Primary Survey & Damage Control Resuscitation
ATLS ABCDE framework, medication contraindications, and DCR principles for the severely injured patient.
Updated: 2024–2025
ATLSABCDEx-ABCCABDCRTXAPermissive hypotensionLethal triadKetamineCrystalloidOn this page6 sectionsHide sections
No local AHS protocol — general educational reference only. Use with attending guidance and institutional policy.
⚠️ General educational reference — no confirmed AHS local MTP/DCR protocol exists. Use with attending guidance.
✈️Primary Survey — ATLS ABCDE
▼A
Airway (+ C-spine protection)
Establish patent airway. RSI if GCS <8, airway compromise, or anticipated deterioration. C-spine immobilization until cleared per AHS C-Spine Clearance CPG.
B
Breathing
Assess ventilation and oxygenation. Needle decompression (2nd ICS MCL) or finger thoracostomy for tension pneumothorax. Target SpO₂ >95%. Confirm ETT position with EtCO₂ + CXR.
C
Circulation — Hemorrhage Control + Early Blood Products
External bleeding: tourniquets + direct pressure. Large-bore IV × 2 or IO in extremis. FAST exam. 1:1:1 ratio (pRBC:FFP:platelets). TXA 2g IV if <3h from injury. Minimize crystalloid.
D
Disability
GCS (E+V+M). Pupillary response and equality. Lateralizing signs. Blood glucose. GCS ≤8 or declining → protect airway immediately.
E
Exposure + Temperature Control
Full exposure for complete exam. Active rewarming — warm blankets, Bair Hugger, warm IV fluids. Prevent hypothermia (<35°C worsens coagulopathy).
🩸Alternate Sequence — x-ABC / CAB for Exsanguinating Hemorrhage
▼⚠️
Use only when major hemorrhage is the immediate life threat. This is evidence-informed reference guidance, not a confirmed local AHS protocol. Trauma attending leads the sequence decision.
| Use Standard ABCDE First When | Use x-ABC / CAB First When |
|---|---|
| Airway obstruction, major face/neck airway injury, severe hypoxia, ventilatory failure, or inability to oxygenate/ventilate with basic maneuvers. | Exsanguinating hemorrhage or hemorrhagic shock is dominant: uncontrolled external bleeding, penetrating torso hemorrhage, unstable pelvis, positive FAST with shock, MTP concern, or peri-arrest from blood loss. |
| Secure airway immediately while the rest of the team continues hemorrhage control. | Temporize airway while hemorrhage control and blood product resuscitation happen first; delay RSI/intubation until circulation is supported unless airway fails. |
x
External hemorrhage control before anything else
Tourniquet for extremity bleeding. Direct pressure, wound packing, hemostatic dressing. Pelvic binder over greater trochanters when unstable pelvic injury suspected. Do not wait for airway setup to stop visible bleeding.
C
Restore circulation before RSI if possible
Large-bore IV/IO, activate MTP, start balanced blood products, TXA if appropriate, calcium monitoring/repletion, FAST, and immediate OR/IR decision for torso hemorrhage. Avoid crystalloid-heavy resuscitation.
A/B
Temporize airway and breathing during hemorrhage control
Jaw thrust, suction, high-flow oxygen, BVM as needed, OPA/NPA if appropriate, chest decompression for tension physiology. Defer intubation briefly if oxygenation is acceptable and intubation would risk circulatory collapse.
A
Intubate after initial circulatory support, or sooner if airway fails
If airway obstruction, severe hypoxia, ventilatory failure, severe TBI requiring airway control, or failed basic airway support: proceed with RSI immediately while another team member continues x/C interventions.
Evidence basis: ACS summary of CAB literature review (2023) and Brito/Schreiber TSACO review (2025) describe avoiding routine early intubation in exsanguinating trauma unless anatomic airway injury or severe hypoxia is present.
⚠️Lethal Triad — Address All Three Simultaneously
▼🌡️
Hypothermia
Core <35°C
Warm blankets, Bair Hugger, warm fluids
Warm blankets, Bair Hugger, warm fluids
🧪
Acidosis
pH <7.35 / BD
Hemorrhage control, blood products
Hemorrhage control, blood products
🩸
Coagulopathy
TIC / INR >1.5
FFP, plt, calcium, TXA, TEG guidance
FFP, plt, calcium, TXA, TEG guidance
💊Medication Contraindications & Cautions
▼TXA 2g IV — Give <3 hours from injury
- Contraindicated: Subarachnoid hemorrhage (↑ cerebral edema/infarction risk)
- Contraindicated: Active DIC
- >3h post-injury: may increase mortality — avoid
- Isolated severe TBI without extracranial hemorrhage: use judiciously — observational harm signal
Ketamine — Preferred induction in hemodynamically unstable
- Contraindicated: Situations where ↑BP or ↑HR would be hazardous (aortic dissection, hypertensive crisis)
- Contraindicated: Infants <3 months
- Contraindicated: Known hypersensitivity
Crystalloids — Minimize aggressively
- Aggressive crystalloid → worsening TIC, ARDS, ↑ morbidity
- Prefer blood products (1:1:1)
- If TBI suspected: Normal Saline preferred (not balanced crystalloid) — avoid hypotonicity
Opioids — Acute resuscitation phase
- Fentanyl preferred over morphine/hydromorphone (less hemodynamic effect)
- CNS + respiratory depression may confound neurologic assessment
TBI — Specific Medication Restrictions
- Avoid benzodiazepines (confound neuro exam, lower seizure threshold)
- Avoid seizure threshold-lowering drugs: bupropion, typical antipsychotics
- Seizure prophylaxis: Levetiracetam (Keppra) OR phenytoin × 7 days in severe TBI
- NSAIDs: avoid in active hemorrhage, coagulopathy, or renal hypoperfusion
🎯Permissive Hypotension Targets
▼| Scenario | BP Target | Rationale |
|---|---|---|
| Hemorrhagic shock — no TBI | SBP ~80–90 mmHg | Reduces clot disruption and dilutional coagulopathy |
| TBI present (with or without hemorrhage) | MAP ≥85 mmHg (SBP ≥110) | Maintains cerebral perfusion pressure; prevents secondary brain injury |
| Hemorrhage controlled | MAP ≥65 mmHg (normotension) | Restore normal perfusion once bleeding controlled |
⚠️
No permissive hypotension in TBI — hypotension causes secondary brain injury and significantly worsens outcomes.
🔬Adjuncts & Monitoring
▼- TEG/ROTEM: Viscoelastic testing guides ongoing blood product and adjunct therapy after initial hemorrhage control
- Calcium: Monitor ionized Ca during massive transfusion; replete with calcium gluconate or chloride
- Anticoagulation reversal: See Anticoagulation Reversal protocol — critical in TBI
- MTP prediction: Use ABC Score (now), add TASH Score when labs available — see Calculators → Resus tab
- Status
- General Educational Reference
- Source
- AAST/ACS DCR Clinical Protocol 2024 · King DR NEJM 2019 · ACS Best Practices Guidelines · ACS CAB review 2023 · Brito/Schreiber x-ABC review 2025
- Last reviewed / updated
- 2024–2025