Trauma primary survey and adjuncts

Advanced Trauma Life Support, Primary Survey & Life-Threatening Thoracic Injuries

Trauma remains a leading cause of mortality and permanent disability worldwide. In Australia, trauma care is structured according to the Early Management of Severe Trauma (EMST) principles established by the Royal Australasian College of Surgeons (RACS), adapted from the international Advanced Trauma Life Support (ATLS) framework. The fundamental core of trauma management is the primary survey with simultaneous resuscitation, designed to rapidly identify and treat immediately life-threatening injuries in order of physiological priority.

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The EMST / ATLS Philosophy & The <C>ABCDE Sequence

Trauma resuscitation operates on the premise that severe physiological derangements must be addressed concurrently with their detection. In modern civilian and military trauma protocols, the traditional ABCDE sequence is preceded by the control of catastrophic external haemorrhage, creating the <C>ABCDE algorithm.

<C> — Catastrophic Haemorrhage Control

Exsanguinating external haemorrhage from extremities or junctional zones kills faster than airway compromise. Prior to standard airway interventions:

• Apply immediate, direct, firm manual pressure over the bleeding site.
• Pack deep junctional or cavitary wounds (groin, axilla) with kaolin- or chitosan-impregnated haemostatic gauze and maintain pressure for at least 3 minutes.
• Apply a commercial arterial tourniquet (e.g., Combat Application Tourniquet [CAT]) high and tight on the affected limb for uncontrolled extremity arterial bleeding. Document application time precisely.
• Apply a pelvic binder if there is clinical or mechanical suspicion of an unstable open-book pelvic fracture with hemodynamic shock.

A — Airway with Cervical Spine Protection

Assume a cervical spine injury in any patient with blunt trauma above the clavicle, high-energy impact, or altered mental status.

• Manual In-Line Stabilization (MILS): Maintain manual in-line stabilization immediately whenever the rigid cervical collar is opened or adjusted. Avoid traction or cervical extension.
• Airway Patency: Inspect the oropharynx for blood, vomitus, teeth, secretions, or foreign bodies. Clear the airway using rigid wide-bore suction (Yankauer catheter) under direct vision.
• Basic Airway Manoeuvres: Perform a jaw thrust or chin lift without head-tilt. Avoid neck extension.
• Adjuncts: Insert a nasopharyngeal airway (NPA) in conscious or semi-conscious patients (avoid if base-of-skull fracture is suspected). Use an oropharyngeal airway (OPA / Guedel) only in unconscious patients without a gag reflex.
• Definitive Airway: An endotracheal tube with an inflated cuff secured in the trachea. Indications include:
  1. Inability to maintain airway patency or clear secretions.
  2. Severe traumatic brain injury ($GCS \le 8$).
  3. Inadequate ventilation or oxygenation refractory to supplemental oxygen.
  4. Anticipated deterioration (e.g., extensive facial burns, smoke inhalation, expanding neck haematoma).
• Failed Airway / CICO Algorithm: If a "Cannot Intubate, Cannot Oxygenate" scenario arises, perform an immediate surgical cricothyroidotomy (scalpel-finger-bougie technique).

B — Breathing and Ventilation

Assess lung mechanics and gas exchange:

• Administer high-flow supplemental oxygen via a non-rebreather mask with reservoir bag ($15\text{ L/min}$) targeting an oxygen saturation $\ge 94\%$ (or $88\%\text{ to }92\%$ in patients with known chronic hypercapnic respiratory failure).
• Inspect chest wall excursion, respiratory rate, symmetry of movement, and bruising.
• Palpate for subcutaneous emphysema, rib fractures, and flail segments.
• Percuss for unilateral hyperresonance (pneumothorax) or dullness (haemothorax).
• Auscultate bilateral breath sounds in the axillae and anterior chest.
• Rapidly identify and immediately decompress life-threatening chest injuries: tension pneumothorax, open pneumothorax, massive haemothorax, flail chest, and cardiac tamponade.

