Trauma: Primary and Secondary Survey

In depth

The one-page summary above is what the PDF prints. These sections go further.

The primary survey in depth: xABCDE and its adjuncts

The order follows what kills fastest: exsanguinating external bleeding can kill before an obstructed airway does, so ATLS 11 (2025) moved hemorrhage control ahead of A. In a staffed bay the steps run in parallel, one clinician on the bleeding and another on the airway; any deterioration sends the team back to x. Asking the patient's name and what happened is a 10-second screen (ATLS 11 teaching summary): a clear answer shows a patent airway, breath to speak and a perfused brain.

Intubate for GCS 8 or less, an airway the patient cannot protect, an expanding neck hematoma, inhalation injury, major facial injury, or failing oxygenation or ventilation. Induction removes sympathetic tone and positive pressure cuts venous return, so ATLS 11 teaching is to restore volume with blood before rapid sequence intubation. In an EAST observational study of hypotensive patients (Ferrada 2024), delaying intubation until blood was running or bleeding controlled went with 24-h mortality of 11.1% vs 69.2%, and post-intubation hypotension tracked with worse outcomes. Record the GCS motor score and pupils before any drug, and correct hypoxia and hypotension before blaming a low GCS on the brain.

Hemorrhage control: tourniquets, junctional bleeding, pelvic binders, REBOA

A limb tourniquet must stop arterial inflow; one that occludes only veins traps blood while the artery keeps bleeding. In a Baghdad combat hospital (Kragh 2009), survival was 90% when tourniquets went on before shock and 10% after, and no limb was lost to the tourniquet itself. TCCC 2024 aims to convert to a pressure dressing within 2 h when the patient is not in shock and the limb is not amputated; after 6 h, removal waits for monitoring and labs, because reperfusion releases potassium, acid and myoglobin.

Junctional wounds (groin, axilla, base of the neck) are packed to the vessel and held for 3 minutes or more, adding a junctional tourniquet if one fits. In pelvic fractures, 80–90% of bleeding is venous or from cancellous bone and 10–20% arterial (WSES 2017). A binder centered on the greater trochanters closes the ring and tamponades venous bleeding; WSES advises removal within 24–48 h, because skin pressure above 9.3 kPa (about 70 mm Hg) for 2–3 h causes necrosis. Shock that persists with a binder calls for preperitoneal packing with external fixation, angioembolization, or both.

REBOA inflates an aortic balloon through a femoral sheath: Zone 1 (descending thoracic aorta) for abdominal or retroperitoneal bleeding, Zone 3 (infrarenal) for pelvic or groin bleeding; Zone 2 holds the visceral arteries. The 2019 ACS-COT/ACEP/NAEMSP/NAEMT statement limits Zone 1 to patients who can reach definitive control within 15 min, notes more complications and deaths after 30 min of occlusion, sets a Zone 3 target under 30 and at most 60 min, and contraindicates REBOA with thoracic bleeding or tamponade. UK-REBOA (2023) found higher 90-day mortality with emergency-department REBOA (54% vs 42%).

Hemorrhagic shock and trauma-induced coagulopathy

Adult blood volume is about 70 mL/kg. Baroreflexes raise heart rate and constrict arterioles and veins, holding diastolic pressure, so pulse pressure narrows before systolic pressure falls. The ATLS classes assume that sequence, yet only 9.3% of 36,504 German registry patients matched the ATLS heart rate, SBP and GCS pattern (Mutschler 2013). Base deficit and shock index sort patients by transfusion need better.

About a quarter of severely injured patients arrive coagulopathic before much fluid is given (24.4%, with mortality 46.0% vs 10.9%; Brohi 2003). Tissue injury plus shock activates protein C, which inactivates factors Va and VIIIa and releases the brake on fibrinolysis; the endothelial glycocalyx sheds, platelets fail and fibrinogen falls early. Dilution, cold, acid and low calcium then compound it. Fibrinolysis on TEG is U-shaped (Moore 2014): hyperfibrinolysis (LY30 ≥3%) carried 44% mortality, physiologic lysis 3%, and shutdown (64% of patients) 17%.

