Secondary survey and penetrating trauma

• The secondary survey is the head-to-toe examination and focused history that follows only after the primary survey (airway, breathing, circulation, disability, exposure) is complete and life threats are controlled. It is the step that prevents the "missed injury" in a trauma patient.
• All trauma is classified by mechanism. Penetrating trauma is defined by violation of the platysma in the neck and of the abdominal fascia in the trunk. The mechanism predicts the organs at risk and the required treatment.
• Neck zones still guide exposure, but modern care is driven by hard signs of vascular injury: an expanding haematoma, severe bleeding, shock not responding to fluids, absent pulse, bruit or thrill, airway compromise and cerebral ischaemia all mandate immediate surgical exploration.
• Penetrating chest wounds cause six immediately life-threatening injuries: airway obstruction, tension pneumothorax, open pneumothorax, massive haemothorax, flail chest and cardiac tamponade. Beck triad (muffled heart sounds, raised jugular venous pressure and hypotension) is present in only about one third of tamponades, so ultrasound is essential. ^{[1] [4]}
• Penetrating abdominal wounds need immediate laparotomy for haemodynamic instability, peritonitis, evisceration or impalement. Stable patients can undergo local wound exploration and, when appropriate, selective non-operative management.
• Extremities need a documented neurovascular examination and repeated checks for compartment syndrome: a delta pressure (diastolic pressure minus compartment pressure) of 30 mmHg or below indicates acute compartment syndrome and timely fasciotomy. ^[8]
• Impaled objects are never removed outside theatre; with very few exceptions they are removed only under direct vision after the bleeding site is exposed. External haemorrhage from a limb that persists is controlled first with direct pressure and then with a commercial tourniquet, which is left visible, marked with the time, and not loosened.

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

1. State when the secondary survey begins and what it must include, including the AMPLE history and a head-to-toe examination.
2. Define a penetrating injury in the neck and abdomen, and use neck zones I to III to predict the structures at risk.
3. Distinguish hard from soft signs of vascular injury and state their immediate management.
4. Recognise and state the immediate management of open pneumothorax, massive haemothorax and cardiac tamponade, including Beck triad.
5. State the indications for immediate laparotomy after penetrating abdominal trauma and the steps of selective non-operative management, including local wound exploration and CT.
6. Examine an injured extremity neurovascularly, recognise acute compartment syndrome by clinical signs and pressure thresholds, and state the principles of open fracture and tetanus care.
7. State how to manage an impaled object and how to apply, time and convert a tourniquet.
8. Recognise the classic deceleration injuries and the organs at risk in blunt trauma.

Trauma care is divided into two consecutive surveys. The primary survey identifies and treats immediately life-threatening injuries using the xABCDE approach: exsanguinating haemorrhage, airway, breathing, circulation, disability (neurological state) and exposure (with temperature control). Only once the primary survey is complete, resuscitation is under way and the patient's vital functions have improved does the secondary survey begin. When more staff are available, parts of the secondary survey can run alongside the primary survey, but the rule is that nothing in the secondary survey may delay a life-saving intervention.

The secondary survey is an expedited, full history and head-to-toe physical examination to make sure no injury is missed. In unresponsive or altered patients it is difficult and relies heavily on examination findings, imaging and information from bystanders and pre-hospital teams. Commonly missed injuries include blunt abdominal trauma with internal organ injury, penetrating abdominal trauma, penetrating thoracic trauma, and extremity trauma such as fractures and compartment syndrome. ^[1]

The mechanism of injury predicts the injuries. Trauma is broadly divided into penetrating, blunt, deceleration and thermal injuries. Penetrating injuries include stab wounds, gunshot wounds and foreign body injuries. Blunt injuries include falls, motor vehicle collisions, assaults and blast injury. Some injuries are mixed: impalement carries both blunt and penetrating elements.

