Trauma Assessment

Introduction

Trauma assessment applies the ABCDE framework with modifications specific to injury: catastrophic haemorrhage is controlled first, cervical spine protection runs alongside airway assessment, and breathing assessment specifically hunts for a short list of immediately life-threatening chest injuries. The approach is taught as the primary survey, followed by a secondary survey once the patient is physiologically stable enough to tolerate a more detailed examination.¹

Trauma deaths follow a recognised pattern: some occur within minutes from unsurvivable injury or airway obstruction, some within the first hours from haemorrhage or other treatable causes (the window this article is built around), and some days later from sepsis or multi-organ failure. The primary survey exists to catch everything treatable in that first, early window.

It is worth being explicit about why the order matters so much here. Each letter represents a threat that kills faster than the one after it - exsanguination and airway loss within minutes, a tension pneumothorax or tamponade within tens of minutes, occult intra-abdominal bleeding over hours. Working through the letters strictly in sequence, and treating each abnormality the moment it is found, is what stops a survivable combination of injuries from becoming fatal simply because attention went to the wrong problem first.

Primary survey: <C>ABCDE

The trauma primary survey adds catastrophic haemorrhage control as the first step, written as <C>ABCDE, and folds cervical spine protection into the airway assessment.

<C> - Catastrophic haemorrhage

• Direct pressure on any visible external bleeding
• A tourniquet for catastrophic limb haemorrhage not controlled by pressure alone
• A pelvic binder for suspected pelvic fracture with haemodynamic instability, applied at the level of the greater trochanters before the patient is moved further

A - Airway with cervical spine protection

Assess and secure the airway as in any acutely unwell patient, but with manual in-line cervical spine immobilisation maintained throughout for any mechanism with plausible risk of spinal injury - a jaw thrust rather than a head tilt-chin lift is used to open the airway without moving the neck.

B - Breathing

Expose the chest fully and specifically look for the immediately life-threatening chest injuries, since these are common, rapidly fatal, and immediately treatable.

C - Circulation with haemorrhage control

Assess for shock and continue to control haemorrhage as in any major bleeding presentation: large-bore IV access, bloods including group and save or crossmatch, and activation of the major haemorrhage protocol if indicated. A FAST scan (Focused Assessment with Sonography in Trauma) is frequently performed during this step - a rapid bedside ultrasound looking for free fluid in the pericardium, hepatorenal space, splenorenal space and pelvis, to identify occult internal bleeding needing urgent surgical or interventional control.

Resuscitation follows damage control principles: balanced blood products rather than large volumes of crystalloid, tranexamic acid within 3 hours of injury, and permissive hypotension (accepting a lower blood pressure until bleeding is surgically controlled) in penetrating or uncontrolled trauma without a head injury. These principles, and the physiology behind them, are covered in full separately.

D - Disability

GCS, pupils and blood glucose, as in any acutely unwell patient. A focused assessment of gross limb movement and sensation is added where spinal injury is suspected.

E - Exposure and environment

Fully expose the patient to find all injuries, including a log-roll to inspect the back and spine, while actively preventing hypothermia - cold, injured trauma patients coagulate poorly, compounding blood loss.

Cervical spine clearance

Immobilisation is maintained until the cervical spine can be safely cleared clinically or radiologically. Clinical clearance uses a validated decision rule (such as the Canadian C-Spine Rule or NEXUS criteria) to identify patients who need imaging versus those in whom a normal, pain-free examination with full range of movement safely excludes significant injury. High-risk features - age over 65, a dangerous mechanism, paraesthesia in the limbs, or any factor precluding a reliable examination such as intoxication or a distracting injury - lower the threshold for imaging rather than clinical clearance alone.

Adjuncts to the primary survey

• Continuous monitoring - ECG, pulse oximetry, blood pressure, capnography if intubated
• Urinary catheter to monitor output as a marker of perfusion, unless urethral injury is suspected (blood at the meatus, a high-riding prostate)
• Gastric tube to decompress the stomach and reduce aspiration risk - orogastric rather than nasogastric if a base of skull fracture is suspected
• Trauma imaging - a trauma CT (head to pelvis) is now standard in many UK major trauma centres for patients meeting activation criteria, alongside a plain chest and pelvis X-ray where CT is delayed or unavailable

Secondary survey

The secondary survey is a systematic head-to-toe examination performed once the primary survey is complete and the patient's physiology is controlled, aimed at finding injuries that are not immediately life-threatening but still need treatment.

• Head and face - scalp lacerations, facial fractures, ocular injury
• Neck - further assessment of the cervical spine once imaging allows
• Chest - re-examine for injuries not caught on the primary survey, such as simple pneumothorax or rib fractures
• Abdomen and pelvis - tenderness, distension, pelvic stability (assessed once only, since repeated springing can dislodge a stabilising clot)
• Limbs - fractures, dislocations, neurovascular status distal to any injury, and compartment syndrome (pain out of proportion to the injury and worsened by passive stretch is the earliest sign - pallor, paraesthesia, paralysis and pulselessness are late and mean irreversible muscle damage may already be underway)
• Back and spine - via log-roll, looking for step deformity, bruising or a penetrating wound
• Neurological examination - full assessment once the patient can cooperate

AMPLE history

A structured history taken from the patient, family or paramedics in parallel with the examination:

• Allergies
• Medications, particularly anticoagulants and antiplatelets
• Past medical history
• Last meal (relevant to aspiration risk if anaesthesia is needed)
• Events and environment surrounding the injury - the mechanism, and details from the scene

Major trauma networks and triage

England, Scotland and Wales are organised into regional major trauma networks, each centred on a major trauma centre with 24/7 access to neurosurgery, interventional radiology, cardiothoracic surgery and specialist orthopaedic and plastic surgery. Patients meeting defined physiological or mechanistic criteria are triaged by paramedics to bypass a nearer trauma unit and go directly to the major trauma centre where survival benefit is clearest, even if this means a longer prehospital journey.²

• Physiological criteria - abnormal GCS, respiratory rate or blood pressure
• Anatomical criteria - penetrating injury to the torso, neck or head; two or more long bone fractures; suspected pelvic fracture; amputation proximal to the wrist or ankle
• Mechanistic criteria - high-speed collision, ejection from a vehicle, fall from height, or a pedestrian/cyclist struck at speed

A pre-alert call to the receiving hospital, giving mechanism, injuries found and vital signs, allows the trauma team to be assembled and ready before the patient arrives - a structured handover (commonly ATMIST: Age, Time of injury, Mechanism, Injuries, Signs, Treatment given) keeps this efficient.

Damage control surgery

In severely injured patients with deranged physiology - the lethal triad of hypothermia, acidosis and coagulopathy - definitive surgical repair of every injury in one long operation can itself kill the patient. Damage control surgery instead performs the minimum necessary to control haemorrhage and contamination (for example packing the abdomen and temporary closure, rather than complete repair), allowing the patient to be resuscitated and warmed in critical care before returning for definitive surgery once physiology has been corrected.

Red flags

Prognosis

Outcome after major trauma depends on injury severity, physiological reserve, and how quickly the patient reaches definitive care - which is precisely why triage tools exist to route the most severely injured directly to a major trauma centre. Within a well-organised trauma network, mortality from major trauma has fallen substantially compared with care delivered outside such systems, reflecting faster access to blood products, interventional radiology and specialist surgery.