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ICU TopicsResuscitation

ICU · Resuscitation

Trauma resuscitation and primary survey (ATLS)

Also known as ATLS primary survey · ABCDE approach to trauma · Damage control resuscitation (DCR) · Traumatic cardiac arrest

Trauma resuscitation in the ICU and resuscitation bay: ATLS 10, tension pneumothorax and traumatic cardiac arrest (HOTT), acute traumatic coagulopathy, permissive hypotension, tranexamic acid (CRASH-2, MATTERs, PATCH-Trauma), balanced transfusion (PROPPR, PAMPer), European guideline targets, pelvic haemorrhage, damage control surgery, TBI (hypotension, RSI, CPP, RESCUEicp, CRASH-3), blunt aortic injury, crush and rhabdomyolysis, abdominal compartment syndrome and fat embolism.

high37 referencesUpdated 8 Oct 20268 min readSource-verified · Oct 2026

Checked against its sources on 8 Oct 2026

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CICMFFICMEDIC

Red flags

  • Catastrophic external haemorrhage: control with direct pressure/tourniquet BEFORE airway management
  • Tension pneumothorax: needle decompression (2nd ICS midclavicular or 5th ICS midaxillary) — do NOT wait for CXR
  • Permissive hypotension is CONTRAINDICATED in traumatic brain injury (need MAP >80 for CPP)
  • Traumatic cardiac arrest: focus on reversible causes (4 Hs and 4 Ts), not standard CPR algorithm
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Practise this topic8 MCQs with explanations

Target exams

CICMFFICMEDIC

Red flags

  • Catastrophic external haemorrhage: control with direct pressure/tourniquet BEFORE airway management
  • Tension pneumothorax: needle decompression (2nd ICS midclavicular or 5th ICS midaxillary) — do NOT wait for CXR
  • Permissive hypotension is CONTRAINDICATED in traumatic brain injury (need MAP >80 for CPP)
  • Traumatic cardiac arrest: focus on reversible causes (4 Hs and 4 Ts), not standard CPR algorithm

The structured approach

ATLS 10th edition recommends a highly structured approach to the injured patient and endorses several advances: less stringent crystalloid guidance, video-assisted laryngoscopy, viscoelastic methods to guide transfusion, a trauma-team approach, more focus on special populations, and restriction of spinal motion rather than routine spinal immobilisation.[1]