This page covers the complete in-hospital initial assessment of a multiply injured adult trauma patient: the secondary survey, plus the region-by-region management of penetrating injury. Indications for its use are any patient who has sustained major trauma and survived to hospital. Contraindications are not really applicable, but two cautions are. First, in a haemodynamically unstable patient with an obvious injury (for example a penetrating chest wound), do not delay definitive management (transfer to theatre, the angiography suite, or a trauma centre) to complete a detailed secondary survey. Second, where the patient cannot be examined reliably (because of brain injury, spinal injury, intoxication or sedation), the survey must be supported by imaging and repeated clinical examination rather than relied on alone.

Anatomy needed is covered in each region. The trauma team needs a clear airway algorithm, blood products, cross-matched blood, a resuscitative thoracotomy set, chest drain sets, a FAST (focused assessment with sonography for trauma) machine, and CT access.

Consent in major trauma is implied where the patient is incapacitated and there is an immediate threat to life; where time allows, a separate consent for procedures is documented. Preparation means pre-arrival notification, a defined team with named roles (primary survey leader, airway, circulation, scribe), personal protective equipment, warmed intravenous fluids and a way to record: every tube, line, image, drug, and the time of every tourniquet application. Reassessment is continuous. If the patient deteriorates at any point, return immediately to xABCDE.

A penetrating injury breaches the skin and underlying tissues. In the neck, the critical boundary is the platysma: a wound that appears to be only skin may still be deep, while one that breaches the platysma is, by definition, a penetrating neck injury with potential damage to vessels, airway, oesophagus, nerves and the cervical spine. ^[2] Many penetrating neck injuries that breach the platysma have no deeper injury, but all need expert assessment because a patient who looks stable can decompensate rapidly. ^[2]

In the abdomen, the equivalent boundary is the anterior abdominal fascia. A wound that does not breach it is a superficial injury; one that does can still be managed selectively, but with a higher index of suspicion and a lower threshold for intervention. ^[3]

Three wound characteristics guide the whole assessment: the mechanism (stab, low-energy; gunshot, high-energy, with cavitation and fragmentation; blast, multiple mechanisms), the number of wounds (entry and exit wounds are counted; an odd number means a retained projectile or an internal tract) and the energy involved. The "secondary survey attitude" is to look for the injury you did not see first: distracting injuries hide other damage, and mechanisms such as blast usually cause multiple injuries.

The approach to penetrating trauma is to identify the body region, decide whether the patient is stable, and route accordingly:

The secondary survey has two parts: a focused history and a head-to-toe physical examination. The history can be remembered with AMPLE:

• A (allergies): drug allergies, especially to antibiotics and latex.
• M (medications): prescribed and over-the-counter medicines, anticoagulants, antiplatelet agents, insulin, and recreational drugs.
• P (past medical history and pregnancy): including tetanus immunisation status, which matters for every wound.
• L (last meal): relevant to the timing of any anaesthetic.
• E (events and environment): the mechanism of injury in the patient's own words, the time it happened, what weapon was used and its length, how many shots were heard, whether the patient walked or was carried, and what has happened since. In penetrating injury the mechanism is decisive: a stab wound is low-velocity; a gunshot is high-velocity; blast injury combines all mechanisms and usually causes multiple injuries.

Mechanism details that change management include: in penetrating trauma, the type and length of the penetrating object, the calibre and number of gunshots, and the distance (a near miss can still be a penetrating wound at the edge of the blast). Body habitus, intoxication, distracting injuries and agitated behaviour make the history and examination unreliable, and in these patients imaging carries more weight.

The head-to-toe examination is systematic and repeated. It covers:

