An ambulance trolley wheels into the A&E department, the patient has a severe penetrating injury of the chest, you are the senior resident on duty and everyone is looking to you to call the shots.

Don’t panic, no-one is at ease in this situation and just at the moment no-one knows more about this particular situation than you.  What you do is determined by where you are, who you are, what supports you have, associated injuries, even the time of the day and the day of the week. Cardiothoracic surgeons who tend to be the second level of referral cannot lay down rules for those on the front lines – only guidelines.

Whether you realise it or not you have already started to make your assessment. You can see instantly that the patient is either “walking and talking” which means you have a chance to catch your breath before an orderly history and examination, he is moribund and a major decision has to be made quickly, or he is somewhere in between and you have to rapidly but smoothly work through the ABC of resuscitation and the steps that ATLS has taught you. (Flowchart)