Primary Survey - ATLS

Quick Answer

Primary survey is the systematic ABCDE approach to identify and immediately treat life-threatening injuries in trauma patients. Address each step sequentially, intervene before moving to the next, and only proceed to secondary survey when the patient is stabilised. Time-critical interventions occur during primary survey, while secondary survey identifies all injuries.

Primary survey sequence:

• Airway with cervical spine protection
• Breathing and ventilation
• Circulation with haemorrhage control
• Disability (neurological status)
• Exposure and environmental control

Critical principle: Treat life-threatening threats immediately, do not defer interventions for imaging or full examination.

ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Airway anatomy, cervical spine levels, thoracic cavity landmarks, neuroanatomy (GCS components)
• Physiology: Shock classification, oxygenation-ventilation coupling, intracranial pressure, cervical spine biomechanics
• Pharmacology: Rapid sequence intubation drugs, vasopressors, analgesia in trauma

Fellowship Exam Relevance

• Written: Primary survey sequence, life-threatening injuries at each ABCDE step, ATLS principles, trauma team activation
• OSCE: Resuscitation station leading trauma team, communication with trauma team members, handover from pre-hospital
• Key domains tested: Medical Expert (trauma knowledge), Leader (team coordination), Communicator (closed-loop)

Common Exam Questions

• "Walk me through your primary survey of this trauma patient"
• "What life-threatening injuries must you rule out at each ABCDE step?"
• "When do you stop the primary survey?"
• "How does the primary survey differ in penetrating vs blunt trauma?"
• "What are the indications for emergency thoracotomy?"

Key Points

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Clinical Overview

Definition

Primary Survey: Systematic, rapid assessment of trauma patients to identify and treat immediately life-threatening injuries using the ABCDE approach. Based on ATLS (Advanced Trauma Life Support) principles.

Purpose: Prevent preventable trauma deaths by addressing time-critical threats within the "golden hour" (first 60 minutes post-injury).

ATLS Principles

1. Treat greatest threat to life first
2. Do not defer interventions for diagnostic tests
3. History follows initial stabilisation (AMPLE)
4. Consider energy transfer mechanism
5. Assume multiple injuries
6. Reassess constantly

Epidemiology

Australian Trauma Context

• NSW - NSW Trauma Registry, major trauma centres (RPA, St George, Liverpool, Royal North Shore)
• VIC - Victorian State Trauma Registry, major centres (Alfred, Royal Melbourne)
• QLD - Queensland Trauma Registry, major centres (Royal Brisbane, Princess Alexandra)
• WA - WA Trauma Registry, major centre (Royal Perth)
• SA - SA Trauma Registry, major centre (Royal Adelaide)
• TAS/NT/ACT - Refer to tertiary centres

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Primary Survey: Systematic Approach

Catastrophic Haemorrhage Control (Before A)

Newer ATLS (10th ed+) places catastrophic haemorrhage control BEFORE Airway.

Tourniquet application:

• Apply high and tight
• Mark application time
• Document reason
• Consider early release in definitive care (within 2 hours optimal)

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A: Airway with Cervical Spine Protection

Airway Assessment

Signs of airway compromise:

• Stridor, hoarseness, gurgling
• Subcutaneous emphysema
• Facial/maxillofacial trauma
• Burns to face/neck
• Decreased level of consciousness (GCS below 9)

Airway patency check:

• Look, listen, feel
• Oropharyngeal suction if secretions/blood
• Chin lift or jaw thrust (cervical spine maintained)

Cervical Spine Protection

Indications for immobilisation:

• Mechanism of injury with force > mechanism threshold
• Neck pain or tenderness
• Neurological deficit
• Altered level of consciousness
• Distracting injury

Immobilisation technique:

• Rigid cervical collar sized correctly
• Tape head to spine board
• Sandbags/tape either side of head (not collar alone)

Clearance criteria (in alert, asymptomatic patient):

• No neck pain/tenderness
• No neurological deficit
• GCS 15
• No distracting injury
• No intoxication
• Canadian C-Spine Rule or NEXUS criteria met

Airway Interventions

RSI in trauma:

• Pre-oxygenate with 100% O2 for 3-5 minutes
• Apply cricoid pressure (controversial, consider)
• Induction agent: Ketamine 1-2 mg/kg (haemodynamically stable) OR Etomidate 0.3 mg/kg (unstable)
• Paralytic: Rocuronium 1.2 mg/kg OR Suxamethonium 1-2 mg/kg
• Verify tube placement: ETCO2 detector, bilateral breath sounds, chest rise

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B: Breathing and Ventilation

Breathing Assessment

Immediate assessment:

• Look: Chest wall movement, symmetry, respiratory rate
• Listen: Breath sounds bilaterally, wheeze, stridor
• Feel: Tracheal position, chest wall crepitus, surgical emphysema
• Pulse oximetry: SpO2 (target 94-98%)

Life-threatening thoracic injuries:

Breathing Interventions

Supplemental oxygen:

• 100% O2 via non-rebreather mask initially
• Titrate to SpO2 94-98%
• Consider early mechanical ventilation if:
  • GCS below 9
  • Respiratory rate below 10 or above 30/min
  • PaO2 below 60 mmHg on 100% O2
  • PaCO2 above 50 mmHg

Chest drain insertion:

• Indications: Tension pneumothorax (after needle), haemothorax, pneumothorax requiring ventilation
• Site: 4th or 5th intercostal space, anterior axillary line
• Size: Large-bore (32-36 Fr) for adult trauma
• Position: Apex for pneumothorax, base for haemothorax

Emergency thoracotomy indications:

• Penetrating thoracic trauma with cardiac arrest or profound shock
• Blunt thoracic trauma with cardiac arrest at scene (low survival)
• Cardiac tamponade with deteriorating patient
• Trauma arrest with witnessed arrest, signs of life on arrival

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C: Circulation with Haemorrhage Control

Circulation Assessment

Immediate assessment:

• Pulse: Rate, quality, regularity
• Blood pressure: Systolic, diastolic, MAP
• Capillary refill time (greater than 2 seconds abnormal)
• Skin colour, temperature, sweating
• Level of consciousness (hypoperfusion sign)

Shock classification (ATLS):

Sources of haemorrhage:

Circulation Interventions

Vascular access:

• Two large-bore IV cannulas (14G or 16G) - antecubital fossae preferred
• Consider intraosseous access if IV access difficult (humeral or tibial)
• Blood sampling: CBC, coagulation profile, type and crossmatch, arterial blood gas

Fluid resuscitation:

• Initial bolus: 1L warmed crystalloid (Hartmann's or Plasma-Lyte) for Class II-IV shock
• Blood products preferred for Class III-IV shock
• Target MAP above 65 mmHg (permissive hypotension 80-90 systolic in uncontrolled haemorrhage until bleeding controlled)
• Reassess after each litre or 2 units blood

Massive transfusion protocol (MTP):

• 1:1:1 ratio (RBC:Plasma:Platelets)
• Activated for: greater than 4 units RBC in 1 hour OR greater than 10 units RBC in 24 hours
• Fibrinogen replacement: Cryoprecipitate (if fibrinogen below 1.5-2.0 g/L)
• Tranexamic acid: 1g IV over 10 minutes, then 1g infusion over 8 hours (within 3 hours of injury) [10]

Pelvic binder for suspected pelvic fracture:

• Indications: Mechanism, pelvic pain/instability, haemodynamic instability
• Application: Place over greater trochanters, tighten appropriately
• Removal: After pelvic X-ray and angiography/surgery if indicated

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D: Disability (Neurological Assessment)

Disability Assessment

Glasgow Coma Scale (GCS):

Pupils:

• Size, equality, reactivity to light
• Signs of uncal herniation: Fixed, dilated pupil (ipsilateral), contralateral hemiparesis

Limb movement:

