Major trauma resuscitation — the team-based systematic approach

Major trauma resuscitation is the team-based, systematic approach to the multiply-injured patient, and it is the condition that tests every component of the emergency physician's training — the leadership, the airway, the procedures, the decision-making and the team coordination — simultaneously. The Fellowship candidate must lead the trauma team, run the primary survey, apply the damage-control-resuscitation principles, and know when to go to the theatre and when to go to the CT scanner.[1][2]

The trauma team — the roles and the activation

The major trauma patient is resuscitated by a team with allocated roles, not by a solo clinician.[1] The team is activated by the pre-hospital notification or by the ED triage criteria (a high-energy mechanism, a deranged physiology, or a high-risk patient). The roles are allocated at the start: the team leader (the most senior person, standing back from the patient to direct the team and make the decisions — not performing the procedures themselves); the airway doctor (managing the cervical spine, the airway, the intubation); the procedure doctor (the chest drains, the pelvic binder, the lines, the FAST); the nurse (the observations, the drugs, the cannulation); and the scribe (the documentation, the timeline, the blood results). The closed-loop communication — the instruction repeated back and confirmed — is the standard. The team leader avoids the fixation error (the persistence with a wrong diagnosis despite contradictory information) by performing the structured reassessment after every intervention.

Differential diagnosis — what the primary survey seeks to exclude

The primary survey is the systematic, prioritised search for the immediately life-threatening conditions. The differential at each step is the set of conditions that kill fastest, and each is managed before moving to the next letter. [1]

The primary survey — the ABCDE applied to the major trauma

The primary survey is the sequential, prioritised assessment that treats the most immediately fatal derangement before moving to the next.[2] It is the same ABCDE framework applied to every trauma patient, but the Fellowship candidate must know the trauma-specific modifications at each step.

A — Airway with the cervical-spine control. The airway is assessed for the patency, the protection and the maintainability. The cervical spine is immobilised in-line (a rigid collar, head blocks, and the manual in-line stabilisation during the intubation). The airway is cleared (the suction, the jaw thrust), and the adjuncts (the oropharyngeal, the nasopharyngeal airway) are used. The definitive airway — the rapid-sequence intubation — is performed if the airway is threatened, the GCS is 8 or below, or the patient is unable to maintain the oxygenation or the ventilation. The difficult airway equipment (the videolaryngoscope, the surgical airway kit) is prepared from the start. [1]

B — Breathing with the ventilation. The breathing is assessed for the work, the effectiveness and the symmetry. The oxygen is given at 100 per cent via the non-rebreather mask. The immediately life-threatening breathing problems (the tension pneumothorax, the massive haemothorax, the open pneumothorax, the flail chest with the pulmonary contusion) are identified and treated before the examination is completed. The chest is examined for the symmetry, the percussion and the auscultation; the FAST and the chest radiograph are the adjuncts. [1]

C — Circulation with the haemorrhage control. The circulation is assessed for the perfusion (the blood pressure, the heart rate, the capillary refill, the lactate, the urine output). The external haemorrhage is controlled with the direct pressure, the tourniquet (for the exsanguinating limb), and the pelvic binder (for the unstable pelvic fracture). The internal haemorrhage is identified (the FAST for the intra-abdominal, the chest radiograph for the chest, the pelvic radiograph for the pelvis). The massive haemorrhage protocol is activated — the blood products in the 1:1:1 ratio, the tranexamic acid 1 g intravenously, the permissive hypotension, and the calcium replacement (the calcium chloride 10 mL of 10 per cent after every four units).[1] Two large-bore cannulae are sited; the bloods (the group and crossmatch, the full blood count, the coagulation, the urea and electrolytes, the lactate) are drawn.

