# Primary and Secondary Survey: A Systematic Approach to the Trauma Patient

## Trauma System Overview

### Trauma Team Activation

Trauma team activation is tiered based on acuity. Level 1 activation triggers full trauma team mobilization based on mechanism, vital signs, or injuries meeting institutional criteria. Level 2 activation covers moderate mechanism or injury patterns. Common criteria for the highest-level activation include GCS of 13 or below, SBP below 90, penetrating injury to the head, neck, or torso, flail chest, pelvic instability, paralysis, and amputation above the wrist or ankle. Early activation improves outcomes, and overtriage is always preferred to undertriage.

### ATLS Framework

The Advanced Trauma Life Support framework provides a standardized, reproducible approach that prioritizes life threats in order of lethality. The cardinal principle is "treat first what kills first" — immediately life-threatening injuries should be addressed as they are identified rather than waiting until the entire primary survey is completed.

## Primary Survey (ABCDE)

### A — Airway with Cervical Spine Protection

A talking patient has a patent airway, at least for the moment. Assessment involves looking for stridor, gurgling, snoring, hoarseness, facial and neck trauma, and expanding hematomas. Interventions begin with a jaw thrust (head tilt-chin lift is avoided in trauma), suctioning of blood, secretions, and foreign bodies, and placement of oropharyngeal or nasopharyngeal airways (avoiding NPA in suspected basilar skull fracture). Definitive airway management with endotracheal intubation is indicated for GCS of 8 or below, airway compromise, or an anticipated clinical course that will require protection. Cervical spine immobilization is maintained throughout — in-line stabilization during any airway manipulation, with a cervical collar applied until the spine is cleared clinically or radiographically.

### B — Breathing and Ventilation

The chest must be fully exposed. Assessment involves looking at chest wall movement symmetry, respiratory effort, wounds, and paradoxical movement suggesting a flail segment. Listening confirms bilateral breath sounds — absent breath sounds suggest pneumothorax or hemothorax. Palpation assesses tracheal position, subcutaneous emphysema, and chest wall instability. Four immediately life-threatening conditions must be identified and treated: tension pneumothorax (needle or finger decompression followed by tube thoracostomy), open pneumothorax (three-sided occlusive dressing followed by tube thoracostomy), massive hemothorax (large-bore tube thoracostomy with anticipation of autotransfusion and preparation for thoracotomy), and flail chest (pain control, with intubation considered if respiratory failure develops).

### C — Circulation with Hemorrhage Control

Assessment includes pulse quality, heart rate, capillary refill, skin color and temperature, and mental status. External hemorrhage must be identified and controlled immediately with direct pressure, tourniquets for extremity hemorrhage (applied early and properly), and wound packing with hemostatic gauze for junctional hemorrhage. Two large-bore IVs (14 to 16 gauge) or IO access are established. Resuscitation begins with balanced crystalloid (limited to 1-2 liters), followed by blood products. The massive transfusion protocol is activated if hemorrhagic shock is suspected. A pelvic binder is applied for suspected unstable pelvic fracture. The FAST exam is performed during C to identify free fluid in the abdomen and pericardial effusion. Hemorrhagic shock is classified by volume loss: Class I (below 15 percent, normal vitals), Class II (15-30 percent, tachycardia and narrowed pulse pressure), Class III (30-40 percent, tachycardia, hypotension, and altered mental status), and Class IV (above 40 percent, severe hypotension, lethargy, and imminent cardiac arrest).

| Class | Blood Loss | Heart Rate | Blood Pressure | Mental Status | Treatment |
|-------|-----------|------------|----------------|---------------|-----------|
| I | < 15% (< 750 mL) | Normal | Normal | Normal | Crystalloid |
| II | 15–30% (750–1500 mL) | > 100 | Narrowed pulse pressure | Anxious | Crystalloid + type & cross |
| III | 30–40% (1500–2000 mL) | > 120 | Decreased | Confused | Blood products, MTP |
| IV | > 40% (> 2000 mL) | > 140 | Severely decreased | Lethargic/obtunded | MTP, emergent intervention |

### D — Disability (Neurologic Status)

The Glasgow Coma Scale is assessed — eye opening (1-4), verbal (1-5), and motor (1-6) — with the motor component being most predictive. Pupil size and reactivity are checked, with asymmetry suggesting herniation. Lateralizing signs such as hemiparesis and posturing are noted. Blood glucose is checked to exclude hypoglycemia as a cause of altered mental status. The need for emergent CT head and neurosurgical consultation is determined.