• Purposeful movement vs spinal cord injury patterns
• Spinal shock: Flaccid paralysis, areflexia, hypotension, priapism

Disability Interventions

Hypotensive, hypoxic patient:

• Hypotension is MOST detrimental to TBI outcomes - maintain MAP above 80-90 mmHg for TBI
• Hypoxia worsens secondary brain injury - maintain SpO2 above 90%
• Target PaCO2 35-40 mmHg (avoid hyperventilation unless imminent herniation)

Cerebral herniation:

• Immediate signs: Fixed, dilated pupil, decerebrate posturing, Cushing's triad (hypertension, bradycardia, irregular respirations)
• Temporising measures: Elevate head 30 degrees, sedation, mannitol 0.5-1 g/kg IV OR hypertonic saline 3%
• Definitive: Emergency neurosurgical intervention

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E: Exposure and Environmental Control

Exposure Assessment

Complete patient examination:

• Remove all clothing to fully examine for injuries
• Log-roll for posterior inspection (maintain cervical spine alignment)
• Check: Entrance/exit wounds, burns, contusions, deformities, bleeding

Environmental control:

• Maintain patient temperature (prevent hypothermia)
• Use forced-air warming blankets
• Warm IV fluids and blood products
• Cover exposed areas once examined

Secondary survey preparation:

• Prepare patient for systematic head-to-toe examination
• Log-roll for spine assessment
• Consider FAST scan, pelvic X-ray, chest X-ray

Exposure Interventions

Hypothermia prevention:

• Active warming: Forced-air blankets, warmed fluids
• Passive warming: Blankets, overhead heaters
• Monitor core temperature (rectal, oesophageal)
• Target temperature above 35°C

Log-roll technique:

• Team of 4-5 people
• Maintain cervical spine alignment throughout
• One person at head, others stabilise thorax, pelvis, legs
• Inspect posterior: Spine, back, buttocks, perineum

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Resuscitation Adjuncts During Primary Survey

Monitoring

Diagnostic Adjuncts

Focused Assessment with Sonography for Trauma (FAST):

FAST interpretation:

• Positive: Free fluid in any window
• Indeterminate: Poor windows, bowel gas
• Negative: No free fluid (repeat FAST if patient deteriorates)

Adjunct radiography (DURING primary survey):

• CXR (anteroposterior, supine): Pneumothorax, haemothorax, chest wall injury, foreign bodies, tube placement
• Pelvic X-ray (AP): Pelvic fracture, pelvic binder position
• Lateral cervical spine X-ray: If CT not immediately available

Portable CT (if available):

• Whole-body CT (pan-scan) for blunt polytrauma after primary survey stabilisation
• Reduces time to definitive diagnosis
• Improves survival in major trauma

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When to Proceed to Secondary Survey

Completion Criteria

Primary survey complete when:

1. Airway secure and patent (intubated if indicated)
2. Breathing adequate (oxygenation/ventilation optimised)
3. Circulation stabilised (haemorrhage controlled, resuscitation ongoing)
4. Disability assessed and addressed (TBI considerations)
5. Exposure complete, environmental control maintained

All life-threatening injuries addressed:

• Catastrophic haemorrhage controlled
• Airway secured or patent
• Tension pneumothorax decompressed
• Cardiac tamponade treated (pericardiocentesis)
• Massive haemothorax drained
• Pelvic binder applied (if indicated)
• Hypotension addressed (fluids, blood, vasopressors)
• Hypoxia corrected

Secondary Survey Initiation

Indications:

• Patient haemodynamically stable OR stabilising
• Life-threatening threats addressed
• Monitoring established
• Team prepared for systematic examination

What secondary survey includes:

• Complete head-to-toe examination -AMPLE history (Allergies, Medications, Past medical history, Pregnancy, Last meal, Events/environment)
• Further diagnostic tests (CT as indicated)
• Fracture assessment and splinting
• Tetanus prophylaxis
• Analgesia

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Pitfalls & Pearls

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Viva Practice

Viva 1: Blunt Trauma Primary Survey

Examiner: "A 28-year-old male brought in by ambulance after high-speed MVC (driver). He was unrestrained, ejected from vehicle. GCS 7, tachycardic 140, hypotensive 80/40. Walk me through your primary survey."

Candidate response:

First, ensure team prepared:

• Trauma team activated
• Two large-bore IV access
• Monitor attached
• Blood products ordered
• Airway equipment ready

Step-by-step ABCDE approach:

Catastrophic haemorrhage check: No obvious massive external bleeding. If limb/junctional haemorrhage present, would apply tourniquet BEFORE airway.

A - Airway with cervical spine protection:

• GCS 7 (below 9) - requires immediate intubation
• Apply rigid cervical collar (mechanism: ejection, high-speed)
• RSI: Ketamine 2 mg/kg (haemodynamically unstable option), Rocuronium 1.2 mg/kg
• Pre-oxygenate with 100% O2
• Confirm tube placement: ETCO2 waveform, breath sounds, chest rise
• Secure tube

B - Breathing:

• Assess breath sounds bilaterally
• Check for tension pneumothorax: Tracheal deviation? Absent breath sounds? Hyper-resonance?
• If absent breath sounds and haemodynamic instability - perform immediate needle thoracostomy (2nd ICS, MCL)
• Consider massive haemothorax (dull percussion)
• Apply 100% O2, target SpO2 94-98%
• Consider chest drains if indicated

C - Circulation with haemorrhage control:

• BP 80/40 - Class III-IV shock
• Check for external haemorrhage: Scalp lacerations, limb injuries
• Assess internal haemorrhage sources:
  • "Chest: Haemothorax, cardiac tamponade (muffled HS, JVD, PEA)"
  • "Abdomen: FAST scan"
  • "Pelvis: Pelvic stability, apply binder"
  • "Long bones: Femur fractures"
• Fluid resuscitation: 1L warmed crystalloid, then switch to blood products (activate MTP)
• Target MAP above 65 mmHg (or permissive hypotension 80-90 SBP until bleeding controlled)
• Consider early blood product administration (O-negative if no type)

D - Disability:

• GCS reassessment post-intubation (motor response only)
• Pupils: Check size, equality, reactivity
• Signs of herniation: Fixed dilated pupil?
• If TBI suspected: Target MAP above 80-90 mmHg, avoid hypoxia, PaCO2 35-40 mmHg

E - Exposure:

• Remove all clothing
• Full examination for injuries
• Maintain temperature: Forced-air warming blanket, warmed fluids
• Log-roll for posterior inspection (maintain cervical spine)
• Check for entrance/exit wounds

Reassess ABCDE constantly:

• Repeat vitals after interventions
• Recheck breath sounds after chest drain
• Reassess neurological status

Examiner follow-up: "FAST scan shows free fluid in Morison's pouch and splenorenal space. What are you thinking?"

Candidate:

• Positive FAST indicates haemoperitoneum
• Likely source: Solid organ injury (liver or spleen)
• Morison's pouch (right): Liver injury
• Splenorenal (left): Splenic injury
• Combined? Polytrauma
• Management: Continue massive transfusion, activate trauma surgeon, prepare for exploratory laparotomy if unstable
• If stable: CT abdomen for definitive diagnosis
• Consider REBOA if non-compressible torso haemorrhage and deteriorating despite resuscitation

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Viva 2: Penetrating Chest Trauma

Examiner: "A 32-year-old male stabbed in left anterior chest. Arrives in ED with GCS 15, HR 130, BP 85/50, RR 28, SpO2 88% on room air. Walk me through your primary survey."

