Trauma Primary & Secondary Survey
ATLS framework: ABCDE primary survey identifies life threats in minutes. Adjuncts: FAST, CXR, pelvic XR. Secondary survey is head-to-toe after stabilization. Hemorrhagic shock classification guides resuscitation.
🔍 Overview
Primary Survey (ABCDE)
| Step | Assessment | Interventions |
|---|---|---|
| A -Airway | Patent? Speaking? Stridor? Facial/neck trauma? | Jaw thrust (maintain C-spine), suction, definitive airway if needed |
| B -Breathing | RR, SpO₂, breath sounds bilateral? Tracheal deviation? Chest wall movement? | Needle decompression (tension pneumo), chest tube, seal open pneumo |
| C -Circulation | HR, BP, skin (cool/clammy?), active bleeding? Pelvis stable? | 2 large-bore IVs, tourniquets, pelvic binder, MTP if needed |
| D -Disability | GCS, pupils, gross motor/sensory | Treat ↑ ICP (HOB 30°, mannitol/HTS), identify herniation |
| E -Exposure | Fully undress, log roll, inspect everywhere | Warm blankets, prevent hypothermia |
Hemorrhagic Shock Classification
| Class | Blood Loss | HR | BP | Mental Status |
|---|---|---|---|---|
| I | < 750 mL (15%) | Normal | Normal | Normal |
| II | 750–1500 mL (15–30%) | ↑ (100–120) | Normal | Anxious |
| III | 1500–2000 mL (30–40%) | ↑ (>120) | ↓ | Confused |
| IV | > 2000 mL (>40%) | ↑ (>140) | ↓↓ | Obtunded |
Glasgow Coma Scale (GCS)
| Component | Response | Score |
|---|---|---|
| Eye Opening (E) | Spontaneous | 4 |
| To voice | 3 | |
| To pain | 2 | |
| None | 1 | |
| Verbal (V) | Oriented | 5 |
| Confused | 4 | |
| Inappropriate words | 3 | |
| Incomprehensible sounds | 2 | |
| None | 1 | |
| Motor (M) | Obeys commands | 6 |
| Localizes pain | 5 | |
| Withdraws from pain | 4 | |
| Abnormal flexion (decorticate) | 3 | |
| Extension (decerebrate) | 2 | |
| None | 1 |
GCS Classification: Severe TBI = GCS 3-8 (intubate). Moderate = 9-12. Mild = 13-15. Always report components (e.g., E3V4M6 = GCS 13) not just the total.
🚨 Management
Adjuncts to Primary Survey
- FAST exam -Focused Assessment with Sonography in Trauma. 4 views: RUQ, LUQ, subxiphoid, suprapubic. Identifies free fluid.
- CXR (AP supine) -pneumothorax, hemothorax, mediastinal widening
- Pelvic XR -pelvic fracture (hemodynamic instability source)
- Foley -urine output monitoring (do NOT place if blood at meatus, high-riding prostate, scrotal hematoma)
- NGT/OGT -decompress stomach. OGT if midface fracture suspected.
Secondary Survey
Head-to-toe exam AFTER primary survey and stabilization. "Fingers and tubes in every orifice." Log roll to examine spine. Complete neuro exam. Document all injuries.
Key Evidence: Balanced resuscitation with 1:1:1 ratio reduces 24h mortality from exsanguination PROPPR, 2015. TXA within 3 hours of injury reduces all-cause mortality CRASH-2, 2010. Whole blood resuscitation may be superior to component therapy PILOT, 2022. Permissive hypotension (SBP 80-90) in penetrating trauma reduced mortality vs aggressive resuscitation Bickell, 1994.
Damage Control Surgery Principles
| Phase | Goal | Key Actions |
|---|---|---|
| Phase 1: OR | Stop hemorrhage, limit contamination | Abbreviated surgery: pack bleeding, ligate vessels, staple bowel, temporary abdominal closure |
| Phase 2: ICU | Correct lethal diamond | Rewarm (target ≥ 36°C), correct acidosis (resuscitate), fix coagulopathy (products), replace calcium |
| Phase 3: Return to OR | Definitive repair | Remove packing, definitive vascular repair, bowel anastomosis, abdominal closure (24-72h later) |
🧪 Workup
- FAST exam -bedside, during primary survey
- CXR, pelvic XR
- CT pan-scan (head, C-spine, chest, abdomen/pelvis with IV contrast) -stable patients
- CBC, BMP, coags, type & crossmatch, lactate, ABG
- Urine drug screen, blood alcohol, pregnancy test
- Tetanus status
💊 Medications
| Drug | Dose | Purpose |
|---|---|---|
| Tranexamic Acid (TXA) | 1g IV over 10 min → 1g over 8h | Antifibrinolytic -within 3h of injury |
| pRBC / FFP / Platelets | 1:1:1 ratio | MTP for hemorrhagic shock Class III–IV |
| Ketamine (Ketalar) | 1–2 mg/kg IV | RSI induction -hemodynamically stable, bronchodilator |
| Rocuronium (Zemuron) | 1.2 mg/kg IV | Paralytic for RSI -longer duration but sugammadex reversible |
| Norepinephrine (Levophed) | 0.1–0.5 mcg/kg/min | Vasopressor -AFTER volume resuscitation, not as substitute |
📋 On Rounds
Pimp Questions
When is a FAST exam unreliable?
