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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Trauma-team primary and secondary surveys

Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Physiology before anatomy

Airway obstruction, inadequate ventilation, uncontrolled haemorrhage and traumatic cardiac arrest kill before a complete diagnosis is available, and several threats may coexist.

Action: Activate the trauma team, use a shared CABCDE sequence, treat each life threat when found, call senior surgical and anaesthetic help early, and repeat the survey after every intervention or physiological change.

Overview

Run a disciplined trauma-team assessment that identifies and treats immediate threats, coordinates parallel action, and prevents important injuries being lost during handover or deterioration.

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.

Practice

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Musculoskeletal medicine and orthopaedicsOriginal SBA

Transient response to blood

An adult with blunt abdominal trauma becomes briefly normotensive after blood, then develops recurrent hypotension and a rising lactate. What is the most appropriate interpretation and next priority?

Choose one answer, then submit
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG39 Major trauma: assessment and initial management
  • NICE NG40 Major trauma: service delivery
  • Resuscitation Council UK 2025 special circumstances guidelines
  • Cyklokapron 100 mg per mL solution for injection SmPC

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom

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.

Key points

  • Use CABCDE when catastrophic external bleeding is evident; otherwise follow ABCDE while another team member obtains monitoring, access and a concise ATMIST handover.
  • Call out each finding, intervention and response. A named leader maintains the overview while airway, procedure, nursing, imaging and scribing roles work in parallel.
  • Do not wait for the end of the primary survey to decompress a tension pneumothorax, control major bleeding, apply a correctly positioned pelvic binder or initiate blood-component resuscitation.
  • Record Glasgow Coma Scale components, pupils, glucose and limb neurology; a falling score is a clinical deterioration, not an imaging result to await.
  • Expose sufficiently to find posterior, perineal and junctional injury, while using warmed blankets, fluid warmers and active warming to prevent hypothermia.
  • Begin the secondary survey only after immediate threats have been treated and physiology is stabilising; return to CABCDE whenever observations worsen.
  • Use whole-body CT for appropriate haemodynamically stable or responding adults with suspected multiple injuries; an unstable non-responder needs haemorrhage control, not a diagnostic tour.
  • Close every transition with a structured handover, explicit outstanding actions and a planned tertiary survey because resuscitation, transfer and altered consciousness conceal injuries.

Aetiology

01

Blunt energy transfer

Road collisions, falls, crush and assault transmit energy across several body regions, so an obvious limb injury may distract from occult thoracic, abdominal, pelvic or cranial trauma.

02

Penetrating injury

Stab, ballistic and impalement wounds create tract-dependent vascular and visceral damage; the external wound does not reliably indicate depth, direction or number of injured structures.

03

Physiological vulnerability

Age, pregnancy, frailty, anticoagulation, intoxication and cardiorespiratory disease alter presentation, reserve and treatment tolerance even when the anatomical injury appears similar.

Pathophysiology

  1. 1
    Immediate oxygen failure

    Obstruction, hypoventilation, tension pneumothorax or major chest disruption rapidly reduces oxygen delivery and can progress to peri-arrest before detailed imaging is possible.

  2. 2
    Haemorrhagic shock

    Loss of circulating volume reduces preload and tissue perfusion; acidosis, hypothermia, endothelial injury and coagulopathy then amplify bleeding unless haemorrhage and heat loss are controlled.

  3. 3
    Secondary tissue injury

    Hypoxaemia, hypotension, hypercarbia and fever worsen injured brain and spinal cord, making apparently general resuscitation choices central to neurological outcome.

  4. 4
    Dynamic deterioration

    Compensated patients can decompensate after transfer, analgesia, positive-pressure ventilation or clot disruption, so a normal early observation set is not a clearance test.

Clinical features and red flags

Catastrophic haemorrhage

Pulsatile or uncontrolled external bleeding, traumatic amputation or rapidly expanding junctional wound is controlled immediately with direct pressure, packing or an appropriate tourniquet while the rest of CABCDE continues.

Threatened airway

Inability to speak, stridor, gurgling, facial or neck injury, soot, expanding haematoma, agitation followed by fatigue, or falling consciousness requires early expert airway planning.

Breathing threat

Unilateral absent breath sounds with severe distress or shock, open chest wound, paradoxical movement or massive haemothorax features demand immediate treatment based on clinical findings.

