Residency · Residency · General Surgery

Initial Assessment and Resuscitation of the Trauma Patient

Overview

Trauma is the leading cause of death in patients aged 1-44 years. The trimodal distribution of trauma death includes immediate deaths (seconds to minutes, from non-survivable injuries), early deaths (minutes to hours, from treatable hemorrhage and traumatic brain injury), and late deaths (days to weeks, from sepsis and multiorgan dysfunction syndrome). ATLS (Advanced Trauma Life Support) provides the systematic framework for assessment. Damage control resuscitation principles have replaced traditional high-volume crystalloid resuscitation as the standard of care.

Prehospital Considerations

Prehospital management begins with scene safety and mechanism of injury assessment. On-scene time should be minimized, targeting the "platinum 10 minutes." Hemorrhage control includes direct pressure and tourniquets, which are now widely endorsed for extremity hemorrhage. Spinal immobilization is applied using selective criteria such as NEXUS and the Canadian C-Spine Rule. Prehospital activation of the trauma team is based on mechanism and physiologic criteria.

Primary Survey (ABCDE)

A -- Airway with Cervical Spine Protection

Airway patency is assessed by evaluating speech, stridor, gurgling, and obstruction. A jaw thrust (not head tilt in the trauma setting), suction, and oropharyngeal or nasopharyngeal airways are initial maneuvers. A definitive airway through endotracheal intubation or a surgical airway is indicated for GCS of 8 or less, inability to maintain the airway, severe facial or neck trauma, or anticipated airway deterioration. In-line cervical spine stabilization is maintained during intubation. A surgical airway (cricothyroidotomy) is performed when intubation fails or is contraindicated, as with massive facial trauma. The technique involves identifying the cricothyroid membrane, making a vertical skin incision and a horizontal membrane incision. Cricothyroidotomy is contraindicated in children under 12 years, for whom needle cricothyroidotomy is used instead.

B -- Breathing and Ventilation

The chest is exposed and examined by inspection, auscultation, and percussion. Immediately life-threatening thoracic injuries must be identified and treated. Tension pneumothorax presents with tracheal deviation, absent breath sounds, hypotension, and jugular venous distension. Treatment is needle decompression at the second intercostal space in the midclavicular line or the fifth intercostal space at the anterior axillary line, followed by tube thoracostomy. Open pneumothorax (sucking chest wound) is treated with a three-sided occlusive dressing followed by a chest tube. Massive hemothorax is defined as more than 1500 mL of blood in the chest or output exceeding 200 mL per hour, warranting a chest tube and possible thoracotomy. Flail chest presents with paradoxical chest wall movement, and the associated pulmonary contusion is the main clinical concern. A chest X-ray or eFAST (extended FAST with thoracic views) is obtained in the trauma bay.

C -- Circulation with Hemorrhage Control

Circulation is assessed by evaluating mental status, skin color, pulse quality, capillary refill, and blood pressure. External hemorrhage is controlled with direct pressure, tourniquets for extremity bleeding, and pelvic binders. Two large-bore IV lines (minimum 16-gauge, antecubital) are established. Intraosseous access is used if IV access cannot be obtained rapidly. Initial fluid is a balanced crystalloid such as Ringer's lactate, and large-volume normal saline is avoided due to the risk of hyperchloremic acidosis. The massive transfusion protocol is activated early for hemorrhagic shock.

D -- Disability (Neurologic Assessment)

The GCS (Glasgow Coma Scale) is calculated as the sum of eye opening, verbal, and motor scores (range 3-15). Pupil size and reactivity are assessed, and lateralizing signs (unequal pupils, hemiparesis) are noted. Glucose is checked because hypoglycemia can mimic traumatic brain injury. Herniation signs include unilateral pupil dilation and the Cushing triad (hypertension, bradycardia, irregular respirations), which demand emergent intervention.

E -- Exposure and Environment

The patient is completely undressed for a full examination. A log-roll is performed to examine the back, spine, and perineum. Hypothermia must be prevented with warm blankets, warm fluids, and a warm environment, as hypothermia worsens coagulopathy.