Hypothermia slows clotting enzymes, but labs warm samples to 37 °C, so the PT and aPTT understate it; acidosis weakens the same enzymes. Ionized calcium is factor IV: low iCa on arrival is common even without prehospital blood (mean 1.08 mmol/L; Rushton 2024), and citrate in every product pushes it lower. Adding calcium to make a lethal diamond predicted 24-h death no better than the triad (Dupuy 2025), but it is the easiest corner to fix.

Damage control resuscitation and damage control surgery

Damage control resuscitation buys time until a surgeon or interventional radiologist stops the bleeding: permissive hypotension, early blood in balanced ratios or as whole blood, little crystalloid (ATLS 11 teaching warns against more than 1 L), tranexamic acid within 3 h, calcium and warming. Activate massive transfusion early; an ABC score of 2 or more was 75% sensitive and 86% specific (Nunez 2009). The European guideline (2023) sets these targets while bleeding continues:

• SBP 80–90 mm Hg (MAP 50–60) without brain injury, MAP ≥80 if GCS 8 or less; brief norepinephrine if SBP stays below 80 despite volume
• Hemoglobin 7–9 g/dL; platelets above 50 × 10⁹/L (100 × 10⁹/L with brain injury)
• Fibrinogen above 1.5 g/L; if lower, 3–4 g as concentrate or 15–20 single-donor cryoprecipitate units
• Ionized calcium 1.1–1.3 mmol/L; core temperature 36–37 °C

At the bedside, massive transfusion is logistics: a rapid infuser with an in-line warmer, a runner, calcium after the first units, labs about every 30–60 min (CBC, INR, fibrinogen, iCa, potassium, blood gas, lactate, viscoelastic test), and stopping the protocol once bleeding is controlled. Expect hyperkalemia, citrate-driven low calcium, later metabolic alkalosis, and TACO or TRALI.

Damage control surgery (Rotondo 1993) controls bleeding and contamination, packs, and closes the abdomen temporarily, deferring repair until physiology recovers. In Rotondo's patients with major vascular and two or more visceral injuries, survival was 77% vs 11% with definitive laparotomy; they spent a mean of about 32 h in the ICU and were rewarmed from 33.2 to 37.7 °C before reoperation. The European guideline recommends it for hemorrhagic shock with ongoing bleeding or coagulopathy, and for hypothermia, acidosis, inaccessible injuries or long procedures.

1. Ground zero: control bleeding, resuscitate, go straight to the OR or hybrid suite.
2. Abbreviated operation: stop bleeding and contamination, pack, close temporarily.
3. ICU, often 24–48 h: rewarm, correct coagulation, calcium and acidosis, measure bladder pressure.
4. Planned return: remove packs, repair, close the fascia in the same admission if possible (WSACS 2013).

Brain and spinal cord injury in the first hours

The first hours are about preventing secondary brain injury. A single SBP below 90 or PaO₂ below 60 roughly doubled mortality in the Traumatic Coma Data Bank, and when Arizona EMS adopted the prehospital TBI guidelines (EPIC, Spaite 2019), adjusted survival doubled in severe TBI and tripled in intubated patients.

• SpO₂ ≥90%; EtCO₂ 35–45 mm Hg at about 10 breaths/min when bagging; EtCO₂ 30–35 only for signs of herniation, as a bridge (BTF prehospital 2023)
• SBP ≥110 in adults (BTF prehospital 2023; BTF 4th edition accepts ≥100 at age 50–69); no permissive hypotension when TBI and bleeding coexist
• Head up 30° (reverse Trendelenburg until the spine is cleared), neck midline, nothing tight around the neck
• Herniation: mannitol or hypertonic saline, CT and neurosurgery
• Reverse anticoagulants at once; TXA within 3 h helped only mild to moderate TBI (CRASH-3, RR 0.78); steroids raised 2-week mortality (21.1% vs 17.9%, CRASH 2004)

