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Primary survey - Trauma, Study notes of Traumatology

Jordan University of Science and TechnologyTraumatology

The document highlighted the main points in primary survey in trauma cases, including the ABCDE protocol, diagnosis and treatment of the main life threatening cases. The document is summarized to fit students and residents who are interested in General surgery.

Typology: Study notes

2025/2026

Available from 04/03/2026

Dr.Abdalla
Dr.Abdalla 🇯🇴

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Trauma
❖ A cellular disruption caused by an exchange with environmental energy.
❖ Incidence: leading cause of death for individuals ages 1 – 44 years old.
❖ Cause: more than 50% of these deaths are caused by motor vehicle collisions (MVCs)
❖ The 3rd most common cause of death regarding of age after cardiovascular causes (1st) and
cancer (2nd).
❖ Patient evaluation:
• The American college of surgeons (ACS) through the advanced life trauma life support
(ATLS) teaches a systematic approach to the initial evaluation of trauma patients.
• It consists of: primary survey and resuscitation, secondary survey and definitive care.
❖ Primary survey:
• The goal here is to identify and treat conditions that can constitute into a life threatening
conditions.
• Primary survey = ABCDE
1. Airway
2. Breathing
3. Circulation
4. Disability
5. Exposure
• Should be taken within a few minutes.
• Everything should be identified and treated before proceeding into secondary survey.
Airway with C-spine precaution:
• Ensuring a patent airway is the 1st priority.
• Inspect the oropharynx for any potential obstruction (blood, teeth, etc..)
• Severely injured patients can develop airway obstruction leading to hypoxia and
hypoventilation within minutes.
• Cervical spine immobilization ( especially in patients with blunt trauma ) should be
done by: Hard collar (not soft) or by placing sandbags on both sides of the head.
• Patients who are conscious, no tachypnea and have a normal voice can be
proceeded into secondary survey immediately.
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Trauma

❖ A cellular disruption caused by an exchange with environmental energy. ❖ Incidence: leading cause of death for individuals ages 1 – 44 years old. ❖ Cause: more than 50% of these deaths are caused by motor vehicle collisions (MVCs) ❖ The 3rd^ most common cause of death regarding of age after cardiovascular causes (1st) and cancer (2nd).

❖ Patient evaluation:

  • The American college of surgeons (ACS) through the advanced life trauma life support (ATLS) teaches a systematic approach to the initial evaluation of trauma patients.
  • It consists of: primary survey and resuscitation, secondary survey and definitive care.

❖ Primary survey:

  • The goal here is to identify and treat conditions that can constitute into a life threatening conditions.
  • Primary survey = ABCDE
    1. Airway
    2. Breathing
    3. Circulation
    4. Disability
    5. Exposure
  • Should be taken within a few minutes.
  • Everything should be identified and treated before proceeding into secondary survey. Airway with C-spine precaution:
  • Ensuring a patent airway is the 1st^ priority.
  • Inspect the oropharynx for any potential obstruction (blood, teeth, etc..)
  • Severely injured patients can develop airway obstruction leading to hypoxia and hypoventilation within minutes.
  • Cervical spine immobilization ( especially in patients with blunt trauma ) should be done by: Hard collar (not soft) or by placing sandbags on both sides of the head.
  • Patients who are conscious, no tachypnea and have a normal voice can be proceeded into secondary survey immediately.
  • Patients who have one of the following, should undergo elective intubation before evidence of airway compromise: 1. Expanding hematoma. 2. Chemical or thermal injury to the mouth, hypopharynx, etc.. 3. Complex maxillofacial trauma. 4. Extensive subcutaneous air in the neck. 5. Airway bleeding. 6. Upper airway inhalational injury. 7. GCS < 9
  • Patients with abnormal voice or altered mental status ( the most common indication for intubation in trauma patient ) require further airway evaluation; upper airway can be obstructed due foreign body of the pharynx, blood, vomiting, the tongue (which is the MC cause of obstruction if the patient is comatose):
    • That’s why suctioning affords immediate relief in many patients.
  • In case of tongue thrust (reverse swallow), a head tilt-chin lift or jaw thrust should be done, after which an oral airway should be obtained.
  • What type of airway is recommended in a trauma patient?
    • Orotracheal intubation is the most common used method.
  • There are also surgical airways: Cricothyrotomy and Tracheostomy. 1. Cricothyrotomy: - the surgical airway of choice (vertical incision); it’s easier and faster to perform with fewer complications.
  • Treatment:Initial: needle thoracostomy decompression with a 14 - gauge Angio- catheter in the 2nd^ intercostal space at the midclavicular line.  Definite: chest tube insertion (tube thoracostomy) in triangle of safety between the 4th^ or 5th^ intercostal space at the midaxillary line into the chest.
  • Open pneumothorax (Sucking chest wound):
  • It’s a full thickness chest wall injury (at least 2/3 the diameter of trachea) that allows for free communication between the pleural space and the atmosphere. هنا الضغط يكون متساوي = صفر
  • Normal tracheal diameter is 1.8 - 2.2 cm.
  • Treatment:Initial: covering the wound with an occlusive dressing tapped on three sides NOT all four sides, why? → because it may convert open pneumothorax into tension pneumothorax.  Definite: closure of the chest wall defect and tube thoracostomy. Do not close the chest wall defect without inserting a chest tube; it converts open pneumothorax into tension pneumothorax.
  • Flail chest with underlying pulmonary contusion:
  • Three or more contagious ribs fractured in at least sites leading to paradoxical motion of chest wall, often have underlying lung contusion.
  • Pulmonary contusion often progresses during the first 12 hours, often not seen on initial chest x-ray.
  • These patients need: 1. Close monitoring. 2. Frequent clinical re-evaluation.
  • Pulmonary contusion leads to hypoxia + hypoventilation which may require intubation and mechanical ventilation.
  • Treatment :  Analgesia (Thoracic epidural catheter) and physiotherapyIntubation and mechanical ventilation: if oxygenation or ventilation is compromised(hypoxia).