<image>ATLS primary survey algorithm showing the systematic ABCDE approach with key interventions at each step and decision points for life-threatening injuries</image>

Hemorrhagic Shock Classification

Hemorrhagic shock is classified into four classes:

Class I involves less than 15% blood loss (under 750 mL) with a heart rate below 100, normal blood pressure, and slight anxiety. Class II involves 15-30% blood loss (750-1500 mL) with a heart rate of 100-120, normal blood pressure, and anxiety. Class III involves 30-40% blood loss (1500-2000 mL) with a heart rate of 120-140, decreased blood pressure, and confusion. Class IV involves greater than 40% blood loss (over 2000 mL) with a heart rate above 140, decreased blood pressure, and lethargy. Tachycardia may be absent in athletes, patients on beta-blockers, and elderly patients. Base deficit and lactate are sensitive markers of tissue hypoperfusion.

Damage Control Resuscitation (DCR)

Principles

The principles of DCR include permissive hypotension (target MAP 50-60 mmHg or SBP 80-90 mmHg until hemorrhage control), with the exception of traumatic brain injury where SBP should be maintained above 110 mmHg to protect cerebral perfusion. Crystalloid administration should be minimized, avoiding more than 1-2 liters before blood products. Early balanced blood product transfusion is initiated, and the lethal triad of hypothermia, acidosis, and coagulopathy must be prevented and treated.

Massive Transfusion Protocol (MTP)

The MTP is activated for an anticipated need of 10 or more units of packed red blood cells in 24 hours or 4 or more units in 1 hour. The PROPPR trial demonstrated that a 1:1:1 ratio of packed RBCs, FFP, and platelets reduces mortality from exsanguination at 24 hours compared to a 1:1:2 ratio. Products are delivered in coolers with pre-packaged 1:1:1 ratios. Tranexamic acid (TXA) is administered as a 1 g IV bolus within 3 hours of injury, followed by 1 g over 8 hours, as established by the CRASH-2 trial. TXA reduces mortality from hemorrhage and is most effective when given within 1 hour. It should not be given beyond 3 hours after injury, as it may increase mortality.

Whole Blood

Whole blood is increasingly used in trauma resuscitation, building on military experience and now adopted in civilian practice. Low-titer O whole blood (LTOWB) is immediately available and contains red blood cells, plasma, platelets, and clotting factors. It simplifies transfusion logistics and may be physiologically superior to component therapy. Growing evidence supports its use as an initial resuscitation product.

Viscoelastic Testing (TEG/ROTEM)

Viscoelastic testing provides point-of-care assessment of clot formation, strength, and fibrinolysis. TEG measures R time (clot initiation), MA (clot strength and platelet function), and LY30 (fibrinolysis). ROTEM measures EXTEM (extrinsic pathway), INTEM (intrinsic pathway), and FIBTEM (fibrinogen contribution). These tests guide targeted blood product administration and allow goal-directed transfusion, reducing unnecessary product use.

<image>Viscoelastic testing (TEG) tracing comparing a normal tracing with tracings showing coagulopathy patterns: prolonged R time (factor deficiency), decreased MA (platelet dysfunction), and increased LY30 (hyperfibrinolysis)</image>

Adjuncts to Primary Survey

FAST Exam (Focused Assessment with Sonography for Trauma)

The FAST exam includes four views: RUQ (Morrison's pouch), LUQ (splenorenal recess), pelvis (pouch of Douglas or rectovesical space), and subxiphoid (pericardial). The eFAST adds bilateral anterior chest views for pneumothorax detection. A positive FAST in a hemodynamically unstable patient mandates proceeding to the operating room for laparotomy. A negative FAST does not rule out injury, as sensitivity is approximately 85% for free fluid and the exam misses retroperitoneal and solid organ injuries without free fluid. Limitations include operator dependence, body habitus, and subcutaneous emphysema.

Chest X-Ray

A portable supine AP chest film in the trauma bay provides rapid assessment for hemothorax, pneumothorax, widened mediastinum, and rib fractures.

Pelvic X-Ray

A pelvic X-ray is obtained for blunt trauma with suspected pelvic fracture. An open-book fracture is managed with a pelvic binder or sheet. CT has largely replaced plain films for definitive pelvic assessment in stable patients.

