Consider need for transferDecide early if higher-level care is needed.Expand ▾
Early decision on transfer to a higher-level trauma centre or specialist service based on injuries, physiology, and local capability.
7Secondary SurveyHead-to-toe assessment once stabilised.Expand ▾
Systematic head-to-toe assessment plus focused history (AMPLE) to identify additional injuries.
8Adjuncts to Secondary SurveyFurther tests guided by findings.Expand ▾
CT imaging, targeted X-rays, blood tests, and specialist input once stabilised.
9Monitoring & EvaluationReassess trends and response to treatment.Expand ▾
Ongoing reassessment of vital signs, response to interventions, urine output, pain, and trends (including repeat exams and imaging if needed).
10Transfer to Definitive CareGet to the right destination for definitive management.Expand ▾
Movement to the appropriate destination: theatre, IR, ICU/HDU, ward, or transfer to major trauma centre.
👥
ATLS · Major Trauma

The Trauma Team

Coordinated multidisciplinary care — DGH vs Major Trauma Centre
Trauma team
District General Hospital
Typical DGH Trauma Team
In a DGH, the trauma team will be smaller but may consist of any of the following:
👑 Team Leader
Coordinates priorities, decisions, and escalation.
🩺 ED Doctor
Primary survey, procedures, trauma assessment.
💉 ED Nurse(s)
Monitoring, access, drugs, bloods, documentation.
🫁 Anaesthetist / ITU
Airway support, RSI, ventilation, haemodynamic support.
🩸 General Surgery SpR/SHO
Abdominal trauma, haemorrhage concerns.
🦴 Orthopaedic SpR/SHO
Fractures, pelvic trauma, limb injuries.
🧸 Paediatrics
Paediatric trauma expertise where relevant.
🤰 Obstetrics
Required for pregnant trauma patients.
⚙️ ODP
Airway equipment, procedural support, theatre readiness.
🏃 Runner / Porter
Transfers, equipment, blood products, logistics.
Major Trauma Centre
Extended MTC Trauma Team
In an MTC, the core team is supplemented by on-site specialties for definitive trauma care.
🩸 Vascular Surgery
Major vascular injury and haemorrhage control.
❤️ Cardiothoracic Surgery
Major thoracic/cardiac injury, complex chest trauma.
✋ Plastic Surgery
Soft tissue injury, limb salvage, complex wounds.
🧠 Neurosurgery
Severe TBI, intracranial injury, spinal injury.
ABCDE
ATLS · Quick Reference

Primary Survey (ABCDE)

Identify and treat immediately life-threatening problems. Treat as you find. Re-check after every intervention.
Video
Primary Survey Demonstration
Demonstration of a structured ATLS primary survey (ABCDE approach)
Tap to expand each step:
AAirway with C-spine controlIs the airway patent? Protect the neck.Expand ▾
Goal: Prevent hypoxia and secondary spinal cord injury.

Assess: Speech, airway sounds (snoring/stridor/gurgling), facial trauma, vomit/blood, burns, swelling.
Act: Jaw thrust + suction, high-flow O₂, airway adjuncts (OPA/NPA if appropriate), manual in-line stabilisation, early anaesthetic input if concern.
BBreathing & VentilationIs oxygenation and ventilation adequate?Expand ▾
Goal: Prevent hypoxia and ventilatory failure.

Assess: RR, SpO₂, work of breathing, chest expansion, trachea, breath sounds, wounds/bruising.
Act: Oxygen, ventilatory support if needed, seal open pneumothorax, decompress suspected tension pneumothorax, analgesia for rib fractures.
CCirculation with Haemorrhage ControlStop bleeding first, then restore perfusion.Expand ▾
Goal: Prevent death from haemorrhagic shock.

Assess: Major external bleeding, pulse, BP, cap refill, skin temperature, likely internal sources (chest/abdomen/pelvis/long bones).
Act: Direct pressure/haemostatic dressing, tourniquet if indicated, pelvic binder if suspected, IV/IO access, bloods + group & save, activate major haemorrhage protocol early.
DDisability (Neurological)Rapid neuro check + reversible causes.Expand ▾
Goal: Identify brain injury and reversible causes of reduced consciousness.

Assess: GCS/AVPU, pupils, limb movement, glucose, lateralising signs.
Act: Correct hypoxia/hypotension, treat hypoglycaemia, manage seizures, maintain C-spine protection until cleared.
EExposure / Environmental ControlExpose to find injuries — prevent hypothermia.Expand ▾
Goal: Prevent missed injuries and hypothermia.

