Trauma Primary and Secondary Survey — Part 1: Trauma Team Activation & Primary Survey (ABCDE)

1. Trauma Team Activation

1.1 Principles of Team Activation

Trauma team activation (TTA) is a structured response system designed to ensure that critically injured patients are met by a prepared, multidisciplinary team upon arrival to the trauma center. Most verified trauma centers employ a two-tier (or multi-tier) activation system to allocate resources proportionally to injury severity, reserving full team mobilization for the most critically injured patients while still providing an organized response for patients with significant but not immediately life-threatening injuries.^{1 2}

The goals of a tiered activation system are:

• Ensure the most critically injured patients receive immediate, senior-level surgical presence
• Minimize over-triage (full activation for patients who do not require it), which wastes resources and leads to team fatigue
• Minimize under-triage (failure to activate for patients who need it), which is associated with increased mortality
• The national recommended target: over-triage rate of ≤ 25-35% and under-triage rate of ≤ 5%²

1.2 Two-Tier Activation Criteria

Tier 1 — Full Trauma Team Activation (Highest Level)

Requires immediate presence of the attending trauma surgeon (or senior surgical resident acting under attending direction), emergency physician, anesthesiologist, nursing team, respiratory therapy, blood bank notification, and operating room standby. Tier 1 criteria typically include:^{1 2 3}

Physiologic Criteria:

Anatomic Criteria:

Additional Tier 1 Criteria (Vary by Institution):

• Traumatic cardiac arrest with signs of life in the field
• Intubated patients transferred from the field with ongoing hemodynamic instability
• Emergency physician or trauma surgeon clinical judgment

Tier 2 — Modified/Partial Trauma Team Activation

Requires presence of the emergency physician (or trauma team leader), trauma nurse, and key ancillary staff. The attending trauma surgeon is notified but need not be at bedside on arrival. Tier 2 criteria typically include:^{1 2}

Mechanism of Injury Criteria:

Special Considerations Criteria:

1.3 CDC Field Triage Decision Scheme

The national field triage guidelines, published by the Centers for Disease Control and Prevention, provide a four-step algorithm for prehospital providers to determine the appropriate level of trauma center destination and team activation.^{3 4}

Step 1 — Physiologic Criteria (Highest Priority):

• GCS ≤ 13
• Systolic blood pressure < 90 mmHg
• Respiratory rate < 10 or > 29 breaths/min (< 20 in infant < 1 year)

If any criterion is positive: transport to the highest-level trauma center within the trauma system.

Step 2 — Anatomic Criteria:

• All penetrating injuries to head, neck, torso, and extremities proximal to elbow/knee
• Chest wall instability or deformity (e.g., flail chest)
• Two or more proximal long bone fractures
• Crushed, degloved, mangled, or pulseless extremity
• Amputation proximal to wrist or ankle
• Pelvic fractures
• Open or depressed skull fracture
• Paralysis

If any criterion is positive: transport to the highest-level trauma center.

Step 3 — Mechanism of Injury Criteria:

• Falls: Adults > 20 feet (one story equals 10 feet); Children > 10 feet or 2-3 times the child’s height
• High-risk auto crash: intrusion (> 12 in. occupant side; > 18 in. any side), ejection (partial or complete) from vehicle, death in same passenger compartment, vehicle telemetry data consistent with high risk of injury
• Auto vs. pedestrian/bicyclist: thrown, run over, or with significant impact
• Motorcycle crash > 20 mph

If any criterion is positive: transport to trauma center; need not be the highest level.