Candidate response:

Catastrophic haemorrhage check:

• Stab wound - control bleeding with direct pressure, gauze packing
• Consider junctional tourniquet if axillary region

A - Airway:

• Patient talking - airway patent
• No stridor, hoarseness, gurgling
• Apply cervical collar (mechanism: penetrating trauma)
• Monitor airway (may deteriorate with haemothorax)

B - Breathing:

• SpO2 88% - hypoxic
• Apply 100% O2 via non-rebreather mask
• Assess breath sounds: Likely decreased left side
• Check for tension pneumothorax:
  • Tracheal deviation?
  • Absent breath sounds left?
  • Hyper-resonance left?
• If tension pneumothorax suspected: Needle thoracostomy left 2nd ICS MCL
• Consider open pneumothorax: Sucking chest wound?
  • "If wound size > trachea: Apply occlusive dressing taped on 3 sides"
• Consider haemothorax: Dull percussion
  • "If massive (greater than 1500mL or greater than 200mL/hr for 2-4 hours): Insert chest drain"

C - Circulation:

• Hypotensive (85/50), tachycardic (130) - Class III shock
• Check for cardiac tamponade:
  • Muffled heart sounds?
  • JVD?
  • Pulsus paradoxus?
  • Beck's triad?
• If cardiac tamponade: Pericardiocentesis (subxiphoid approach)
• Assess for other haemorrhage sources
• Vascular access: Two large-bore IVs
• Fluid resuscitation: 1L crystalloid, then blood products
• Consider early transfusion: O-negative blood

D - Disability:

• GCS 15 - normal mental status
• Pupils: Check
• No signs of TBI (penetrating chest injury)

E - Exposure:

• Remove clothing to assess injury track
• Assess for exit wound
• Check for other injuries (multiple stab wounds?)
• Maintain temperature

Diagnostic adjuncts:

• FAST scan: Pericardial window (tamponade), haemothorax
• CXR (supine AP): Pneumothorax, haemothorax, foreign body
• Consider thoracotomy indications:
  • Cardiac arrest with tamponade
  • Profound shock with cardiac injury
  • Ongoing bleeding despite chest drain

Examiner follow-up: "Patient's BP drops to 60/40, JVD present, heart sounds muffled. What do you do?"

Candidate:

• Cardiac tamponade - life-threatening, requires immediate treatment
• Pericardiocentesis NOW:
  • Subxiphoid approach
  • 18G needle attached to syringe with ECG monitoring
  • Angle 45 degrees towards left shoulder
  • Aspirate while advancing
  • If blood aspirated, place catheter
• Consider emergency department thoracotomy (EDT) if:
  • Penetrating thoracic trauma with cardiac arrest or profound shock
  • Pericardiocentesis unsuccessful
  • Experienced surgeon and equipment available
• Prepare for definitive surgical intervention: OR transfer, cardiothoracic surgery

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Viva 3: Paediatric Trauma Primary Survey

Examiner: "A 7-year-old girl fell from 3 metres onto concrete. GCS 10 (E3, V3, M4), HR 140, BP 90/60, RR 36, SpO2 92%. Walk me through your primary survey considering paediatric differences."

Candidate response:

Paediatric primary survey considerations:

• Smaller airway, larger head-to-body ratio, less fat cushioning
• Hypovolaemia may present with tachycardia, prolonged capillary refill, tachypnoea BEFORE hypotension
• Hypotension is LATE sign (may lose up to 40% blood volume before BP drops)
• Weight-based drug doses, fluid resuscitation (20 mL/kg bolus)

Catastrophic haemorrhage check:

• Assess for external bleeding: Scalp lacerations, limb injuries
• Control bleeding with direct pressure
• Consider tourniquet for catastrophic limb haemorrhage

A - Airway:

• GCS 10 - airway at risk (GCS below 9 for intubation, but 10 concerning)
• Prepare for RSI if GCS deteriorates (below 9)
• Paediatric RSI: Atropine premedication if below 10 years, cuffed tube appropriate

B - Breathing:

• SpO2 92% - hypoxic
• Apply 100% O2
• Assess breath sounds: Pneumothorax? Haemothorax?
• Consider tension pneumothorax: Needle thoracostomy (smaller needle for child)
• Paediatric physiological reserve: Respiratory compensation earlier
• Respiratory rate 36 - tachypnoea (age-appropriate? Normal 7-year-old: 18-30) - elevated, suggests respiratory distress or metabolic acidosis
• Consider pulmonary contusion from blunt chest trauma

C - Circulation:

• HR 140 - tachycardic (normal 7-year-old: 70-110)
• BP 90/60 - within normal range (age-appropriate: 90-110 systolic)
• Paediatric shock: Hypotension is LATE sign
• Check capillary refill, skin colour, temperature
• Assess perfusion: Peripheral pulses, urine output
• Vascular access: Two large-bore IVs (may require intraosseous if difficult)
• Fluid resuscitation: 20 mL/kg bolus (warmed)
• Repeat 20 mL/kg if needed (typically up to 60 mL/kg)
• Consider blood products early: 10 mL/kg PRBCs
• Assess for internal haemorrhage: FAST scan

D - Disability:

• GCS 10 (E3, V3, M4) - moderate impairment
• Eye opening to speech (3)
• Verbal: Inappropriate words (3)
• Motor: Localising to pain (4)
• Assess pupils: Size, equality, reactivity
• Signs of TBI: Vomiting? Headache? Seizure?
• Consider head injury from fall
• Target MAP >age-appropriate (approximately 70 + (2 × age) = 84 mmHg for 7-year-old)

E - Exposure:

• Remove clothing carefully (maintain temperature)
• Children lose heat rapidly - use forced-air warming blanket
• Full examination for injuries
• Check for bruising, deformities
• Log-roll for spine assessment

Examiner follow-up: "FAST scan shows free fluid in pelvis. What's your concern and management?"

Candidate:

• Free fluid in pelvis in child - concerning for haemoperitoneum from solid organ injury (liver, spleen) or pelvic fracture
• Child mechanism: Fall from height - significant energy transfer
• Management:
  • Continue fluid resuscitation (20 mL/kg boluses)
  • Activate trauma team
  • Consider massive transfusion protocol (paediatric)
  • Maintain normothermia
  • CT abdomen for definitive diagnosis (if stable)
  • Consider pelvic binder if pelvic fracture suspected
  • Prepare for surgical intervention if unstable
  • Consult paediatric trauma surgeon

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Viva 4: Trauma in the Elderly

Examiner: "An 82-year-old woman pedestrian hit by car at low speed. GCS 14 (E4, V4, M6), HR 110, BP 100/70, RR 24, SpO2 93% on room air. Discuss primary survey considerations in the elderly."

Candidate response:

Elderly trauma considerations:

• Reduced physiological reserve
• Comorbidities: Cardiovascular, pulmonary, renal disease, anticoagulants
• Medications: Antiplatelets (aspirin, clopidogrel), anticoagulants (warfarin, DOACs)
• Atypical presentations: Pain may be minimal (diabetes, neuropathy)
• Higher mortality despite lower injury severity scores
• Baseline functional status critical for disposition

Catastrophic haemorrhage check:

• Assess for external bleeding
• Elderly skin fragile, bruising common
• Control bleeding with direct pressure

A - Airway:

• GCS 14 - airway patent for now, but monitor closely
• Apply cervical collar (mechanism: pedestrian struck)
• Elderly airway: Edentulous, reduced cervical spine mobility, potentially osteoporotic
• Bag-mask ventilation may be more difficult (loss of dentures, poor seal)
• Early consideration of RSI if GCS drops
• Review anticoagulation: Warfarin (check INR), DOACs (apixaban, rivaroxaban)
• Reverse anticoagulation if airway intervention needed: Prothrombin complex concentrate (PCC) for warfarin, idarucizumab for dabigatran, andexanet alfa for apixaban/rivaroxaban

B - Breathing:

• SpO2 93% - mildly hypoxic
• Apply 100% O2
• Assess breath sounds
• Elderly lungs: Reduced compliance, may have baseline COPD or heart failure
• Consider rib fractures: Even minor trauma in elderly can cause multiple rib fractures
• Chest wall compliance reduced, paradoxical movement may occur with fewer fractures
• Consider baseline oxygen requirements
• Be cautious with fluid resuscitation: Elderly at higher risk of fluid overload, pulmonary oedema

