Increasing experience of major trauma in combat has led to the recognition that even before airway obstruction, catastrophic external arterial bleeding will lead to rapid exsanguination and death. This is particularly common in traumatic limb amputation, where arteries are often incompletely transected and hence unable to fully retract and constrict to limit haemorrhage. The ladder approach to significant bleeding enables rapid haemostatic control.

If the patient is talking, the airway is presumed clear. If the patient is not talking, look, listen and feel for breathing while simultaneously feeling for a central pulse. If the patient is not breathing and a pulse is absent, manage cardiac arrest according to cause. If the patient is not breathing, open the mouth and look for obvious causes of upper airway obstruction, e.g. foreign body (remove if easily accessible), vomitus/blood (suction). Additional sounds such as snoring imply partial upper airway obstruction due to loss of oropharyngeal tone and can be managed using the airway management ladder (manoeuvres/adjuncts/supraglottic devices/definitive airway); stridor, indicating distal upper airway obstruction, and significant orofacial trauma/inhalational injury may require a surgical airway. Manual in-line stabilisation of the cervical spine (C-spine) is of paramount importance to reduce risk of further damage/death from potential unstable C-spine fracture and goes hand-in-hand with assessment of the airway. After securing the airway, all patients must receive high flow oxygen to maximise oxygenation and minimise tissue hypoxia.

The C-spine is typically secured with three-point immobilisation. At the same time, all monitoring should be applied to the patient.