Step 4 — Special Considerations:

• Older adults: risk of injury and death increases after age 55; SBP < 110 may represent shock; low-impact mechanisms may produce severe injury
• Children: should be triaged preferentially to pediatric-capable trauma centers
• Anticoagulant and antiplatelet agents: increase hemorrhage risk
• Burns: triage to burn center (see burn section); with concurrent trauma mechanism, triage to trauma center
• Pregnancy > 20 weeks
• EMS provider judgment

2. Primary Survey — Overview

The primary survey is a rapid, systematic assessment designed to identify and treat immediately life-threatening conditions in the order in which they kill most quickly. It follows the ABCDE mnemonic and should be completed within minutes of patient arrival. Each element is assessed sequentially, and any life-threatening finding is addressed immediately before proceeding to the next step. The primary survey is repeated whenever the patient deteriorates.^{1 5 6}

Sequence:

3. A — Airway with Cervical Spine Protection

3.1 Initial Assessment

The airway is assessed first because airway obstruction is the fastest cause of preventable death in trauma. Assessment begins with a direct question to the patient: “What is your name?” A patient who responds verbally in a clear voice has a patent airway, adequate breathing to support speech, and sufficient cerebral perfusion to generate a meaningful response. A patient who cannot speak or speaks with a garbled or stridorous voice requires immediate airway intervention.^{1 5}

Signs of airway compromise:

• Agitation (suggests hypoxia)
• Obtundation (suggests hypercarbia)
• Stridor, hoarseness, or voice change
• Accessory muscle use, tracheal tug
• Cyanosis (late sign)
• Facial, mandibular, or tracheal/laryngeal fractures
• Foreign body (blood, vomitus, teeth, debris)
• Expanding neck hematoma
• Subcutaneous emphysema of the neck
• Burns to the face and/or oropharynx with singed nasal hairs, carbonaceous sputum

3.2 Cervical Spine Protection

All trauma patients with a mechanism capable of producing cervical spine injury are managed with inline cervical spine immobilization until the cervical spine is cleared. This includes:^{1 7}

• Manual inline stabilization (MILS) during airway interventions — anterior portion of the rigid cervical collar is removed to allow maximal mouth opening, while an assistant maintains MILS
• Semi-rigid cervical collar, supplemented by head blocks and straps on a rigid backboard during transport (backboard removed upon arrival to prevent pressure injury)
• The rigid cervical collar does not provide complete immobilization and must be supplemented by MILS during any procedure that moves the head/neck

3.3 Basic Airway Maneuvers

3.4 Airway Adjuncts

Oropharyngeal Airway (OPA)

• Indication: Unconscious patient (absent gag reflex) with airway obstruction from tongue collapse
• Contraindication: Conscious or semi-conscious patients (will trigger gag reflex and vomiting)
• Sizing: Measure from the corner of the mouth to the tragus of the ear, or from the center of the lips to the angle of the mandible
• Insertion technique: Insert with the concavity facing the palate (upside down), then rotate 180 degrees as it passes the soft palate; OR use a tongue depressor to depress the tongue and insert directly in the anatomic position
• Pediatric consideration: In children, insert in the anatomic position using a tongue depressor (do not rotate, as this may injure the soft palate)

Nasopharyngeal Airway (NPA)

• Indication: Patient with intact gag reflex who requires an airway adjunct; semi-conscious patients; patients with trismus or oral trauma preventing OPA placement
• Relative contraindication: Suspected basilar skull fracture (risk of intracranial placement) — though this remains debated and NPAs have been used safely in this population when placed carefully; if concern exists, use the OPA or proceed to a definitive airway
• Sizing: Measure from the tip of the nose to the tragus of the ear; select the largest diameter that will pass easily through the nostril
• Insertion technique: Lubricate generously; insert along the floor of the nasal cavity (not superiorly toward the cribriform plate), perpendicular to the face; the bevel should face the septum; advance gently until the flange rests at the nostril

3.5 Indications for a Definitive Airway

A definitive airway is defined as an endotracheal tube with the cuff inflated in the trachea, secured in place, and connected to an oxygen-enriched ventilation source with confirmed end-tidal CO2 detection. Indications for a definitive airway in the trauma patient include:^{1 5 8}

3.6 Rapid Sequence Intubation (RSI)

RSI is the technique of choice for definitive airway management in the trauma patient. A detailed discussion of RSI pharmacology, technique, and difficult airway algorithms is provided in the Airway Management and RSI guideline (cross-reference: Airway Management & RSI).⁸

