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Trauma Assessment
The initial assessment and management of seriously injured patients is a challenging task and requires a rapid
and systematic approach.
This systematic approach can be practised to increase speed and accuracy of the process but good clinical
judgement is also required. [1] [2] Although described in sequence, some of the steps will be taken simultaneously.
The aim of good trauma care is to prevent early trauma mortality. Early trauma deaths may occur because of
failure of oxygenation of vital organs or central nervous system injury, or both.
Injuries causing this mortality occur in predictable patterns and recognition of these patterns led to the
development of advanced trauma life support (ATLS) by the American College of Surgeons. A standardised
protocol for trauma patient evaluation has been developed. [3] [4] The protocol celebrated its 25th anniversary in
2005. [5] Good teaching and application of this protocol are held to be important factors in improving the survival
of trauma victims worldwide. [6]
Different systems of trauma scoring have been developed.

Aims of the initial evaluation of trauma patients

Stabilise the patient.
Identify life-threatening conditions in order of risk and initiate supportive treatment.
Organise definitive treatments or organise transfer for definitive treatments.

Preparation and co-ordination of care

Assessment and management will begin out of hospital at the scene of injury and good communication with the
receiving hospital is important. The preparatory measures are outlined below to 'set the scene'.

The pre-hospital phase

Co-ordination and communication with the receiving hospital so that the trauma team can be alerted
and mobilised.
Airway maintenance.
Control of external bleeding shock.
Keeping the patient immobilised.
Information gathering: time of injury; related events; patient history. Key elements are the mechanism
of injury to alert the trauma team to the degree and type of injury.
Keeping time at the scene to a minimum.

The hospital phase

Preparation of a resuscitation area.
Airway equipment - laryngoscopes, etc (accessible, tested).
Intravenous (IV) fluids (warming equipment, etc).
Immediately available monitoring equipment.
Methods of summoning extra medical help.
Prompt laboratory and radiology backup.
Transfer arrangements with trauma centre.
Guidelines on protection when dealing with body fluid should be followed throughout this and subsequent
procedures.

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Triage and organisation of care

See separate related article Trauma Triage and Scoring.
This is the sorting of patients according to their need for treatment and the resources available. It starts at the
scene (see above) and continues at the receiving hospital. [7] Priority is given to patients most likely to deteriorate
clinically and triage takes account of vital signs, pre-hospital clinical course, mechanism of injury, age and other
medical conditions. In trauma centres, teamwork should ensure critically injured patients are evaluated as
diagnostic procedures are performed simultaneously, thus reducing the time to treatment. A team approach is
demanding of personnel and resources and, in smaller institutions, non-hospital settings or with mass casualties,
available personnel and resources can rapidly be overwhelmed:

Triage: is done according to the 'ABCDE' principles (Airway maintenance with cervical spine
protection, Breathing and ventilation, Circulation with haemorrhage control, Disability: neurological
status, Exposure/environmental control).
Selection of hospital : is according to available services, so that trauma patients should be taken to
trauma centres.

Multiple casualties: where the number of patients and severity of injury do not exceed the capacity of
the treatment centre, life-threatening injuries and multiple system injuries are treated first.
Mass casualties: when the the number of patients and severity of injury do exceed capacity of the
treatment centre, patients are selected for treatment according to best chance of survival with least
expenditure of resources (time, personnel, equipment, supplies).

Initial assessment
This comprises:
Resuscitation and primary survey.
Secondary survey.
Definitive treatment or transfer for definitive care.

