ATLS and Spinal Clearance

Introduction

In your clinical station it is very common for one of your scenarios to be an ATLS situation. Knowing your ATLS and A-E approach should be your bread and butter before going into the interview. The best students will combine the ATLS principles and BOAST guidelines to formulate a sound approach.

Example Scenario:

A 25-year-old male is brought into the Emergency Department following a high-speed car crash. He was the driver, airbags deployed, and he was wearing a seatbelt. On arrival, he is conscious but appears distressed and is complaining of severe chest pain and difficulty breathing. How would you approach this patient?

Example Answer:

You should start off by saying 'This is a high energy/impact injury and I would like to approach it using my ATLS principles...'

Primary Survey – ABCDE

Airway with Cervical Spine Protection
- Assess airway patency, look for obstruction (blood, vomit, facial trauma).
- Triple Immobilization of the Spine until cleared.
- Definitive airway may require intubation.
Breathing
- Assess chest movement, respiratory rate, oxygen saturations.
- Auscultate for breath sounds.
- Identify and immediately treat life-threatening chest injuries (TOMCAT)
  - Tension pneumothorax
  - Open pneumothorax
  - Flail chest
  - Massive haemothorax
  - Tracheobronchial injury
- Start the patient on 15L O2
Circulation with Haemorrhage Control
- Assess heart rate, blood pressure, capillary refill.
- Control external bleeding with direct pressure/tourniquet.
- Establish IV/IO access (two large-bore cannulae).
- Take bloods: FBC, U&E, coagulation, group & cross-match.
- Consider pelvic binder, chest drain, blood product resuscitation.
- Blood product resus in trauma should be at a ratio of 1:1:1
- Consideration of TXA - especially if this is a pelvic fracture as that is part of the BOAST guidelines.
Disability (Neurological Assessment)
- Rapid assessment using AVPU (Alert, Voice, Pain, Unresponsive) or GCS.
- Check pupils and limb movement.
- Look for hypoglycaemia as reversible cause.
Exposure / Environment
- Fully expose patient to assess for injuries, log-roll with spinal precautions.
- Prevent hypothermia with blankets/warm fluids.

Adjuncts to Primary Survey

Monitoring: ECG, SpO₂, BP.
Portable chest and pelvic X-ray, FAST/extended FAST scan.
Catheterization (unless contraindicated by urethral injury).
- As mentioned in the Pelvic Fracture section. One attempt at urethral catheterization should be attempted. If this fails then retrograde cystourethrogram is needed.
- PR is needed to check for high riding prostate to rule out bladder rupture.
- This is all found in the BOAST guidelines of Pelvic Fractures and Urological Trauma.

Secondary Survey

Head-to-toe assessment once patient is stabilised.
Full history (AMPLE: Allergies, Medications, Past history, Last meal, Events).
Systematic examination including spine, pelvis, long bones.
Document all findings.
Is the patient Neurovascularly Intact with a closed injury?

Key Principles for Interview

Always approach systematically: “My approach is based on ATLS principles, starting with a primary survey (ABCDE).”
Mention cervical spine protection early.
Be able to name the life-threatening injuries.
Highlight hemorrhage control as a key step and know about resus protocols (1:1:1).
Learn the BOAST guidelines for trauma, especially spinal and pelvic injuries as these already have designated pathways.
Conclude by mentioning involvement of the MDT, AMPLE history taking and secondary survey.

Scotland ST1 Orthopaedic National Selection Preparation