• General assessment and vital signs. Recheck temperature, pulse, blood pressure, respiratory rate, oxygen saturation and Glasgow Coma Scale after the primary survey.
• Head and face. Scalp lacerations, skull deformity, facial fractures, eye injury, dental trauma, nasal bleeding, CSF rhinorrhoea or otorrhoea, pupillary size and reaction, and ear drums (haemotympanum suggests a base-of-skull fracture).
• Neck. Look for midline tenderness, deformity, wounds and platysma violation; check the carotid pulses; listen for a bruit; palpate for subcutaneous emphysema; and keep the neck immobilised until cervical spine injury is excluded by imaging or clinical criteria.
• Chest. Reinspect for wounds and bruising, palpate for rib fractures and crepitus, check chest wall stability (flail segment), auscultate breath sounds in all zones, and re-examine after any intervention (for example, chest tube placement).
• Abdomen and flanks. Reinspect for wounds, bruising, distension and the seatbelt sign; gently palpate for tenderness, guarding and rigidity; check for organ evisceration and palpable swellings (haematoma from pelvic fracture).
• Pelvis and genitourinary. Palpate the pelvis for instability only if indicated and gently; inspect the perineum, genitalia and urethral meatus for bleeding; record urine output. Routine digital rectal examination has limited diagnostic utility in trauma and is not needed as a standard part of every secondary survey.
• Limbs. Undress each limb fully, check for wounds, deformity, swelling and crepitus; re-examine neurovascular status after any reduction or splinting; and compare with the uninjured side. The spine and posterior surfaces must not be forgotten: log-roll the patient (with spinal precautions if indicated) to inspect the back, buttocks and perineum for wounds and bruising.
• Skin. Lacerations, bruising and evidence of missed penetrating wounds.

Adjuncts to the secondary survey include laboratory testing (full blood count, coagulation, group and save, blood gas, lactate, renal function), imaging (chest and pelvic radiographs, FAST, CT), and simple dressings and neurovascular checks. A tertiary survey, performed after the patient is stabilised (often the next day), catches injuries missed by the first two surveys in multisystem trauma.

Neck zones in penetrating trauma still describe the anatomy, even though management is now driven by hard and soft signs. The neck is divided into three zones: ^[2]

Up to 10% of trauma cases involve isolated neck injury, with mortality up to 10%; vascular injury occurs in up to 25% of cases, aerodigestive injury in up to 30%, and about half of deaths are due to haemorrhage from vascular injuries. ^[2]

Hard and soft signs of injury to vital structures are the basis of modern management. Hard signs demand immediate operation; soft signs in a stable patient prompt CT angiography; an absence of signs allows observation. ^[2]

Permissive hypotension (a systolic blood pressure around 90 mmHg, higher in traumatic brain injury) is appropriate in penetrating neck bleeding where the bleeding is not yet controlled, with haemostatic gauze and direct pressure as first measures and a balloon catheter (Foley) inflated in the wound as a bridge. ^[2] In children, stridor should be treated as an additional hard sign because it warns of impending airway loss from bleeding or swelling. ^[2] Vascular injury occurs within the "cardiac box" (midclavicular lines, clavicles and costal margins) as well: any penetrating chest wound must be treated as a possible cardiac or great-vessel injury until excluded. ^[4]

Six injuries are immediately life-threatening and must be excluded first: airway obstruction, tension pneumothorax, open pneumothorax, massive haemothorax, flail chest and cardiac tamponade. ^[1] Of these, open pneumothorax, haemothorax and tamponade are the classic penetrating injuries dealt with here. Penetrating chest injuries are a minority of chest trauma in most civilian settings; a minority of those require operation, and most are managed with simple procedures such as chest drainage. ^[1]

Open pneumothorax ("sucking chest wound"). A defect in the chest wall communicates with the pleural cavity, so air rushes in through the wound instead of through the trachea, and the lung collapses. Pre-hospital management is a vented (three-sided or valved) occlusive dressing; in hospital a chest drain is placed and the wound is closed or allowed to epithelialise. If the patient deteriorates with hypoxia or shock, an open thoracostomy is performed. ^[1] In the emergency department open pneumothorax is uncommon among major trauma patients. ^[1]

Haemothorax. Bleeding into the pleural space, most often from intercostal vessels, lung laceration or a great vessel. Typical findings are decreased breath sounds and dullness to percussion, hypovolaemia and shock without distended neck veins (distinguishing it from tension pneumothorax, where neck veins are distended). Massive haemothorax is defined as more than 1,500 mL of blood lost initially or more than 200 mL per hour for 2-4 hours, and it indicates thoracic surgical intervention. ^[1] Initial management is large-bore chest drainage (ch. 28-40) and rapid volume restoration, with operative thoracotomy when bleeding thresholds are reached. ^[1]