Secondary Survey

The secondary survey is a complete head-to-toe examination performed after the primary survey and initial resuscitation. An AMPLE history is obtained: Allergies, Medications, Past medical history, Last meal, and Events/mechanism. The comprehensive physical examination includes assessment of the scalp and face; eyes for pupils and visual acuity; ears for hemotympanum and CSF otorrhea; nose for CSF rhinorrhea; neck for tenderness, subcutaneous emphysema, and tracheal deviation; chest for auscultation and palpation of instability; abdomen for tenderness, distension, and seat belt sign; pelvis for stability with a single compression test only; perineum and rectum for blood at the urethral meatus, perineal laceration, and rectal tone; extremities for deformity, pulses, and compartment syndrome; neurologic status including complete GCS, motor and sensory examination, and reflexes; and back via log-roll for spinal tenderness, step-off, and wounds.

Imaging in the Stable Trauma Patient

CT Scan

CT of the head, cervical spine, chest, and abdomen/pelvis with IV contrast provides comprehensive evaluation. A "pan-scan" is used for significant mechanism or unclear injury pattern. CT angiography is obtained for suspected vascular injury in the neck, chest, or extremity. CT is performed only for hemodynamically stable patients who can safely be transported to the scanner.

Diagnostic Peritoneal Aspiration/Lavage (DPA/DPL)

DPA/DPL has largely been replaced by FAST and CT but remains useful when these modalities are unavailable. Positive criteria include more than 10 mL of gross blood on aspiration, or lavage fluid containing more than 100,000 RBCs per mm3, more than 500 WBCs per mm3, or enteric contents, bile, or bacteria. It cannot assess retroperitoneal injuries.

<image>Extended FAST exam technique showing the four standard abdominal views (RUQ, LUQ, pelvis, subxiphoid) plus bilateral anterior thoracic views for pneumothorax detection</image>

Special Populations

Pediatric Trauma

Children compensate longer than adults, making hypotension a late and ominous sign. Fluid and medication dosing is weight-based. The higher head-to-body ratio results in more traumatic brain injury. A more elastic skeleton means internal organ injury can occur without overlying fracture.

Geriatric Trauma

Elderly patients have lower physiologic reserve, and medications may mask signs of shock (beta-blockers prevent tachycardia). Anticoagulant and antiplatelet medications complicate hemorrhage management. A lower threshold for overtriage and aggressive evaluation is appropriate. Falls are the most common mechanism of injury.

Pregnant Trauma

Physiologic changes of pregnancy include a 30-50% increase in blood volume, increased heart rate, decreased blood pressure, and an elevated diaphragm. Left lateral decubitus positioning prevents IVC compression. The principle is to resuscitate the mother to save the fetus, as there are two patients. RhoGAM should be administered to Rh-negative patients with any abdominal or pelvic trauma. Perimortem cesarean section is performed if cardiac arrest occurs, within 4-5 minutes of arrest for fetal viability.

Clinical Pearls

The primary survey should take less than 2 minutes, and life-threatening injuries should be treated as they are identified rather than waiting until the survey is complete. Permissive hypotension saves lives in hemorrhagic shock, but SBP must be maintained above 110 mmHg in patients with TBI. Tranexamic acid must be given within 3 hours of injury to be beneficial and should be part of the early resuscitation protocol. A negative FAST does not rule out intra-abdominal injury, and if the mechanism and clinical picture are concerning, CT should be obtained. Hypothermia is lethal in trauma, and aggressive rewarming should begin from the moment of arrival. Base deficit and lactate are the most sensitive early markers of shock, and a normal blood pressure does not mean adequate perfusion. In the unstable patient with a positive FAST, the patient should go directly to the operating room without delay for CT.

References

• American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS). 10th ed. 2018.
• Holcomb JB, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs. a 1:1:2 ratio (PROPPR). JAMA. 2015;313(5):471-482.
• CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients (CRASH-2). Lancet. 2010;376(9734):23-32.
• Kirkpatrick AW, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces. J Trauma. 2004;57(2):288-295.
• Duchesne JC, et al. Damage control resuscitation: The new face of damage control. J Trauma. 2010;69(4):976-990.

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