Initial trauma assessment: the primary survey

• Trauma is a leading cause of death through early and middle age, and most preventable deaths after injury come from bleeding, a blocked airway, or a pressure build-up in the chest. The primary survey is a rapid, repeated, whole-team assessment that finds and treats these threats in order of what kills fastest.
• The current ATLS sequence is xABCDE: control exsanguinating external haemorrhage, then Airway with cervical spine protection, Breathing, Circulation, Disability (neurology), Exposure and environment. Each step must be completed, or definitively treated, before moving to the next, while the team works in parallel when the patient is peri-arrest.
• Almost every life-saving act is done during this survey: stop bleeding with direct pressure, wound packing or a tourniquet; open or secure the airway with the neck protected; decompress a tension pneumothorax; put in two large-bore intravenous lines and give blood; check the brain with the Glasgow Coma Scale; find other sources of bleeding with FAST and X-rays; and keep the patient warm.
• The primary survey is never a checklist to be finished once. Reassess after every intervention and whenever the patient changes, and only start the detailed head-to-toe secondary survey when the immediate threats are controlled.
• Transfer is part of the survey: if the patient needs care the hospital cannot give (haemorrhage control, neurosurgery, massive transfusion), start the process early and keep resuscitating while they leave.

By the end of this page you should be able to:

1. Run through the xABCDE primary survey in order and name the life-threatening condition each step is looking for.
2. Protect the cervical spine while assessing and securing an airway, including the indications for a definitive airway.
3. Recognise and treat tension pneumothorax, open pneumothorax, massive haemothorax and flail chest.
4. Classify haemorrhagic shock by the ATLS classes, plan vascular access, permissive hypotension and massive transfusion, and use FAST and a pelvic binder.
5. Perform and interpret the Glasgow Coma Scale, pupil and glucose checks in a trauma patient.
6. Minimise heat loss during exposure and know the tube and catheter cautions and transfer triggers that keep the survey safe and complete.

A trauma patient rarely arrives dying from one injury. More often they are bleeding from several places, have a chest that no longer ventilates, and are becoming hypothermic and acidotic at the same time. The primary survey exists because the human brain cannot hold all of that at once: it forces an order on chaos so that the team treats the greatest threat first and does not miss a quieter one behind it. ^[1]

The original ATLS sequence was ABCDE (Airway, Breathing, Circulation, Disability, Exposure). After years of military and civilian data showing that exsanguinating external bleeding kills in seconds while airway obstruction takes minutes, trauma courses now place an x at the front: eXsanguinating (catastrophic external) haemorrhage is controlled first, by direct pressure, wound packing or a tourniquet, often by other team members at the same time as airway work. ^[1] The x step does not replace the circulation step later; it only recognises that a limb or junctional wound can bleed out before the airway is even assessed. ^[2]

Three rules hold throughout:

• Treat as you go. Every abnormality found is treated before the next letter is addressed (or, in the peri-arrest patient, several letters are treated at once).
• Reassess. The survey is repeated whenever consciousness, vital signs or the examination change.
• Keep the cervical spine safe. Until proven otherwise, assume a spinal injury in any patient with a dangerous mechanism, an altered level of consciousness, or neck pain and tenderness. The head is kept in a neutral in-line position by a second person during every airway manoeuvre.

Pre-arrival preparation matters as much as the hands-on survey. The team, roles (leader, airway, access, scribe, runner), monitoring, and equipment (airway, suction, pelvic binder, warmed fluids) are set out before the patient arrives, and the handover from pre-hospital staff happens while the survey begins. ^[1]

Everyone with significant trauma gets at least the airway and breathing steps; the full xABCDE survey is completed for any patient with physiological abnormality (tachycardia, hypotension, tachypnoea, low oxygen saturation, impaired consciousness), a mechanism likely to produce major injury (high-speed crash, fall from height, blast, stab or gunshot wound, pedestrian struck by a vehicle), injury patterns suggesting major trauma, or special circumstances (elderly patient, pregnancy, anticoagulated patient, anyone in whom instability could be masked). Serious injury can be hidden by alcohol, drugs, age, hypothermia or a language barrier, and a normal first impression is not a reason to skip steps; where there is doubt, do the survey.

There is no contraindication to performing the primary survey: it is an assessment, not a treatment, and its elements are adapted rather than omitted (for example, avoiding a cervical collar when it obstructs airway access, or modifying transfer plans in pregnancy).