Circulation

  • The goal is to secure adequate tissue perfusion; checking pulses is the initial step here, it gives an approximation of the systolic blood pressure.
  • Accomplished by palpation of carotid, femoral and radial arteries:
    • Carotid pulse = 60 mmHg.
    • Femoral pulse = 70 mmHg.
    • Radial pulse = 80 mmHg. Ex.: if the redial pulse is palpable, then the systolic blood pressure is at least 80 mmHg.
  • If a trauma patient is hypotensive (SBP < 90mmHg), it’s bleeding (Hemorrhagic or hypovolemic shock) until proven otherwise:
    • Fluids must be given immediately (Ringer lactate).
    • Establish peripheral IV access with two large-bore IVs (16 gauge or larger) in the upper extremities, and begin fluid resuscitation.
    • At the same time, blood should be drawn and sent for measurement of hematocrit, typing and cross-matching (for possible blood transfusion).
    • If IV access failed: in adults → Greater saphenous vein (transverse cut down). in children (<6y.o) → intraosseous needle.
    • If peripheral access can’t be obtained at all, a line can be placed in an intraosseous location (preferably proximal tibia or distal femur of an unfractured extremity). o Intraosseous infusions are indicated for children < 6 y.o if two or more attempts of IV access have failed.
    • During this time, Bleeding can be: o Revealed : managed by a manual compression with a single 4*4 gauze and a gloved hand o Unrevealed (deep): can be in the abdomen (hemoperitoneum), chest (hemothorax) or unstable pelvic fracture.
    • For scalp lacerations: a large full thickness continuous nylon stich is performed.
  • If hypotension is still present after resuscitation, then consider one of these life threatening conditions: 1. Massive hemothorax. 2. Cardiac Tamponade. 3. Massive hemoperitoneum. 4. Mechanically unstable pelvic fracture.
    • To distinguish between them, three critical tools are obtained:
      1. Chest X-ray
      2. Pelvis X-ray
      3. FAST scan (Ultrasonography)

o If pericardial sac pressure exceeds cardiac filling pressure, this will lead to complete circulatory collapse.

  • Rapid (acute) accumulation of fluid ( even if < 100 ml ) is the main factor in developing cardiac tamponade; due to inability of pericardial sac to accommodate by stretching.
  • Treatment:Initiate: pericardiocentesis (ultrasound guided placement of a pericardial catheter.  Definite: opening the pericardium (to relieve the pressure) and repairing the underlying cardiac injury ( via median sternotomy ).  if the patient’s SBP < 70 mmHg, then emergency department thoracotomy with opening of the pericardium is indicated. Disability
  • Rapidly assess the patient’s GCS (Glasgow coma score).
  • Scores range from 3 (the lowest) to 15 (normal).
  • Classification:
  1. 13 – 15: Mild head injury.
  2. 9 – 12: Moderate head injury.
  3. < 9: Severe head injury.
  • GCS < 9 is an indication for endotracheal intubation.
  • If a tube is inserted, add (T) to the end (e.g., GCS 8T)

Modality Options

M otor response

  1. Obeys commands
  2. Localises to pain
  3. Withdraws from pain
  4. Abnormal flexion to pain (decorticate posture)
  5. Extending to pain (decerebrate)
  6. None

V erbal response

  1. Orientated
  2. Confused
  3. Words
  4. Sounds
  5. None

E ye opening

  1. Spontaneous
  2. To speech
  3. To pain
  4. None
  • e.g., GCS = 13, M 5 , V 4 , E 4 at 22:

Exposure

  • Patient is fully disrobed for complete physical examination.
  • Logroll maneuver is performed to evaluate the patient’s spine and remove the long spine board while limiting spinal movement ( clothes should be removed). Shock
  • Defined as low tissue perfusion.
  • Classical signs and symptoms are: tachycardia, tachypnea, hypotension, mental status changes, diaphoresis and pallor.
  • Tachycardia is the earliest sign of shock.
  • Hypotension is a late sign of shock, meaning it appears only if blood loss is 30-40%, which is 1500 – 2000 ml of blood ( class 3 ).
  • E.g., if a patient has lost 1000 ml of blood, would he experience hypotension?
    • No, he’s on class 2, shock appears on class 3. Parameter Class I Class II Class III Class IV Blood loss ml <750ml 750 - 1500ml 1500 - 2000ml >2000 ml Blood loss % <15% 15 - 30% 30 - 40% >40% Pulse rate <100 >100 >120 > Blood pressure Normal Normal Decreased Decreased Respiratory rate 14 - 20 20 - 30 30 - 40 > Urine output >30 ml 20 - 30 ml 5 - 15 ml < 5ml Symptoms Normal Anxious Confused Lethargic Potential sources of blood loss Scalp Chest Abdomen Pelvis Extremities