C — Circulation with Haemorrhage Control

Evaluate cardiovascular status and tissue perfusion:

• Clinical Markers of Shock: Tachycardia (earliest sign), weak thready pulses, delayed central capillary refill ($> 2\text{ seconds}$), cool clammy peripheries, altered mentation, and narrowed pulse pressure preceding frank hypotension.
• Vascular Access: Secure two large-bore (14-gauge or 16-gauge) peripheral intravenous cannulas in the antecubital fossae. If peripheral access cannot be established within 90 seconds, immediately establish intraosseous (IO) access (proximal humerus or proximal tibia).
• Laboratory Investigations: Immediately obtain blood for cross-match (or un-crossmatched O-negative blood in extreme exsanguination), full blood count, electrolytes, urea, creatinine, liver function tests, lipase, coagulation screen, and arterial/venous blood gas (monitoring base deficit and serum lactate as markers of occult shock).
• Critical bleeding protocol: Activate the hospital major haemorrhage protocol and use its blood-component packs with laboratory or viscoelastic reassessment. The Australian guideline recommends at least one FFP unit per two RBC units and one adult platelet dose per eight RBC units. Published 2:1:1 or 1:1:1 ratios often express platelets as donor-unit equivalents: one adult pooled platelet dose is not equivalent to one RBC unit. Prevent hypothermia and monitor ionised calcium, fibrinogen and clotting.

D — Disability (Neurological Evaluation)

Rapid neurological examination to establish baseline cerebral function before sedation or neuromuscular blockade:

• Calculate the Glasgow Coma Scale (GCS) score (Eye Opening 1–4, Verbal Response 1–5, Motor Response 1–6).
• Assess pupillary size, symmetry, and light reflex.
• Check for gross lateralizing motor deficits.
• Measure point-of-care blood glucose to exclude hypoglycaemia as a cause of altered mental state.

E — Exposure and Environmental Control

• Completely undress the patient by cutting off clothing to permit full inspection of the anterior and posterior body surfaces, axillae, groin, and perineum.
• Perform a coordinated log roll while maintaining strict spinal alignment to palpate the entire vertebral column, inspect the back, and perform a digital rectal examination if indicated.
• Prevent Hypothermia: Hypothermia exacerbates trauma-induced coagulopathy and acidosis ("lethal triad"). Immediately warm the environment, apply forced-air warming blankets, and infuse all intravenous fluids and blood products through fluid warmers at $39^\circ\text{C}$.

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Primary Survey Adjuncts: eFAST and Plain Radiography

Adjuncts are diagnostic procedures performed during or immediately following the primary survey that provide critical information without interrupting active resuscitation.

Extended Focused Assessment with Sonography for Trauma (eFAST)

The eFAST examination is a rapid bedside ultrasound protocol evaluating six anatomical acoustic windows for pathological fluid (blood) and air:

1. Right Upper Quadrant (Morison's Pouch / Hepatorenal Recess): Evaluates the potential space between the liver and right kidney, as well as the right subdiaphragmatic space and right hemithorax (identifying haemothorax above the diaphragm).
2. Left Upper Quadrant (Splenorenal Recess): Evaluates the subphrenic space around the spleen, the splenorenal recess, and the left hemithorax.
3. Pelvic View (Suprapubic): Evaluates the rectovesical pouch in men and the pouch of Douglas (rectouterine pouch) in women. Must be imaged before bladder catheterization.
4. Pericardial View (Subxiphoid or Parasternal Long-Axis): Identifies anechoic fluid within the pericardial sac separating the epicardium and parietal pericardium.
5. Bilateral Anterior Thoracic Views (Pleural Apices): Evaluates the 2nd to 4th intercostal spaces in the midclavicular line for pneumothorax.
   • Normal: Lung sliding (visceral pleura gliding on parietal pleura) producing "ants marching" in B-mode and a "sandy beach / seashore sign" in M-mode.
   • Pneumothorax: Absence of lung sliding, absence of comet-tail artefacts, and the "stratosphere sign" or "barcode sign" in M-mode. Visualizing a lung point (the boundary where normal sliding transitions to absent sliding) is 100% specific for pneumothorax.

Primary references (checked 7 October 2026): NSW trauma pathway.