Consent is implied by the emergency. The one exception is a competent patient who refuses treatment; this must be documented and discussed with a senior clinician, but it does not slow a life-saving survey.

Equipment that must be ready before arrival:

• Cardiac monitor, non-invasive blood pressure, pulse oximetry, thermometer.
• Airway: suction, oxygen, bag and mask, airway adjuncts, laryngoscope, tube, cricothyroidotomy set, and a rigid cervical collar with manual stabilisation.
• Haemorrhage control: dressings, gauze for packing, tourniquets, pelvic binder or a broad sheet, two large-bore intravenous (IV) cannulae and intraosseous (IO) needles.
• Warmth: warm blankets, warmed fluids, a forced-air warmer, and a warm room.
• Adjuncts: FAST probe, X-ray, trauma shears, warming cabinet.

Aim for a normal oxygen saturation with supplemental oxygen as needed during the survey."

This step is seconds, not minutes. Look at the patient before touching them: is there a pool of blood, saturated clothing, an amputated or badly mangled limb, a pulsating junctional wound? Compressible bleeding is controlled directly (direct pressure, packing and a pressure dressing), and limb bleeding with a tourniquet placed above the wound, as tight as needed to abolish the distal pulse, with the time of application written down. Junctional or groin bleeding may need wound packing and sustained pressure. Review every limb wrap and pressure dressing when the patient is exposed; blood trapped under clothing is easy to miss.

The x step also buys time for circulation later. Exsanguinating external bleeding kills in seconds while airway obstruction takes minutes, which is why control of major external bleeding precedes airway assessment in the xABCDE sequence. ^[1]

How to assess. A conscious patient who answers clearly has a patent airway. Listen and look for obstruction: stridor, hoarseness, paradoxical chest or abdominal movement, snoring, blood, vomitus, a foreign body, a swollen or unstable midface fracture, a haematoma or penetrating wound to the neck. ^[1]

Cervical spine control. In any patient with a dangerous mechanism, neck pain or tenderness, an altered level of consciousness, midline cervical tenderness, a neurological deficit, or a distracting injury, keep the neck in a neutral in-line position. One provider maintains manual in-line stabilisation, jaw thrust is used in preference to head tilt and chin lift, and the neck is not released until it has been cleared or imaged. ^[1]

Opening the airway. Clear visible foreign material and secretions (suction under direct vision), and use a jaw thrust to lift the mandible. Simple adjuncts (oropharyngeal or nasopharyngeal airway) bridge the gap, but they do not protect against aspiration.

Definitive airway indications. Intubation (or a surgical airway if intubation fails) is needed when a patient cannot maintain or protect the airway, or has inadequate oxygenation or ventilation despite initial measures. In practice this includes a Glasgow Coma Scale (GCS) score of 8 or less, or one falling, a deteriorating conscious level, severe facial or airway injury, airway burns or swelling, massive bleeding into the airway, respiratory failure or apnoea, and a high risk of aspiration. ^[1]

Important cautions during intubation in trauma.

• Hypotension and hypoxia around intubation are themselves lethal. In the exsanguinating patient, basic airway manoeuvres and oxygenation are started while volume resuscitation is begun, before giving rapid sequence drugs.
• A surgical airway (cricothyroidotomy) is needed when less invasive measures cannot maintain oxygenation.

A cervical collar does not immobilise a neck; manual in-line stabilisation is the real protection. Spinal motion restriction should be individualised rather than applied to every patient regardless of mechanism. ^[1]

What to look for. Respiratory rate and effort, symmetry of chest movement, oxygen saturation, tracheal position, and findings on inspection, auscultation and palpation: decreased or absent breath sounds, tenderness, instability, crepitus, paradoxical movement of a flail segment, and penetrating wounds. Clinical assessment comes first, even when oximetry is available, because serious respiratory problems evolve quickly. ^[1]

Four immediately life-threatening chest injuries are sought and treated here.

Tension pneumothorax. Air enters the pleural space through a one-way valve so that pressure rises with each inspiration, collapsing the lung and shifting the mediastinum, which compresses the opposite lung and the great veins. It is a clinical diagnosis: severe respiratory distress, hypoxia, tachycardia, hypotension, absent breath sounds and hyper-resonance on the affected side, tracheal deviation away from it, and distended neck veins (which may be absent once hypotension is severe). ^{[4] [5]}

If tension pneumothorax is suspected in an unstable patient, do not wait for imaging: decompress immediately. A 14-gauge needle through the second intercostal space in the midclavicular line (or the fifth intercostal space in the anterior axillary line, which may fail less often in larger body habitus) is followed in hospital by tube thoracostomy (open thoracostomy followed by a chest drain in-hospital). ^{[4] [5]} Tension pneumothorax is a particular danger once an occlusive dressing has sealed a sucking wound.

