Trauma Management & ATLS Protocols for NEET PG — Complete Guide 2026

Version 1.0 — Published April 2026

Trauma is the leading cause of death in Indians aged 1–44 years, and the ATLS protocol is the globally standardised approach for the first hour of trauma care — making it a NEET PG goldmine across surgery, critical care, and emergency medicine. The student who memorises the ABCDE sequence, lethal six, hemorrhage classes, and Parkland formula covers 3–4 marks across papers. Pair this guide with daily MCQ practice on the surgery subject hub, cross-reference the surgery high-yield topics overview, and revise the shock and sepsis management guide for critical care integration.

ATLS primary survey — the ABCDE sequence

The ATLS primary survey is a structured 5-minute assessment that identifies and treats immediately life-threatening injuries in the order of their lethality — airway first, then breathing, circulation, disability, and exposure.

Key principles:

• Treat as you go — identify and treat life threats before moving on
• Reassess after every intervention (ABCDE-A-B-C…)
• Team approach — horizontal (simultaneous) rather than purely sequential in mature trauma centres
• Adjuncts — monitoring, labs, imaging added in parallel once stable

Primary survey adjuncts (monitor + investigate):

• Continuous ECG, pulse oximetry, BP cuff
• Urinary catheter (contraindication: blood at meatus, perineal haematoma, high-riding prostate → suspect urethral injury)
• Nasogastric / orogastric tube (OG if suspected basilar skull fracture — raccoon eyes, Battle sign, CSF rhino/otorrhoea)
• Arterial blood gas, lactate
• Type and cross-match, CBC, coagulation, biochemistry, pregnancy test (all fertile-age females), drug / alcohol screen, troponin, urinalysis
• Trauma series X-rays: chest, pelvis; C-spine lateral (if CT not immediately available)
• FAST / eFAST bedside ultrasound

After primary survey → secondary survey (head-to-toe, AMPLE history, reassess).

Airway with C-spine control

Airway is the first priority in the primary survey — ensuring patency and protection while maintaining cervical spine immobilisation in every blunt trauma patient until spine is cleared.

Airway assessment:

• Talk to the patient — an ability to speak normally confirms patent airway and adequate cerebral perfusion
• Inspect for: facial trauma, blood, vomitus, foreign bodies, loose teeth, burns, soot in mouth, hoarseness
• Auscultate for stridor, gurgling
• Look, listen, feel

Indications for definitive airway (endotracheal intubation):

Rapid Sequence Intubation (RSI) in trauma:

• Pre-oxygenate 3 minutes
• Induction + paralysis simultaneously
• Induction agents: ketamine (preferred in shock — maintains BP), etomidate (haemodynamically neutral; single dose in septic is controversial), propofol (avoid in hypotension)
• Paralysis: rocuronium (1 mg/kg) or succinylcholine (1–1.5 mg/kg — avoid in crush injury, burns >24 h, paraplegia, hyperkalaemia)
• In-line manual stabilisation of cervical spine (collar opened anteriorly, neck held manually)
• Cricoid pressure (controversial — may obscure view; applied per unit protocol)
• Confirm tube: capnography (gold standard), auscultation, chest rise, mist in tube

Difficult airway / failed airway:

• Supraglottic rescue: laryngeal mask airway (LMA), i-gel
• Surgical cricothyroidotomy — definitive surgical airway; incision over cricothyroid membrane; 6.0–7.0 ETT; contraindicated in children <12 years (use needle cricothyroidotomy with jet ventilation)

C-spine protection:

• Manual in-line stabilisation (do NOT pull)
• Hard collar (Philadelphia, Aspen); head blocks; long spine board for transport (remove within 2 h)
• NEXUS criteria or Canadian C-Spine Rule to clear low-risk patients without imaging

Breathing and ventilation — the lethal six

Breathing assessment identifies and treats immediate threats to ventilation and oxygenation — the "lethal six" chest injuries — in the B step.

Assessment:

• Expose chest
• Inspect — asymmetry, paradoxical movement, wounds, seatbelt sign, use of accessory muscles
• Palpate — crepitus (subcutaneous emphysema), tenderness, instability
• Percuss — hyperresonance (pneumothorax), dullness (hemothorax)
• Auscultate — absent / decreased breath sounds
• Pulse oximetry, ABG, capnography

Lethal six (immediately life-threatening — diagnose and treat in B):

Seventh "lethal": Tracheobronchial disruption — persistent large air leak despite adequate chest tube, continued pneumothorax; bronchoscopy; surgical repair.