Resuscitation and primary survey

For speed and efficacy a logical sequence of assessment to establish treatment priorities must be gone through
sequentially although, with good teamwork, some things will be done simultaneously (resuscitation procedures
will begin simultaneously with the assessment involved in the primary survey, ie lifesaving measures are initiated
when the problem is identified). Special account should be taken of children, pregnant women and the elderly as
their response to injury is modified. [8] The primary survey is according to:

A = Airway maintenance cervical spine protection

Are there signs of airway obstruction, foreign bodies, facial, mandibular or laryngeal fractures?
Management may involve secretion control, intubation or surgical airway (eg, cricothyroidotomy,
emergency tracheostomy).
Establish a clear airway (chin lift or jaw thrust) but protect the cervical spine at all times. [9] If the
patient can talk, the airway is likely to be safe; however, remain vigilant and recheck. A nasopharyngeal
airway should be used in a conscious patient; or, as a temporary measure, an oropharyngeal airway in
an unconscious patient with no gag reflex. Definitive airway should be established if the patient is
unable to maintain integrity of airway; mandatory if Glasgow Coma Scale (GCS) is less than 8.
Cervical spine protection is critical throughout the airway management process. Movement of the
cervical spine could cause spinal injury so movement of the cervical spine should be avoided unless
absolutely necessary for maintaining an airway. [9] The trauma mechanism or history may suggest the
likelihood of a cervical spine injury, but always assume there is a spinal injury until proven otherwise,
especially in any multisystem trauma or if there is an altered level of consciousness. Inline
immobilisation and protection of the spine should be maintained and X-rays can be taken once
immediately life-threatening conditions have been dealt with.

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B = Breathing and ventilation

Provide high-flow oxygen through a rebreather mask if not intubated and ventilated. [10] Evaluate breathing: lungs,
chest wall, diaphragm. Chest examination with adequate exposure: watch chest movement, auscultate, percuss
to detect lesions acutely impairing ventilation:
Tension pneumothorax - requires needle thoracostomy followed by drainage.
Flail chest - management involves ventilation.
Haemothorax - will usually require intercostal drain insertion.
Pneumothorax - may require intercostal drain insertion.

Note: it can be difficult to tell whether the problem is an airway or ventilation problem. What appears to be an
airway problem, leading to intubation and ventilation, may turn out to be a pneumothorax or tension pneumothorax
which will be exacerbated by intubation and ventilation.

C = Circulation with haemorrhage control

Blood loss is the main preventable cause of death after trauma. To assess blood loss rapidly observe:
Level of consciousness.
Skin colour.
Pulse.
Bleeding - this should be assessed and controlled:
IV access should be achieved with two large cannulae (size and length of cannula is
determinant of flow not vein size) in an upper limb. Access by cut down or central venous
catheterisation may be done according to skills available. At cannula insertion, blood should
be taken for crossmatch and baseline investigations.
IV fluids will need to be given rapidly, usually as 250 ml to 500 ml warmed boluses (10-20
ml/kg in children). Often a total of 2-3 L of IV fluids is necessary (40 ml/kg in children),
which will then need to be followed by blood transfusion (O negative to begin with, if typed
blood is not available). Ringer's lactate is the preferred initial crystalloid solution. [11]
Direct manual pressure should be used to stem visible bleeding (not tourniquets, except for
traumatic amputation, as these cause distal ischaemia).
Transparent pneumatic splinting devices may control bleeding and allow visual monitoring;
surgery may be necessary if these measures fail to control haemorrhage.
Occult bleeding into the abdominal cavity and around long-bone or pelvic fractures is
problematic but should be suspected in a patient not responding to fluid resuscitation.

Note: response to blood loss differs in:

Elderly - limited ability to increase heart rate; poor correlation between blood loss and blood pressure.
Children - tolerate proportionately large volume loss but then rapidly deteriorate.
Athletes - do not show the same heart rate response to blood loss.
Chronic conditions and medication may affect response and early on in trauma management will not
be known about.