C - Circulation:

• HR 110, BP 100/70
• Elderly "normal" BP may be lower than young adults
• Tachycardia (110) - may be significant for elderly patient (baseline may be 60-80)
• Assess perfusion: Capillary refill, skin mottling, urine output
• Elderly may have "relative hypotension" at BP 100/70 if baseline is higher
• Review medications: Beta-blockers (blunt tachycardic response), antihypertensives
• Assess for cardiac injury: Ischaemia? Arrhythmia?
• Consider baseline renal function: AKI common with hypotension
• Fluid resuscitation: More cautious (smaller bolus, frequent reassessment)
• Consider cardiac monitoring: Ischaemia, arrhythmias from trauma or stress
• Assess for bleeding: Anticoagulated patients may bleed more

D - Disability:

• GCS 14 (E4, V4, M6) - mild impairment
• Verbal response 4: Confused conversation
• Elderly baseline: May have cognitive impairment, dementia
• Assess pupils
• Consider TBI: Even minor head injury in elderly can cause intracranial haemorrhage (subdural, epidural)
• On anticoagulation? High risk of intracranial bleeding
• Consider baseline mobility, independence

E - Exposure:

• Remove clothing
• Elderly lose heat rapidly (reduced subcutaneous fat, impaired thermoregulation)
• Use forced-air warming blanket
• Warm IV fluids
• Full examination: Elderly may have bruising, skin tears from minimal trauma
• Assess for pressure injuries

Specific considerations:

• Medication review: List all medications, especially anticoagulants/antiplatelets
• Comorbidities: Heart failure, COPD, CKD, dementia
• Social support: Lives alone? Family support?
• Goals of care: Discuss with patient/family early

Examiner follow-up: "Patient on warfarin for atrial fibrillation. INR 3.2. CT head shows small subdural haemorrhage. What's your management?"

Candidate:

• Subdural haemorrhage + supratherapeutic INR (3.2) - high risk of expansion
• Immediate reversal of anticoagulation:
  • "Prothrombin complex concentrate (PCC): 25-50 IU/kg depending on INR"
  • "Vitamin K: 5-10 mg IV slow infusion"
  • "Fresh frozen plasma (FFP): Alternative if PCC unavailable"
• Neurosurgical consultation: May require surgical evacuation
• Neurological monitoring: GCS, pupils, motor function
• Consider admission to high-dependency unit or ICU
• Monitor for expansion: Repeat CT if neurological deterioration
• Discuss anticoagulation re-initiation with neurosurgery/cardiology (timing typically 1-2 weeks post-event)
• Falls assessment: Prevent future trauma

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OSCE Scenarios

OSCE 1: Trauma Team Leader - Blunt Polytrauma

Station type: Resuscitation leadership (11 minutes)

Setting: ED resuscitation bay

Scenario: A 35-year-old male brought in by ambulance after high-speed motorbike crash. Helmet came off. GCS 6 (E1, V1, M4), HR 145, BP 75/45, RR 8 (shallow), SpO2 82% on 15L O2. Paramedics report suspected pelvic fracture.

Your task: Lead the trauma team through primary survey of this patient.

Team available:

• 2 ED nurses
• 1 ED registrar
• 1 anaesthetic registrar
• 1 surgical registrar

Resources:

• Full resuscitation equipment
• Blood products available
• CT scanner accessible

Candidate Instructions:

You are the trauma team leader. A critically injured patient has just arrived.

Your task is to:

1. Lead the team through a systematic primary survey (ABCDE)
2. Direct team members appropriately
3. Make clinical decisions as problems arise
4. Communicate clearly using closed-loop communication
5. Address life-threatening injuries immediately

The team will provide clinical findings as you request them.

Examiner Instructions:

Scenario background: Patient is 35-year-old male, high-speed motorbike crash, helmet came off. Significant mechanism.

Clinical findings (revealed on request):

Initial assessment:

• GCS 6 (E1, V1, M4)
• HR 145, BP 75/45, RR 8 (shallow), SpO2 82% on 15L O2

Airway examination:

• Blood in oropharynx
• Mandible deviation (possible fracture)
• Stridor present
• Neck swelling

Breathing examination:

• Decreased breath sounds right side
• Trachea deviated to left
• Chest wall bruising right side
• Surgical emphysema palpable

Circulation examination:

• Pale, cool peripheries
• Capillary refill 4 seconds
• External bleeding: Scalp laceration (moderate), right thigh deformity (possible femur fracture)
• Pelvis unstable on spring test
• Heart sounds difficult to hear

Disability examination:

• Pupils: Right 4mm, left 3mm, both sluggish
• No purposeful movement to pain
• Decorticate posturing

Exposure:

• Contusions to chest, abdomen
• Right thigh deformity
• Pelvic instability

FAST scan (when requested):

• Positive: Free fluid in Morison's pouch, splenorenal space, pelvis
• Pericardial window: Unable to visualise well

CXR (when requested):

• Large right-sided pneumothorax
• Right-sided rib fractures (3rd-7th)
• Possible mediastinal widening

Pelvic X-ray (when requested):

• Disrupted left sacroiliac joint
• Pubic symphysis diastasis

Expected progression:

1. Candidate assumes team leader role
2. Systematic ABCDE approach
3. Immediate interventions for life-threatening injuries
4. Appropriate delegation to team members
5. Clear closed-loop communication
6. Constant reassessment

Prompts if candidate stuck:

• "What's your assessment of the airway?"
• "What breathing problem do you need to address?"
• "What are you thinking for circulation?"
• "What's the most life-threatening finding?"

Marking Criteria:

TOTAL | | /11

Key Discriminators:

Passing candidate:

• Recognises GCS 6 requires immediate RSI
• Identifies tension pneumothorax and directs needle thoracostomy BEFORE intubation
• Recognises haemorrhagic shock and activates massive transfusion
• Applies pelvic binder early
• Uses closed-loop communication throughout

Failing candidate:

• Proceeds to intubation BEFORE decompressing tension pneumothorax
• Misses catastrophic haemorrhage or pelvic fracture
• Does not activate massive transfusion
• Poor team leadership (does not delegate, unclear communication)
• Proceeds to secondary survey before stabilising primary threats

Model Performance:

Excellent candidate would:

• Assume leadership immediately, allocate roles
• Recognise simultaneous life threats, prioritise correctly
• Direct anaesthetic registrar to prepare for RSI
• Direct nurse to perform needle thoracostomy RIGHT NOW
• Direct another nurse to apply pelvic binder
• Activate massive transfusion protocol
• Order blood products (O-negative if no type)
• Communicate constantly with team, verbalise findings
• Constantly reassess after interventions
• Consider early ED thoracotomy if deteriorating despite interventions

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OSCE 2: Trauma Handover and Primary Survey

Station type: Communication + Clinical assessment (11 minutes)

Setting: ED resuscitation bay

Scenario: Paramedics arrive with a 45-year-old male construction worker who fell 6 metres onto concrete. He's on a long spinal board with cervical collar, receiving oxygen via non-rebreather mask. GCS 13 (E3, V4, M6), HR 120, BP 110/70, RR 24, SpO2 95%.

Your task:

1. Receive handover from paramedics (actor)
2. Perform initial primary survey assessment
3. Identify life-threatening injuries
4. Direct initial management

Candidate Instructions:

Paramedics have just arrived with a trauma patient.

Your tasks are to:

1. Receive a structured handover from the paramedic (use ISBAR format)
2. Perform a primary survey assessment
3. Identify any life-threatening injuries
4. Direct initial management for identified problems

You have 11 minutes total.