Cardiac tamponade. Penetrating injury to the "cardiac box" should raise immediate suspicion of tamponade. As little as 100 mL of blood in the pericardium after penetrating cardiac injury can impair venous return, reduce ventricular filling and produce circulatory collapse. ^[4] Beck triad (muffled heart sounds, raised jugular venous pressure and hypotension) is classic but appears in only about one third of tamponades; electrical alternans and pulsus paradoxus (a fall in systolic pressure of more than 10 mmHg during inspiration) are also described. Bedside ultrasound (FAST or extended FAST) showing pericardial fluid has replaced clinical signs as the key diagnostic test, and the pericardium must always be opened at thoracotomy because external inspection is insensitive. ^[4] The mortality of penetrating cardiac trauma is high, with death from exsanguination or tamponade occurring before hospital arrival in many patients.

Immediate management depends on stability. A stable patient with pericardial fluid can go to theatre for median sternotomy and pericardiotomy; an unstable or pulseless patient requires resuscitative thoracotomy (left anterolateral, or clamshell), pericardiotomy, control of haemorrhage and, where necessary, open cardiac massage and aortic cross-clamping for up to 30 minutes. Penetrating bodies found in situ (such as a knife still in the chest) are generally left alone until the chest is opened, to avoid sudden massive bleeding. ^[4] Intubation and positive-pressure ventilation can convert a tamponade into cardiac arrest by further reducing venous return, so delay intubation until the surgical team and blood are ready. ^[4]

Penetrating abdominal trauma makes up a large proportion of urban trauma. Indications for immediate laparotomy are: ^[3]

• haemodynamic instability (unresponsiveness to initial resuscitation);
• signs of peritonitis;
• organ evisceration;
• impalement;
• haematemesis or blood on nasogastric aspiration;
• blood per rectum;
• enteric contents seen in the wound;
• a retained foreign body with suspected visceral injury;
• gunshot wounds with certain trajectory or abdominal tenderness;
• failed selective management.

Where none of these is present the patient is a candidate for selective (non-operative) management. Local wound exploration, using local anaesthetic, determines whether the anterior fascia is breached: if it is not, the wound is superficial and the patient can be discharged once other injuries are excluded. If it is, the patient is admitted for serial clinical examinations by the same experienced clinician, vital signs monitoring and serial inflammatory markers, with prompt access to theatre and CT available. ^[3]

Practical points in selective management:

• It is best studied for anterior abdominal stab wounds; it applies less well to gunshot wounds (irregular trajectories, cavitation and a higher rate of hollow-viscus injury) and to flank or posterior wounds, where CT is essential.
• Sensitivity of local wound exploration varies with clinician experience and smaller stab wounds can be falsely negative.
• A haemoglobin fall of more than 2 g per dL from baseline, without another explanation, mandates exploration. ^[3]
• Observation must last at least 24-48 hours; conversion to operation must always be possible. ^[3]
• Computed tomography has a sensitivity of about 88% for bowel injury in penetrating trauma and adds most for flank, back and gunshot wounds. Highly specific CT findings in this setting include extraluminal air, extraluminal contrast, bowel-wall defects and metallic fragments in the wall or lumen of the bowel. Serial clinical examination and CT are complementary rather than alternatives. ^[3]
• Trauma patients who cannot be clinically examined (brain, spinal or severe other injuries, intoxication, sedation) should not be selected for non-operative management. ^[3]
• Selective management requires resources: experienced clinicians, repeated examination, access to theatre and ICU care if needed. ^[3]

Diagnostic laparoscopy, in haemodynamically stable patients with suspicious CT findings, can clarify diaphragmatic or visceral injury and is sometimes therapeutic, but it misses 22-45% of injuries in less experienced hands; therapeutic laparoscopy is promising but a laparotomy remains the safe default when physiology is poor. ^[3]

Extremity injury is a leading cause of compartment syndrome, and the examination must be complete and documented before and after any manipulation or splinting.