Assess: Fully expose (front/back when safe), look for hidden bleeding, deformity, penetrating injury.
Act: Warm blankets, warmed fluids, minimise exposure time, document temperature early.
Key principle: ABCDE is done in order. Do not move on if a life-threatening issue is identified. Intervene immediately and re-assess from the top.
A
ATLS · Primary Survey

Airway with C-spine Control

Airway first — obstruction → hypoxia → death within minutes. Manage while protecting the cervical spine.
Airway anatomy
Fast check: Talking in full sentences = airway patent. Stridor, gurgling, or silence = airway compromise.
C-spine rule: In trauma, assume cervical spine injury until proven otherwise. Airway assessment and C-spine protection should occur simultaneously by different team members.
Step 1
Assess the airway
  • Look: obstruction (blood, vomit, foreign body), facial trauma, burns, swelling.
  • Listen: talking? stridor? gurgling? silence?
  • Feel: airflow from mouth/nose; note chest movement.
Immediate threats — treat now:
  • Airway obstruction
  • Expanding neck haematoma
  • Significant facial trauma
  • Head injury with low GCS
  • Burns / inhalational injury
Facial trauma
Step 2
Actions & Common Adjuncts
  • Avoid head tilt where possible
  • Jaw thrust with manual in-line stabilisation
  • Suction and remove visible foreign bodies
  • Airway adjuncts
  • Endotracheal intubation if required
Common adjuncts
OPA
Oropharyngeal airway
NPA
Nasopharyngeal airway
LMA
Laryngeal mask airway
Tip: choose adjuncts based on consciousness level, gag reflex, and facial/base-of-skull injury suspicion.
Skills video
Application of a Cervical Collar
~2–3 min
Focus on: sizing, maintaining manual stabilisation throughout, confirming neutral alignment.
⚠️ Maintain C-spine immobilisation throughout. Airway interventions must be performed with cervical spine protection until injury is excluded.
B
ATLS · Primary Survey

Breathing and Ventilation

Once the airway is secure — ensure adequate oxygenation and ventilation.
Ventilation
Document:
  • Respiratory rate
  • Oxygen saturation
  • Amount of oxygen required
Step 1
Inspection
  • Chest asymmetry
  • Abnormal chest movement
  • Tracheal deviation
  • Reduced air entry
  • Signs of respiratory distress
Step 2
Palpation
  • Tracheal position
  • Surgical emphysema
  • Chest expansion
Step 3
Percussion and Auscultation
These help identify underlying pathology such as pneumothorax or haemothorax.
Immediately life-threatening chest injuries:
  • Tension pneumothorax
  • Massive haemothorax
  • Open pneumothorax
  • Flail chest
⚠️ Suspected tension pneumothorax is a clinical diagnosis. We do not wait for imaging. Immediate decompression may be lifesaving.
Tension Pneumothorax
Tension Pneumothorax: one-way valve — air fills pleural cavity and can't escape.
Chest drain
Chest Drain: used for pneumothorax/haemothorax once stabilised.
Flail chest
Flail Chest: 3+ consecutive ribs fractured in 2 places — paradoxical movement.
C
ATLS · Primary Survey

Circulation & Haemorrhage Control

Shock is haemorrhage until proven otherwise. Control bleeding first, restore perfusion second.
Blood transfusion
Document: Heart rate · Blood Pressure · Capillary refill time (central & peripheral)
Recognise shock early
  • Tachycardia
  • Hypotension (late sign)
  • Cool peripheries / delayed capillary refill
  • Altered consciousness
Where is the blood? — "On the floor and four more"
  • Chest
  • Abdomen
  • Pelvis (3000–5000 mL)
  • Long bones (femur 1500–2000 mL)
  • External wounds (on the floor)
Blood loss from different injuries
Step 1
Control haemorrhage first
  • Direct pressure to external bleeding (haemostatic dressing/tourniquet when appropriate).
  • Pelvic binder if pelvic instability or high-energy mechanism.
  • Splint long bones (reduces bleeding and pain).
Step 2
Restore circulating volume & perfusion
  • Large-bore IV access (or IO if needed) and early bloods (group & save / crossmatch).
  • Activate Major Haemorrhage Protocol early when indicated.
  • Give TXA early where appropriate within local protocol.
  • Use fluids cautiously — aim for blood products in haemorrhagic shock.
💉 Crystalloid is not definitive treatment for haemorrhagic shock.
Blood saves lives — control the bleed and escalate early.
Skills video
Pelvic Binder Application
Stop at 9 min
Haemorrhagic Shock Classification
ParameterClass IClass IIClass IIIClass IV
Blood loss (mL)<750750–15001500–2000>2000
HR<100100–120120–140>140
BPNormalNormalDecreasedDecreased
Mental stateSl. anxiousMildly anxiousAnxious/confusedConfused/lethargic
Urine (ml/hr)>3020–305–15Minimal
Clinical pearl: Hypotension is a late sign. Tachycardia, tachypnoea, and altered mental state often appear earlier — act then.
D
ATLS · Primary Survey