Key trauma-specific RSI considerations:

• Maintain manual inline stabilization (MILS) throughout the procedure; remove the anterior portion of the cervical collar to allow mouth opening
• Avoid nasal intubation in suspected basilar skull fracture
• Have surgical airway equipment immediately available (see below)
• Induction agents: Ketamine (1-2 mg/kg IV) is preferred in the hemodynamically unstable trauma patient due to sympathomimetic properties; etomidate (0.3 mg/kg IV) is an alternative with hemodynamic stability but concern for adrenal suppression (single dose likely clinically insignificant in trauma)
• Paralytic agents: Succinylcholine (1.5 mg/kg IV) for rapid onset; rocuronium (1.2 mg/kg IV) for prolonged paralysis and when succinylcholine is contraindicated (burns > 24 hours, crush injury > 24 hours, hyperkalemia, spinal cord injury > 24 hours)
• Video laryngoscopy is recommended as the first-line technique in trauma to optimize first-pass success while maintaining cervical immobilization⁸

3.7 Surgical Airway — Cricothyrotomy

When orotracheal intubation fails or is impossible (cannot intubate, cannot oxygenate), a surgical cricothyrotomy is the rescue technique of choice in the trauma setting.^{1 5 8}

Indications:

• Failed orotracheal intubation with inability to oxygenate (CICO — “can’t intubate, can’t oxygenate”)
• Massive facial trauma precluding oral or nasal intubation
• Upper airway obstruction that cannot be relieved (angioedema, laryngeal fracture, foreign body above the cords)

Contraindications:

• Age < 12 years (relative) — needle cricothyrotomy with jet insufflation is preferred in young children due to the small, pliable cricothyroid membrane; surgical cricothyrotomy can be performed in adolescents
• Laryngeal fracture through the cricothyroid membrane (consider tracheostomy)

Technique — Open Surgical Cricothyrotomy:

1. Position: Supine with neck in neutral position (cervical spine protection maintained)
2. Identify landmarks: Palpate the thyroid cartilage notch; move inferiorly to the cricothyroid membrane (soft depression between the thyroid and cricoid cartilages)
3. Stabilize the larynx: Grasp the thyroid cartilage with the nondominant hand
4. Incision: Vertical skin incision (approximately 3-4 cm) over the cricothyroid membrane — a vertical skin incision reduces risk of lateral vessel injury and is preferred when landmarks are difficult; alternatively, a transverse skin incision can be used when landmarks are easily palpable
5. Identify the membrane: Bluntly dissect through subcutaneous tissue to clearly identify the cricothyroid membrane
6. Horizontal stab incision: Make a transverse (horizontal) incision through the lower half of the cricothyroid membrane
7. Dilate: Insert a tracheal hook or the handle of the scalpel and rotate 90 degrees to open the airway, or use a Trousseau dilator
8. Insert tube: Place a 6.0 cuffed tracheostomy tube or a 6.0 cuffed endotracheal tube (cut short) through the incision into the trachea
9. Inflate cuff and confirm placement: Auscultation, end-tidal CO2, and chest rise
10. Secure the tube

4. B — Breathing and Ventilation

4.1 Assessment

Once a patent airway is established, the adequacy of breathing and ventilation is assessed. Even with a patent airway, ventilatory function can be critically impaired by thoracic injuries. Assessment includes:^{1 5}

• Inspection: Respiratory rate, depth, and effort; symmetry of chest wall expansion; paradoxical movement (flail segment); use of accessory muscles; visible wounds (sucking chest wound); tracheal position (deviation suggests tension pneumothorax or massive hemothorax); jugular venous distension (may be absent in hypovolemia)
• Auscultation: Bilateral breath sounds — absent or diminished unilaterally suggests pneumothorax or hemothorax
• Percussion: Hyperresonance suggests pneumothorax; dullness suggests hemothorax
• Palpation: Subcutaneous emphysema, chest wall tenderness, crepitus, flail segment
• Pulse oximetry: Applied immediately; however, may be unreliable in hypothermia, vasoconstriction, and severe shock

