Evidence-based guideline for systematic trauma evaluation including ABCDE primary survey, hemorrhagic shock management, damage control resuscitation, injury-specific assessment, and special populations.
A comprehensive, evidence-based clinical guideline for the systematic evaluation and initial management of adult and pediatric trauma patients, encompassing trauma team activation, the ABCDE primary survey, adjuncts to primary survey, secondary survey with head-to-toe examination, hemorrhagic shock classification and management, damage control resuscitation, injury-specific focused assessment, and special trauma populations. This resource synthesizes recommendations from the major international trauma surgery and emergency medicine professional societies, national trauma quality programs, injury scaling committees, and critical care consensus groups into a single integrated reference for emergency physicians, trauma surgeons, intensivists, anesthesiologists, and advanced practice providers who manage injured patients.1 2 3 4 5 6 7 8
Trauma remains the leading cause of death for individuals aged 1 to 44 years and accounts for approximately 4.4 million deaths worldwide annually. In the United States, injury-related deaths exceeded 278,000 in 2022, with motor vehicle crashes, falls, and firearms representing the leading mechanisms. The structured approach to trauma evaluation – a rapid, reproducible primary survey identifying and treating immediately life-threatening conditions, followed by a thorough secondary survey – has been the international standard of care since the 1970s and is credited with significant reductions in preventable trauma mortality. Damage control resuscitation, balanced transfusion strategies, and selective nonoperative management of solid organ injuries represent major paradigm shifts of the past two decades that are now firmly embedded in contemporary trauma care.
Contents:
| Part | Title | Coverage |
|---|---|---|
| Part 1 | Trauma Team Activation & Primary Survey (ABCDE) | Two-tier trauma team activation criteria; CDC field triage decision scheme; Airway with C-spine protection (jaw thrust, oropharyngeal/nasopharyngeal airways, definitive airway indications, RSI cross-reference, cricothyrotomy technique); Breathing (tension pneumothorax, open pneumothorax, massive hemothorax, flail chest); Circulation with hemorrhage control (direct pressure, tourniquets, pelvic binder, permissive hypotension, massive transfusion protocol, FAST exam, REBOA); Disability (complete 15-point GCS scoring table, pupil assessment, lateralizing signs); Exposure/Environment |
| Part 2 | Adjuncts to Primary Survey, Secondary Survey & Hemorrhagic Shock | FAST and eFAST (technique and interpretation); chest and pelvis radiography; Foley catheter; NG/OG tube; secondary survey head-to-toe examination; AMPLE history; hemorrhagic shock classification (Classes I-IV complete table); physiologic response to hemorrhage |
| Part 3 | Damage Control Resuscitation & Transfusion | Permissive hypotension (targets, TBI exception); massive transfusion protocol (1:1:1 ratio, activation criteria); tranexamic acid (CRASH-2 protocol); crystalloid limitation; hypothermia prevention (lethal triad); acidosis correction; calcium supplementation; viscoelastic hemostatic assays (TEG/ROTEM); whole blood resuscitation |
| Part 4 | Focused Injury-Specific Assessment | Head injury (scalp lacerations, basilar skull fracture signs, CSF leak); C-spine clearance (Canadian C-Spine Rule, NEXUS criteria, clearance algorithm); Chest (rib fractures, pulmonary contusion, aortic injury, cardiac contusion); Abdomen (FAST, CT, DPL, AAST solid organ injury grading for liver, spleen, kidney); Pelvis (stability, binder, embolization); Extremities (vascular injury hard/soft signs, compartment syndrome, fracture priorities); Spine (TLICS scoring, neurologic exam, steroid controversy) |
| Part 5 | Special Trauma Populations | Pediatric trauma (vital signs by age, Broselow, injury patterns, non-accidental trauma screening); Geriatric trauma (anticoagulant reversal, lower activation thresholds, occult shock); Pregnant trauma (physiologic changes, fetal monitoring, perimortem cesarean delivery, Rh testing); Burns (Parkland formula, rule of nines, inhalation injury, escharotomy); Penetrating vs blunt (selective non-operative management criteria) |
American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 10th ed. Chicago: American College of Surgeons; 2018. URL: https://www.facs.org/quality-programs/trauma/atls/ ↩︎
Galvagno SM Jr, Nahmias JT, Young DA. “Advanced Trauma Life Support Update 2019: Management and Applications for Adults and Special Populations.” Anesthesiol Clin. 2019;37(1):13-32. DOI: 10.1016/j.anclin.2018.09.001 ↩︎
National Institute for Health and Care Excellence. “Major Trauma: Assessment and Initial Management (NG39).” London: NICE; 2016 (updated 2023). URL: https://www.nice.org.uk/guidance/ng39 ↩︎
Cannon JW, Khan MA, Raja AS, et al. “Damage Control Resuscitation in Patients with Severe Traumatic Hemorrhage: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma.” J Trauma Acute Care Surg. 2017;82(3):605-617. DOI: 10.1097/TA.0000000000001333 ↩︎
Sauaia A, Moore FA, Moore EE. “Postinjury Inflammation and Organ Dysfunction.” Crit Care Clin. 2017;33(1):167-191. DOI: 10.1016/j.ccc.2016.08.006 ↩︎
Mock C, Lormand JD, Goosen J, Joshipura M, Peden M. Guidelines for Essential Trauma Care. Geneva: World Health Organization; 2004. URL: https://www.who.int/publications/i/item/guidelines-for-essential-trauma-care ↩︎
Holcomb JB, Tilley BC, Baraniuk S, et al. “Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients with Severe Trauma: The PROPPR Randomized Clinical Trial.” JAMA. 2015;313(5):471-482. DOI: 10.1001/jama.2015.12 ↩︎
CRASH-2 trial collaborators. “Effects of Tranexamic Acid on Death, Vascular Occlusive Events, and Blood Transfusion in Trauma Patients with Significant Haemorrhage (CRASH-2): A Randomised, Placebo-Controlled Trial.” Lancet. 2010;376(9734):23-32. DOI: 10.1016/S0140-6736(10)60835-5 ↩︎
Pediatric trauma (vital signs by age, Broselow, non-accidental trauma), geriatric trauma (anticoagulant reversal, occult shock), pregnant trauma (physiologic changes, perimortem C-section), burns (Parkland formula, rule of nines, escharotomy), and penetrating vs blunt selective non-operative management.
Head injury assessment, cervical spine clearance (Canadian C-Spine Rule, NEXUS), chest injury evaluation, abdominal assessment with AAST organ injury grading (liver, spleen, kidney), pelvic fracture management, extremity vascular injury and compartment syndrome, and spinal injury with TLICS scoring.
Permissive hypotension, massive transfusion protocol with 1:1:1 ratio, tranexamic acid (CRASH-2), crystalloid limitation, hypothermia prevention, acidosis correction, viscoelastic hemostatic assays, and whole blood resuscitation.
Extended FAST technique, chest and pelvis radiography, Foley and NG tube placement, complete head-to-toe secondary survey, AMPLE history, and hemorrhagic shock classification with Classes I-IV.
Two-tier trauma team activation criteria, CDC field triage, and complete ABCDE primary survey including airway with C-spine protection, breathing and ventilation, circulation with hemorrhage control, disability assessment with GCS, and exposure/environment.