D — Disability. The Glasgow Coma Score, the pupils (the size, the symmetry and the reactivity — a unilateral fixed dilated pupil is the uncal herniation), and the bedside glucose (the hypoglycaemia mimics the TBI and must be corrected). The AVPU (the Alert, the Voice, the Pain, the Unresponsive) is the quick bedside alternative. The cerebral perfusion pressure is protected (the SBP 110 or above, the SpO₂ 90 or above, the normocapnia). [1]

E — Exposure with the temperature control. The patient is fully exposed for the complete examination, then covered immediately and warmed — the hypothermia feeds the lethal triad (the coagulopathy and the acidosis). The core temperature is monitored. A forced-air warmer, a fluid warmer and the ambient temperature are used. [1]

The adjuncts to the primary survey

The adjuncts are performed during or immediately after the primary survey, once the immediately life-threatening conditions are treated. The FAST (the focused assessment with sonography in trauma) screens for the intra-abdominal and the pericardial free fluid. The chest and the pelvic radiographs screen for the chest injuries (the pneumothorax, the haemothorax, the widened mediastinum) and the pelvic fractures. The blood tests (the group and crossmatch, the coagulation, the lactate, the venous gas) and the urinary and the gastric catheters (if not contraindicated by a urethral injury — check for the blood at the meatus, the perineal haematoma and the high-riding prostate before the urinary catheter). [1]

The resuscitation targets — the damage-control principles

The resuscitation follows the damage-control-resuscitation principles (cross-link to the dedicated topic): the permissive hypotension (SBP 80 to 90, not in the TBI); the blood-product-first strategy (the 1:1:1 ratio, not the crystalloid); the tranexamic acid 1 gram intravenously within 3 hours of the injury; the calcium chloride 10 mL of 10 per cent intravenously after every four units of blood; the analgesia (morphine 5 to 10 mg intravenously, or fentanyl 50 to 100 micrograms) titrated; the warming; and the surgical control of the bleeding before the definitive repair. The resuscitation is dynamic — the team leader reassesses after every intervention and adjusts the plan, because the patient's trajectory (the blood pressure, the lactate, the FAST, the conscious level) determines the next step, whether it is the CT scanner or the theatre. [1]

The secondary survey — the head-to-toe after the stabilisation

The secondary survey is the complete, systematic head-to-toe examination performed AFTER the primary survey has identified and treated the immediately life-threatening conditions and the patient is stabilised.[1] It examines the head (the scalp, the eyes, the ears, the nose, the mouth, the facial bones), the neck (the cervical spine, the trachea, the vascular structures, the bruises), the chest (the clavicles, the ribs, the heart sounds, the breath sounds), the abdomen (the tenderness, the guarding, the peritonism), the pelvis (the stability — do NOT rock the pelvis if a fracture is suspected), the perineum (the blood at the meatus, the rectal examination for the tone and the blood, the vaginal examination in the female), the back (the log-roll for the spinal tenderness, the bruising, the wounds), and the limbs (the deformity, the swelling, the wounds, the pulses, the sensation and the power). The AMPLE history (the Allergies, the Medications, the Past medical history, the Last meal, the Events) is taken. The complete imaging (the CT trauma series — the head, the cervical spine, the chest, the abdomen and the pelvis with the contrast) is performed once the patient is stable enough for the scanner.

The disposition decision — the theatre or the CT

The disposition decision is the team leader's call, and it is the decision that most often distinguishes the experienced from the inexperienced trauma physician. The patient who responds to the resuscitation (the blood pressure stabilises, the lactate falls, the FAST is positive with a known source) goes to the CT scanner for the full trauma series, then to the theatre or the ward. The patient who does NOT respond — the persistent hypotension despite the blood-product resuscitation, the rising lactate, the clinical deterioration — goes directly to the theatre for the damage-control surgery, bypassing the CT.[2] This is the decision the Fellowship candidate must be able to defend at a viva, because the wrong choice (the CT scanner for the patient bleeding to death) is the fatal error.