Disability (Neurological Assessment)

Quick neurological screen — identify brain/spinal cord injury and reversible causes of reduced consciousness.
Disability (ATLS)
Document:
  • GCS/AVPU (trend)
  • Pupils (size, symmetry, reaction)
  • Blood glucose
  • Limb movement and focal deficits
Red flags:
  • Falling GCS (even 1–2 points)
  • Unequal pupils
  • Seizures or posturing
  • New weakness/numbness
Key reminder
Worsening neurology? Re-check A,B & C
Reduced consciousness may be caused by hypoxia or shock. Always reassess airway, breathing, and circulation alongside neurological causes.
Interactive activity
GCS — record E + V + M and total (3–15)
Select the best response for each component in the scenario, then check your total and interpretation.
Scenario

A 45-year-old falls from a ladder. He opens his eyes only when spoken to, uses inappropriate words, and withdraws from pain.

Eye Opening
E (1–4)
Spontaneous4
To speech3
To pain2
None1
Motor Response
M (1–6)
Obeys commands6
Localises pain5
Withdraws from pain4
Abnormal flexion3
Extension2
None1
Verbal Response
V (1–5)
Oriented5
Confused4
Inappropriate words3
Incomprehensible sounds2
None1
Total GCS: —
Choose E, V and M.
Tip: if intubated, document verbal response as "V = T" and record components clearly (e.g. E3 Vt M5).
Spinal cord screen
How to check a sensory level
  1. Explain what you're doing and ask the patient to close their eyes.
  2. Test light touch and/or pin-prick on both sides.
  3. Start at the shoulders (C5) and work down in steps.
  4. Ask: "Does this feel the same on both sides? Is it normal or reduced?"
  5. Identify where sensation changes — that's the sensory level.
Concerning if:
  • Progressive weakness or rising sensory level
  • New bowel/bladder dysfunction
  • Significant neck/back pain with neurological signs
Dermatomes
Use dermatomes to approximate the level — document clearly and recheck after any change.
E
ATLS · Primary Survey

Exposure & Environmental Control

Fully expose to allow a complete assessment — then actively re-warm to prevent hypothermia.
Document: Temperature (core if available) · Skin: colour, mottling, sweating · Warmth measures started: blankets, forced-air warming, warmed fluids
Key concept
Hypothermia & the lethal triad

Exposure causes rapid hypothermia, which worsens coagulopathy and contributes to the lethal triad:

  • Hypothermia — impaired clotting and myocardial irritability
  • Acidosis — reduced enzyme function and poorer coagulation
  • Coagulopathy — ongoing bleeding worsens shock and hypothermia
Lethal Triad
The lethal triad is self-reinforcing — break it early with haemorrhage control, warming, and appropriate resuscitation.
Skills
Log roll & posterior examination
Before you roll
  • Assign roles: team leader, head holder (in-line stabilisation), 2–3 rollers, examiner.
  • Prepare: warm blankets, scissors, lighting, suction if needed.
  • Tell the patient: "Please don't move or shake your head — just say yes or no."
During posterior examination
  • Inspect: back, buttocks, perineum — bruising, wounds, penetrating injury, bleeding.
  • Palpate the spine: midline tenderness · step deformity · crepitus · paraspinal spasm.
  • Re-cover and warm immediately after inspection.
Skills video
How to log roll a trauma patient
~40s
Focus on: neutral alignment, clear commands ("roll on three"), complete posterior check quickly.
SS
ATLS · Major Trauma