Open pneumothorax ("sucking chest wound"). A chest wall defect communicates freely with the pleural space, so during inspiration air is drawn in through the wound instead of through the trachea. Cover the wound immediately with an occlusive dressing sealed on three of four sides (or a vented chest seal) so that air can leave but not enter. Watch afterwards for the development of tension physiology, and treat the wound at surgery. ^[5]

Massive haemothorax. Defined as more than 1500 mL of blood in the pleural space in an adult. ^[4] A third of circulating blood or more can collect in one chest. Suspect it with blunt or penetrating trauma, diminished or absent breath sounds, dullness to percussion, and hypovolaemic shock. It is an indication for urgent tube thoracostomy and then operative control of bleeding, but the patient is first stabilised with thoracostomy to re-expand the lung. ^[4]

Flail chest. Three or more adjacent ribs fractured in at least two places produce a free-floating segment that moves paradoxically: in during inspiration, out during expiration. ^[4] The fracture pattern itself is less dangerous than the pulmonary contusion beneath it, which often worsens initially and drives hypoxia and hypoventilation. Analgesia, oxygen, pulmonary toilet and careful monitoring come first; positive-pressure ventilation and surgical rib fixation are reserved for respiratory failure or instability. ^[4]

At the bedside breathing step also check for cardiac tamponade (part of the differential of shock in chest trauma) and great vessel injury, and make sure the trachea is midline before declaring the airway safe. ^[4]

Identify bleeding and its source. Haemorrhage is the leading preventable cause of death after trauma. Examine peripheral and central pulses, skin colour and temperature, capillary refill, mental status and blood pressure, and look again for ongoing external bleeding. ^{[1] [2]} Then search for internal bleeding: the chest, abdomen, retroperitoneum, pelvis and long bones are the major sources, on top of any external wound. ^[1]

Haemodynamic instability in the trauma setting is, by the ATLS convention, a blood pressure under 90 mm Hg together with a heart rate over 120 per minute, plus cool clammy skin, delayed capillary refill, altered consciousness or shortness of breath. ^[6] Tachycardia is usually the first abnormal vital sign, and older people or patients taking beta-blockers or antihypertensives may not mount it, so shock can present more subtly in these groups. ^[6]

The ATLS classes of haemorrhagic shock link how much blood has been lost to the expected response in a previously healthy 70 kg adult (total blood volume about 5 litres, 7 percent of body weight). ^[2]

Vascular access. Put in two large-bore peripheral IV lines as early as possible; if peripheral access fails, use intraosseous access rather than delay. ^{[1] [7]} One line is often not enough when blood and products are running; large-bore lines matter more than the number of lumens.

Permissive hypotension. In the shocked trauma patient without a head injury, restrict crystalloid and aim for a systolic blood pressure in the region of 80-90 mm Hg until haemorrhage is controlled, accepting a short period of suboptimal end-organ perfusion so that recently formed clots are not blown off. ^{[2] [6]} Other guidance uses a target of 90 mm Hg. ^[2] This is not appropriate when raised intracranial pressure is suspected, where cerebral perfusion must be maintained; use vasopressors for spinal or cerebral perfusion targets. ^[6]

Fluids and blood products. Avoid flooding with crystalloid in significant traumatic bleeding; blood (whole blood where available and appropriate, otherwise balanced components of packed red cells, plasma and platelets) is the resuscitation fluid of choice, following the local massive transfusion protocol. ^{[1] [2]} A trial quoted in the haemorrhagic shock literature found no significant difference in 24-hour or 30-day mortality between 1:1:1 and 1:1:2 plasma:platelets:packed red cells, but the more balanced 1:1:1 ratio produced more haemostasis and less death from exsanguination; reducing the time to first plasma also reduces mortality. ^[2] Tranexamic acid is given within 3 hours of injury (and at least within 8 hours) where haemorrhage is significant. ^[2]

Reverse anticoagulation (if any) on the basis of the drug, its timing, the severity and site of bleeding, and the reversal agents available. ^[1]