### E — Exposure and Environmental Control

The patient is completely undressed to identify all injuries. A logroll with spinal precautions is performed to examine the back, spine, and perineum. Preventing hypothermia is critical — warm blankets, warmed IV fluids, and a warm environment are all employed. Hypothermia worsens coagulopathy and acidosis, completing the lethal triad (hypothermia, acidosis, coagulopathy). The rectal exam rarely changes acute management and is increasingly deferred unless a specific indication exists.

## Adjuncts to the Primary Survey

### Monitoring

Continuous SpO2, cardiac monitoring, and blood pressure measurement are established. ETCO2 is monitored after intubation. A urinary catheter is placed (contraindicated if there is blood at the urethral meatus, perineal ecchymosis, or high-riding prostate). A gastric tube is placed orogastrically if basilar skull fracture is suspected.

### FAST Exam

The Focused Assessment with Sonography for Trauma uses four views: RUQ (Morrison's pouch), LUQ (splenorenal recess), suprapubic (pelvis), and subxiphoid (pericardium). It identifies free intraperitoneal fluid and pericardial effusion with a sensitivity of 73 to 88 percent for hemoperitoneum, which is operator-dependent and improves with experience. Its limitations include an inability to detect retroperitoneal hemorrhage, solid organ injury without significant free fluid, or hollow viscus injury. The Extended FAST (eFAST) adds bilateral anterior chest ultrasound for pneumothorax detection.

### Initial Imaging

A portable AP chest X-ray evaluates for pneumothorax, hemothorax, mediastinal widening, and ET tube position. A pelvic X-ray identifies pelvic ring fractures but may be deferred if CT is planned and the patient is stable. Lateral C-spine X-ray has been largely replaced by CT at most trauma centers.

### Laboratory Studies

Priority labs include type and crossmatch, CBC, BMP, coagulation studies (PT/INR and fibrinogen), lactate, blood gas (VBG or ABG), urine drug screen, blood alcohol level, and a pregnancy test (mandatory in reproductive-age females).

## Secondary Survey

### Head-to-Toe Examination

The secondary survey is a systematic head-to-toe examination. The head is assessed for scalp lacerations (which can cause significant hemorrhage), palpable skull fractures, and basilar skull fracture signs (raccoon eyes, Battle sign, hemotympanum, CSF rhinorrhea or otorrhea). The face is evaluated for midface stability, dental trauma, orbital rim fractures, and mandible stability. The neck is examined for tenderness, deformity, penetrating wounds (platysma violation requires surgical exploration or CTA), subcutaneous emphysema, and JVD. The chest is re-examined with palpation of all ribs and the sternum. The abdomen is assessed for distension, tenderness, guarding, and the seat belt sign (which increases the risk of mesenteric and bowel injury). The pelvis receives a single gentle compression test — the pelvis should never be repeatedly rocked — and instability should prompt binder application. The perineum and genitalia are examined for blood at the urethral meatus, scrotal hematoma, vaginal bleeding, and rectal bleeding. Extremities are assessed for deformity, open fractures, compartment syndrome, and distal pulses and neurovascular status. The back is examined during the logroll for penetrating wounds, spinal tenderness, step-offs, and flank ecchymosis.

### Focused History (AMPLE)

The AMPLE history covers Allergies, Medications (with anticoagulants being critical information), Past medical and surgical history, Last meal, and Events and environment of the injury (mechanism).

### Pan-CT Scanning

CT of the head, cervical spine, chest, and abdomen/pelvis with IV contrast has become the standard for significant blunt trauma. Advocates argue it identifies occult injuries, while critics point to over-imaging, incidental findings, radiation exposure, and CT-related delays. Selective CT scanning based on mechanism and examination findings is an alternative, but in obtunded or unreliable patients, pan-CT is generally justified.

## Tertiary Survey

A complete re-examination within 24 hours of admission reviews all imaging and lab results and identifies injuries missed during the primary and secondary surveys. The missed injury rate in trauma is 2 to 10 percent, and the tertiary survey significantly reduces this.