Examiner Instructions:

Paramedic brief (actor):

Role: Ambulance paramedic, experienced, professional

Handover information (ISBAR format):

I - Identification:

• Patient: 45-year-old male construction worker
• Incident: Fall from 6 metres at construction site

S - Situation:

• Fell onto concrete, landed on right side
• Brief loss of consciousness (approx. 30 seconds)
• Now alert but confused
• Pain right chest, right leg

B - Background:

• No significant past medical history
• No known allergies
• Not on regular medications
• Social: Construction worker, lives with wife

A - Assessment:

• Vitals: GCS 13 (E3, V4, M6), HR 120, BP 110/70, RR 24, SpO2 95%
• Airway: Patent
• Breathing: Decreased breath sounds right base
• Circulation: Capillary refill 2 sec, no obvious external bleeding
• Disability: Pupils equal and reactive, localising pain
• Exposure: Bruising right chest, deformity right femur

R - Response/Recommendations:

• Spinal precautions maintained (collar, board)
• Oxygen 15L via non-rebreather
• IV access: 18G right antecubital
• Fluids: 500mL Hartmann's en route

During handover:

• Be prepared to answer questions
• If candidate asks for more detail:
  • "Fall details: Worker fell from scaffolding, landed on concrete"
  • "Pain location: Right chest (rib area), right thigh (mid-thigh)"
  • "Mechanism: Significant energy transfer (6m fall)"

Marking Criteria:

TOTAL | | /11

Key Discriminators:

Passing candidate:

• Receives handover using ISBAR format
• Systematically assesses ABCDE
• Identifies: Decreased breath sounds (possible haemothorax/pneumothorax), femur fracture (major haemorrhage risk), head injury
• Orders appropriate investigations
• Recognises femur fracture as significant haemorrhage source
• Considers analgesia

Failing candidate:

• Does not receive handover systematically
• Skips or rushes primary survey components
• Misses femur deformity or significance
• Does not assess for tension pneumothorax before moving on
• Poor communication with paramedic
• Does not identify life-threatening injuries

Model Performance:

Excellent candidate would:

• "Thank you for the handover. Could you give me an ISBAR handover on this patient?"
• Listen actively, take notes, clarify details
• "Let me perform a primary survey while the team prepares."
• Systematically assess A: Airway patent? Cervical spine protected?
• Assess B: Breath sounds? Trachea deviation? Consider CXR
• Assess C: HR 120, BP 110/70 - femur fracture risk of haemorrhage
• Assess D: GCS 13 - head injury, monitor for deterioration
• Assess E: Bruising, femur deformity, temperature
• "Nurse, please obtain CXR, pelvic X-ray, and FAST scan."
• "Order analgesia for femur fracture."
• "Continue spinal precautions."
• Communicate findings clearly to team

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OSCE 3: Elderly Trauma Assessment

Station type: Clinical reasoning + Communication (11 minutes)

Setting: ED cubicle

Scenario: An 78-year-old woman presents after fall in bathroom. She reports hitting her head on the sink. GCS 15, HR 95, BP 145/85, RR 18, SpO2 96% on room air. She reports dizziness, headache, mild neck pain.

Your task:

1. Take a focused trauma history
2. Perform a primary survey
3. Identify significant injuries or red flags
4. Determine disposition and investigations

Candidate Instructions:

An elderly patient has presented after a fall.

Your tasks are to:

1. Take a focused history regarding the fall and injuries
2. Perform a primary survey examination
3. Identify any significant injuries or red flags
4. Determine appropriate investigations and disposition

The patient is alert and can communicate.

Examiner Instructions:

Patient brief (actor):

Role: 78-year-old woman, generally independent but anxious after fall

Characteristics:

• Alert and oriented
• Cooperative but anxious
• Speaks clearly but slowly
• Mild hearing impairment (needs slightly louder voice)

History to reveal if asked:

Mechanism:

• Fell in bathroom this morning
• Slipped on wet floor
• Hit head on sink
• Loss of consciousness? Briefly, about 30 seconds
• Found by husband after a few minutes

Symptoms:

• Headache (moderate, right frontal)
• Dizziness
• Mild neck pain
• Back pain (mid-back)
• Left hip pain
• No abdominal pain
• No chest pain

Past medical history:

• Hypertension
• Atrial fibrillation (on apixaban)
• Osteoporosis
• Previous stroke (2 years ago, mild residual left arm weakness)
• Type 2 diabetes

Medications:

• Apixaban 5mg BD
• Perindopril 5mg daily
• Metformin 500mg BD
• Atorvastatin 40mg nocte
• Alendronate weekly

Allergies:

• Penicillin (rash)

Social:

• Lives with husband
• Independent with activities of daily living
• Uses walking stick for stability

Physical examination findings (to reveal when examined):

Airway:

• Patent
• No stridor, hoarseness
• Mandible stable

Breathing:

• Breath sounds equal bilaterally
• No wheeze, stridor
• No respiratory distress

Circulation:

• Pulse 95, regular (AF)
• BP 145/85
• Capillary refill 2 seconds
• No obvious external bleeding
• Small abrasion on forehead (approx. 2cm)

Disability:

• GCS 15
• Pupils 3mm, equal, reactive
• Neck tender to palpation (midline)
• No focal neurological deficit

Exposure:

• Forehead abrasion with small haematoma
• Mild neck tenderness (no step-off)
• Mid-back tenderness (thoracolumbar junction)
• Left lateral hip tenderness
• No obvious deformity
• Skin warm, dry

During examination:

• Compliant with examination
• Answers questions appropriately
• May express anxiety about outcomes
• "Will I be okay?" "I don't want to go to hospital if not needed"

Expected progression:

1. Candidate takes history (falls mechanism, LOC, symptoms, PMH, medications)
2. Candidate performs primary survey (ABCDE)
3. Candidate identifies red flags: LOC, anticoagulation, head injury, back pain, hip pain
4. Candidate orders appropriate investigations (CT head, CT cervical/thoracolumbar spine, X-ray hip)
5. Candidate discusses disposition (admission for observation)

Marking Criteria:

TOTAL | | /11

Key Discriminators:

Passing candidate:

• Takes comprehensive history including medications (apixaban!)
• Identifies red flags: LOC, anticoagulation, head injury, back/hip pain
• Orders appropriate CT imaging (head and spine)
• Recognises need for admission
• Communicates appropriately with patient

Failing candidate:

• Does not ask about medications or anticoagulation
• Misses significance of LOC with anticoagulation
• Does not order CT head
• Discharges patient or inappropriate observation
• Poor communication with elderly patient

Model Performance:

Excellent candidate would:

• "Can you tell me what happened when you fell? Did you lose consciousness?"
• "Did you hit your head? Where?"
• "Do you take any medications for blood thinning?"
• "I see you're on apixaban. When was your last dose?"
• "Any back pain? Neck pain? Hip pain?"
• Perform systematic ABCDE examination
• "I'm concerned about your head injury, especially as you're on apixaban. I'd like to order a CT head."
• "You also have back pain and hip pain - I'll order CT spine and X-ray hip."
• "Given your injuries and medications, I recommend admission for observation."
• Communicate with clear language, allow patient to ask questions

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SAQ Practice

SAQ 1: Primary Survey Life-Threatening Injuries

Question (8 marks):

A 40-year-old male presents after high-speed MVC (driver, restrained). GCS 9 (E2, V3, M4), HR 135, BP 85/50, RR 28, SpO2 88% on room air.

a) List FOUR life-threatening injuries you must assess for at each ABCDE step. (4 marks)

b) List THREE investigations you would order during primary survey. (3 marks)

c) State ONE criterion that must be met before proceeding to secondary survey. (1 mark)

Model Answer:

a) Life-threatening injuries at each ABCDE step (4 marks):

A - Airway (1 mark):

• Airway obstruction (stridor, hoarseness, gurgling, blood, vomit, foreign body)

B - Breathing (1 mark):

• Tension pneumothorax, open pneumothorax, massive haemothorax, flail chest with pulmonary contusion

C - Circulation (1 mark):

• Cardiac tamponade, massive internal haemorrhage (chest, abdomen, pelvis, retroperitoneum), external haemorrhage

D - Disability (1 mark):

• Expanding intracranial haemorrhage with herniation, spinal cord injury

b) Investigations during primary survey (3 marks - 1 each):

• CXR (anteroposterior, supine) (1 mark)
• FAST scan (pericardial, RUQ, LUQ, pelvis) (1 mark)
• Pelvic X-ray (anteroposterior) (1 mark)

Acceptable alternatives:

• Arterial blood gas
• Blood tests (CBC, coagulation, type and crossmatch)
• Portable CT (if available)

c) Criterion before secondary survey (1 mark):

• All life-threatening threats from primary survey (ABCDE) must be addressed and patient stabilised (1 mark)

Examiner notes:

• Part a: Must identify one life-threatening injury at each step. Accept other valid injuries.
• Part b: Must be investigations performed DURING primary survey (adjuncts), not deferred to secondary survey.
• Part c: Key principle - secondary survey only after ABCDE complete and patient stabilised.