"Deadly dozen" of chest trauma (primary + secondary survey):

Circulation and hemorrhage control

Circulation assessment identifies haemorrhagic shock, controls external bleeding, establishes IV access, and initiates fluid resuscitation — with permissive hypotension now favoured in select patients.

Assessment:

• Level of consciousness (poor perfusion → confusion, agitation, lethargy)
• Skin colour, temperature, capillary refill (>2 s abnormal)
• Pulse — rate, quality, regularity
• BP (late sign of shock — reflects compensated vs decompensated state)
• External bleeding — direct pressure, pressure dressing, tourniquet for limb haemorrhage (>2 h ideally, mark time)

Classes of haemorrhagic shock (ATLS):

Key NEET PG takeaway: Hypotension appears only in Class III — a normotensive trauma patient can still have lost up to 30% of blood volume. Tachycardia and narrowed pulse pressure are earlier signs.

Sources of major bleeding (think "blood on the floor and 4 more"):

1. External (floor)
2. Chest
3. Abdomen / pelvis
4. Long bones (femur: 1.5 L; pelvis: up to 3 L)
5. Retroperitoneum

Vascular access:

• Two large-bore (16 G or larger) peripheral IVs in antecubital fossae
• Failed peripheral → intraosseous (IO) or central venous catheter (femoral, subclavian, IJV)
• Central line via cutdown of saphenous vein is a backup

Fluid resuscitation:

• Initial bolus: 1 L crystalloid (Ringer lactate preferred) in adults; 20 mL/kg in children
• Reassess
• Responders vs transient responders vs non-responders
• Early use of blood products for Class III/IV shock
• Massive transfusion protocol — 1:1:1 ratio of PRBC : FFP : platelets (CRASH-2, PROPPR trial evidence)
• Tranexamic acid 1 g over 10 min then 1 g over 8 h — within 3 h of injury reduces mortality (CRASH-2)

Permissive hypotension:

• Target SBP 80–90 mmHg (or palpable radial pulse) until surgical control
• Rationale: prevent clot disruption and dilution
• Indicated: penetrating truncal trauma without head injury
• NOT for: traumatic brain injury (MAP >80), spinal cord injury (perfusion targets), elderly (higher baseline BP), renal disease

Damage control resuscitation:

• Permissive hypotension + balanced transfusion + minimize crystalloid + early surgical haemorrhage control + rewarming + correction of acidosis + correction of coagulopathy
• "Lethal triad" — hypothermia + acidosis + coagulopathy — each exacerbates the others

Pelvic binder: Apply at greater trochanter level for suspected pelvic fracture with haemodynamic instability — reduces pelvic volume and tamponades venous bleeding; interventional angioembolisation or preperitoneal packing for refractory bleeding.

Disability — GCS, pupils, glucose

Disability assessment is a rapid neurological exam in the primary survey — GCS, pupils, and glucose — looking for traumatic brain injury and other causes of altered mental status.

Glasgow Coma Scale (GCS):

Total: 3 (minimum) to 15 (maximum).

TBI severity by GCS:

• Mild: 13–15
• Moderate: 9–12
• Severe: <=8

GCS <=8 → intubate (inability to protect airway).

Pupils:

• Size (measure in mm)
• Symmetry — asymmetry (>1 mm) suggests ipsilateral intracranial mass effect (e.g., uncal herniation compressing CN III)
• Reactivity — fixed, dilated, sluggish
• Bilateral fixed dilated pupils — severe global injury / brainstem / pharmacological

Signs of raised ICP / impending herniation:

• GCS decline >2 points
• Pupillary asymmetry or dilation
• Cushing's triad — hypertension + bradycardia + irregular respiration
• Decerebrate / decorticate posturing

Immediate measures for herniation:

• Head of bed up 30° (if no spine injury)
• Hyperventilation to PaCO2 30–35 (temporarily — causes cerebral vasoconstriction)
• Osmotic therapy: mannitol 0.25–1 g/kg IV OR 3% hypertonic saline 250 mL bolus
• Neurosurgical consult + non-contrast CT head

Check blood glucose in all patients with altered mental status — hypoglycaemia mimics head injury.

Exposure with environmental control

Exposure is the final step of the primary survey — full undressing and log-roll for complete body inspection, while actively preventing hypothermia.

