Trauma Assessment: Primary Survey (ABCDE), Haemorrhage Control, Massive Transfusion

Trauma Assessment: Primary Survey (ABCDE), Haemorrhage Control, Massive Transfusion

A high-density, practical guide for immediate application in emergency and critical care.

What Is This?

The Primary Survey (ABCDE) is a systematic approach to rapidly identify and treat life-threatening injuries in trauma patients. Haemorrhage control and massive transfusion are critical interventions to prevent exsanguination and restore circulating volume.

Why use it today? Seconds count in trauma. This framework ensures clinicians prioritize interventions that save lives—preventing hypoxia, shock, and death before secondary injuries are addressed.

Why It Matters

• Prevents avoidable deaths: 30–40% of trauma fatalities are due to uncontrolled bleeding.
• Standardizes care: Used globally in prehospital, ED, and ICU settings.
• Guides resource allocation: Directs teams to focus on the most critical threats first.
• Legal and ethical imperative: Failure to follow ABCDE can result in negligence claims.

Core Concepts

1. Primary Survey (ABCDE)

A sequential, time-sensitive assessment to identify and treat immediate threats to life. Do not progress to the next step until the current one is stabilized.

Golden Rule: Treat as you go—do not delay interventions for diagnostics.

2. Haemorrhage Control

Goal: Stop bleeding within 3–5 minutes to prevent irreversible shock.

Hierarchy of Control

1. Direct pressure (manual or dressing) – First line for external bleeding.
2. Tourniquets – For extremity haemorrhage (apply 5–7 cm above wound, tighten until bleeding stops).
3. Myth: "Tourniquets cause limb loss." False—prolonged ischemia (>6 hours) causes damage, but uncontrolled bleeding kills faster.
4. Haemostatic dressings (e.g., QuikClot, Celox) – For junctional bleeding (neck, axilla, groin).
5. Pelvic binders – For suspected pelvic fractures (reduces volume, tamponades bleeding).
6. Operative control – Laparotomy/thoracotomy for internal bleeding.

Key Tools: - Combat Application Tourniquet (CAT) – Standard for prehospital use. - Junctional Tourniquets (e.g., SAM Junctional Tourniquet) – For groin/axilla. - Tranexamic Acid (TXA) – 1g IV over 10 mins (within 3 hours of injury) to reduce fibrinolysis.

3. Massive Transfusion (MT)

Definition: Replacement of ?1 blood volume in 24 hours or ?50% in 3 hours (adult: ~70 mL/kg).

Goal: Restore oxygen delivery while preventing trauma-induced coagulopathy (TIC).

Massive Transfusion Protocol (MTP)

• Ratio-based resuscitation: 1:1:1 (PRBC:FFP:Platelets) to mimic whole blood.
• Balanced approach: Avoid crystalloid overload (worsens coagulopathy, dilutes clotting factors).
• Adjuncts:
• Calcium (1g IV after every 4 units PRBC to prevent hypocalcemia).
• TXA (1g IV bolus, then 1g over 8 hours).
• Fibrinogen (if <1.5 g/L, give cryoprecipitate or fibrinogen concentrate).

Triggers for MTP Activation: - SBP <90 mmHg + HR >120 bpm. - Penetrating torso trauma + shock. - Positive FAST scan (free fluid in abdomen/chest). - Estimated blood loss >1500 mL.

Complications of MT: - Hypothermia (use fluid warmers, blankets). - Acidosis (monitor lactate, pH). - Hyperkalemia (from stored PRBCs; check K+ after 4 units). - Citrate toxicity (from FFP; causes hypocalcemia).

How It Works (Step-by-Step Workflow)

1. Scene Assessment (Prehospital)

• Safety first: Ensure scene is safe for providers.
• Rapid triage: Identify mechanism of injury (MOI) (e.g., MVC, fall, GSW).
• C-spine control: Manual inline stabilization if MOI suggests spinal injury.

2. Primary Survey (ABCDE)

A – Airway - Assess: Can the patient speak? Stridor? Gurgling? - Intervene: - No airway: Jaw thrust, OPA/NPA. - Obstructed: Suction, remove foreign bodies. - GCS ?8: Intubate (RSI with ketamine/etomidate + rocuronium).

B – Breathing - Assess: Chest rise, breath sounds, SpO?, tracheal deviation. - Intervene: - Tension pneumothorax: Needle decompression (2nd ICS, midclavicular line). - Open pneumothorax: 3-sided occlusive dressing. - Flail chest: Positive pressure ventilation (PPV).

C – Circulation - Assess: Pulse (central vs. peripheral), skin (pale/clammy?), BP, capillary refill. - Intervene: - External bleeding: Direct pressure-tourniquet. - Internal bleeding: FAST scan (if available), pelvic binder if unstable. - IV access: 2 large-bore (14–16G) IVs, IO if IV fails. - Fluids: Permissive hypotension (SBP 80–90 mmHg) if bleeding uncontrolled; aggressive resuscitation if head injury (SBP ?100 mmHg).

D – Disability - Assess: GCS, pupils, lateralizing signs. - Intervene: - Hypoglycemia: 50 mL 50% dextrose. - Herniation: Hyperventilate (PaCO? 30–35 mmHg), mannitol (1g/kg).

E – Exposure - Assess: Full body exam (log-roll for posterior injuries). - Intervene: - Hypothermia prevention: Warm blankets, warmed fluids.

3. Haemorrhage Control

• Extremity bleeding: Tourniquet (mark time applied).
• Junctional bleeding: Haemostatic dressing + direct pressure.
• Pelvic fracture: Pelvic binder (level of greater trochanters).