4.2 Life-Threatening Thoracic Injuries Identified in the Primary Survey

Four life-threatening thoracic conditions must be identified and treated during the primary survey. These conditions can kill within minutes if not recognized and treated immediately.^{1 5 9}

4.2.1 Tension Pneumothorax

Pathophysiology: Air enters the pleural space through a one-way valve mechanism (from the lung parenchyma or chest wall) and cannot escape. Progressive accumulation of air causes complete lung collapse, mediastinal shift to the contralateral side, compression of the contralateral lung and great veins (SVC/IVC), and ultimately obstructive shock with cardiovascular collapse.^{1 9}

Clinical findings:

CRITICAL: Tension pneumothorax is a clinical diagnosis. Treatment must NOT be delayed for radiographic confirmation.

Treatment options:

1. Needle Decompression (Temporizing Measure):

• Use a catheter ≥ 8 cm (3.25 inches) in length; standard 5-cm catheters have a significant failure rate, particularly at the 2nd ICS MCL
• After needle insertion, leave the catheter in place and proceed to definitive treatment with tube thoracostomy
• A rush of air upon entering the pleural space confirms the diagnosis

2. Finger Thoracostomy:

• Increasingly favored as the primary decompression technique, particularly in the prehospital and combat settings
• Make a 3-4 cm incision in the 4th or 5th ICS at the anterior or midaxillary line
• Bluntly dissect through the chest wall musculature with a clamp
• Puncture the parietal pleura with a finger and perform a finger sweep to confirm entry into the pleural space and ensure no lung adhesions
• A rush of air confirms decompression
• This is then followed by formal chest tube insertion

3. Tube Thoracostomy (Definitive Treatment):

• Place a large-bore chest tube (28-36 Fr in adults) in the 4th or 5th ICS at the anterior or midaxillary line (the “safe triangle” — bordered by the anterior border of latissimus dorsi, lateral border of pectoralis major, and a line superior to the horizontal level of the nipple)
• Connect to an underwater seal drainage system or a Heimlich valve

4.2.2 Open Pneumothorax (Sucking Chest Wound)

Pathophysiology: A large defect in the chest wall (generally exceeding approximately two-thirds the diameter of the trachea) creates a path of least resistance for air to enter the pleural space directly from the atmosphere during inspiration, causing the lung to collapse and impairing ventilation.^{1 5}

Clinical findings:

• Audible air movement through the chest wall wound (“sucking” sound)
• Open wound visible on the chest wall
• Respiratory distress
• Decreased breath sounds on the affected side

Treatment:

1. Immediately apply an occlusive dressing taped on three sides — this creates a flutter-valve effect: during inspiration, the dressing is drawn against the wound and seals it, preventing air entry; during expiration, the open (untaped) side allows air to escape from the pleural space. Alternatively, a commercially available chest seal with a one-way valve may be used.
2. CAUTION: A dressing taped on all four sides may convert an open pneumothorax to a tension pneumothorax if air continues to leak from the injured lung and cannot escape through the sealed wound.
3. Definitive management: Tube thoracostomy placed at a site remote from the wound, followed by operative closure of the chest wall defect.

4.2.3 Massive Hemothorax

Definition: Accumulation of ≥ 1,500 mL of blood (or one-third or more of the patient’s blood volume) rapidly in the pleural space, OR ongoing bleeding at a rate of ≥ 200 mL/hour for 2-4 hours after chest tube insertion.^{1 9 10}

Clinical findings:

Treatment:

1. Volume resuscitation — begin immediately with blood products (massive transfusion protocol if indicated)
2. Tube thoracostomy — large-bore chest tube (32-36 Fr) placed in the 4th or 5th ICS at the anterior axillary line. This simultaneously drains the hemothorax, allows quantification of ongoing blood loss, and may allow autotransfusion of shed blood
3. Autotransfusion — collected pleural blood can be autotransfused using commercially available cell-saver or autotransfusion devices connected to the chest drainage system; this is particularly valuable when banked blood is not immediately available
4. Indications for emergent thoracotomy (operating room):
   • Initial chest tube output of ≥ 1,500 mL of blood
   • Ongoing output of ≥ 200 mL/hour for 2-4 consecutive hours
   • Persistent hemodynamic instability despite resuscitation and chest tube drainage
   • Need for ongoing blood transfusion to maintain hemodynamic stability

4.2.4 Flail Chest

Definition: A segment of the chest wall that has lost bony continuity with the rest of the thoracic cage due to fractures of ≥ 3 consecutive ribs in ≥ 2 places each (creating a free-floating segment).^{1 9}

Pathophysiology:

• The flail segment moves paradoxically with respiration — inward during inspiration and outward during expiration
• The primary cause of respiratory failure is the underlying pulmonary contusion, not the mechanical flail itself
• Pulmonary contusion leads to intrapulmonary shunting, ventilation-perfusion mismatch, and progressive hypoxemia

Clinical findings:

• Paradoxical chest wall motion (may not be immediately apparent if the patient is splinting due to pain, or may become more obvious after intubation and positive pressure ventilation)
• Chest wall crepitus, tenderness
• Hypoxemia, respiratory distress
• Pain out of proportion to apparent injury

Treatment:

1. Adequate analgesia — this is critical. Options include:
   • IV opioids (titrated to pain control)
   • Epidural analgesia (thoracic epidural is the gold standard for pain management in flail chest)
   • Intercostal nerve blocks
   • Paravertebral nerve blocks
   • Serratus anterior plane block
2. Supplemental oxygen and pulmonary toilet (incentive spirometry, coughing, deep breathing)
3. Judicious IV fluid administration — avoid fluid overload, which worsens pulmonary contusion
4. Positive pressure ventilation (intubation and mechanical ventilation) — indicated for respiratory failure (PaO2 < 60 mmHg on supplemental O2, PaCO2 > 50 mmHg, respiratory rate > 35, or progressive fatigue)
5. Surgical fixation of rib fractures — increasingly performed for patients with flail chest who require mechanical ventilation or have severe chest wall deformity; evidence suggests reduced duration of mechanical ventilation and ICU stay¹¹

5. C — Circulation with Hemorrhage Control

5.1 Assessment

Hemorrhage is the leading preventable cause of death in trauma patients. The circulatory assessment focuses on rapidly identifying the source and severity of hemorrhage and initiating control and resuscitation simultaneously.^{1 5 12}

Clinical assessment of circulatory status:

5.2 Sources of Major Hemorrhage

There are five locations where life-threatening hemorrhage occurs. These are often described as “blood on the floor and four more”:^{1 5}

5.3 Hemorrhage Control Techniques

5.3.1 Direct Pressure

The first and most fundamental technique for external hemorrhage control. Apply firm, direct pressure with gauze directly to the wound. If initial gauze becomes saturated, do not remove it — add additional layers on top and maintain pressure.¹

5.3.2 Wound Packing

For deep, cavitating wounds (e.g., junctional hemorrhage in the groin, axilla, or neck) where direct pressure alone is inadequate:

• Pack the wound tightly with hemostatic gauze (kaolin-impregnated or chitosan-based) directly into the wound cavity
• Apply firm, sustained direct pressure for at least 3 minutes after packing
• Hemostatic agents significantly improve hemorrhage control in junctional wounds compared to standard gauze¹³

5.3.3 Tourniquets

• Indication: Life-threatening hemorrhage from an extremity that cannot be controlled with direct pressure
• Placement: Apply high and tight on the extremity, proximal to the wound; if bleeding continues, apply a second tourniquet proximal to the first
• Effectiveness: When properly applied, tourniquets are highly effective (> 90% hemorrhage control) and are associated with improved survival in military and civilian settings^{13 14}
• Time limit: Prolonged tourniquet time (> 2 hours) increases ischemic injury risk; however, saving the life takes priority over limb preservation
• Documentation: Record the time of tourniquet application prominently