What to do:

• Remove all clothing (cut off if needed; preserve for forensics in penetrating / sexual assault cases)
• Log-roll (4-person, C-spine-protected) to inspect back, flanks, perineum; palpate spine for step-offs, tenderness
• Rectal exam: tone, blood, high-riding prostate
• Limbs: swelling, deformity, open fractures, compartments
• External signs of pelvic injury: perineal bruising, scrotal haematoma

Prevent hypothermia:

• Warm blankets; forced-air warming (Bair Hugger)
• Warm crystalloid (40°C) and blood products
• Warm room temperature
• Cover patient immediately after inspection

Hypothermia in trauma (<35°C) is part of the lethal triad — worsens coagulopathy and acidosis; each 1°C drop increases blood loss.

Secondary survey and ongoing management

The secondary survey is a systematic head-to-toe examination performed after the primary survey is complete and the patient is stabilised — the AMPLE history anchors it.

AMPLE history:

• A — Allergies
• M — Medications
• P — Past medical / surgical history; Pregnancy
• L — Last meal
• E — Events surrounding injury

Head-to-toe exam:

1. Head — scalp laceration, skull fracture signs (raccoon eyes, Battle sign, CSF leak, haemotympanum)
2. Face — midface stability (Lefort fractures), mandible, dental, eyes
3. Neck — C-spine tenderness, tracheal position, carotid bruits, JVD, subcutaneous emphysema
4. Chest — full re-exam; injury mechanism; seatbelt sign
5. Abdomen — inspection, auscultation, palpation for tenderness, rebound, guarding; seatbelt sign (high association with hollow viscus injury)
6. Pelvis — stability (single palpation only to avoid clot disruption); perineum
7. Rectal and genital — tone, blood, prostate; vaginal exam if indicated
8. Limbs — 5Ps (pain, pallor, pulselessness, paresthesia, paralysis); deformity, compartments, pulses; dressing of open fractures; splinting
9. Back — via log-roll
10. Neurological — detailed cranial nerves, motor, sensory, reflexes; sensory level if spinal injury

Continuous reassessment and monitoring for deterioration.

Missed injuries are common — up to 10% in polytrauma; a tertiary survey within 24 hours is recommended.

Burns — assessment and fluid resuscitation

Burns are thermal, chemical, electrical, or radiation injuries — the acute resuscitation phase depends on accurate TBSA estimation and Parkland formula fluid calculation.

Burn depth classification:

Wallace rule of 9 (adult):

Paediatric differences:

• Infant head: 18% (higher surface-to-volume ratio)
• Each leg in infant: 14%
• Use Lund and Browder chart for precise paediatric TBSA (adjusts for age)

Palm method: the palm of the patient's hand (including fingers) ≈ 1% TBSA — useful for scattered small burns.

Note: Count only partial-thickness and full-thickness burns in TBSA for Parkland formula (exclude first-degree erythema).

Parkland formula:

• 4 mL × body weight (kg) × %TBSA of Ringer lactate in first 24 hours
• Half in first 8 hours (from time of burn, NOT arrival)
• Half in next 16 hours
• Example: 70 kg with 30% TBSA → 4 × 70 × 30 = 8400 mL/24h → 4200 mL in first 8 h

Monitoring:

• Urine output: target 0.5 mL/kg/h in adults, 1 mL/kg/h in children <30 kg
• Electrical burns: target 1–1.5 mL/kg/h (myoglobinuria)
• Titrate fluids to urine output — over- and under-resuscitation both harmful
• Avoid colloids in first 24 h (increased third-spacing); add at 24 h if hypoalbuminaemia

Alternative formulas:

• Modified Brooke: 2 mL/kg/%TBSA RL in first 24 h
• ABLS consensus formula (2016): 2 mL/kg/%TBSA RL for adults; 3 mL/kg/%TBSA for children; 4 mL/kg/%TBSA for electrical injuries

Criteria for burn centre referral (ABA):

• Partial thickness >10% TBSA
• Any full thickness
• Burns involving face, hands, feet, genitalia, perineum, major joints
• Electrical, chemical, inhalation injury
• Circumferential burns needing escharotomy
• Associated trauma, comorbidities, paediatrics

Airway management in burns:

• Early intubation if: facial burns, singed nasal hair, carbonaceous sputum, hoarseness, stridor, dyspnoea, circumferential neck burns, GCS drop
• Airway oedema peaks at 24–48 h — late intubation is extremely difficult

Carboxyhaemoglobin — pulse oximetry reads falsely normal; send ABG co-oximetry. 100% O2 halves CO half-life from 4 h to 1 h.