FAST detects free fluid (≥ 200 mL) but cannot identify retroperitoneal bleeding (renal, vascular, pelvic fractures), hollow viscus injury, or diaphragmatic injury. Sensitivity is operator-dependent (~85–96% for hemoperitoneum). A negative FAST does NOT rule out intra-abdominal injury -if clinical suspicion remains high, proceed with CT.
Why do you NOT place a Foley if there is blood at the urethral meatus?
Blood at the meatus, high-riding prostate on DRE, or scrotal/perineal hematoma suggest urethral injury. Blindly inserting a Foley could convert a partial urethral tear into a complete transection. Get a retrograde urethrogram (RUG) first. If positive, urology places a suprapubic catheter instead.
What is the "lethal diamond" in trauma?
Extension of the lethal triad: hypothermia + acidosis + coagulopathy + hypocalcemia (from massive transfusion). Citrate in blood products chelates calcium → cardiac dysfunction. The damage control resuscitation approach addresses all four: warm products, limit crystalloid (worsens acidosis), 1:1:1 ratio, and replace calcium (1g CaCl per 4 units pRBC).
What is damage control resuscitation?
Limit crystalloid (worsens acidosis/coagulopathy), use 1:1:1 blood products, permissive hypotension (target SBP 80-90 until surgical hemostasis), and damage control surgery (abbreviated laparotomy, pack and close, ICU resuscitate, return to OR). Holcomb JAMA Surg, 2015.
What are indications for emergent thoracotomy in trauma?
Penetrating thoracic trauma with loss of vital signs in ED or en route (within ~15 min). >1500 mL initial chest tube output or >200 mL/hr ongoing. Cardiac tamponade. Survival is ~35% for stab wounds but <5% for blunt trauma. EAST Guidelines, 2015.
What is the MARCH mnemonic for tactical trauma?
M = Massive hemorrhage (tourniquet), A = Airway, R = Respiration (needle decompress, chest seal), C = Circulation (IV access, TXA, blood products), H = Hypothermia prevention. Prioritizes hemorrhage control before airway, unlike traditional ABCDE.
When do you activate massive transfusion protocol (MTP)?
ABC score ≥ 2 (penetrating mechanism, SBP ≤ 90, HR ≥ 120, positive FAST). Also: estimated blood loss > 1500 mL, anticipated need for > 10 units pRBC in 24h, hemodynamic instability despite 2L crystalloid. Cotton, 2009.
What is the difference between primary and secondary brain injury in TBI?
Primary = mechanical damage at time of impact (contusion, diffuse axonal injury, epidural/subdural hematoma). Cannot be reversed. Secondary = preventable cascade: hypotension, hypoxia, hyperthermia, hyperglycemia, seizures. A single episode of SBP < 90 doubles mortality. Focus is preventing secondary injury.
What is permissive hypotension and when is it contraindicated?
Target SBP 80-90 in hemorrhagic shock to minimize ongoing bleeding until surgical control. Reduces dilutional coagulopathy from excess crystalloid. Contraindicated in TBI (need SBP > 100 for cerebral perfusion) and spinal cord injury. Bickell, 1994.
Clinical Examples
📋 Case 1, Blunt Polytrauma with Hemorrhagic Shock
Patient: 28M MVC unrestrained driver, GCS 13 (E3V4M6). HR 132, BP 78/42, RR 28. Distended abdomen, pelvic instability on exam. FAST positive (Morrison's pouch).
Key findings: Class IV hemorrhagic shock (tachycardic, hypotensive, AMS). FAST positive = intra-abdominal hemorrhage. Unstable pelvis = likely pelvic fracture with venous plexus bleeding.
Management:
- Activate massive transfusion protocol, 1:1:1 (pRBC:FFP:platelets) PROPPR, 2015
- Pelvic binder immediately (reduces venous bleeding volume by ~50%)
- TXA 1g IV over 10 min → 1g over 8h (must give within 3h of injury) CRASH-2, 2010
- Permissive hypotension: target SBP 80-90 until surgical control
- OR for exploratory laparotomy, damage control surgery
Teaching point: In penetrating/blunt trauma with hemorrhagic shock, the ED goal is stop the bleeding, not normalize vitals with crystalloid. Crystalloid worsens coagulopathy, hypothermia, and acidosis.
📋 Case 2, Tension Pneumothorax
Patient: 35F stab wound to left chest. Initially stable, now HR 140, BP 62/40, SpO₂ 82%. Absent breath sounds on left. Tracheal deviation to the right. JVD.