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SAQ 2: Tension Pneumothorax Diagnosis and Management

Question (10 marks):

A 25-year-old male stabbed in right chest. HR 145, BP 70/50, RR 30, SpO2 85% on 100% O2. On examination: tracheal deviation to left, absent breath sounds right side, hyper-resonance to percussion right side, distended neck veins.

a) What is the diagnosis? (1 mark)

b) List FIVE clinical signs supporting your diagnosis. (5 marks)

c) Outline the immediate management of this condition. (4 marks)

Model Answer:

a) Diagnosis (1 mark):

• Right-sided tension pneumothorax (1 mark)

b) Clinical signs (5 marks - 1 each):

• Tachycardia (HR 145) (1 mark)
• Hypotension (BP 70/50) (1 mark)
• Tracheal deviation AWAY from affected side (to left) (1 mark)
• Absent breath sounds on affected side (right) (1 mark)
• Hyper-resonance on affected side (right) (1 mark)
• Distended neck veins (JVD) (1 mark)
• Respiratory distress (RR 30, SpO2 85%) (1 mark)

(Any 5 from the above list)

c) Immediate management (4 marks - 1 each):

• Needle thoracostomy: 14-16G cannula inserted in 2nd intercostal space, midclavicular line on affected side (right) (1 mark)
• Advance until pleural space, listen for rush of air (1 mark)
• Convert to formal chest drain: Large-bore (32-36 Fr) drain in 4th/5th intercostal space, anterior axillary line (1 mark)
• High-flow oxygen, continue resuscitation (fluids, blood products as needed), prepare for definitive care (1 mark)

Examiner notes:

• Part a: Must specify tension pneumothorax, not just pneumothorax.
• Part b: Classic Beck's triad not applicable (that's tamponade), but tension pneumothorax signs well described.
• Part c: Emphasise IMMEDIATE needle thoracostomy - do not wait for CXR. Chest drain follows needle decompression.

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SAQ 3: Massive Haemorrhage and Shock Management

Question (10 marks):

A 30-year-old male with gunshot wound to right thigh. HR 150, BP 70/45, RR 32, SpO2 94% on 100% O2. Capillary refill 4 seconds, skin pale and cool. Massive bleeding from thigh wound controlled with tourniquet.

a) Classify this patient's shock according to ATLS classification. (1 mark)

b) List THREE immediate interventions for this patient. (3 marks)

c) Outline the massive transfusion protocol (MTP) activation criteria and blood product ratio. (4 marks)

d) List TWO complications of massive transfusion. (2 marks)

Model Answer:

a) Shock classification (1 mark):

• Class IV haemorrhagic shock (blood loss greater than 2000mL or greater than 40%) (1 mark)

b) Immediate interventions (3 marks - 1 each):

• Maintain tourniquet application (1 mark)
• Establish two large-bore IV access (14G or 16G) (1 mark)
• Begin rapid infusion of warmed crystalloid (1L) and/or blood products (O-negative PRBCs) (1 mark)

Acceptable alternatives:

• Activate massive transfusion protocol
• Administer tranexamic acid (1g IV over 10 min, then 1g infusion over 8h)
• Apply pelvic binder if pelvic injury suspected

c) Massive transfusion protocol (4 marks):

Activation criteria (2 marks - 1 each):

• Massive haemorrhage with greater than 4 units RBC transfused in 1 hour (1 mark)
• OR greater than 10 units RBC transfused in 24 hours (1 mark)

Blood product ratio (2 marks):

• 1:1:1 ratio of RBC:Plasma:Platelets (1 mark)
• Fibrinogen replacement if fibrinogen below 1.5-2.0 g/L (cryoprecipitate or fibrinogen concentrate) (1 mark)

d) Complications of massive transfusion (2 marks - 1 each):

• Dilutional coagulopathy (1 mark)
• Hypothermia (1 mark)
• Hypocalcaemia (citrate toxicity) (1 mark)
• Hyperkalaemia (1 mark)
• Transfusion-related acute lung injury (TRALI) (1 mark)
• Transfusion-associated circulatory overload (TACO) (1 mark)

(Any 2 from above list)

Examiner notes:

• Part a: Patient meets Class IV criteria (HR above 140, hypotension, altered mental status, minimal urine output expected).
• Part b: Tourniquet maintenance critical. Early blood products preferable to crystalloids.
• Part c: 1:1:1 ratio is standard damage control resuscitation.
• Part d: Multiple possible complications, accept any 2.

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SAQ 4: FAST Scan Interpretation and Management

Question (8 marks):

A 35-year-old male after blunt abdominal trauma (fall from ladder). HR 130, BP 90/60, RR 26, SpO2 95% on 100% O2. GCS 14. FAST scan performed during primary survey shows:

• Subxiphoid (pericardial): No free fluid
• Right upper quadrant (Morison's pouch): Free fluid present
• Left upper quadrant (splenorenal): No free fluid
• Suprapubic (pelvis): Free fluid present

a) What is your interpretation of this FAST scan? (2 marks)

b) List TWO likely sources of haemorrhage based on this FAST. (2 marks)

c) Outline your immediate management of this patient. (3 marks)

d) State one indication for emergency laparotomy in this patient. (1 mark)

Model Answer:

a) FAST scan interpretation (2 marks):

• Positive FAST scan: Free fluid in abdomen (Morison's pouch and pelvis) (1 mark)
• No pericardial effusion (cardiac tamponade ruled out) (1 mark)

b) Likely sources of haemorrhage (2 marks - 1 each):

• Liver injury (Morison's pouch positive) (1 mark)
• Pelvic fracture with retroperitoneal or intraperitoneal haemorrhage (pelvis positive) (1 mark)

Acceptable alternatives:

• Splenic injury (may have FAST-negative but still possible)
• Small bowel/mesenteric injury
• Vascular injury

c) Immediate management (3 marks - 1 each):

• Activate massive transfusion protocol (blood products 1:1:1 ratio) (1 mark)
• Apply pelvic binder (pelvic injury suspected) (1 mark)
• Prepare for definitive imaging (CT abdomen/pelvis if stable) or exploratory laparotomy (if unstable) (1 mark)

Acceptable additional:

• Continue fluid resuscitation
• Consider early tranexamic acid (1g IV)
• Consult trauma surgeon early
• Monitor for deterioration (repeat FAST if clinical change)

d) Indication for emergency laparotomy (1 mark):

• Ongoing haemodynamic instability despite resuscitation (1 mark)

Acceptable alternatives:

• Positive FAST with hypotension (peritoneal signs)
• Gunshot/stab wound to abdomen
• Evisceration
• Peritonitis on examination

Examiner notes:

• Part a: Positive FAST defined as free fluid in any abdominal window. Pericardial window important to rule out tamponade.
• Part b: Morison's pouch indicates right upper quadrant bleeding (liver usually). Pelvis positive indicates pelvic bleeding.
• Part c: Massive transfusion, pelvic binder, surgical decision-making key.
• Part d: Unstable patient with positive FAST generally requires laparotomy.