Tetanus prophylaxis and analgesia (morphine IV titrated) are routine.

Blunt vs penetrating trauma — decision frameworks

Blunt and penetrating trauma have different injury patterns and different decision-making frameworks for operative vs non-operative management.

Blunt trauma:

• Mechanisms: road traffic accident, fall, assault, crush, deceleration
• Most common injured organ in abdomen: spleen, followed by liver, kidneys, mesentery
• Multiple organ injury common
• Deceleration injuries: aortic tear at ligamentum arteriosum, mesenteric tears, shear injury

Investigation pathway for blunt abdominal trauma:

Non-operative management (NOM) for stable solid organ injury:

• Haemodynamically stable
• No peritonitis
• Grade I–III splenic / hepatic injuries
• Monitoring in ICU / surgical ward
• Angioembolisation for blush on CT
• Operative if deterioration

Penetrating trauma:

• Stab wounds and gunshot wounds
• Gunshot wound to abdomen: traditionally mandatory laparotomy (high incidence of visceral injury); selective non-operative management in select stable patients in mature centres
• Stab wound to abdomen:
  • Hemodynamically unstable → laparotomy
  • Evisceration of omentum / bowel → laparotomy
  • Peritoneal signs → laparotomy
  • Anterior abdominal stab wound, stable, no peritoneal signs → local wound exploration (assess peritoneal breach); if breach or equivocal → CT and serial abdominal exams or DPL
• Thoracoabdominal stab wound (between nipple line and costal margin anteriorly; between inferior scapular tip and costal margin posteriorly) — high diaphragm injury risk; liberal laparoscopy or thoracoscopy

Damage control surgery:

• Indications: unstable, coagulopathic, hypothermic, acidotic, multiple injuries
• Phase 1: abbreviated laparotomy — control bleeding, contamination; pack + temporary abdominal closure
• Phase 2: ICU resuscitation — rewarm, correct coagulopathy and acidosis
• Phase 3: return to OR within 24–48 h for definitive repair

Zone of injury in neck trauma (penetrating):

• Zone I (sternal notch to cricoid) — highest mortality (major vessels)
• Zone II (cricoid to angle of mandible) — most common; easiest surgical access
• Zone III (angle of mandible to skull base) — distal ICA; difficult exposure; angiography preferred

"No-zone" approach — clinical findings (hard signs like expanding haematoma, pulsatile bleeding, bruit, airway compromise) drive surgical vs imaging decisions rather than anatomical zone alone.

Sources and references

1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 10th Edition (2018).
2. Bailey & Love's Short Practice of Surgery, 28th Edition (Williams, Bulstrode, O'Connell, Eds., 2023) — Chapter on Trauma.
3. Sabiston Textbook of Surgery, 21st Edition (Townsend, Beauchamp, Evers, Mattox, Eds., 2021) — Chapters on Trauma and Burns.
4. Schwartz's Principles of Surgery, 11th Edition (Brunicardi et al., 2019) — Chapter on Trauma and Burns.
5. CRASH-2 Collaborators. 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 2010; 376:23-32.
6. Holcomb JB 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; 313(5):471-482.
7. American Burn Association. Advanced Burn Life Support (ABLS) Provider Manual (2018).

Frequently asked questions

How many trauma and ATLS questions appear in NEET PG?

Trauma and ATLS contribute 3-4 direct questions per NEET PG paper across surgery, critical care, and emergency medicine. ABCDE primary survey order, lethal six of chest trauma, hemorrhage class classification, GCS scoring, FAST scan indications, and Parkland formula for burns are the most tested subtopics based on 2019-2025 pattern analysis.

What is the ATLS primary survey?

ATLS primary survey is the rapid 5-minute ABCDE assessment that identifies and treats immediately life-threatening injuries in the order of their lethality. A — Airway with cervical spine control (intubate if GCS less than 8), B — Breathing and ventilation (treat tension pneumothorax, open pneumothorax, flail chest), C — Circulation with hemorrhage control (two large-bore IVs, crystalloid, permissive hypotension for penetrating injuries), D — Disability (GCS, pupils), E — Exposure with environmental control (full undressing, prevent hypothermia). Done in strict sequence and reassessed after every intervention.

What is the lethal six of chest trauma?

The lethal six are immediately life-threatening chest injuries identified in the primary survey: airway obstruction, tension pneumothorax, open pneumothorax (sucking chest wound), massive hemothorax (greater than 1500 mL or 1500 mL loss with ongoing 200 mL/h), flail chest, and cardiac tamponade. Some texts include tracheobronchial disruption as a seventh. All require immediate clinical diagnosis and treatment in the B or C step of the primary survey, not radiological confirmation first.