Secondary Survey

Only once haemodynamically stable — complete head-to-toe examination plus focused history.
Principle
Don't stop cycling ABCDE
If the patient deteriorates during secondary survey, return to ABCDE immediately.
Focused history
AMPLE
A
Allergies
Drug allergies, latex, contrast reactions. Document reaction type.
M
Medications
Anticoagulants/antiplatelets, insulin, steroids, opioids.
P
Past medical history
Comorbidities, previous surgery, pregnancy, baseline mobility.
L
Last meal
Time of last oral intake — important for anaesthetic planning.
E
Events surrounding injury
Mechanism, time, LOC, entrapment, pre-hospital interventions, current pain.
Demonstration
Secondary Survey Video
~5–10 min
Documentation aid
Secondary Survey Checklist
Head & Face
Scalp wounds/haematoma, facial tenderness, bleeding from nose/ears, eyes.
Neck
C-spine tenderness/step, trachea midline, neck wounds, surgical emphysema.
Chest
Wall tenderness, equal expansion, breath sounds, heart sounds.
Abdomen
Tenderness, guarding, distension, seatbelt sign, penetrating wounds.
Pelvis & Perineum
Pain/instability, wounds, blood at meatus, perineal bruising.
Back & Spine
Log roll. Midline tenderness/step, wounds, bruising.
Limbs
Deformity, wounds, neurovascular status, splintage.
Neurology
Repeat GCS, pupils, motor/sensory deficits, pain score.
Tip: document both positives and key negatives to improve handover and reduce missed injuries.
65+
ATLS · Major Trauma

Silver Trauma

Serious injury with apparently minor mechanisms. Physiological reserve is reduced — escalate earlier.
Think early about (any patient 65+)
  • Mechanism that may be underestimated
  • Physiological abnormality even if subtle
  • Anticoagulation / coagulopathy
  • Head, chest, pelvic, and spinal injury
  • Frailty, comorbidity, and baseline function
Infographic
Silver trauma triggers and warning signs
Silver trauma
Key concept
Occult shock and under-triage

Older patients may not mount the expected tachycardic or hypotensive responses due to beta-blockers, pacemakers, or limited physiological reserve.

  • SBP <110 may already indicate significant compromise
  • GCS <15 in an older trauma patient is concerning
  • Low-energy mechanisms can still produce major injury
Do not miss
  • Occult shock
  • Intracranial bleeding, especially on anticoagulation
  • Spinal injury after apparently minor falls
  • A second injury found only on secondary survey
  • Important regular medications e.g. Parkinson's medication
ICH
ATLS · Neurosurgical Trauma

Intracranial Haemorrhage in Trauma

Haemorrhage types, key actions after CT, and neurosurgical referral pathway.
Core message

ICH can deteriorate quickly. Priorities after CT: prevent secondary brain injury, reverse anticoagulation where relevant, and obtain a documented neurosurgical plan.

Red flags — escalate if:
  • Falling GCS, new focal deficit, seizures
  • Abnormal pupils / signs of herniation
  • Anticoagulated patient with any bleed
  • Significant midline shift on CT
Types of intracranial haemorrhage — Learn by clicking each type
    Quick check
    Test your knowledge
    Key actions after CT confirms a bleed
    1. Prevent secondary brain injury: avoid hypoxia and hypotension; correct glucose and temperature.
    2. Clarify anticoagulation/antiplatelets: last dose time, indication; send coagulation bloods.
    3. Urgent neurosurgical referral by A&E prior to T&O referral — request a clear written plan.
    4. Document escalation triggers: fall in GCS, pupillary change, seizures, worsening headache/vomiting.
    ⚠️ Do not accept the patient under T&O until there is a documented plan from neurosurgery confirming the patient is for local/conservative management.

    Anticoagulants — Reversal (Practical Summary)

    In suspected or confirmed intracranial haemorrhage on anticoagulants, A&E should discuss reversal urgently with the on-call haematologist (and ensure neurosurgery are aware) and document the agreed plan.

    What to prepare before you call
    • Drug(s) + time of last dose (warfarin / DOAC / antiplatelet)
    • Indication for anticoagulation (AF, VTE, valve, etc.)
    • Renal function (U&E), coagulation profile (INR/APTT), FBC
    • CT summary + current neuro status trend
    What you should record
    • Name/grade of haematologist and time of discussion
    • Reversal plan and monitoring (e.g. repeat INR/coags)
    • Prescribe the reversal agent (e.g Octaplex prescribed on pink transfusion prescription form)

    ☐ GCS documented (trend)  ☐ Pupils documented  ☐ Glucose checked
    ☐ CT head reviewed: type of bleed recorded
    ☐ Anticoagulant/antiplatelet status clarified
    ☐ Haematology discussed if anticoagulated: plan documented and actioned
    ☐ Neurosurgery contacted and plan recorded in notes
    ☐ Neuro obs frequency + repeat CT timing + escalation triggers documented
    🦴
    ATLS · Pelvic Trauma

    Pelvic & Acetabular Injuries

    Recognise instability, control haemorrhage early, identify associated injuries, and escalate promptly.
    Core message

    Pelvic trauma can cause life-threatening haemorrhage. Early priorities: treat haemorrhage, stabilise the pelvis, and escalate to the right team.

