Trauma - primary survey

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  • See also

    Resuscitation: Care of the seriously unwell child
    Resuscitation: Hospital Management of Cardiopulmonary Arrest
    RCH Paediatric Trauma Manual
    Trauma – secondary survey

    Key points

    1. The purpose of the primary survey is to rapidly identify and manage impending or actual life threats to the patient
    2. Priorities are the parallel assessment and management of:
      • < c >      Catastrophic haemorrhage
         A         Airway (with c-spine control)
         B         Breathing
         C         Circulation
         D         Disability
         E         Exposure / Environment


    • The primary survey is the initial assessment and management of a trauma patient. It is conducted to detect and treat actual or imminent life threats and prevent complications from these injuries
    • A systematic approach using <c>ABCDE is used
    • If a group of clinicians is assembled to perform the initial assessment, there will be multiple simultaneous activities occurring and resuscitation does not always proceed in a purely linear, sequential fashion
    • Many tertiary hospitals will have a ‘trauma team’ – a multidisciplinary group drawn from the specialties of emergency medicine, intensive care, surgery, nursing, allied health and support staff – who work together as a team to assess and manage trauma patients.  Their actions are usually coordinated by a team leader

    Assessment and management

    Prior to arrival:

    • Activate trauma team and/or advise relevant personnel (eg radiographer and blood bank)
    • Conduct a pre-arrival briefing for team with a verbal synthesis of the anticipated injuries and management priorities
    • Use a pre-arrival checklist to help with role and task allocation
    • Estimate the child’s weight
    • Prepare age/weight appropriate doses of medication and equipment
    • Consider personal protective equipment (PPE) and lead apron for trauma team members

    On arrival:

    • Obtain handover from ambulance staff (unless there is a life threat requiring immediate action) - ‘hands-off’
    • Perform primary survey
    • Obtain further information from family where possible
    • Ensure a dedicated member of staff is available to provide support for the family



    < Circulation >

    Control of exsanguinating external haemorrhage is the first priority

    • Assess and expose all wounds
    • Bandages controlling significant bleeding should not be removed until the child is stable and IV access is secured
    • Assess for ongoing bleeding – including losses into bandages/gauze
    • Apply direct pressure to the wound with a gauze pad
    • Use a tourniquet to control life-threatening limb haemorrhage
    • Do not use layers of gauze/bandages that may absorb and conceal blood loss
    • Apply a pelvic binder if a pelvic fracture is suspected and there is haemodynamic compromise
    • Activate the hospital massive transfusion protocol if appropriate

    Airway and cervical spine

    Assess for airway obstruction

    • Typically role of airway doctor though may be shared by assessment doctor
    • Assess airway, anterior neck and level of consciousness (using AVPU)
    • Look for evidence of facial fractures, blood/vomit/loose teeth in airway
    • If burns present, assess for:
      • Singeing of facial / nasal hair
      • Facial burns
      • Hoarseness of voice
      • Harsh cough
      • Head or neck swelling
      • Soot in mouth, nose or saliva
    • Anterior neck should be assessed for blunt or penetrating trauma by looking/feeling for the following (TWELVE-C):
      • Tracheal deviation
      • Wounds
      • Emphysema (subcutaneous)
      • Laryngeal tenderness/crepitus
      • Venous distension
      • OEsophageal injury (unlikely if can swallow easily)
      • Carotid haematoma/bruits/swelling
    • Causes of airway obstruction include:
      • Direct trauma to airway or laryngeal structures
      • Contamination of airway due to debris
      • Loss of pharyngeal tone (due to head injury or intoxication with drugs / alcohol)
      • Incorrect positioning (hyperflexion of infant due to large occiput)
    • Use an age appropriate neutral head position
    • Use a thoracic elevation device or towel under shoulder blades to achieve this if <8 years old
    • Regardless of the need for airway support, all spontaneously breathing patients should have high-flow oxygen applied (typically 10-15 L via non-rebreather mask)
    • Support the airway if needed using the following techniques:
      • Jaw thrust (avoiding head-tilt or chin lift)
      • Gentle suction of airway to remove blood/vomitus/secretions
      • Oropharyngeal airway if tolerated, or nasopharyngeal airway (if base of skull fracture unlikely)
      • Endotracheal intubation
    • Cervical spine should be protected with manual in-line stabilisation until a soft foam collar is applied, see Cervical spine assessment


    • Assessment doctor: Look, Listen and Feel for:
      • Work of breathing
      • Effectiveness of breathing
      • Signs of inadequate respiration
      • Signs of injury (seatbelt marks, bruising, wounds)
      • Crepitus indicating Surgical emphysema
      • Chest wall tenderness
    • The life threats to identify and manage with regards to breathing include:
      • Tension pneumothorax
      • Open pneumothorax
      • Massive haemothorax
      • Flail chest
      • Tracheo-bronchial injury
    • If life threat has been identified, assessment doctor communicates to team leader
    • Assessment doctor continues the primary survey. The procedure doctor should carry out any interventions
    • Ensure all spontaneously breathing patients have high-flow oxygen applied
    • If required:
      • Tension pneumothorax: chest decompression with a finger or instrument, thoracostomy or intercostal catheter insertion. Needle decompression may be used in emergencies but is unlikely to be effective
      • Open pneumothorax: immediate closure and chest drain insertion
      • Massive haemothorax: Chest drain insertion and blood transfusion  
      • Flail chest: analgesia, consider positive pressure ventilation
    • Request a portable chest X-Ray
    • In intubated children, insert an orogastric tube to prevent gastric dilatation which can impair effective ventilation