D = Disability: neurological status

After A, B and C above, rapid neurological assessment is made to establish:
Level of consciousness, using GCS.
Pupils: size, symmetry and reaction.
Any lateralising signs.
Level of any spinal cord injury (limb movements, spontaneous respiratory effort).
Oxygenation, ventilation, perfusion, drugs, alcohol and hypoglycaemia may all also affect the level of
consciousness.
Patients should be re-evaluated frequently at regular intervals, as deterioration can occur rapidly and often
patients can be lucid following a significant head injury before worsening. Signs such as pupil asymmetry or
dilation, impaired or absent light reflexes, and hemiplegia/weakness all suggest an expanding intracranial mass
or diffuse oedema. This requires IV mannitol, ventilation and urgent neurosurgical opinion. Hypertonic saline can
be used as an alternative to mannitol especially in hypovolaemic patients.

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E = Exposure/environmental control
Undress the patient, but prevent hypothermia. Clothes may need to be cut off but, after examination, attend to
prevention of heat loss with warming devices, warmed blankets, etc. Also check blood glucose levels.

Additional considerations to primary survey and resuscitation

ECG monitoring: this can guide resuscitation by diagnosing dysrhythmias, ischaemia, cardiac injury, pulseless
electrical activity (PEA) - which may indicate cardiac tamponade - hypovolaemia, tension pneumothorax, and
extreme hypovolaemia. Hypoxia or hypoperfusion should be suspected if there is bradycardia, aberrant
conduction, and premature beats. Hypothermia produces dysrhythmias.

Urinary/gastric catheters:
Output of urine can guide fluid replacement (reflects renal perfusion). Adequate output is 0.5-1
ml/kg/hour. Note: prior to catheter insertion urethral injury should be excluded - suspect if there is
blood at meatus, pelvic fracture, scrotal blood, perineal bruising. Per rectum and genital examination
are mandatory prior to catheter insertion.
Gastric catheters are inserted to reduce aspiration risk. Suction should be applied. Note: care should
be taken not to provoke aspiration by triggering gagging.

Other monitoring: monitoring of resuscitation by measuring various important parameters measures adequacy
of resuscitation efforts. Values for various parameters should be obtained soon after the primary survey and
reviewed regularly. Important parameters are:
Pulse rate, [12] blood pressure, ventilatory rate, arterial blood gases, body temperature and urinary
output.
Carbon dioxide detectors may identify dislodged endotracheal tubes.
Pulse oximetry measures oxygenation of haemoglobin colorimetrically (sensor on finger, ear lobe,
etc.).

Remember: blood pressure is a poor measure of perfusion.

Diagnostic procedures: care should be taken that these do not hamper resuscitation. They may be best

deferred to the secondary survey. Modifications to the ATLS guidelines have been suggested. [13] [14] X-rays most
likely to guide resuscitation early on, especially in blunt trauma, include:
CXR.
Pelvic X-ray. It has been suggested that CT scans may be used in some stable patients. [13]
Lateral cervical spine X-ray.
Other useful procedures include FAST (= focused assessment with sonography for trauma), eFAST (= extended
focused assessment with sonography for trauma) and/or CT scanning to detect occult bleeding.

Secondary survey
This begins after the 'ABCDE' of the primary survey, once resuscitation is underway and the patient is responding
with normalisation of vital signs. The secondary survey is essentially a head-to-toe examination with completion
of the history and reassessment of progress, vital signs, etc. It requires repeat physical examinations and may
require further X-ray and laboratory tests. It comprises:

History
A = Allergies.
M = Medication currently used.
P = Past illnesses/Pregnancy.
L = Last meal.
E = Events/Environment related to injury

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Physical examination
This will repeat some examinations already undertaken in the primary survey and will be further informed by the
progress of the resuscitation. It aims to identify serious injuries, occult bleeding, etc. A review of neurological
status including GCS score is also undertaken. Back and spinal injuries are commonly missed and pelvic
fractures cause large blood loss which is often underestimated.

Beware: burns (fluid requirements, inhalation injury); cold injury (continue resuscitation until rewarmed); highvoltage electricity injuries (extensive muscle injury likely to be concealed).

Additional considerations to secondary survey

A range of further diagnostic tests and procedures may be required after the secondary survey. These include CT
scans , ultrasound investigations, contrast X-rays, angiography, bronchoscopy, oesophageal ultrasound, etc.

