Trauma-team primary and secondary surveys

A trauma survey is a prioritisation system rather than a single examination. Preparation begins before arrival: activate the appropriate team, allocate a leader and roles, check difficult-airway, thoracostomy, haemorrhage-control and warming equipment, alert blood bank and theatre or interventional radiology when the pre-alert suggests need, and agree where the patient will go if immediate source control is required. The pre-hospital ATMIST account—age, time, mechanism, injuries suspected, signs and treatment—predicts hazards but must not replace direct reassessment.

During the primary survey, findings and treatments occur together. Catastrophic compressible bleeding is controlled at once. Airway is assessed with cervical-spine protection; breathing requires inspection, palpation, auscultation and immediate treatment of clinical tension pneumothorax. Circulation combines pulse, skin, mental state and haemodynamic trends with an active search for external, thoracic, abdominal, pelvic and long-bone blood loss. Disability includes pupils, GCS components, glucose and lateralising signs. Exposure includes the back and perineum when indicated, but heat conservation continues throughout.

Team leadership changes outcome because serial tasks are too slow. The leader stands where they can see the patient and monitors, states priorities, uses closed-loop communication and prevents competing procedures. A scribe time-stamps observations, blood products, drugs and decisions. The airway clinician announces tube depth and capnography; the circulation clinician reports access, samples and response; the examining clinician identifies injuries. Anyone can voice a safety concern, while one person retains authority over transfer to CT, theatre or interventional radiology.

A secondary survey is a deliberate head-to-toe assessment after resuscitation has started to work. Obtain AMPLE history—allergies, medicines including anticoagulants, past history and pregnancy, last meal, and events or environment—then inspect scalp, face, neck, chest, abdomen, pelvis, perineum and all limbs; assess the spine and posterior surfaces with movement tailored to injuries. Reconcile every wound, swelling and neurological finding with imaging. Analgesia, splintage and wound care are treatment, not optional additions to examination.

Physiology is interpreted as a trend. Young adults may maintain blood pressure despite significant loss, beta-blockade can blunt tachycardia, pregnancy alters baseline pulse and circulating volume, and older people can decompensate with little reserve. Repeated capillary refill, mental state, skin temperature, blood pressure, pulse pressure, lactate or base deficit, urine output and response to blood are more informative than one normal value. A transient responder still has active bleeding until proven otherwise.

Destination decisions should be made early and revisited. A stable or responding patient with suspected multisystem blunt trauma may benefit from rapid whole-body CT with the trauma team present. Persistent instability with a likely source may require direct theatre, interventional radiology or a hybrid pathway. Transfer between hospitals needs the same preparation as initial reception: secure airway and drains, continue warming and haemorrhage control, send images and results, provide blood capability when needed, and name the receiving clinician.

Good documentation supports later diagnosis. Record pre- and post-procedure neurovascular status, the reason an area was not examined, tourniquet and binder application times, blood products, TXA timing, lines, drains and pending reports. A final radiology report may differ from the preliminary interpretation. Injuries discovered after admission are not merely administrative events: they should trigger treatment, communication with the patient and review of why the original process did not reveal them.