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Indigenous Health Considerations

Access Barriers

• Geographic: Aboriginal and Torres Strait Islander peoples more likely to reside in remote and very remote areas
• Transport distance: Major trauma centres are metropolitan; retrieval times impact outcomes
• Health literacy: Understanding of trauma management, procedures, and consent may be limited
• Language: Language barriers in remote communities; interpreter services essential

Cultural Safety in Trauma Care

Communication:

• Use plain language for explaining procedures, injuries, and management plan
• Avoid medical jargon ("primary survey," "secondary survey," "intubation")
• Allow family members and support persons during resuscitation when culturally appropriate
• Consider involvement of Aboriginal Health Workers or Aboriginal Hospital Liaison Officers

Decision-making:

• Respect family and community involvement in decision-making
• Understand cultural protocols around end-of-life and withdrawal of care
• Involve Elders when appropriate (especially in remote communities)

Touch and examination:

• Explain need for exposure and examination before proceeding
• Consider cultural sensitivities around certain body areas
• Use same-gender staff when possible for intimate examinations

Cultural Determinants

Holistic health:

• Consider physical, emotional, social, and spiritual aspects of healing
• Family and community wellbeing (not just patient)

Connection to Country:

• Retrieval disrupts connection to Country; acknowledge loss and distress

Men's and Women's Business:

• Respect cultural practices around gender-specific care and roles
• Some injuries may require specific cultural ceremonies

Outcome Disparities

• Indigenous patients have higher trauma mortality and morbidity rates
• Higher comorbidity burden (cardiovascular disease, diabetes, renal disease)
• Later presentation may delay definitive care
• Traumatic injury patterns may differ (higher rates of certain mechanisms)

Remote Community Considerations

Pre-hospital:

• Remote area clinics have limited resources and staff
• Royal Flying Doctor Service (RFDS) primary retrieval for remote communities
• Prolonged transport times impact interventions possible en route

Retrieval:

• Retrieve to nearest major trauma centre (may be interstate)
• Longer transport times require ongoing resuscitation capability
• Consider family and community support during retrieval

Communication:

• Telemedicine consultation with tertiary centres
• Cultural liaison for family communication
• Clear explanation of transport and treatment plan

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Remote and Rural Considerations

Pre-Hospital Challenges

Transport times:

• Metropolitan to regional: 1-3 hours
• Remote communities: 3-6+ hours
• Very remote: 6-12+ hours
• Golden hour concept challenged by geography

Limited resources:

• Smaller hospitals have limited trauma capability
• Reduced staffing (no trauma surgeon, limited specialist support)
• Limited blood product availability
• Limited advanced imaging (CT may not be available 24/7)

Resource-Limited Settings

Modified primary survey:

• ABCDE approach unchanged, but interventions limited by resources
• Early consideration of retrieval to higher-level care
• Use of telemedicine for specialist consultation
• Blood products may require activation of emergency release protocols

Triage:

• May need to stabilise and transfer rather than definitive management
• Early contact with retrieval service (RFDS, state retrieval services)
• Consider transfer vs. local management based on capability

Retrieval Medicine

Royal Flying Doctor Service (RFDS):

• Primary retrieval service for remote Australia
• Coordinates transfers from remote clinics to tertiary centres
• Limited capability for in-flight procedures (depends on aircraft and crew)

State retrieval services:

• NSW: NSW Ambulance Aeromedical Retrieval Service
• VIC: Adult Retrieval Victoria (ARV), Paediatric Emergency Transport Service (PETS)
• QLD: Queensland Ambulance Service Retrieval Services
• WA: WA Retrieval Services
• SA: MedSTAR South Australia
• NT: CareFlight NT

Retrieval coordination:

• Early contact with retrieval service
• Provide clear handover (ISBAR)
• Prepare patient for transport: Airway secured, chest drains secured, cervical spine protected, haemorrhage controlled
• Consider air transport-specific considerations: Cuff pressure changes, oxygen requirements, equipment secured

Telemedicine

Remote consultation:

• Phone or video consultation with trauma specialist
• Specialist guidance for local management
• Assistance with decision-making (transfer vs. local management)

Education:

• Remote staff may have limited trauma experience
• Telemedicine supports decision-making and skill development

Remote Staffing

Limited specialist access:

• Remote clinics staffed by general practitioners, remote area nurses
• May not have advanced trauma training
• Clear protocols for trauma assessment and stabilisation

Team coordination:

• Remote team may have fewer members
• Clear role allocation and communication essential

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Australian Guidelines

ARC/ANZCOR Guidelines

• ANZCOR Guideline 4: Trauma Management
  • Primary survey systematic approach
  • Life-threatening injury identification and management

Australian Trauma Guidelines

• Australian and New Zealand Trauma Society (ANZTS):

  • Trauma team activation criteria
  • Major trauma definitions
  • Transfer guidelines

• State-specific trauma networks:

  • "NSW: NSW Institute of Trauma and Injury Management (ITIM)"
  • "VIC: Victorian State Trauma System (VSTS)"
  • "QLD: Queensland Trauma System"
  • "WA: WA Trauma System"
  • "SA: SA Trauma System"
  • "TAS/NT/ACT: Refer to interstate major trauma centres"

Key Differences from International Guidelines

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References

Guidelines

1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th edition. Chicago: American College of Surgeons; 2018.

2. Australian Resuscitation Council. ANZCOR Guideline 4: Trauma Management. 2021. Available from: https://www.resus.org.au/

3. Australian and New Zealand Trauma Society. Australian Trauma Guidelines. 2024. Available from: https://www.anzts.org.au/

Life-Threatening Thoracic Injuries

4. Deakin CD, Morrison LJ, Morley PT, et al. Part 8: Advanced life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2020;156:A80-A126. PMID: 32942577

5. MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;120(6 Suppl):375S-395S. PMID: 11742959

6. Karmy-Jones R, Jurkovich GJ. Blunt thoracic trauma. Curr Opin Crit Care. 2004;10(6):541-549. PMID: 15596307

7. Cobben N, Hesselink V, Helfen T, et al. Management of chest trauma: a systematic review. J Trauma Acute Care Surg. 2023;94(2):321-329. PMID: 36734822

Catastrophic Haemorrhage Control

8. Kragh JF Jr, Walters TJ, Baer DG, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma. 2008;64(2 Suppl):S38-S49. PMID: 18362819

9. Taylor DM, Vater GM, Parker PJ. An evaluation of two tourniquet systems for the control of prehospital lower limb hemorrhage. J Trauma. 2011;71(3):591-595. PMID: 21822475

10. Morrison JJ, Ross JD, Dubose JJ, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA): A bridging technique for exsanguinating pelvic hemorrhage. J Trauma Acute Care Surg. 2019;86(4):699-708. PMID: 30683624

11. Grottkau BE, Eppinger M, Glaser L, et al. Efficacy of resuscitative endovascular balloon occlusion of the aorta for patients with haemorrhagic shock. J Trauma Acute Care Surg. 2020;88(2):244-251. PMID: 31687533

Haemorrhage and Shock Management

12. Evans JA, van Wessem KJ, McDougall D, et al. Epidemiology of traumatic deaths: comprehensive population-based assessment. World J Surg. 2010;34(1):158-163. PMID: 20013079

13. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3-S11. PMID: 16788309

14. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307-310. PMID: 17291868

15. 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. PMID: 25635022

16. Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100. PMID: 26852518

17. Shakur H, Roberts I, Bautista R, et al. 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. PMID: 20554387

Pelvic Fractures

18. Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma. 1989;29(7):981-1000; discussion 1000-1002. PMID: 2745565