Neurovascular examination. Assess distal pulses (radial, ulnar, dorsalis pedis, posterior tibial, brachial, popliteal), capillary refill, skin colour and temperature, and both sensory and motor function in the nerve distributions distal to the injury. In penetrating extremity trauma, hard signs of vascular injury (absent pulse, expanding haematoma, active bleeding, bruit or thrill, limb ischaemia) mandate operative exploration; soft signs (proximity, minor bleeding, small haematoma) are investigated with imaging such as CT angiography. ^[8] Neurovascular checks should be repeated and compared side to side. Arterial bleeding may be intermittent because of vessel spasm, so a normal examination does not exclude injury.

Acute compartment syndrome. Tissue pressure rises inside a closed fascial space until perfusion is lost, beginning a process that becomes irreversible after about 6 hours and can cost the limb if not treated. Classically the 6 P's are taught: pain out of proportion to the injury, pain on passive stretch, pallor, paraesthesia, paralysis and pulselessness; pain on passive stretch is the earliest and most reliable sign, while pulselessness is late. ^{[8] [6]} The diagnosis is supported by measuring intracompartmental pressure: a delta pressure (diastolic pressure minus compartment pressure) of 30 mmHg or less indicates acute compartment syndrome and fasciotomy. ^[8] Note that the "5 P's" and "6 P's" are both taught and that pressure measurement is not a substitute for the clinical picture: single readings can mislead and repeated measurements with attention to the pressure trend are required. ^[8] Open fractures do not prevent compartment syndrome, because the compartments can still be compressed, so repeated checks are still needed. ^[8]

Open fractures. Any fracture near a wound is assumed to be open. Open fractures require sterile dressings, tetanus prophylaxis, broad-spectrum antibiotics (typically a second-generation cephalosporin plus an aminoglycoside) and surgery to irrigate and debride the wound. Antibiotics should be given as early as possible, within 1 hour of presentation to the emergency department to minimise infection. ^[6] The Gustilo-Anderson classification (I to III, including subtype C for arterial injury requiring repair) grades them by wound size, contamination and soft-tissue damage and higher grades carry a much higher infection and osteomyelitis risk. ^[6] Patients with pelvic or femoral fractures are also assessed for haemorrhagic shock from occult blood loss. ^[6]

Tetanus prophylaxis must be considered for every traumatic wound, and is part of open-fracture care. Wounds are split into clean and minor (low risk) or dirty and major (increased risk). Dirty and major wounds include penetrating and puncture wounds, wounds containing soil, faeces or saliva, and wounds with devitalised tissue such as burns, compound fractures, crush injuries and necrotic wounds. ^[7] Antibiotics are not recommended to prevent tetanus. ^[7] Tetanus toxoid is given if the vaccination history is unknown, incomplete, or (for a clean and minor wound) the last dose was 10 or more years ago, or (for a dirty and major wound) 5 or more years ago. ^[7] Tetanus immune globulin, 250 international units intramuscularly, is given for dirty and major wounds in patients with unknown, absent or incomplete tetanus vaccination, and in immunocompromised patients (including those with HIV). ^[7] It is never indicated for clean and minor wounds. ^[7]

An impaled object is left in place. Removal outside theatre risks dislodging any tamponade effect on vessels and major cavities and can cause sudden fatal haemorrhage. ^[9] The object is shortened if it obstructs transport (for example, cutting a metal bar) but it is not removed at the scene. In hospital the patient is resuscitated along ATLS lines, broad-spectrum antibiotics and tetanus prophylaxis are given, and the object is removed only under direct vision in theatre after the track has been identified by imaging or direct exploration. ^[9] Impalement injuries are a mixture of blunt and penetrating trauma and are commonly contaminated (soil, wood, metal, bone). Type I impalements occur when the body hits a stationary object (fall, vehicle collision); Type II when a moving object pierces a stationary body (assault, spear). ^[9] Impaled objects often near vessels and organs; cardiopulmonary bypass should be available in the theatre when thoracic impalement is near the heart or great vessels. ^[9]