Occult shock

Cool mottled skin, delayed refill, confusion, narrow pulse pressure, tachypnoea, lactate rise or a transient response may reveal hypoperfusion before conventional hypotension appears.

Neurological deterioration

A falling GCS, unequal pupils, new weakness, seizure or repeated vomiting changes urgency and requires renewed airway, oxygenation, perfusion and intracranial-injury assessment.

Limb threat

Absent pulses, deteriorating sensation or motor function, disproportionate pain, tense swelling and open fracture require time-stamped neurovascular findings and immediate orthopaedic or vascular escalation.

Red flags requiring action

  • Absent or threatened airway, severe respiratory distress, shock, reduced consciousness

Investigations

  1. 01
    First-line continuous monitoringFirst stepFirst line
    Why
    Detect deterioration during assessment and intervention.
    Interpretation and limitations
    Use ECG, pulse oximetry, repeated non-invasive pressure, respiratory rate, temperature and waveform capnography after advanced airway placement; trends and treatment response matter more than isolated values.
  2. 02
    Immediate blood panel
    Why
    Prepare transfusion and identify reversible physiological derangement.
    Interpretation and limitations
    Send FBC, group and crossmatch, coagulation including fibrinogen where available, blood gas with lactate, electrolytes, renal function, glucose and ionised calcium; a normal early haemoglobin does not exclude major blood loss.
  3. 03
    Bedside chest and pelvic imaging
    Why
    Find a source when instability makes CT unsafe.
    Interpretation and limitations
    Portable radiographs and focused ultrasound can direct chest or pelvic intervention, but a negative FAST does not exclude retroperitoneal, hollow-viscus or early intraperitoneal bleeding.
  4. 04
    Preferred definitive imaging in stable polytraumaPreferred
    Why
    Map injuries rapidly across body regions.
    Interpretation and limitations
    NICE supports immediate whole-body CT for adults with blunt major trauma and suspected multiple injuries; image from vertex to mid-thigh without repositioning and add limb imaging when clinically required.

Differential diagnosis

01

Medical collapse causing trauma

Arrhythmia, acute coronary syndrome, stroke, seizure, hypoglycaemia or sepsis may have caused the fall or collision and still require treatment alongside injuries.

02

Intoxication

Alcohol, opioids and sedatives can mimic brain injury, but intoxication must not be accepted as the cause of reduced consciousness until traumatic threats are excluded.

03

Neurogenic shock

Hypotension with relative bradycardia, warm peripheries and neurological deficit suggests loss of sympathetic tone, but occult haemorrhage remains the first exclusion.

04

Obstructive shock

Tension pneumothorax or tamponade may present with hypotension and tachycardia; mechanism, chest findings and focused ultrasound can redirect immediate source control.

Management

01ImmediateRun and repeat CABCDEFirst stepAny patient with suspected major trauma or abnormal physiology.+
  1. 1Control catastrophic external haemorrhage, assess airway with spinal protection, give oxygen when critically ill and call anaesthetic help for a threatened airway.
  2. 2Identify and treat breathing threats clinically, attach monitoring, obtain large-bore intravenous or intraosseous access and activate major-haemorrhage support when indicated.
  3. 3Assess circulation, disability and exposure in parallel, prevent heat loss, splint painful deformity and announce each intervention with the observed response.
  4. 4Return to the start after every procedure, transfer or deterioration; a completed form never overrides changing physiology.
02Definitive routeChoose CT or source controlDefinitiveThe primary survey has identified likely injury distribution and response to resuscitation.

Complications

01

Missed time-critical injury

Fixation on the most visible lesion, poor exposure or incomplete handover can delay treatment of pneumothorax, internal bleeding, spinal injury or limb ischaemia.

02

Trauma-induced coagulopathy

Shock, tissue injury, dilution, hypothermia and low ionised calcium impair clot formation and contribute to continued haemorrhage and organ failure.

03

Iatrogenic deterioration

Excess crystalloid, hypothermia, unrecognised tube displacement, prolonged pelvic binding or unsafe transfer can convert a controlled situation into further harm.

04

Multiple-organ dysfunction

Persistent oxygen debt, inflammatory injury and delayed source control can cause renal, pulmonary, cardiac and neurological failure despite later anatomical repair.