Pelvic binder. If a pelvic fracture is suspected on mechanism or examination, apply a binder or a firmly tied broad sheet centred over the greater trochanters (never over the abdomen or waist), flat against the skin, with the legs adducted and the hips internally rotated, as early as possible, ideally in the field or ambulance. ^[6] It reduces pelvic volume, promotes tamponade of venous and bony bleeding, and can improve haemodynamics and reduce transfusion. ^[6] It is a temporary measure, should be removed after 24-48 hours, and avoided or limited to 2-3 hours if skin pressure is high because of necrosis. ^[6] Apply it once only, with care, and do not repeatedly compress the pelvis. ^[6]

FAST and eFAST. FAST is performed during the circulation step (usually within minutes) to look for free fluid in the pericardium and three peritoneal spaces; extended FAST (eFAST) adds a view of each hemithorax for pneumothorax and haemothorax. ^{[1] [7]} It is rapid, non-invasive and can be repeated, but a negative scan does not exclude significant injury or haemorrhage, especially in penetrating abdominal trauma. ^[1]

Level of consciousness is recorded with the Glasgow Coma Scale immediately the airway and breathing are secure enough to allow it, and then repeatedly. A GCS of 8 or less warrants airway protection and ventilation. ^{[1] [3]}

Severity of traumatic brain injury by GCS: severe 3-8, moderate 9-12, mild 13-15. ^[3] The pupil and motor findings, not just the total, drive decisions: the motor response dominates in severe injury.

Pupils: size, equality and reaction to light. Asymmetry, dilation or unreactive pupils can indicate herniation, eye injury, brainstem injury or toxins.

Motor and sensation in all four limbs and along the spine; look for lateralising signs and spinal cord injury.

Glucose. Measure blood glucose. Hypoglycaemia mimics altered consciousness and worsens brain injury, and is quickly corrected. Sedation, alcohol and drugs also confound the GCS; record them and reassess once they wear off. ^[3]

Spinal protection during the whole survey: minimise spinal movement, and keep the patient log-rolled by a team.

Remove all clothing so that hidden injuries (entry and exit wounds, stab wounds, burns, seatbelt marks) are found. At the same time, treat the patient as if they are losing heat: untreated hypothermia is part of the lethal triad of trauma, alongside acidosis and coagulopathy, and hypothermia of less than 34 degrees Celsius compounds coagulopathy and is an independent risk factor for death. ^[2]

Practical warming steps: warmed blankets and a warm room, warmed intravenous fluids, forced-air warming, and avoiding unnecessary exposure. Cover the patient as soon as the survey is complete, and check temperature repeatedly. ^{[1] [2]}

X-rays. Plain radiographs are chosen by mechanism, examination and clinical condition. A chest radiograph is recommended in blunt trauma and in essentially all penetrating chest trauma (up to a fifth of such patients have pneumothorax or haemothorax with normal examination); pelvic radiographs help when the pelvis is unstable or pelvic bleeding is suspected. ^{[4] [6]} Do not send a haemodynamically unstable patient to the scanner or X-ray suite if it delays resuscitation or haemorrhage control. ^[1]

FAST/eFAST is covered in the circulation step; repeat it if the clinical picture changes. ^[1]

Lines and tubes: cautions.

• Bladder catheter: useful for monitoring urine output, but only place it when there is no suspected urethral injury. Blood at the urethral meatus, a scrotal or perineal haematoma, a high-riding prostate, or saddle-type fractures should prompt a retrograde urethrogram first. ^[7] Blood at the meatus occurs in a large minority to the large majority of posterior urethral injuries. ^[7]
• Gastric tube: avoid blind passage with severe craniofacial trauma, because inadvertent intracranial placement can occur.
• Chest drain: the definitive treatment after needle decompression; large-bore when there is haemorrhage.
• Analgesia: severe pain (especially rib fractures) splints ventilation; effective analgesia and an incentive spirometer protect the lungs. ^[4]

Other adjuncts that do not replace the survey but assist it: electrocardiography (which cannot confirm tension pneumothorax), arterial blood gas, urinary dipstick, and, in the stable patient, CT of the head, neck, chest and abdomen and specific X-ray of the pelvis and cervical spine.

The primary survey is repeated, as xABCDE, every time the patient changes. If deterioration occurs, go back to the start and look for a new tension pneumothorax, a re-bleed, or a missed injury.

