Primary survey key principles

South East Scotland Major Trauma Guidelines
NHS Lothian

Airway

  • Use drug assisted RSI to secure the airway.
  • If RSI fails, use basic manoeuvres and adjuncts and/or supraglottic device to oxygenate until:
    • either a surgical airway or
    • assisted tracheal placement is performed.

Breathing

  • Perform CXR and/or eFAST in all patients with haemodynamic instability or severe respiratory compromise.
  • Decompress the chest using an open thoracostomy followed by intercostals chest drain insertion. 
  • Perform immediate CT in other patient with significant chest injury.

Paediatrics - immediate chest CT is not indicated in children with a normal CXR chest examination.

Circulation and haemorrhage control

Please also refer to the NICE guidelines on

Major trauma: initial assessment and management.

Dressings and tourniquets 

  • Use simple dressings with direct pressure to control external haemorrhage.
  • In patients with major limb trauma use a tourniquet if direct pressure has failed to control haemorrhage.
  • It may be appropriate to use a tourniquet first line in some situations.  A second tourniquet is sometimes required.  Check the tourniquet after patient movement and consider replacing with a pneumatic tourniquet following resuscitation.

Tranexamic Acid (TXA)

  • Administer TXA in patients with major trauma and active or suspected bleeding (SBP <90 and/or HR>110).
  • Do not administer TXA if >3 hours after injury unless hyperfibrinolysis is demonstrated on ROTEM.

Access

  • Use peripheral intravenous access.
  • If peripheral IV access fails, consider intra-osseous access while central access is being achieved.

Volume resuscitation 

  • Restrict volume resuscitation in patients with active bleeding until haemorrhage control is achieved.  Where time to definitive care is prolonged/delayed balance the risks of permissive hypotension against blood loss.
  • Haemorrhage control is the priority.  Titrate volume to a central pulse.
  • For patients with haemorrhagic shock and a traumatic brain injury (TBI):
    • Restrict volume resuscitation if haemorrhagic shock predominates.
    • Use a less restrictive approach if TBI predominates.
  • DO NOT use crystalloids for patients with active bleeding.
  • Use a ratio of 1RCC:1FFP to replace volume remembering to include pre-hospital blood.
  • Start with a fixed-ratio protocol for blood components and change to lab/ROTEM/VBG guided once available.

Paediatrics: permissive hypotension should not be used in paediatric trauma patients. 

Imaging

  • Limit imaging to CXR, Pelvis XR and FAST in patients not adequately responding to volume to direct early surgical intervention.
  • A negative FAST does not exclude intraperitoneal or retroperitoneal haemorrhage.
  • Use immediate CT in haemodynamically normal patients/volume responders.

Paediatrics

Please also refer to the Royal College of Radiologist's guidelines for guidance on paediatric trauma.

Definitive Care

Involve specialty consultants (Orthopaedics, Vascular, IR and General Surgery) ensuring joint decision making regarding the following definitive care principles:

  • Consider damage control surgery in patients with instability who do not adequately respond to volume.
  • Use definitive surgery in haemodynamically normal patients.
  • Consider IR in patients with active arterial pelvic haemorrhage unless open surgery required for other injuries.
  • Consider IR in patients with solid organ arterial haemorrhage (spleen, liver or kidney).
  • Consider a joint IR/Surgical strategy for inaccessible regions.
  • Consider an endovascular stent for patients with blunt thoracic aortic injury.

Disability 

  • Use intravenous morphine 1st line (5mg aliquots, reduced in elderly).
  • Use intravenous ketamine 2nd line (0.2-0.5mg/kg).
  • Consider intranasal ketamine if IV access not established (0.7mg/kg).

Paediatrics: Paediatric morphine dose (IV) is 0.05 - 0.1mg/kg 

Environment

Use fluid warming devices, warm blankets and a BAIR HUGGER in all major trauma patients where haemorrhage is suspected or proven.

Editorial Information

Last reviewed: 01/09/2021

Next review date: 01/09/2024

Version: 1.0