5.3.4 Pelvic Binder

• Indication: Suspected mechanically unstable pelvic fracture with hemorrhage
• Placement: Apply a commercial pelvic binder (or a tightly wrapped sheet) centered over the greater trochanters (NOT over the iliac crests). The binder reduces pelvic volume and opposes fractured bony surfaces, tamponading venous and cancellous bone bleeding
• Effectiveness: Reduces pelvic volume, decreases hemorrhage from venous plexus and bone surfaces, and serves as a temporizing measure
• Leave in place until definitive fixation or angiographic embolization is planned¹⁵

5.3.5 Permissive Hypotension

In patients with ongoing hemorrhage that has not been definitively controlled, aggressive fluid resuscitation to normalize blood pressure may worsen hemorrhage by disrupting early clot formation and diluting clotting factors. Permissive hypotension (also called hypotensive resuscitation or damage control resuscitation) targets a lower-than-normal blood pressure until surgical hemorrhage control is achieved:^{12 16}

Detailed damage control resuscitation is covered in Part 3.

5.3.6 Massive Transfusion Protocol (MTP)

The massive transfusion protocol should be activated early in patients with significant hemorrhage. Activation criteria vary by institution but typically include:^{12 17 18}

• SBP < 90 mmHg with an injury mechanism consistent with hemorrhage
• Clinical evidence of active, ongoing hemorrhage
• Anticipated need for > 10 units of packed red blood cells (PRBCs) in 24 hours
• ABC Score ≥ 2 (Assessment of Blood Consumption)

ABC Score for MTP Activation:

Score ≥ 2: activate MTP (sensitivity ~75-85%, specificity ~85-90%)

Initial MTP delivery (balanced resuscitation): 1:1:1 ratio of PRBCs : FFP : Platelets (typically packaged as “trauma packs” — 6 units PRBCs : 6 units FFP : 1 apheresis platelet unit)

Detailed MTP management is covered in Part 3.

5.3.7 FAST Examination

The Focused Assessment with Sonography in Trauma (FAST) is a bedside ultrasound examination performed during the primary survey to rapidly detect free fluid (blood) in the peritoneal cavity and pericardium. It is a key component of the circulatory assessment in the hemodynamically unstable trauma patient.^{1 19}

Four Standard FAST Views:

Interpretation:

• Positive FAST in a hemodynamically unstable patient = indication for emergent operative intervention (exploratory laparotomy or thoracotomy)
• Negative FAST does not exclude intra-abdominal injury — sensitivity is approximately 73-88% and is lower for solid organ injuries without significant free fluid, retroperitoneal hemorrhage, and hollow viscus injury
• Indeterminate or equivocal studies should prompt serial FAST examinations or CT scanning (if hemodynamically stable)

The extended FAST (eFAST) is covered in Part 2.

5.3.8 REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta)

REBOA is an endovascular technique for temporary aortic occlusion used as a bridge to definitive hemorrhage control in patients with non-compressible torso hemorrhage (NCTH) who are in extremis.^{20 21}

Indication: Hemodynamically unstable patient with suspected non-compressible hemorrhage below the diaphragm (abdominal/pelvic hemorrhage) who is not responding to resuscitation and in whom emergent operative intervention is indicated

Contraindications:

• Known thoracic aortic injury
• Hemorrhage source above the diaphragm

Zones of aortic occlusion:

Key considerations:

• Maximum inflation time should be limited (< 60-90 minutes) due to distal ischemic risk
• Partial REBOA (partial balloon inflation to allow some distal flow) is increasingly used to extend tolerable occlusion time
• Requires arterial access (common femoral artery) and fluoroscopic or external landmark-based positioning
• Used as a temporizing bridge — definitive surgical hemorrhage control must follow promptly