Once the patient is stable enough to leave the resuscitation area, perform the secondary survey: a focused history plus a full head-to-toe examination, with genital and perineal inspection as indicated, and targeted imaging. Injuries missed in multisystem trauma (abdominal, thoracic, extremity) are common, and routine digital rectal examination and urethral catheterisation are no longer automatic. ^[1] A tertiary survey later catches injuries that declared themselves after admission. ^[1]

Transfer starts when the patient needs something the hospital cannot deliver: massive transfusion beyond local stock, haemorrhage control, neurosurgery, thoracic surgery, specialist paediatric care, or intensive care the hospital cannot provide. The rule is: recognise early, start the process, and continue resuscitating while the patient is moved. Do not let transfer, imaging or investigations delay definitive haemorrhage control or the departure of an unstable patient. ^[1] Arrange the right level of escort, equipment and a warmed environment, and give a structured handover (S-xABCDE-BAR style).

• Fixation on the obvious injury (a dramatic limb fracture, a burn) while a hidden chest or pelvic bleed goes untreated.
• Intubating before controlling exsanguinating haemorrhage, causing a post-intubation hypotensive collapse.
• Assuming a single normal FAST scan rules out abdominal injury, especially in penetrating trauma.
• Missing a tension pneumothorax in a patient who already has a chest drain that has clotted or displaced.
• Hypothermia left uncorrected until a coagulopathy has developed.
• Forgetting to re-examine after every intervention.

• Children: rib elasticity makes flail chest rare but indicates severe trauma; paediatric haemorrhage may be hidden until decompensation.
• Older adults: blunted tachycardia and signs of shock; lower thresholds for instability. ^[6]
• Pregnancy: the binder must not compress the gravid uterus or the inferior vena cava; disproportionate maternal volume and fetal loss are risks; tilt the patient left and prioritise the mother's physiology.
• Low-resource settings: the whole survey can be done with hands, eyes, a stethoscope and a strip of cloth or sheet as a pelvic binder; oxygen, two large IV lines and warmth change survival more than imaging. A CXR and ultrasound identify chest bleeding and pneumothorax; transfer early to a facility that can operate.

• The primary survey is a rapid, sequential, repeated assessment: x (exsanguinating haemorrhage), A (airway with cervical spine protection), B (breathing), C (circulation), D (disability), E (exposure and environment). ^[1]
• Exsanguinating external bleeding is controlled first; other team members may do this while airway work starts, but it does not replace the later circulation assessment. ^[1]
• A patent airway is indicated by coherent speech; definitive airway is needed at GCS 8 or less or with inadequate oxygenation or ventilation. ^[1]
• Jaw thrust, not head tilt, protects the cervical spine; manual in-line stabilisation is essential. ^[1]
• Tension pneumothorax is clinical and decompressed immediately without waiting for imaging. ^{[4] [5]}
• Open pneumothorax is covered with a three-sided (or vented) occlusive dressing. ^[5]
• Massive haemothorax is more than 1500 mL of blood in the pleural space in an adult. ^[4]
• Flail chest is three or more adjacent ribs fractured in two or more places, with paradoxical movement. ^[4]
• Circulatory classes I-IV relate blood loss (up to 15 percent, 15-30 percent, 30-40 percent, over 40 percent) to heart rate, pressure, respiration, pulse pressure, urine and mental status. ^[2]
• Two large-bore peripheral IV lines or intraosseous access, and blood rather than crystalloid, are the access of choice in major bleeding. ^{[1] [7]}
• Permissive hypotension targets roughly 80-90 mm Hg systolic, or around 90 mm Hg by other guidance; avoid it with suspected raised intracranial pressure. ^{[2] [6]}
• Massive transfusion ratios of 1:1:1 (plasma:platelets:packed red cells) produce more haemostasis than 1:1:2; tranexamic acid reduces mortality within 3 hours. ^[2]
• FAST and eFAST are quick and safe but a negative scan does not exclude bleeding. ^[1]
• Pelvic binder goes over the greater trochanters early as a temporary measure, 24-48 hours maximum. ^[6]
• GCS, pupil and glucose checks are the disability step; GCS 8 or less is a severe brain injury. ^[3]
• Hypothermia below 34 degrees Celsius worsens coagulopathy and is an independent risk factor for death. ^[2]
• Do not place a bladder catheter blindly when urethral injury is suspected; use retrograde urethrography first. ^[7]
• Transfer early and keep resuscitating while moving. ^[1]

• Shock (hypovolaemic and haemorrhagic)
• Traumatic brain injury
• Spinal cord injury and cervical spine clearance
• Thoracic trauma, including pneumothorax and haemothorax
• Pelvic fractures and haemorrhage control
• Damage control resuscitation and massive transfusion protocols