    Think pelvic bleeding if:
    • High-energy mechanism + pelvic pain/deformity
    • Haemodynamic instability without another clear source
    • Unstable pelvic ring injury on imaging
    • Ongoing transfusion requirement
    Pelvic Ring Injuries — Interactive Activity
    Click each injury type to explore its mechanism, stability, and haemorrhage risk. Then test your knowledge.
    Teaching point: The more disrupted the posterior ring, the more unstable and dangerous the injury. Vertical shear injuries carry the highest risk of life-threatening haemorrhage.
    Once you've reviewed all four types, test your knowledge below.

    Immediate Management

    ☐ Escalate to a senior SpR or Consultant if not already involved
    ☐ Treat haemodynamic instability as haemorrhage until proven otherwise
    ☐ Minimise pelvic movement
    ☐ Apply pelvic binder early if suspected unstable pelvic ring injury over greater trochanters
    ☐ Activate major haemorrhage protocol if unstable and suspected pelvic bleeding
    ☐ Screen for associated injuries: GU, bowel, spine, long bones
    ☐ Imaging: pelvic X-ray early if unstable; CT when stable enough
    ☐ VTE prophylaxis plan documented:
    • If surgery/transfer anticipated → anticoagulants may be held if safe.
    • If urgent transfer is not required and haemostasis is secure → start VTE prophylaxis

    Referral Workflow

    Urgent discussion via the Major Trauma Network if: (to be arranged by A&E)
    • Haemodynamic instability with suspected pelvic bleeding
    • Unstable pelvic ring injury / ongoing transfusion requirement
    • Open pelvic fracture, vascular injury, significant GU injury
    • Complex acetabular fracture, hip dislocation with fracture, neurovascular deficit
    For stable but complex pelvic and acetabular injuries
    • Our local pelvic and acetabular surgical team are based in Addenbrookes Hospital
    • Transfer any relevant images to Addenbrookes Hospital
    • An online referral is done through Refer a Patient
    • Select New referral → Addenbrookes Hospital → Complex Orthopaedic Trauma and fill in the referral form
    Isolated Pubic Rami Fractures
    • If there is no concern of further pelvic injury these patients can be conservatively managed as a fragility fracture with analgesia and physiotherapy
    • Refer to the medical team as per the trust's Emergency Admissions Policy
    • No orthopaedic follow up is required
    🦴
    ATLS · Spinal Injuries

    Spinal Injuries

    Maintain spinal precautions until injury excluded — escalate any neurological deficit urgently.
    Core message

    Treat any suspected spinal injury with spinal precautions until cleared. Early priorities: protect the cord, recognise neurological deficit, obtain appropriate imaging, and determine whether the injury is stable or unstable.

    Escalate urgently if
    • Any new or evolving neurological deficit
    • Suspected spinal cord compression
    • Unstable injury pattern on CT/MRI
    • Persistent severe midline spinal pain/tenderness with high-risk mechanism
    Types of spinal fractures — Learn by clicking each type
    Determining stability
    • Neurology: any deficit implies high concern and urgent escalation
    • Alignment: malalignment/subluxation suggests instability
    • Posterior elements/PLC: disruption increases instability (MRI may be needed)
    • Canal compromise: retropulsion ± symptoms = urgent review
    • Multiple levels: non-contiguous injuries — image the whole spine as appropriate
    Initial management
    ☐ For unstable fractures or neurological deficit, escalate to SpR or Consultant
    ☐ Maintain spinal precautions until injury confirmed stable (collar, logroll, bed rest if required)
    ☐ Document neuro exam: power/sensation in limbs, bladder/bowel symptoms
    ☐ Analgesia
    ☐ Look for associated injuries (head, chest, pelvis, long bones)
    ☐ Catheterise
    Referral to the spinal unit
    Urgent referral required for:
    • Any neurological deficit (new or worsening)
    • Suspected cord compression / cauda equina features
    • Facet dislocation / translation / flexion-distraction injuries
    • Unstable burst fracture with canal compromise
    Referral process
    • Local Spinal Unit: Ipswich Hospital
    • Transfer images via PACS (9am–5pm) or on-call radiographer (5pm–9am)
    • Online referral: referapatient.org → New Referral → Ipswich Hospital → Spinal Surgery
    • 8am–8pm: phone call to spinal fellow at Ipswich (usually T&O SpR)
    • Urgent overnight: On-Call T&O SpR at Ipswich via switchboard
    📋
    ATLS · Clinical Scenario 1

    Mind the Cat

    Trauma Assessment Scenario
    Scenario illustration
    Scenario
    You are called to the ED
    You are the orthopaedic SHO on-call. A 76-year-old woman is brought to the Emergency Department.