A tourniquet is not a first-line measure for most bleeding: stepwise haemorrhage control is direct pressure, elevation of the limb, pressure dressing with wound packing, and then a tourniquet if these fail. It is indicated for extreme life-threatening limb bleeding or a mangled or amputated limb with multiple bleeding points, for inaccessible bleeding points (entrapment) and for mass-casualty situations. ^[5] It is never applied to the torso, neck or head. A properly applied tourniquet hurts, and strong analgesia is required once the patient is stable.

Application principles, from a civilian pre-hospital review: ^[5]

• Use a proven commercial device (such as the Combat Application Tourniquet), not an improvised one.
• Place it on exposed skin, as distal as possible but at least 5 cm proximal to the injury, sparing joints. ^[5]
• Tighten until bleeding stops and the distal pulse disappears (checking a distal pulse is not enough in itself); a second tourniquet placed side by side is used if bleeding persists.
• Effectiveness is judged by cessation of haemorrhage, not by the absence of a distal pulse; medullary bleeding in an amputation may ooze despite an effective tourniquet.
• Record the time of application on the tourniquet, on the documentation and on the casualty's visible skin, and hand it over clearly.
• Keep the tourniquet visible and never covered by bandages, clothing or blankets.
• Do not remove or loosen the tourniquet for pain, and never apply a policy of periodic loosening, which has led to re-bleeding and death. ^[5]

Time limits, noting the evidence comes largely from military and elective tourniquet use, so they should be treated as guidance rather than absolute cut-offs: continuous application beyond about 2 hours can result in permanent nerve, muscle, vascular and skin injury; muscle damage is nearly complete by 6 hours with likely amputation; tourniquets left up to 6 hours without limb loss have been reported. ^[5] In military data, pre-hospital tourniquet applications resulted in neurological complications in 5.5% of cases, with ischaemic times between 109 and 187 minutes; the mean ischaemic time without complications was 78 minutes. ^[5]

In hospital, if transit time has been under 1 hour and the bleeding is from an isolated injury, the tourniquet usually stays in place until the patient is in the operating theatre. If the transit time has exceeded 1 hour, the other injuries are controlled and the patient is stable, a "trial of tourniquet conversion" may be attempted after wound packing and direct pressure are secured: slowly release and re-tighten if bleeding returns, replacing it as a "tourniquet of last resort" if it cannot be removed safely. ^[5]

Blunt trauma is the commonest mechanism in most series, and blunt thoracic injuries in particular account for about 90% of chest trauma. ^{[1] [10]} The forces are crush, shear and deceleration. The organs most at risk from deceleration are those that are mobile only in part: the aortic isthmus (just distal to the left subclavian artery, tethered by the ligamentum arteriosum), the duodeno-jejunal flexure, the renal pedicle and the splenic pedicle. Blunt thoracic aortic injury is the second most common cause of death from non-penetrating trauma, after head injury; up to 80% of victims die before hospital and the in-hospital mortality is as high as 46%. ^[10] It is rare (about 1.5% of thoracic trauma) but must be suspected from the mechanism (high-speed frontal collision or fall from height), and CT angiography of the chest is the diagnostic test of choice. ^[10] Motor vehicle collisions, particularly head-on collisions, account for 81% of cases. ^[10] Associated injuries that should raise suspicion include sternal fracture, first and second rib fractures, clavicle or scapular fractures, pneumothorax, haemothorax, flail chest, pulmonary contusion, diaphragmatic rupture, and tracheobronchial or oesophageal disruption. ^[10]

Other deceleration patterns: small-bowel and colon rupture (sudden rise in intraluminal pressure at closed loops); duodenal haematoma and pancreatic transection over the spine in "seatbelt" (lap-belt) loading; splenic and hepatic laceration; and renal pedicle avulsion. The "seatbelt sign" (bruising of the abdominal wall where the belt restrained the passenger) is associated with a 12% chance of bowel injury. ^[3] Diaphragmatic rupture on the left is commoner than on the right because the liver buffers the right hemidiaphragm.