A hypotensive patient with a cord injury is bleeding until proven otherwise. Neurogenic shock (injury at T6 or above) brings bradycardia with warm, dry skin; hemorrhage brings tachycardia and cool skin; both often coexist. Restore volume, then add norepinephrine; suctioning and turning can trigger bradycardia that needs atropine. MAP goals are 85–90 for 7 days (AANS/CNS 2013) or at least 75–80, not pushed above 90–95, for 3–7 days (AO Spine 2024). Injury at C3–C5 threatens the diaphragm, so trend vital capacity and cough strength and intubate early and in a controlled way. Decompression within 24 h raised the chance of a 2-grade AIS gain (19.8% vs 8.8%, STASCIS 2012). In obtunded blunt patients, a negative high-quality CT allows collar removal (EAST 2015, conditional).

Chest and abdomen: eFAST, CT and the decision to operate

FAST looks at the hepatorenal space, splenorenal space, pelvis and pericardium; eFAST adds both anterior chests for lung sliding. Positive findings guide action, negative ones rule out little: in blunt trauma, point-of-care ultrasound was 74% sensitive and 96% specific overall but 68% sensitive for abdominal injury and 63% in children (Stengel 2018). For pneumothorax, ultrasound was 90.9% sensitive vs 50.2% for a supine chest film (Alrajhi 2012). FAST misses retroperitoneal, bowel, diaphragm and small solid-organ injuries; repeat it when the patient changes.

Chest: EAST 2021 conditionally recommends 14 Fr pigtail catheters for hemothorax in stable patients and VATS within 4 days, rather than lytics, for retained hemothorax. A normal admission ECG plus a normal troponin I rules out blunt cardiac injury; echo is for hypotension or arrhythmia, and a sternal fracture alone does not predict it (EAST 2012). Blunt aortic injury is diagnosed by CT angiography and repaired endovascularly, often after a delay under strict blood pressure control (EAST 2015).

Abdomen: nonoperative management is standard for hemodynamically stable blunt splenic injury of any grade when monitoring, serial exams and an operating room are available, with angioembolization for a contrast blush (EAST 2012). Bowel, mesentery, pancreas, duodenum and diaphragm are the classic CT misses: a seat-belt sign, free fluid without solid-organ injury, or rising pain, fever, white count or ileus over 24–48 h calls for repeat imaging or laparotomy.

Older adults and pregnancy

After 65, vital signs mislead: beta-blockers and pacemakers fix the heart rate, and chronic hypertension makes a normal-looking pressure relative hypotension. SBP below 90 identifies only 4–5% of seriously injured older adults, so the 2021 national field triage guideline uses SBP below 110 or heart rate above SBP. An EAST multicenter study (Ho 2025) supports head and cervical spine CT for every older blunt trauma patient seen by the trauma team, adding torso CT for an abnormal exam or high-risk features. Anticoagulants turn minor head trauma into hemorrhage: reverse warfarin with 4-factor PCC plus IV vitamin K, dabigatran with idarucizumab, and factor Xa inhibitors with 4-factor PCC (andexanet alfa left the US market in December 2025). Each additional rib fracture raised mortality 19% (Bulger 2000), so treat pain early, often with regional blocks, and screen for frailty, delirium and goals of care.

In pregnancy, resuscitate the mother; maternal perfusion is fetal perfusion. Plasma volume rises 30–40% and heart rate 15–20/min (FEBRASGO 2023), so a mother can lose a large volume before her vital signs change while uterine flow has already fallen; fetal distress may be the first sign. After 20 weeks, displace the uterus to the left. A PaCO₂ near 30 mm Hg is normal late in pregnancy, so 40 signals tiring, and fibrinogen runs 400–600 mg/dL, so 200 is low. Place chest tubes one or two spaces higher. Do not withhold indicated imaging; fetal doses under 50 mGy are acceptable.