    She recalls getting up in the night and tripping over her cat at home, but cannot remember what happened after this.

    She was later found wandering around her kitchen. The ambulance crew noted blood on the corner of a side table at the foot of the stairs.

    She complains of pain and tenderness at the back of her head, where there is a bleeding laceration. You notice she is holding her neck and appears uncomfortable. She looks at you and says:
    "It feels unsteady."
    What are your immediate priorities in the first 60 seconds?

    Think through your ABCDE approach before revealing the answer.

    Immediate priorities

    • A — Maintain manual in-line C-spine immobilisation immediately. She has a neck complaint, back-of-head injury, and possible fall mechanism — assume cervical spine injury until excluded. Do not allow her to move her neck.
    • B — Ensure she is breathing adequately. Apply high-flow oxygen via a non-rebreather mask. Check RR and SpO₂.
    • C — Assess haemodynamic status. Check pulse, BP, cap refill. The head laceration may be bleeding — assess and apply direct pressure if actively bleeding.
    • D — Rapid neuro screen. GCS (this is concerning — she has had LOC and cannot recall events). Check pupils, blood glucose, and limb movement.
    • E — Do not expose fully in the corridor, but note she is a 76-year-old (silver trauma): low threshold for CT head and CT cervical spine, and proactive temperature management.
    ⚠️ Silver trauma alert: Her medications (anticoagulants?), antiplatelet use, and baseline frailty are critical to establish early. A seemingly minor fall in a 76-year-old can result in significant intracranial or spinal injury.
    What injuries must you actively exclude?

    Consider the mechanism — low fall, occipital injury, neck symptoms, LOC, elderly patient.

    Must-not-miss diagnoses

    • Cervical spine injury — she is holding her neck and reports instability. Maintain C-spine immobilisation and request CT cervical spine.
    • Intracranial haemorrhage — LOC + head laceration in an elderly patient = CT head urgently, especially if anticoagulated. Can be EDH, SDH, SAH, or contusion.
    • Occult shock — in a 76-year-old, normal observations do not exclude significant bleeding. A "normal" BP in an elderly hypertensive patient may still represent significant compromise.
    • Syncope as the primary event — consider: did she fall because she collapsed? Is there a cardiac or neurological cause for the collapse? "Trauma causing collapse" vs "collapse causing trauma".
    ⚠️ Pause and decide: How would you escalate this patient if her GCS dropped from 14 to 12 while you were assessing her?
    📋
    ATLS · Clinical Scenario 2

    Break Leg Speed

    Trauma Assessment Scenario
    Motorcyclist scenario
    Scenario
    You are called to the resus bay
    You are the orthopaedic SHO on-call. A 35-year-old motorcyclist is brought in following an RTC at approximately 60 mph.

    He was unable to mobilise at the scene. He reports pain in his left shoulder and severe pain in his left thigh, which appears deformed. The limb was splinted pre-hospital.

    During transfer, observations deteriorated: BP 80/61, HR 120. A pelvic binder was applied en route.

    As you approach, he looks distressed and says:
    "My leg hurts... and I feel really dizzy."
    What are your immediate priorities in the first 60 seconds?

    He is shocked (BP 80/61, HR 120) — work through your ABCDE before revealing.

    Immediate priorities

    • A — Airway with C-spine control. High-energy mechanism at 60 mph = assume cervical spine injury. He is talking (airway currently patent) but maintain in-line stabilisation.
    • B — Breathing. Apply high-flow O₂, check RR and SpO₂, examine the chest — is there a pneumothorax or haemothorax contributing to deterioration?
    • C — Circulation: this patient is in Class III haemorrhagic shock. BP 80/61, HR 120 = significant haemorrhage. Establish two large-bore IVs immediately, take bloods (FBC, U&Es, LFTs, clotting, crossmatch), activate the Major Haemorrhage Protocol, give TXA, and request blood products. The pelvic binder is already in situ — do not remove it.
    • D — Disability. GCS? He is communicating — but dizziness and hypotension may reduce conscious level. Check glucose.
    • E — Exposure. Expose carefully to look for hidden injuries. Keep warm — he is at risk of the lethal triad.
    What are the potential sources of life-threatening haemorrhage?