What are the four classes of hemorrhagic shock?

ATLS classes of hemorrhagic shock by percentage of blood volume lost in a 70 kg adult (total 5 L). Class I: less than 15 percent (less than 750 mL), normal vitals. Class II: 15-30 percent (750-1500 mL), tachycardia over 100, narrowed pulse pressure, mild anxiety. Class III: 30-40 percent (1500-2000 mL), tachycardia over 120, hypotension, oliguria, confusion. Class IV: greater than 40 percent (greater than 2000 mL), severe hypotension, anuria, lethargy. Hypotension is a late sign — it appears only in class III or worse.

What is permissive hypotension?

Permissive hypotension is a fluid resuscitation strategy that accepts a lower-than-normal systolic BP (target approximately 80-90 mmHg, or palpable radial pulse) in patients with uncontrolled hemorrhage until definitive surgical control. It reduces dilution of clotting factors, avoids clot disruption, and limits re-bleeding. Indicated in penetrating truncal trauma without head injury. CONTRAINDICATED in traumatic brain injury (need MAP greater than 80) and elderly (baseline higher BP).

What is the Glasgow Coma Scale and when is intubation indicated?

GCS assesses consciousness on three parameters. Eye opening (E, 1-4): spontaneous 4, to sound 3, to pressure 2, none 1. Verbal response (V, 1-5): oriented 5, confused 4, words 3, sounds 2, none 1. Motor response (M, 1-6): obeys 6, localizes 5, normal flexion 4, abnormal flexion (decorticate) 3, extension (decerebrate) 2, none 1. Total 3-15. GCS less than or equal to 8 is an indication for definitive airway (intubation) because airway protection cannot be guaranteed.

What is the FAST scan and what does it assess?

FAST (Focused Assessment with Sonography for Trauma) is a bedside ultrasound done in the primary survey to detect intraperitoneal or pericardial fluid (blood) in 4 standard views: right upper quadrant (Morison pouch between liver and right kidney), left upper quadrant (spleno-renal recess), pelvis (pouch of Douglas), and subxiphoid (pericardium). Extended FAST (eFAST) adds two anterior chest views for pneumothorax. Sensitivity 60-90 percent for intraperitoneal hemorrhage; a positive FAST in an unstable patient is an indication for immediate laparotomy.

What is the Parkland formula for burns?

Parkland formula calculates fluid requirements in the first 24 hours after burn injury: 4 mL Ringer lactate per kg body weight per percent total body surface area burned. Half is given in the first 8 hours from the time of burn (not time of arrival), and half over the next 16 hours. Example: 70 kg adult with 30 percent TBSA burn needs 4 x 70 x 30 = 8400 mL over 24 hours, with 4200 mL in first 8 hours. Target urine output: 0.5 mL/kg/hour in adults, 1 mL/kg/hour in children less than 30 kg.

What is the Wallace rule of 9?

Wallace rule of 9 estimates total body surface area burned in adults. Head and neck 9 percent. Each upper limb 9 percent (total 18 percent). Anterior trunk 18 percent (chest 9, abdomen 9). Posterior trunk 18 percent. Each lower limb 18 percent (total 36 percent). Perineum 1 percent. In children, head is larger (up to 18 percent in infants) and lower limbs smaller (13-14 percent each) — use Lund and Browder chart for accurate pediatric estimation. Alternative: palmar surface (including fingers) equals approximately 1 percent TBSA for scattered burns.

How do blunt and penetrating trauma management differ?

Blunt trauma causes multiple organ injuries from deceleration, compression, or shearing — common organs affected are spleen (most common in abdomen), liver, kidneys, and mesentery. Investigation prefers CT scan in stable patients; FAST or DPL in unstable. Non-operative management for stable patients with solid organ injury is often possible. Penetrating trauma (stab or gunshot) is handled with higher suspicion for immediate operative intervention — gunshot wounds to the abdomen are usually explored; stab wounds in the anterior abdomen with peritoneal breach and hemodynamic instability need laparotomy. FAST is useful in both; CT is for stable patients only.

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Written by: NEETPGAI Editorial Team Reviewed by: Pending SME Review Last reviewed: April 2026

This article is reviewed by qualified medical professionals for clinical accuracy and exam relevance. For corrections or updates, contact the editorial team.