• Monitor the fetus for at least 6 h at viable gestations; abruption is the commonest obstetric complication.
• Fetomaternal hemorrhage occurs in 10–30%: give Rh-negative mothers anti-D (300 mcg covers 30 mL of fetal blood).
• Arrest with the fundus above the umbilicus: perimortem cesarean if there is no ROSC after 4 min of CPR.

ICU phase: tertiary survey, missed injuries and late complications

The tertiary survey repeats the head-to-toe exam, reviews every image with its final read and every lab, and retakes the history, usually within 24 h and again when the patient wakes or is extubated. Enderson 1990 found missed injuries in 9% of 399 admissions, mostly extremity fractures, missed mainly because of head injury or intoxication; published rates range from 1.3% to 39% (Pfeifer 2008). Look for hand and foot fractures, ligamentous spine injury, bowel and diaphragm injury, nerve deficits and blunt cerebrovascular injury (1–2% of blunt trauma), which shows up as a delayed stroke unless high-risk patients get CT angiography. Compartment syndrome: pain out of proportion and on passive stretch come first; in sedated patients, measure, and decompress when diastolic minus compartment pressure is below 30 mm Hg (McQueen 1996).

• Rhabdomyolysis: CK peaks at 24–72 h; above 5,000 U/L, renal failure was 19% vs 8% (Brown 2004)
• Give isotonic crystalloid early, aiming for urine output about 200–300 mL/h, and taper as CK falls below about 5,000 (Richert 2026); bicarbonate and mannitol did not prevent renal failure or death (Brown 2004)
• Potassium is the early killer: continuous ECG and frequent levels; early low calcium can rebound high in recovery

Fat embolism syndrome appears 1–3 days after long-bone or pelvic fracture (clinical incidence 1.4–12.5%) as hypoxemia, then confusion, then petechiae on the chest, axillae and conjunctivae, present in fewer than half (Miyake 2026). Care is supportive (up to 44% need intubation); fixation within 24 h is the best prevention, and steroids are not standard.

Enoxaparin beat heparin after major trauma (DVT 31% vs 44%; Geerts 1996); many centers weight-adjust it toward an anti-Xa of 0.2–0.4 IU/mL (AAST 2021). After operative extremity or any pelvic fracture, aspirin 81 mg twice daily was noninferior for 90-day death (0.78% vs 0.73%) with more DVT (2.51% vs 1.71%; PREVENT CLOT 2023).

Evidence and controversies

PROCOAG (2023) added empirical 4-factor PCC without reducing blood use (12 vs 11 units) and with more thromboembolic events (35% vs 24%). Prehospital TXA is still debated: STAAMP (2020) missed its 30-day mortality endpoint (8.1% vs 9.9%). Unsettled: calcium dosing, viscoelastic versus ratio-driven transfusion (ITACTIC 2021 found no difference), whole blood after hospital arrival, REBOA's niche, the blood pressure floor in brain injury and VTE timing after TBI.

Exam pearls

• xABCDE: stop catastrophic external bleeding first; give blood before intubating a hypotensive patient.
• Hypotension first appears in class III (31–40% loss); tachycardia and a narrow pulse pressure come earlier; shock index ≥1 is a warning.
• TXA 1 g over 10 min, then 1 g over 8 h, only within 3 h of injury.
• Permissive hypotension (SBP 80–90) is not for brain or spinal cord injury.
• Pelvic binder at the greater trochanters; REBOA Zone 1 for abdominal, Zone 3 for pelvic bleeding.
• A negative FAST does not rule out abdominal injury; an unstable patient never goes to CT.
• Lethal triad: hypothermia, acidosis, coagulopathy; low ionized calcium makes it a diamond.
• Fat embolism: 1–3 days after a long-bone fracture, with hypoxemia, confusion and petechiae.
• Abdominal compartment syndrome: bladder pressure above 20 mm Hg with new organ dysfunction.