Six anchors for the injured patient
  1. Bleeding patients die early from haemorrhage and coagulopathy: acute traumatic coagulopathy was present in 24.4% of 1088 patients on arrival and was associated with mortality of 46.0% versus 10.9%.[8]
  2. Tranexamic acid early: CRASH-2 reduced death (14.5% vs 16.0%), with benefit only when given within 3 hours.[4][11]
  3. Balanced transfusion: PROPPR's 1:1:1 reduced exsanguination at 24 hours; MTPs should use ratios between 1:1:1 and 1:1:2.[5][2]
  4. Avoid hypotension in brain injury: a single early hypotensive episode doubled mortality after severe TBI (55% vs 27%).[16]
  5. Traumatic cardiac arrest is treatable: HOTT — hypovolaemia, oxygenation, tension pneumothorax, tamponade.[3]
  6. Damage control: rapid haemorrhage and contamination control, physiological correction, delayed reconstruction.[23]
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References37ShowHide
  1. [1]Galvagno SM Jr, Nahmias JT, Young DA Advanced Trauma Life Support(®) Update 2019: Management and Applications for Adults and Special Populations. Anesthesiology clinics, 2019.PMID 30711226
  2. [2]Meneses E, Boneva D, McKenney M, et al. Massive transfusion protocol in adult trauma population. The American journal of emergency medicine, 2020.PMID 33071074
  3. [3]Carenzo L, Calgaro G, Rehn M, et al. Contemporary management of traumatic cardiac arrest and peri-arrest states: a narrative review. Journal of anesthesia, analgesia and critical care, 2024.PMID 39327636
  4. [4]CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet (London, England), 2010.PMID 20554319
  5. [5]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA, 2015.PMID 25647203
  6. [6]CRASH-3 trial collaborators Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet (London, England), 2019.PMID 31623894
  7. [7]Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Critical care (London, England), 2019.PMID 30917843
  8. [8]Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy. The Journal of trauma, 2003.PMID 12813333
  9. [9]Sperry JL, Guyette FX, Brown JB, et al. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. The New England journal of medicine, 2018.PMID 30044935
  10. [10]Costantini TW, Coimbra R, Holcomb JB, et al. Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial. The journal of trauma and acute care surgery, 2016.PMID 26958799
  11. [11]CRASH-2 collaborators, Roberts I, Shakur H, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet (London, England), 2011.PMID 21439633
  12. [12]Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Archives of surgery (Chicago, Ill. : 1960), 2012.PMID 22006852
  13. [13]PATCH-Trauma Investigators and the ANZICS Clinical Trials Group, Gruen RL, Mitra B, et al. Prehospital Tranexamic Acid for Severe Trauma. The New England journal of medicine, 2023.PMID 37314244
  14. [14]Butler FK Jr, Holcomb JB, Shackelford SA, et al. Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02. Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 2018.PMID 29889952
  15. [15]Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. The New England journal of medicine, 1994.PMID 7935634
  16. [16]Chesnut RM, Marshall SB, Piek J, et al. Early and late systemic hypotension as a frequent and fundamental source of cerebral ischemia following severe brain injury in the Traumatic Coma Data Bank. Acta neurochirurgica. Supplementum, 1993.PMID 8310858
  17. [17]Svedung Wettervik T, Howells T, Hillered L, et al. Autoregulatory or Fixed Cerebral Perfusion Pressure Targets in Traumatic Brain Injury: Determining Which Is Better in an Energy Metabolic Perspective. Journal of neurotrauma, 2021.PMID 33504257
  18. [18]Hawryluk GWJ, Aguilera S, Buki A, et al. A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive care medicine, 2019.PMID 31659383
  19. [19]Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. The New England journal of medicine, 2016.PMID 27602507
  20. [20]Spaite DW, Bobrow BJ, Keim SM, et al. Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study. JAMA surgery, 2019.PMID 31066879
  21. [21]Kramer N, Lebowitz D, Walsh M, et al. Rapid Sequence Intubation in Traumatic Brain-injured Adults. Cureus, 2018.PMID 29946498
  22. [22]Fouche PF, Meadley B, St Clair T, et al. The association of ketamine induction with blood pressure changes in paramedic rapid sequence intubation of out-of-hospital traumatic brain injury. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2021.PMID 33759253
  23. [23]Chung CY, Scalea TM Damage control surgery: old concepts and new indications. Current opinion in critical care, 2023.PMID 37861194
  24. [24]Hatch QM, Osterhout LM, Podbielski J, et al. Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy. The Journal of trauma, 2011.PMID 22182860
  25. [25]Lier H, Krep H, Schroeder S, et al. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. The Journal of trauma, 2008.PMID 18849817
  26. [26]Hofer S, Schlimp CJ, Casu S, et al. Management of Coagulopathy in Bleeding Patients. Journal of clinical medicine, 2021.PMID 35011742
  27. [27]Miyake T, Okada H, Kanda N Advances and uncertainties in fat embolism syndrome: a review. Trauma surgery & acute care open, 2026.PMID 42375760
  28. [28]Sen RK, Tripathy SK, Krishnan V Role of corticosteroid as a prophylactic measure in fat embolism syndrome: a literature review. Musculoskeletal surgery, 2012.PMID 21773697
  29. [29]Sever MS, Vanholder R Management of crush victims in mass disasters: highlights from recently published recommendations. Clinical journal of the American Society of Nephrology : CJASN, 2013.PMID 23024157
  30. [30]Nola IA, Dvorski M, Žižak M, et al. CRUSH SYNDROME IN EARTHQUAKES - STAY AND PLAY OR LOAD AND GO? Acta clinica Croatica, 2023.PMID 38966034
  31. [31]Abu-Zidan FM, Idris K, Cevik AA Management of earthquake-related acute renal injury. World journal of nephrology, 2025.PMID 41024944
  32. [32]Scharman EJ, Troutman WG Prevention of kidney injury following rhabdomyolysis: a systematic review. The Annals of pharmacotherapy, 2013.PMID 23324509
  33. [33]Cabral BMI, Edding SN, Portocarrero JP, et al. Rhabdomyolysis. Disease-a-month : DM, 2020.PMID 32532456
  34. [34]Kirkpatrick AW, Roberts DJ, De Waele J, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive care medicine, 2013.PMID 23673399
  35. [35]Embel V, Hafeez MS, Russo L, et al. Non-operative management of blunt traumatic aortic injuries. World journal of cardiology, 2026.PMID 41607614
  36. [36]Tran JN, Byerly S, Gross M, et al. Adherence of Impulse Control in Primary Management of Grade I and II Blunt Thoracic Aortic Injury. The Journal of surgical research, 2026.PMID 42190440
  37. [37]Akhtar S Fat embolism. Anesthesiology clinics, 2009.PMID 19825491

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