6. D — Disability (Neurologic Assessment)

6.1 Rapid Neurologic Assessment

The disability assessment is a rapid neurologic evaluation performed during the primary survey to establish a baseline neurologic status, identify signs of traumatic brain injury, and detect lateralizing signs that may indicate the need for emergent intervention.^{1 5}

The assessment includes:

1. Glasgow Coma Scale (GCS) — the standardized numeric scale
2. Pupil examination — size, symmetry, and reactivity
3. Lateralizing signs — asymmetry of motor function
4. Blood glucose — hypoglycemia can mimic neurologic injury and should be excluded

6.2 Glasgow Coma Scale (GCS) — Complete 15-Point Scoring Table

The GCS was introduced in 1974 and remains the universally used system for rapid assessment and serial monitoring of the level of consciousness in trauma patients. It assesses three independent domains: eye opening, verbal response, and motor response. The total score ranges from 3 (deep coma/death) to 15 (fully alert and oriented).^{1 22}

Complete GCS Scoring Table

Total GCS = E + V + M (Range: 3-15)

GCS Severity Classification

Important GCS Notes

• The best motor response is the most clinically predictive component of the GCS and should always be documented separately (e.g., “GCS 7 = E2V1M4”)
• Always record the component scores in addition to the total (e.g., “GCS 11 = E3V3M5”) — a total score without components can be misleading
• A declining GCS of ≥ 2 points is clinically significant and warrants immediate re-evaluation and imaging
• The GCS should be assessed after resuscitation (hypotension and hypoxia reduce the GCS independent of brain injury)
• Pupil reactivity score: A modification to improve prognostic accuracy subtracts the pupil reactivity score (PRS) from the GCS total: both reactive = 0, one reactive = 1, neither reactive = 2. The GCS-Pupils score (GCS-P) = GCS - PRS, yielding a range of 1-15.²²

6.3 Pupil Assessment

6.4 Lateralizing Signs

• Asymmetric motor response to pain (one side moves purposefully, the other does not or demonstrates abnormal posturing) — suggests a mass lesion (epidural or subdural hematoma) on the side contralateral to the weaker motor response
• Combined with an ipsilateral fixed dilated pupil — classic transtentorial (uncal) herniation syndrome: ipsilateral CN III palsy (dilated pupil) + contralateral hemiparesis

6.5 Blood Glucose

Obtain a point-of-care glucose measurement in all trauma patients with altered mental status. Hypoglycemia (glucose < 60 mg/dL) should be treated immediately with IV dextrose (25-50 mL of D50W in adults, 2-4 mL/kg of D25W in children, 5 mL/kg of D10W in neonates).¹

7. E — Exposure and Environmental Control

7.1 Full Exposure

The patient must be completely undressed to allow a thorough examination. All clothing is cut off using trauma shears. Every surface of the body must be visualized, including:^{1 5}

• Anterior and posterior trunk
• Axillae, perineum, and buttocks
• All extremities
• Scalp (lift the head carefully with C-spine precautions, and palpate the entire scalp)

The log roll (performed with the cervical spine protected by inline stabilization) allows examination of the entire posterior surface — back, buttocks, flanks, and posterior scalp. The rectal examination, if performed, is done at this time.

7.2 Hypothermia Prevention

Hypothermia is a critical threat to the trauma patient and worsens coagulopathy, acidosis, and cardiac dysfunction (the “lethal triad” — see Part 3). Measures to prevent and treat hypothermia should be initiated during the primary survey:^{1 12}

• Remove all wet clothing
• Cover the patient with warm blankets immediately after exposure and examination
• Warm the trauma bay (ambient temperature ≥ 28 degrees C / 82 degrees F)
• Use forced-air warming devices (e.g., Bair Hugger)
• Administer warmed IV fluids and blood products (using inline fluid warmers at 39-42 degrees C)
• Warm humidified oxygen through the ventilator circuit
• In severe hypothermia (< 32 degrees C / 90 degrees F): consider body cavity lavage (warm peritoneal or thoracic lavage) or extracorporeal rewarming in refractory cases

References