Major trauma — ATLS primary/secondary survey, damage control resuscitation

Overview and Framework

The primary survey is the cornerstone of initial trauma management, a structured, iterative assessment designed to identify and simultaneously treat immediately life-threatening injuries before proceeding to definitive care. Originally formalised within the ATLS framework and now embedded in trauma systems worldwide, the primary survey follows the ABCDE sequence: catastrophic haemorrhage control, Airway with cervical spine protection, Breathing and ventilation, Circulation with haemorrhage control, Disability (neurological assessment), and Exposure with Environment control.

For the anaesthetist arriving to a trauma call, or indeed leading resuscitation, the primary survey is not merely a checklist to observe but an active management protocol. The anaesthetist's particular expertise in airway management, haemodynamic resuscitation, and procedural intervention makes their role in trauma resuscitation central rather than peripheral. Understanding the primary survey at consultant level means anticipating the next step before the current one is complete, recognising when a reassessment loop is required, and understanding the physiological rationale for each intervention.

The primary survey is a simultaneous assessment and treatment process, not a sequential checklist. Findings at each step may redirect priorities. A deteriorating patient demands immediate reassessment from the beginning, the "ABCDE loop", rather than continuing linearly. Definitive investigations (CT, formal imaging, laboratory studies) belong to the secondary survey; the primary survey relies on clinical examination and point-of-care findings alone.

Catastrophic Haemorrhage Control: The "C" Before ABCDE

The modification of traditional ABCDE to include , catastrophic haemorrhage, reflects the recognition that uncontrolled exsanguination from extremity injuries or junctional wounds kills patients before any airway intervention can be meaningful. This is the tactical combat casualty care (TCCC) principle now embedded in civilian trauma protocols.

Assessment

• Visual inspection of limbs, groin, axillae, and neck for junctional or compressible haemorrhage
• Identify arterial spurting, major venous haemorrhage, or partial/complete traumatic amputation

Interventions

• Tourniquets for extremity haemorrhage: placed 5-8 cm proximal to wound, tightened until haemorrhage ceases; time of application documented
• Wound packing with haemostatic gauze (e.g. Combat Gauze containing kaolin) for junctional wounds followed by direct pressure for minimum 3 minutes
• Pressure dressings for scalp lacerations and accessible wounds

Key principle: Haemorrhage is the leading cause of preventable traumatic death. If the patient is exsanguinating from a visible extremity wound, the tourniquet goes on first, before even addressing the airway.

A, Airway with Cervical Spine Protection

Assessment

The airway is assessed for patency and maintainability:

A patient who is speaking in clear sentences has a patent airway at that moment, but temporal changes are critical. An airway patent on arrival may deteriorate rapidly with haematoma expansion, oedema, or reduced level of consciousness.

Cervical Spine

C-spine immobilisation is maintained throughout unless clinical clearance criteria are met. Manual in-line stabilisation (MILS) during intubation reduces but does not eliminate the risk of cord injury during laryngoscopy in an unstable injury. MILS slightly worsens the laryngoscopic view (typically Cormack-Lehane grade increases by one). The anaesthetist must balance the risk of cord injury against the risk of failed intubation, in a genuinely compromised airway, securing the airway takes precedence.

Interventions

• Basic manoeuvres: jaw thrust (preferred over chin lift in trauma), suction, removal of foreign bodies
• Adjuncts: oropharyngeal airway (OPA), nasopharyngeal airway (NPA, used cautiously if base of skull fracture suspected)
• Definitive airway, endotracheal intubation or surgical airway, indicated for:
• GCS ≤8
• Inability to protect airway
• Airway obstruction not relieved by basic manoeuvres
• Anticipated deterioration (inhalation injury, expanding neck haematoma)
• Need for controlled ventilation (severe TBI, haemodynamic instability requiring intubation for transfer)

Clinically: Rapid sequence induction (RSI) with ketamine 1-2 mg/kg IV and suxamethonium 1.5 mg/kg IV (or rocuronium 1.2 mg/kg if suxamethonium contraindicated) is the standard in trauma. Ketamine preserves haemodynamic stability and is the induction agent of choice in haemorrhagic shock. In severe TBI without haemodynamic compromise, propofol (0.5-1.5 mg/kg, dose-reduced) or thiopentone may be considered, though caution is warranted given cardiovascular depression.