    Assess for shock and vascular injury

    • Assessment doctor should assess circulation, and then continue with a focussed assessment looking for sites of potential bleeding such as:
      • External bleeding (expose wounds, do not remove penetrating foreign bodies)
      • Intra-thoracic bleeding (assess for massive haemothorax)
      • Intra-abdominal bleeding (inspect for distension, bruising. Palpate for tenderness)
      • Intra-pelvic bleeding – secondary to a pelvic fracture (assess by gentle palpation of pelvic structures)
      • Long bone fractures (particularly femoral)
      • Retroperitoneal bleeding (degree of suspicion should remain high if no other obvious source for bleeding)
      • Scalp or Intracranial bleeding in infants
      • eFAST has a limited role in paediatric trauma
    • Care should also be taken to actively look for and exclude:
      • Obstructive cause for shock (eg tension pneumothorax or cardiac tamponade)
      • Neurogenic shock (associated with spinal injury above T6)
    • In external haemorrhage, bleeding may be stopped with direct pressure
    • Use a tourniquet to control life-threatening limb haemorrhage
    • Establish IV access with two cannulae that are as large as practicable, ideally one in each cubital fossa. Take blood for cross-match, FBE, VBG, LFTs, UEC, lipase, coagulation screen
    • If an IV cannula cannot be inserted rapidly, obtain IO access into a non-traumatised leg or humerus
    • Inserting a chest drain into a massive haemothorax may improve ventilation but stopping ongoing bleeding can only be done in theatre
    • Assessment doctor should, in consultation with the trauma team leader, consider the need for a pelvic X-Ray
    • Life threatening bleeding into the abdomen, pelvis or retroperitoneal space may require surgery or interventional radiology. Early consultation with paediatric surgery +/- interventional radiology is required.
    • Rapid transit to theatre, prior to completion of the secondary survey may be required for bleeding that cannot be controlled in the Emergency Department
    • Consider application of a pelvic binder
    • Bleeding from bone fractures may be reduced through traction
    • If the circulation is inadequate, give 10 mL/kg bolus of sodium chloride 0.9%.
    • If there is ongoing visible bleeding or suspicion of occult bleeding give packed red blood cells (10 mL/kg) if available.
    • Give Tranexamic Acid 15 mg/kg if there is haemodynamic compromise from suspected haemorrhage
    • Consider inserting urinary catheter

    Disability (mental state)

    Assess for traumatic brain injury

    • Initial assessment of conscious state may be done using AVPU scale:
      • A = Alert
      • V = Responds to voice
      • P = Responds to pain
      • U = Unresponsive
    • Any impairment on AVPU scale should prompt a formal assessment of GCS
    • Check pupil response to light
    • Check movement in all four limbs
    • Measure blood glucose level on arrival
    • Assess pain
    • Provide analgesia
    • Avoid secondary brain injury by:
      • maintaining adequate oxygenation
      • correcting hypotension
      • nursing head up to 30 degrees
      • correcting hypoglycaemia
    • Consider need for urgent CT brain and discussion with neurosurgery


    Exposure and environmental control

    • Remove clothing and look for any obvious life-threatening injury 
    • Avoid hypothermia by limiting exposure and by warming all ongoing fluids

    Consider transfer when

    • All children with major trauma should be transferred to a major trauma service for definitive management. This should be done in consultation with the local pre-hospital and inter-hospital transfer guidelines
    • The child requires care beyond the comfort level of the hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Additional Resources

    RCH Paediatric Trauma Manual
    NSW Institute of Trauma and Injury Management – NSW Trauma App


    Last Updated January 2022

  • Reference List

    1. Browne GJ, Cocks AJ, McCaskill ME. Current trends in the management of major paediatric trauma. Emergency Medicine (Fremantle, W.A.). 2001;13(4):418-25.
    2. Cantor RM, Leaming JM. Evaluation and management of pediatric major trauma. Emergency Medicine Clinics of North America. 1998;16(1):229-56.
    3. Mackway-Jones K, Molyneux E, Phillips B, Wieteska S, eds. Advanced Paediatric life Support - the Practical Approach. Third ed. London: BMJ Books, 2001.
    4. Ojanen Thomas, D. (1988). The ABC's of Pediatric Triage. Journal of Emergency Nursing, 14(3), 154 - 159.  
    5. Semonin-Holleran, R. (1991). Paediatric trauma patients: Differences and implications for emergency nurses. Journal of Emergency Nursing, 17(1), 24 - 33.
    6. Soud, T. (1992). Airway, breathing, circulation, and disability: what is different about kids? Journal of Emergency Nursing, 18(2), 107-16.