Initial management of blunt thoracic aortic injury is permissive hypotension and heart-rate control (target systolic pressure of about 100 mmHg and heart rate below 100 beats per minute), using beta-blockade such as esmolol, which dramatically reduces the risk of rupture; pharmacological control allows transfer for endovascular repair when the injury is high grade. ^[10] Endovascular repair has become the mainstay for descending thoracic aortic injury. ^[10]

Traumatic brain and spinal injuries, pneumothorax, haemothorax, rib fractures and solid-organ injuries in blunt trauma are covered in their own topics; this page lists them for completeness in the table below.

Trauma begets complications in predictable windows. Early complications of trauma include haemorrhagic shock, hypoxia, airway obstruction, cardiac tamponade, tension pneumothorax, massive haemothorax and exsanguination from non-compressible haemorrhage. Later complications include acute compartment syndrome (hours), peritonitis and sepsis after missed hollow-viscus injury, osteomyelitis after open fracture, retained foreign bodies and wound infection, thromboembolism (venous and fat) with immobilisation, pulmonary contusion that evolves over 24-72 hours, and reperfusion injury after tourniquet release or massive transfusion. In the ICU, a tertiary survey identifies injuries missed by the first two surveys.

• The secondary survey is a focused history (AMPLE) plus a head-to-toe examination, performed only after the primary survey is complete and life threats are controlled; missed injuries are most often abdominal (blunt or penetrating), thoracic penetrating and extremity injuries.
• Violation of the platysma defines a penetrating neck injury; violation of the anterior fascia defines a penetrating abdominal injury.
• Neck zones (I, II, III) describe the anatomy and access; management is driven by hard signs (expanding haematoma, severe bleeding, shock not responding to fluids, absent pulse, bruit or thrill, cerebral ischaemia, airway compromise) which require immediate operation, versus soft signs which are imaged and observed.
• Open pneumothorax is dressed with a vented occlusive seal and drained; massive haemothorax is drained and operated on when loss exceeds 1,500 mL initially or 200 mL per hour for 2-4 hours. ^[1]
• Cardiac tamponade can follow as little as 100 mL of pericardial blood; Beck triad appears in only about one third of cases, so FAST is essential and the pericardium is always opened at thoracotomy. ^[4]
• Penetrating abdominal wounds need laparotomy for instability, peritonitis, evisceration, impalement and other hard signs; stable patients undergo local wound exploration and selective non-operative management with observation for 24-48 hours, supported by CT where appropriate. ^[3]
• Extremity care rests on a documented neurovascular examination, repeated checks for compartment syndrome, and fasciotomy when the delta pressure is 30 mmHg or less. ^[8]
• Open fractures need antibiotics within about 1 hour, debridement and tetanus prophylaxis. ^[6]
• Tetanus prophylaxis is decided by wound category (clean and minor versus dirty and major) and vaccination history, with 250 units of tetanus immune globulin intramuscularly for at-risk dirty wounds. ^[7]
• Impaled objects are left in situ and removed only in theatre under direct vision.
• Tourniquets are a last resort for extremity haemorrhage after direct pressure, are always visible, marked with the time, not loosened for pain and have a working limit of about 2 hours. ^[5]
• Blunt deceleration injuries risk the aortic isthmus, bowel, duodenum, pancreas, spleen and kidney, and are managed with goal-directed blood pressure and heart-rate control. ^[10]

Acute aortic syndromes; Altered mental state and coma; Head injury; Chest trauma; Massive transfusion; Shock and haemorrhage; Compartment syndrome (musculoskeletal); Open fractures and osteomyelitis; Blunt abdominal trauma; Solid-organ injury; Spinal trauma; Traumatic brain injury; Tetanus; Wound management and infection; Major haemorrhage protocols. These are listed as plain text because the corresponding pages are not all published in this build.