Surgical airway: If intubation fails and oxygenation cannot be maintained, cannot intubate, cannot oxygenate (CICO), a surgical cricothyroidotomy is the definitive rescue. The cricothyroid membrane is the landmark; a scalpel-bougie-tube technique (or commercial device) allows rapid access in 30-60 seconds. This is a core ANZCA competency.

B, Breathing and Ventilation

Airway patency alone does not ensure adequate ventilation. Six immediately life-threatening thoracic injuries must be excluded clinically before proceeding:

Assessment Tools at Primary Survey Stage

• Clinical examination: inspection (respiratory rate, symmetry, effort), palpation (trachea, crepitus), percussion, auscultation
• SpO₂, target ≥94-96% in most trauma; in TBI, target SpO₂ ≥98%
• ETCO₂ once intubated, target PaCO₂ 35-40 mmHg; avoid hypocapnia (causes cerebral vasoconstriction) and hypercapnia (raises ICP)
• Bedside extended FAST (eFAST), rapid assessment for pneumothorax (anterior pleural sliding) and haemothorax (costophrenic angle)

Key principle: Tension pneumothorax is a clinical diagnosis, do not wait for CXR. If haemodynamic collapse follows intubation (especially positive pressure ventilation), presume tension pneumothorax and decompress bilaterally.

C, Circulation with Haemorrhage Control

Haemorrhagic Shock Classification

Understanding the ATLS shock classification guides the aggressiveness of resuscitation:

Examination tip: These thresholds are population averages with substantial individual variation. Athletes may not tachycardia until Class III. The elderly and those on beta-blockade may not mount a tachycardia. Pregnancy shifts baselines. Treat the clinical picture, not the class number.

Assessment

• Pulse rate, quality, and regularity
• Blood pressure (with awareness of target-dependent resuscitation: permissive hypotension, systolic 80-90 mmHg, is acceptable in penetrating trauma without TBI, until surgical haemorrhage control)
• Skin perfusion: colour, temperature, capillary refill time (>2 seconds is abnormal)
• Obvious sources of haemorrhage: external wounds, long bone fractures, pelvis (pelvic binder), thorax, abdomen (FAST ultrasound, free fluid), retroperitoneum

Interventions

Vascular access: Two large-bore (≥16 G) peripheral IVs; if not achievable within 90 seconds, intraosseous (IO) access (proximal tibia, proximal humerus, or sternum) delivers equivalent flow rates and allows infusion of blood products, vasopressors, and medications. Central venous access is not a primary survey priority unless peripheral/IO access fails.

Resuscitation strategy:

• Damage control resuscitation (DCR) is the modern standard: blood product-based, targeting a 1:1:1 ratio of packed red cells: fresh frozen plasma: platelets, with early use of tranexamic acid (TXA)
• Tranexamic acid: 1 g IV over 10 minutes within 3 hours of injury (ideally within 1 hour); second dose 1 g over 8 hours if required. Evidence from CRASH-2 demonstrates mortality benefit; effect is time-dependent, no benefit (and possible harm) if given >3 hours post-injury
• Avoid large-volume crystalloid resuscitation, amplifies the lethal triad of hypothermia, acidosis, and coagulopathy
• Massive transfusion protocol (MTP) activation threshold: haemodynamic instability with suspected major haemorrhage (clinical judgement; some use TASH score or ABC score)
• Point-of-care testing, viscoelastic haemostasis assays (TEG/ROTEM), guide targeted product replacement if available; not always available at primary survey stage

Pelvic fractures: Suspected on mechanism or pelvic instability on clinical examination. Apply a pelvic binder (at greater trochanter level) immediately. Avoid repeated pelvic springing, it displaces clot.