## Special Populations

### Pediatric Trauma

Children have a higher surface area-to-volume ratio, predisposing them to hypothermia. Vital signs vary by age, and age-appropriate normal ranges must be known. Children maintain blood pressure longer than adults by increasing heart rate and SVR — tachycardia is the first sign of shock, and hypotension is a very late and ominous finding. The Broselow tape guides weight-based dosing and equipment sizing. Children are more susceptible to solid organ injury due to less protective abdominal musculature and fat. Non-accidental trauma should be suspected when the mechanism is inconsistent with the injury pattern.

### Geriatric Trauma

Elderly patients have decreased physiologic reserve. Medications like beta-blockers mask tachycardia, and anticoagulants increase bleeding risk. A lower threshold for imaging and admission is appropriate. Falls are the most common mechanism, and even low-level falls can cause significant injury. Pre-injury anticoagulation significantly increases mortality from intracranial hemorrhage. An SBP below 110 may represent shock in previously hypertensive patients.

### Pregnant Trauma Patient

After 20 weeks, left lateral tilt or manual uterine displacement prevents aortocaval compression. The principle of two patients applies: maternal stabilization is the best fetal resuscitation. Rh status must be determined for all injured pregnant patients, and Rh immunoglobulin given if Rh-negative. Fetal heart rate monitoring is indicated for viable gestational ages (beyond 23-24 weeks). Placental abruption is the most common cause of fetal death in maternal trauma. Perimortem cesarean section should be performed within 4 to 5 minutes of maternal cardiac arrest.

<image>A detailed overhead illustration of a trauma bay during primary survey, showing the team positions and simultaneous activities. The trauma team leader stands at the foot of the bed directing operations. A physician at the head manages the airway with in-line cervical stabilization. Two nurses on either side establish bilateral large-bore IVs and draw blood. A FAST ultrasound is being performed by a physician at the right upper quadrant. A recorder stands off to the side documenting interventions and times. A portable chest X-ray machine is positioned nearby. The patient is fully exposed on a backboard with a cervical collar in place. Color-coded labels identify each team member's role and current task in the ABCDE sequence.</image>

<image>A four-panel ultrasound image showing the standard FAST exam views. Panel 1 (RUQ): Morrison's pouch between the liver and right kidney with a small anechoic stripe of free fluid visible. Panel 2 (LUQ): splenorenal recess showing the spleen and left kidney interface. Panel 3 (Suprapubic): transverse view of the pelvis showing the bladder with free fluid posterior to it in the pouch of Douglas. Panel 4 (Subxiphoid): four-chamber cardiac view showing no pericardial effusion. Each panel is labeled with anatomical landmarks and arrows indicating where free fluid would accumulate. A positive versus negative FAST comparison inset is included.</image>

## Clinical Pearls

The primary survey is about finding and treating immediately life-threatening conditions — intervene as you identify threats; do not wait until the survey is "complete." Hypothermia, acidosis, and coagulopathy form the lethal triad, and active hypothermia prevention should begin the moment the patient arrives. The FAST exam is a screening tool for free fluid, not a definitive study — a negative FAST does not exclude injury, especially solid organ injury without significant free fluid. In a tachycardic trauma patient, assume hemorrhagic shock until proven otherwise, as tachycardia is the earliest vital sign change in hemorrhage. Anticoagulated geriatric trauma patients have significantly higher mortality — reverse anticoagulation early and lower the imaging threshold. The rectal exam in trauma rarely changes management and is no longer routinely recommended unless specific clinical suspicion exists. Children compensate for blood loss by increasing heart rate and SVR — hypotension is a very late and ominous sign of pediatric hemorrhagic shock. The best fetal resuscitation is maternal resuscitation — stabilize the mother first.

## References

- American College of Surgeons Committee on Trauma. *Advanced Trauma Life Support (ATLS) Student Course Manual*. 10th ed. 2018.
- Rotondo MF, et al. Trauma team activation and the role of the emergency physician. *Emerg Med Clin North Am*. 2020;38:67-83.
- Stengel D, et al. Whole-body CT versus selective imaging in blunt polytrauma: systematic review. *Lancet*. 2009;373:1455-1461.
- Kirkpatrick AW, et al. Focused Assessment with Sonography for Trauma (FAST): a systematic review. *J Trauma*. 2004;57:168-175.
- Keijzers GB, et al. Tertiary survey of trauma patients. *World J Surg*. 2017;41:2609-2616.