Key findings: Classic tension pneumothorax: hypotension + absent breath sounds + tracheal deviation + JVD. This is a clinical diagnosis, do NOT wait for CXR.
Management:
- Needle decompression IMMEDIATELY, 14g angiocath, 2nd intercostal space midclavicular line (or 5th ICS anterior axillary)
- Follow with tube thoracostomy (chest tube 28-32 Fr) in left 5th ICS anterior axillary line
- Reassess: expect rapid improvement in BP and SpO₂ after decompression
- If persistent hemorrhage (> 1500 mL initial output or > 200 mL/hr) → thoracotomy
- Serial CXR to confirm lung re-expansion
Teaching point: Tension pneumothorax is a clinical diagnosis treated before imaging. The classic triad (hypotension, absent breath sounds, tracheal deviation) may not all be present, decompress based on high clinical suspicion.
📋 Case 3, Traumatic Brain Injury
Patient: 55M fall from ladder, GCS 7 (E1V2M4). Right pupil 6 mm fixed. Left-sided hemiplegia. HR 58, BP 190/100. CT: right-sided epidural hematoma with 8 mm midline shift.
Key findings: Cushing triad (HTN + bradycardia + irregular breathing) = elevated ICP. Ipsilateral fixed dilated pupil + contralateral hemiplegia = uncal herniation. Epidural = "talk and die" lesion if not evacuated.
Management:
- Intubate for airway protection (GCS ≤ 8), avoid hypotension during RSI
- Mannitol 1 g/kg IV or hypertonic saline 23.4% 30 mL IV push (temporizing for herniation)
- Emergent neurosurgery consult for craniotomy and evacuation
- Target SBP > 100 (avoid hypotension, single episode doubles mortality in TBI)
- Head of bed 30°, avoid hyperthermia, maintain PaCO₂ 35-40 mmHg
Teaching point: In TBI, the secondary injury (hypotension, hypoxia, hyperthermia) is preventable. Maintaining SBP > 100 and SpO₂ > 90% is the single most impactful intervention for TBI outcomes.
⚡ Summary
ABCDE, in Order, Every Time
Airway with C-spine control, Breathing, Circulation, Disability, Exposure. The order exists because it treats in the sequence that kills fastest, and you do not move on until the current step is fixed. Any deterioration means going back to A and starting again.
A and B: What Kills in the First Minutes
Airway: can they speak? Stridor, facial or neck trauma, expanding hematoma → jaw thrust with in-line stabilization, suction, then a definitive airway. Breathing: tension pneumothorax is a clinical diagnosis and is decompressed before any x-ray, along with open pneumothorax (three-sided seal), massive hemothorax and flail chest with contusion.
C: Find the Blood
Bleeding hides in five places: the chest, the abdomen, the pelvis or retroperitoneum, the long bones, and the floor (external). Two large-bore IVs, direct pressure and tourniquets, a pelvic binder for an unstable pelvis, and activate massive transfusion early. Give blood, not crystalloid, and TXA within 3 hours (CRASH-2), which increases mortality if given later.
Class of Hemorrhagic Shock, and Its Trap
Class I up to 15% loss, normal vitals. Class II 15 to 30%, tachycardia and a narrowed pulse pressure. Class III 30 to 40%, hypotension and confusion. Class IV above 40%, moribund. A narrowing pulse pressure precedes hypotension, and young patients compensate until they crash. Beta blockade, pacing, pregnancy and the elderly all blunt the tachycardia, so a normal heart rate never excludes shock.
D: Report GCS in Components
Severe TBI is GCS 3 to 8 and means intubate. Moderate 9 to 12, mild 13 to 15. Always report the components, E3V4M6, not just the total: the motor score carries most of the prognostic weight, and two patients with the same total can be very different. Check pupils and look for herniation, treating with head-up positioning and hypertonic saline or mannitol.
E: Exposure Without Hypothermia
Fully undress, log roll and inspect the back, axillae, perineum and scalp, which is where penetrating wounds get missed. Then cover and warm immediately: hypothermia is one third of the lethal triad, and clotting enzymes fail before the patient feels cold to you.
Adjuncts Belong to the Primary Survey
FAST, chest x-ray and pelvic x-ray, plus ECG, blood gas, type and cross. A positive FAST in an unstable patient goes to the operating room, not the CT scanner. A negative FAST does not exclude injury: it misses retroperitoneal bleeding and most solid organ injury without free fluid, so a stable patient with a concerning mechanism still gets a CT.
Secondary Survey and Damage Control
Head-to-toe examination with AMPLE history (allergies, medications, past history, last meal, events) only after the patient is stabilized. Damage control surgery stops bleeding and contamination, then leaves the abdomen open for ICU correction of the lethal triad and delayed definitive repair, because a hypothermic, acidotic, coagulopathic patient does not survive a long definitive operation.
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