Monitoring and follow-up

  • Repeat CABCDE after airway manoeuvres, chest decompression, reduction or splintage, blood-product administration, transfer and any new abnormal observation.
  • Trend consciousness, pupils, respiratory status, capillary refill, temperature, lactate or base deficit, haemoglobin, coagulation, fibrinogen and ionised calcium according to bleeding severity.
  • Record cumulative blood components, fluid, urine output, tourniquet and binder times, analgesia, antimicrobial timing and every invasive device.
  • Ensure final imaging reports are acknowledged and acted upon; communicate discrepancies from preliminary readings to the responsible clinical team.
  • Arrange a documented tertiary survey within the local trauma pathway and again when the patient can cooperate if intubation, intoxication or severe pain limited the first examination.

Special situations

Silence is not stability

A quiet, tiring patient with worsening perfusion may be closer to arrest than an alert patient who is visibly distressed.

Response informs destination

Transient improvement after blood supports continued haemorrhage and should accelerate source control rather than create false reassurance.

Procedures require reassessment

An airway, drain, binder or splint can displace or cause harm; checking effect and distal status completes the intervention.

Normal haemoglobin can mislead

Acute whole-blood loss initially removes plasma and red cells together, so early concentration may remain within range.

Handover is clinical care

A named owner, explicit uncertainty and outstanding task list prevent unresolved concerns disappearing during transitions.

Common pitfalls

  1. 01

    Finishing the history before treating an airway, breathing or bleeding threat.

  2. 02

    Sending a persistently unstable non-responder to CT without a rescue plan or source-control team.

  3. 03

    Assuming one negative FAST examination excludes important abdominal or retroperitoneal haemorrhage.

  4. 04

    Forgetting temperature, calcium and coagulation while counting only units of red cells.

  5. 05

    Documenting a total GCS without its eye, verbal and motor components or trend.

  6. 06

    Treating secondary or tertiary survey completion as proof that no further injury can emerge.

or active external bleeding requires immediate parallel resuscitation rather than completion of history taking.
  • A transient response to blood, recurrent hypotension, rising lactate or increasing vasopressor requirement indicates ongoing haemorrhage until a source has been controlled.
  • Disagreement between apparently minor external injury and abnormal physiology should trigger renewed exposure, ultrasound or imaging review and a search for concealed chest, abdominal, pelvic or long-bone bleeding.
  • 05
    Targeted radiographs
    Why
    Define suspected isolated skeletal injury.
    Interpretation and limitations
    Obtain orthogonal views including the joint above and below when appropriate, but splint gross deformity and treat threatened perfusion before pursuing perfect images.
  • 06
    Pregnancy test and anticoagulant history
    Why
    Modify imaging, haemorrhage and medication plans.
    Interpretation and limitations
    Do not delay lifesaving imaging for a pregnancy result; identify anticoagulant name, last dose, renal function and indication promptly because reversal decisions are time-dependent.
    • +
    1. 1Take a stable or clearly responding adult with suspected multisystem blunt injury to immediate whole-body CT with monitoring and a team capable of rescue.
    2. 2For persistent instability, use bedside findings to identify the most likely bleeding or obstructive source and involve surgery, interventional radiology and transfusion leadership.
    3. 3Move directly to the appropriate haemorrhage-control environment when delay for CT would be unsafe; continue balanced resuscitation and warming during transfer.
    4. 4Document why the destination was selected and define the contingency if physiology worsens before source control.
    03After stabilisationComplete secondary and tertiary surveysImmediate threats have been treated and the patient can tolerate detailed assessment.+
    1. 1Obtain AMPLE history and perform a systematic head-to-toe examination, including wounds, joints, posterior surfaces and neurovascular findings relevant to each limb.
    2. 2Review all preliminary imaging yourself, then reconcile the final report, laboratory trends and procedure outcomes with the examination.
    3. 3Repeat the examination after analgesia, sobriety, extubation or transfer because pain and altered consciousness may have hidden injury.
    4. 4Hand over every confirmed problem, possible injury, incidental finding and outstanding action to a named receiving team.
    Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
    Reduces death from bleeding when delivered early as part of haemorrhage control rather than as a substitute for source control.

    Tranexamic acid

    For an adult with active or suspected major bleeding, give 1 g intravenously over 10 minutes followed by 1 g infused over 8 hours, started as soon as possible and within 3 hours of injury.

    Do not give routinely more than 3 hours after injury unless hyperfibrinolysis is specifically present; reduce maintenance exposure in significant renal impairment and check the current major-haemorrhage protocol.