4. Massive Transfusion

• Activate MTP: Call blood bank, prepare rapid infuser.
• Administer blood products:
• PRBCs: 1 unit (300 mL) raises Hb by ~1 g/dL.
• FFP: 15–20 mL/kg (replaces clotting factors).
• Platelets: 1 apheresis unit (raises count by ~30–50 × 10?/L).
• Monitor:
• Labs: ABG, lactate, Hb, INR, fibrinogen, Ca²?, K?.
• Vitals: BP, HR, SpO?, temperature.

Hands-On / Getting Started

Prerequisites

• Knowledge: Basic anatomy, physiology of shock, blood products.
• Skills: IV insertion, airway management, tourniquet application.
• Equipment:
• Tourniquet (CAT or SOF-T).
• Haemostatic dressing (QuikClot).
• Pelvic binder.
• Rapid infuser (e.g., Belmont, Level 1).
• Blood products (PRBCs, FFP, platelets).

Step-by-Step Minimal Example

Scenario: 25M, GSW to right thigh, SBP 70 mmHg, HR 130 bpm, pale, diaphoretic.

1. A: Patient speaking-airway patent.
2. B: SpO? 92% on RA-apply NRB mask (15 L/min).
3. C:
4. Bleeding: Apply tourniquet to right thigh (mark time: 14:30).
5. IV access: 2 × 16G IVs in antecubital fossae.
6. Fluids: 1L warmed crystalloid (if no response, switch to blood).
7. D: GCS 14, pupils equal-no immediate intervention.
8. E: Log-roll-no other injuries.
9. Haemorrhage control: Tourniquet stops bleeding.
10. Massive transfusion:
11. Activate MTP.
12. Administer 1:1:1 (PRBC:FFP:Platelets).
13. Give TXA 1g IV over 10 mins.
14. Monitor: BP, lactate, Ca²?.

Expected Outcome: - SBP >90 mmHg. - Lactate <4 mmol/L. - No ongoing bleeding.

Common Pitfalls & Mistakes

Best Practices

Prehospital

• Tourniquets: Apply high and tight (proximal to wound).
• Pelvic binders: Place at greater trochanters, not iliac crests.
• TXA: Give 1g IV en route if bleeding suspected.

ED/ICU

• MTP: Use 1:1:1 ratio (PRBC:FFP:Platelets).
• Monitoring: Thromboelastography (TEG) or ROTEM to guide product use.
• Damage control resuscitation:
• Permissive hypotension (SBP 80–90 mmHg) if bleeding uncontrolled.
• Early surgical intervention (laparotomy/thoracotomy if unstable).

Post-Resuscitation

• Rewarm: Use bair hugger, warmed fluids.
• Correct coagulopathy: Target fibrinogen >1.5 g/L, INR <1.5, platelets >50 × 10?/L.
• Prevent complications: Monitor for ARDS, MODS, compartment syndrome.

Tools & Frameworks

Real-World Use Cases

1. Prehospital Trauma (EMS)

Scenario: Motorcycle crash, 30M, open femur fracture, SBP 60 mmHg. - Action: - Apply tourniquet to thigh. - IV access (IO if needed). - TXA 1g IV. - Pelvic binder if unstable. - Outcome: SBP 90 mmHg on arrival; survives to OR.

2. Emergency Department (ED)

Scenario: 20F, stab wound to left chest, HR 140 bpm, SpO? 85%. - Action: - A: Intubate (RSI). - B: Needle decompression (tension pneumothorax). - C: FAST scan-free fluid in abdomen-activate MTP. - D: GCS 3T-hyperventilate, mannitol. - E: Log-roll-no other injuries. - Outcome: Laparotomy-splenectomy; survives.

3. Mass Casualty Incident (MCI)

Scenario: Bombing, 10 patients with traumatic amputations. - Action: - Triage: Red tag (immediate) for active bleeding. - Apply tourniquets to all extremity bleeding. - TXA for all red-tag patients. - MTP for 3 most unstable. - Outcome: 8/10 survive; 2 exsanguinate (uncontrollable torso bleeding).

Check Your Understanding (MCQs)

Question 1

A 45M presents after a MVC with a deformed left thigh, SBP 70 mmHg, and HR 130 bpm. What is the first intervention? A) Apply a pelvic binder B) Insert 2 large-bore IVs and give 1L crystalloid C) Apply a tourniquet to the left thigh D) Perform a FAST scan

Correct Answer: C (Apply a tourniquet to the left thigh) Explanation: The patient has extremity bleeding (deformed thigh + shock). Tourniquets stop bleeding fastest and are the priority in this scenario. Why the Distractors Are Tempting: - A: Pelvic binders are for pelvic fractures, not thigh injuries. - B: Fluids are secondary to stopping bleeding. - D: FAST scan is useful but not the first step—bleeding control is.

Question 2

A trauma patient receives 6 units of PRBCs, 4 units of FFP, and 1 unit of platelets. Their INR is 2.5, and fibrinogen is 1.2 g/L. What is the next best step? A) Give 1g calcium gluconate B) Administer 10 units of cryoprecipitate C) Transfuse 1 more unit of platelets D) Infuse 1L of 0.9% saline

Correct Answer: B (Administer 10 units of cryoprecipitate) Explanation: Fibrinogen <1.5 g/L is the priority. Cryoprecipitate (or fibrinogen concentrate) is the best source of fibrinogen. Why the Distractors Are Tempting: - A: Calcium is important (citrate toxicity), but fibrinogen is lower priority. - C: Platelets are not the main issue (fibrin