    He has a femoral fracture, a pelvic binder in situ, and left shoulder pain — think "on the floor and four more".

    Potential haemorrhage sources

    • Left femoral fracture — can lose 1500–2000 mL. Pre-hospital splinting will have reduced ongoing bleeding. Reassess the limb — is the splint secure?
    • Pelvis — pelvic binder suggests concern for pelvic injury. An unstable pelvic ring can bleed 3000–5000 mL. The binder reduces pelvic volume — do not remove without senior guidance.
    • Chest — high-energy mechanism: haemothorax or tension pneumothorax? Examine the chest formally during primary survey.
    • Abdomen — solid organ injury (spleen, liver) in high-energy RTC. May need FAST scan or urgent CT.
    • Left shoulder pain — could indicate clavicle fracture (lower haemorrhage risk) but also consider subclavian vascular injury or associated thoracic injury.
    💡 Call for help now: This patient is haemodynamically unstable. Your SpR, the ED consultant, anaesthetics, and the on-call radiologist (for potential IR) should all be alerted immediately.
    ⚠️ Pause and decide: After your primary survey, his BP remains 70/50 despite 2 units of blood. What do you do next?
    🧠
    ATLS · Knowledge Check

    Knowledge Check

    Test your understanding of the key principles from this module.
    Question 1 of 5
    A trauma patient is talking but making gurgling sounds. Which ABCDE step takes priority and what is the most important immediate action?
    AB — Breathing: apply high-flow O₂ via non-rebreather mask.
    BD — Disability: check GCS and pupils immediately.
    CA — Airway: jaw thrust with manual in-line stabilisation and suction to clear secretions.
    DC — Circulation: establish IV access and take bloods.
    Question 2 of 5
    A 45-year-old following a high-speed RTC has HR 130, BP 85/50, cool peripheries, and a deformed right femur. What class of haemorrhagic shock is this, and what volume of blood may a femoral fracture lose?
    AClass II shock; femoral fracture loses approximately 500–800 mL.
    BClass III shock; femoral fracture can lose 1500–2000 mL.
    CClass IV shock; femoral fracture can lose up to 5000 mL.
    DClass I shock; femoral fracture loses less than 500 mL.
    Question 3 of 5
    You suspect a tension pneumothorax in a trauma patient. The patient is hypoxic and hypotensive with reduced breath sounds on the left and tracheal deviation to the right. What is the correct immediate management?
    ARequest urgent portable CXR to confirm before any intervention.
    BInsert a chest drain in the left 5th intercostal space immediately.
    CThis is a clinical diagnosis — perform immediate needle decompression without waiting for imaging.
    DIncrease oxygen flow and repeat vital signs in 5 minutes before intervening.
    Question 4 of 5
    An 80-year-old on warfarin trips on the stairs and presents with a GCS of 14, headache, and vomiting. CT head shows a subdural haematoma. What should you NOT do before accepting this patient under Trauma & Orthopaedics?
    ADocument GCS trend and pupillary responses.
    BDiscuss anticoagulant reversal urgently with haematology.
    CAccept the patient under T&O without first obtaining a documented neurosurgical management plan.
    DCheck the patient's INR and coagulation profile.
    Question 5 of 5
    Which of the following best describes the "lethal triad" in major trauma, and why is hypothermia particularly dangerous?
    AHypoxia, hypotension, and hyperglycaemia — hyperglycaemia impairs wound healing.
    BTachycardia, hypovolaemia, and hypoxia — all three directly reduce cardiac output.
    CHypothermia, acidosis, and coagulopathy — they are self-reinforcing: hypothermia worsens coagulopathy which worsens bleeding, which worsens hypothermia.
    DHypothermia, hypertension, and bradycardia — together these indicate neurogenic shock.
    0/5