Definitive care
Choosing where care should continue most appropriately will depend on results of the primary and secondary
surveys and knowledge of the facilities available to receive the patient. The closest appropriate facility should be
chosen.

Records and legal considerations

Remember:
Keep meticulous records (times for all entries, etc). Teamwork with timekeeping and recording of
clinical measurements, and observations can be helpful. Some units have a member of the nursing
staff whose sole role is to record and collate patient care information accurately.
Consent for treatment is not always possible with lifesaving treatment and consent may have to be
given later.
Forensic evidence may be required in injuries caused by criminal activity.

Practice tips
Regular training in resuscitation by the whole practice team is recommended. Attention to a team approach is
essential. Involvement in medical cover at schools, sports events, and car accidents (British Association for
Immediate Care (BASICS) requires higher-level training and regular refresher courses.

Further reading & references

Davis M; Should there be a UK based advanced trauma course? Emerg Med J. 2005 Jan;22(1):5-6.
BASICS - British Association for Immediate Care
1. Scherer LA, Chang MC, Meredith JW, et al; Videotape review leads to rapid and sustained learning. Am J Surg. 2003
Jun;185(6):516-20.
2. Mohammad A, Branicki F, Abu-Zidan FM; Educational and clinical impact of Advanced Trauma Life Support (ATLS) courses:
a systematic review. World J Surg. 2014 Feb;38(2):322-9. doi: 10.1007/s00268-013-2294-0.
3. Bell RM, Krantz BE, Weigelt JA; ATLS: a foundation for trauma training. Ann Emerg Med. 1999 Aug;34(2):233-7.
4. Esposito TJ, KubyA, Unfred C, et al; General surgeons and the Advanced Trauma Life Support course: is it time to
refocus? J Trauma. 1995 Nov;39(5):929-33; discussion 933-4.
5. Collicott PE; ATLS celebrates 25th anniversary. Bull Am Coll Surg. 2005 May;90(5):18-21.
6. Hogan MP, Boone DC; Trauma education and assessment. Injury. 2008 May 24;.
7. Santaniello JM, Esposito TJ, Luchette FA, et al; Mechanism of injury does not predict acuity or level of service need: field
triage criteria revisited. Surgery. 2003 Oct;134(4):698-703; discussion 703-4.
8. Hayden B, Plaat F, Cox C; Managing trauma in the pregnant woman. Br J Hosp Med (Lond). 2013 Jun;74(6):327-30.
9. Austin N, Krishnamoorthy V, Dagal A; Airway management in cervical spine injury. Int J Crit Illn Inj Sci. 2014 Jan;4(1):50-6.
doi: 10.4103/2229-5151.128013.
10. McCullough AL, Haycock JC, Forward DP, et al; Early management of the severely injured major trauma patient. Br J
Anaesth. 2014 Aug;113(2):234-41. doi: 10.1093/bja/aeu235.
11. Harris T, Thomas GO, Brohi K; Early fluid resuscitation in severe trauma. BMJ. 2012 Sep 11;345:e5752. doi:
10.1136/bmj.e5752.
12. Victorino GP, Battistella FD, Wisner DH; Does tachycardia correlate with hypotension after trauma? J Am Coll Surg. 2003
May;196(5):679-84.
13. Hilty MP, Behrendt I, Benneker LM, et al; Pelvic radiography in ATLS algorithms: Adiminishing role? World J Emerg Surg.
2008 Mar 4;3:11.

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14. Kool DR, Blickman JG; Advanced Trauma Life Support. ABCDE from a radiological point of view. Emerg Radiol. 2007
Jul;14(3):135-41. Epub 2007 Jun 12.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its
accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions.
For details see our conditions.
Original Author:
Dr Richard Draper

Current Version:
Dr Gurvinder Rull

Peer Reviewer:
Dr Adrian Bonsall

Document ID:
217 (v26)

Last Checked:
25/11/2014

Next Review:
24/11/2019

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