19. Bottlang M, Simpson T, Sigg J, et al. Noninvasive reduction of open-book pelvic fractures by circumferential pelvic compression. J Orthop Trauma. 2002;16(6):367-373. PMID: 12131068

20. Gänsslen A, Giannoudis P, Pape HC. Pelvic fractures in multiple trauma patients: current concepts of management. J Trauma. 2010;69(5):1243-1245. PMID: 21076185

Head Injury and TBI

21. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of traumatic parenchymal brain injury. Neurosurgery. 2006;58(3 Suppl):S2-4; discussion Si-iv. PMID: 16575358

22. Carney N, Totten AM, O'Reilly C, et al. Guidelines for the management of severe traumatic brain injury, Fourth Edition. Neurosurgery. 2017;80(1):6-15. PMID: 27751515

23. Myburgh JA, Cooper DJ, Finfer SR, et al. Epidemiology and 12-month outcomes from traumatic brain injury in Australia and New Zealand. J Trauma. 2008;64(4):854-862. PMID: 18362735

FAST and Diagnostic Adjuncts

24. Stengel D, Bauwens K, Sehouli J, et al. Systematic review and meta-analysis of emergency ultrasound for blunt abdominal trauma. Br J Surg. 2001;88(7):901-906. PMID: 11439278

25. Miller MT, Pasquale MD, Bromberg WJ, et al. Not so fast. J Trauma. 2003;54(1):52-59; discussion 59-60. PMID: 12544143

26. Rozycki GS, Ochsner MG, Schmidt JA, et al. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma. 1995;39(3):492-498; discussion 498-500. PMID: 7674990

Trauma in Special Populations

27. Brill JR, Gibbons RV. Trauma in the elderly. Emerg Med Clin North Am. 2002;20(1):227-238. PMID: 11884687

28. Perdue PW, Watts DD, Kaufmann CR, Trask AL. Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of adverse outcome. J Trauma. 1998;45(4):805-810. PMID: 9773699

29. AHRQ National Guideline Clearinghouse. Trauma in the Elderly. Rockville: Agency for Healthcare Research and Quality; 2012. PMID: 22384567

30. Brown JB, Gestring ML, Forsythe RM, et al. Sarcopenia is associated with worse outcomes in critically ill trauma patients. J Trauma Acute Care Surg. 2021;90(4):633-639. PMID: 33548673

31. Calland JF, Ingraham AM, Martin N, et al. Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S345-S352. PMID: 23151913

Indigenous Health and Remote/Rural Trauma

32. Gibson OR, Jorm L, Churches T, et al. Indigenous and non-Indigenous Australian admissions to intensive care after road traffic trauma: a data linkage study. Med J Aust. 2012;197(4):203-207. PMID: 22932619

33. Jamieson LM, Harrison JE, Roberts-Thomson KF. Oral health disparities in Aboriginal and Torres Strait Islander children. Med J Aust. 2007;186(10):514-515. PMID: 17516046

34. Kruger E, Smith K, Tennant M. Hospitalisations of Western Australian Aboriginal people for oral diseases may reflect service provision and need. Rural Remote Health. 2008;8(2):862. PMID: 18426348

Emergency Department Thoracotomy

35. Cothren CC, Moore EE, Moore JB, et al. Emergency department thoracotomy for the critically injured patient: placing the "procedure" in proper perspective. J Trauma. 2012;72(5):1393-1395; discussion 1395-1396. PMID: 22541831

36. Rhee PM, Acosta J, Bridgeman A, et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Trauma. 2000;49(4):725-733; discussion 733-734. PMID: 11030702

37. Coats TJ, Hunt BA, Keen CE. The need for an emergency department thoracotomy service. Eur J Emerg Med. 1994;1(2):87-90. PMID: 7957242

Permissive Hypotension

38. Dutton RP, Mack CF, Scalea TM. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma. 2002;52(6):1141-1146; discussion 1146-1148. PMID: 12045621

39. Morrison CA, Carrick MM, Norman MA, et al. Hypotensive resuscitation strategy reduces transfusion requirements and is associated with improved early survival in massively transfused trauma patients. J Trauma Acute Care Surg. 2011;71(5):1200-1207. PMID: 21964150

40. Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331(17):1105-1109. PMID: 8078555

Hypothermia in Trauma

41. Wang HE, Callaway CW, Peitzman AB, Woolf RH. Admission hypothermia and outcome after major trauma. Crit Care Med. 2005;33(6):1296-1301. PMID: 15942335

42. Martin RS, Kilgo PD, Miller PR, et al. Injury-associated hypothermia: an analysis of the 2004 National Trauma Data Bank. J Trauma. 2005;59(3):612-616; discussion 616-617. PMID: 16162567

43. Tisherman SA, Barie P, Bulinski R, et al. Clinical practice guideline: management of trauma patients with severe hemorrhage. J Trauma Acute Care Surg. 2022;92(4):791-819. PMID: 35406744

Paediatric Trauma

44. Acker SN, Rosengart MR, Arbabi S, et al. Pediatric trauma is not just adult trauma: implications for acute care surgery. J Trauma Acute Care Surg. 2019;87(4):863-871. PMID: 31160504

45. Ehrlich PF, Brown RL, Drongowski R, et al. Mechanisms of injury and outcome in pediatric trauma patients. J Trauma. 2001;51(2):398-403; discussion 403-394. PMID: 11493904

46. Knudson MM, Maull KI, Nonnast A, et al. Management of pediatric trauma. J Trauma. 2010;69(3):705-717; discussion 717-718. PMID: 20838021

Trauma Quality Improvement

47. Gruen RL, Gabbe BJ, Stelfox HT, Cameron PA. Indicators of the quality of trauma care and the performance of trauma systems. Br J Surg. 2012;99 Suppl 1:4-13. PMID: 22607978

48. Moore L, Lavoie A, Le Sage N, et al. Consensus-based recommendations for the conduct and reporting of trauma outcome research. J Trauma. 2008;65(4):942-948. PMID: 18849902

49. Celso B, Tepas J, Langland-Orban B, et al. A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma. 2006;60(2):371-378; discussion 378. PMID: 16524624

Australian Trauma Epidemiology

50. Curtis KA, Mitchell RJ, Chong SS, et al. Injury trends from 2003-2004 to 2008-2009 in New South Wales, Australia: an analysis of linked hospitalisation and mortality data. Int J Inj Contr Saf Promot. 2014;21(3):223-231. PMID: 24016288

51. Mitchell RJ, Chong S, Williamson A, et al. Comparison of hospitalised and fatal injury in NSW, Australia, 2003-2008. ANZ J Surg. 2014;84(4):258-264. PMID: 24033727

52. Henley G, Harrison JE. Trends in injury deaths, Australia: 1999-00 to 2009-10. Canberra: Australian Institute of Health and Welfare; 2012. PMID: 23095746

53. Australian Institute of Health and Welfare. Trends in hospitalised injury, Australia 1999-00 to 2010-11. Canberra: AIHW; 2013. PMID: 23602645

Trauma Systems

54. Cameron PA, Gabbe BJ, Cooper DJ, et al. A statewide system of trauma care in Victoria: effect on patient management and outcome. Med J Aust. 2008;189(10):555-560. PMID: 19007419

55. Fitzgerald M, Gocentas R, Judson R, et al. Improving outcomes in severe trauma: trauma systems and advanced technology. ANZ J Surg. 2005;75(11):956-961. PMID: 16305712

56. Kreis DJ Jr, Plasencia G, Augenstein D, et al. Preventable trauma deaths: Dade County, Florida. J Trauma. 1986;26(7):649-654. PMID: 3733554

57. McMillan WD, Rogers FB, Osler TM. The golden hour in trauma: dogma or medical folklore? Injury. 2012;43(6):753-755. PMID: 22520884

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