    🎓
    ATLS / Major Trauma

    Module Complete

    Well done for completing the ATLS / Major Trauma online module.
    🏅
    Congratulations!
    You have completed the ATLS / Major Trauma e-learning module.
    This module is part of the Orthopaedic Emergencies Clinical Education Series.
    What you have covered
    Module Summary
    📖 Introduction
    Origins of ATLS, trauma call workflow at WSH, and the trauma team.
    🔤 Primary Survey
    ABCDE approach — Airway, Breathing, Circulation, Disability, and Exposure.
    📋 Secondary Survey
    Head-to-toe assessment, AMPLE history, and documentation.
    65+ Silver Trauma
    Physiological reserve, occult shock, and common pitfalls in older patients.
    🧠 Intracranial Haemorrhage
    Types of ICH, anticoagulant reversal, and neurosurgical referral pathway.
    🦴 Pelvic & Spinal Trauma
    Pelvic ring injury patterns, spinal fractures, and management escalation.
    📋 Clinical Scenarios
    Applied ATLS assessment in two realistic trauma cases.
    🧠 Knowledge Check
    Five-question quiz covering key principles from across the module.
    ⚠️ Important reminder: This module is not a substitute for the formal ATLS course delivered by the Royal College of Surgeons of England. It is intended as supplementary e-learning. For formal certification, please attend an accredited ATLS course.
    Next steps
    Consolidate your learning
    • Review any sections where you felt less confident using the sidebar navigation.
    • Revisit the Knowledge Check (page 18) if you wish to test yourself again.
    • Attend a formal ATLS course through the Royal College of Surgeons of England.
    • Consider completing the other modules in the Orthopaedic Emergencies series.
    • Apply these principles during your clinical practice — refer back as needed.
    📚
    ATLS / Major Trauma

    References & Further Reading

    Key references, guidelines, and resources underpinning this module.
    Core Text
    ATLS — Advanced Trauma Life Support
    • American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. Chicago: American College of Surgeons; 2018.
    • Royal College of Surgeons of England. ATLS UK — Advanced Trauma Life Support Programme. Available at: rcseng.ac.uk/education-and-exams/courses/atls/
    National Guidelines & Policies
    NHS & NICE
    Haemorrhage & Resuscitation
    Key papers & protocols
    • CRASH-2 Trial Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage. Lancet. 2010;376(9734):23–32.
    • Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma (STOP THE BLEED). Crit Care. 2019;23(1):98.
    • National Blood Transfusion Committee. Patient Blood Management Guidelines. transfusionguidelines.org
    Neurotrauma
    Intracranial haemorrhage & TBI
    • Stocchetti N, Maas AIR. Traumatic intracranial hypertension. N Engl J Med. 2014;370(22):2121–30.
    • Brain Trauma Foundation. Guidelines for the Management of Severe Traumatic Brain Injury. 4th ed. 2016. Available at: braintrauma.org
    • NHS England. Anticoagulation reversal in acute intracranial haemorrhage: NICE pathway and local formulary guidelines. (Reference local trust policy for specific agents.)
    Pelvic & Spinal Trauma
    Classification & management
    • Young JWR, Burgess AR. Radiologic Management of Acetabular Fractures. Baltimore: Urban & Schwarzenberg; 1987. (Original APC/LC/VS pelvic ring classification.)
    • Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br. 1988;70(1):1–12.
    • Vaccaro AR, Oner C, Kepler CK, et al. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine. 2013;38(23):2028–37.
    • AOSpine. Spinal injury classification. Available at: aospine.aofoundation.org
    Silver Trauma
    Older patients & major trauma
    • Kehoe A, Smith JE, Edwards A, Yates D, Lecky F. The changing face of major trauma in the UK. Emerg Med J. 2015;32(12):911–15.
    • Hashmi A, Ibrahim-Zada I, Rhee P, et al. Predictors of mortality in geriatric trauma patients. J Trauma Acute Care Surg. 2014;76(3):894–901.
    • TARN (Trauma Audit and Research Network). Major Trauma in Older People. 2017. Available at: tarn.ac.uk
    Further Learning Resources
    Online & supplementary resources
    • RCEM Learning — Free e-learning from the Royal College of Emergency Medicine: rcemlearning.co.uk
    • e-FAST / eFAST ultrasound — POCUS Atlas and resources at: ultrasoundoftheweek.com
    • Trauma Audit and Research Network (TARN) — National trauma outcomes data: tarn.ac.uk
    • SIGN Guideline 110. Early management of patients with a head injury. Edinburgh: Scottish Intercollegiate Guidelines Network; 2009 (updated 2023).
    • Orthopaedic Trauma Association (OTA) — Classification and educational resources: ota.org
    Disclaimer: This module is intended as supplementary educational content for healthcare professionals and does not constitute clinical guidance. Clinical decisions should always be based on current guidelines, local trust protocols, and individual clinical judgement. Content is reviewed periodically but may not reflect the most recent updates to all referenced guidelines. Always refer to your local trust protocols for patient-specific management.