Permissive hypotension: In uncontrolled haemorrhage, targeting systolic BP 80-90 mmHg (MAP ~50 mmHg) reduces ongoing haemorrhage until surgical control is achieved. This strategy is contraindicated in TBI (where CPP must be maintained, target MAP ≥80 mmHg, or systolic ≥110 mmHg).

D, Disability (Neurological Assessment)

Assessment

Rapid neurological assessment at the primary survey level focuses on:

• Glasgow Coma Scale (GCS): documented as E + V + M with total score (3-15). GCS ≤8 mandates definitive airway
• Pupillary response: size, symmetry, reactivity. Unilateral fixed dilated pupil suggests ipsilateral herniation (Cushing response = hypertension + bradycardia + irregular respirations)
• AVPU scale (Alert, Voice, Pain, Unresponsive), rapid bedside alternative
• Limb movement: gross assessment for lateralising deficits, spinal cord injury (areflexia, priapism, paradoxical breathing)
• Blood glucose: hypoglycaemia mimics or worsens TBI, point-of-care BGL at this stage

TBI Management Priorities at Primary Survey

Key principle: Secondary brain injury from hypoxia (SpO₂ <90%) and hypotension (SBP <90 mmHg) dramatically worsens outcome. These are entirely preventable causes of harm. At the primary survey stage, TBI management is prevention of secondary injury:

• Maintain SpO₂ ≥98%
• Maintain SBP ≥110 mmHg (or MAP ≥80 mmHg)
• Avoid hypocapnia (target ETCO₂ 35-40 mmHg); controlled hyperventilation (ETCO₂ 30-35 mmHg) only as a temporising measure for acute herniation
• Head-up 30° once haemodynamically stable
• Avoid hyperthermia

E, Exposure and Environment

Exposure

The patient must be fully exposed, all clothing cut away, to enable complete assessment. Log-roll with spinal precautions to examine the back, identifying:

• Posterior penetrating wounds
• Spinal deformity or step-off
• Perineal injuries (suggestive of pelvic fracture)
• Burns distribution and depth

Environmental Control

Hypothermia is a critical concern and a potent driver of coagulopathy (platelet dysfunction, reduced clotting factor activity). Even mild hypothermia (core temperature 35-36°C) worsens outcomes in major trauma.

• Remove wet clothing
• Warm IV fluids and blood products
• Warm blankets, forced-air warming device
• Warm resuscitation room
• Target core temperature >36°C

Examination tip: The lethal triad of hypothermia + acidosis + coagulopathy is a vicious cycle, each element worsens the others. Damage control resuscitation is specifically designed to interrupt this cycle by minimising crystalloid (which worsens acidosis and haemodilution), prioritising blood products, and aggressively maintaining normothermia.

Adjuncts to the Primary Survey

These investigations are initiated during or immediately after the primary survey, they do not pause the primary survey:

Reassessment and the ABCDE Loop

The primary survey is dynamic and iterative. Any deterioration, haemodynamic, respiratory, or neurological, mandates return to ABCDE from the beginning. Common causes of deterioration requiring reassessment:

• Tension pneumothorax (especially post-intubation or positive pressure ventilation)
• Ongoing uncontrolled haemorrhage
• Worsening TBI / herniation
• Development of cardiac tamponade

Clinically: The anaesthetist who has secured the airway and established IV access must maintain active surveillance throughout, not disengage from the resuscitation. Deterioration after intubation should prompt immediate reassessment of tube position (ETCO₂, auscultation), pneumothorax, and haemodynamic status.

Summary and Examination Strategy

The primary survey in trauma is a structured, simultaneous assessment-and-resuscitation protocol, sequenced to address the most immediately lethal threats first:

Examination tip: ANZCA MCQ and OSCE questions commonly test the integration of competing priorities, for example, a patient with GCS 8 and suspected tension pneumothorax who is haemodynamically unstable. The answer is almost always to treat the immediately lethal physiology first (tension pneumothorax before RSI if the airway is currently patent), and to recognise that permissive hypotension is contraindicated in TBI. Demonstrate that you understand the rationale behind the sequence, not just the mnemonic.

Sources

• ATLS (Advanced Trauma Life Support)
• ANZCA Professional Documents (PS series)