Special populations

The elderly trauma patient may be seriously injured from a low-energy mechanism (a fall from a standing height); the anticoagulation and the comorbidities increase the mortality, and the threshold for the trauma team activation is lower.[2] The paediatric trauma patient uses the weight-based drug doses, the paediatric trauma team and the different physiological thresholds. The pregnant trauma patient is managed with the left-lateral tilt (the aortocaval decompression), the fetal assessment (the cardiotocography after 20 weeks) and the modified drug choices. The anticoagulated patient is reversed early.

The <C>ABCDE — catastrophic haemorrhage control first

The modern trauma primary survey is the <C>ABCDE: a leading <C> for the catastrophic haemorrhage control inserted before the airway, because the exsanguinating limb wound kills the patient before the airway ever becomes the problem. The rationale is the battlefield evidence (the conflicts in Iraq and Afghanistan and the civilian terror-attack experience) that showed the external, compressible haemorrhage to be the leading cause of the preventable trauma death, and that the early tourniquet saves lives. The civilian translation is the MARCH sequence (the Massive haemorrhage, the Airway, the Respiration, the Circulation, the Head/Hypothermia) used by the pre-hospital services, and the <C>ABCDE taught in the 10th edition of the ATLS. [1]

The <C> step is a 30-second sweep performed at the moment the patient rolls into the bay: the team looks for the catastrophic external haemorrhage — a pumping or a steadily bleeding limb wound, a groin or a neck wound, a scalp laceration, a traumatic amputation. The exsanguinating limb is controlled with a windlass tourniquet applied directly to the skin, 5 to 8 centimetres proximal to the wound, tightened until the distal pulse disappears and the bleeding stops, and the time of application is written on the patient. The junctional wounds (the groin, the axilla, the neck) that a tourniquet cannot reach are packed with a haemostatic gauze (the kaolin-impregnated QuikClot combat gauze or the chitosan-based products) and held with the sustained direct pressure for a minimum of three minutes. The pelvic binder for the unstable pelvic fracture is applied at the <C> step as a circumferential haemorrhage control device, because the pelvic volume is reduced and the retro-pubic venous bleeding is tamponaded. [1]

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The Fellowship candidate must be able to defend the <C> step at a viva: the principle is that the order of the primary survey is the order in which the patient dies, and the exsanguinating limb wound kills faster than the airway obstruction. The team leader assigns the <C> sweep to a named team member at the briefing, so that it is performed in parallel with the airway preparation and not forgotten in the rush to intubate. [1]

The blood products — the emergency, the MTP and the viscoelastic guidance

The blood-product-first resuscitation is the core of the damage-control resuscitation, and the Fellowship candidate must know the four layers: the emergency O-negative, the massive transfusion protocol (the MTP) activation, the fixed-ratio resuscitation, and the viscoelastic (the thromboelastography, TEG, or the rotational thromboelastometry, ROTEM) guided correction. [1]

The emergency O-negative. The exsanguinating trauma patient with an unknown blood group receives the O-negative red cells (the universal donor) immediately, without a crossmatch, on the activation of the MTP. The O-negative is the universal donor because it lacks the A, the B and the RhD antigens, and it does not haemolyse in the recipient. The O-negative stock is held in the ED blood fridge for exactly this scenario. The caveats are: the O-negative is a scarce resource (only around 8 per cent of the donors), the female of the childbearing potential receives the O-negative to avoid the RhD sensitisation, and the patient is switched to the type-specific (the group-confirmed) blood as soon as it is available, usually within 15 to 30 minutes, and then to the fully crossmatched blood within 45 to 60 minutes. The K-negative status is also sought for the female of the childbearing potential to prevent the anti-K sensitisation. [1]

The MTP activation. The massive transfusion is defined as the replacement of one blood volume within 24 hours, or the transfusion of four or more red-cell units within one hour with the ongoing bleeding, or the anticipated need based on the mechanism and the physiology. The activation is a single call to the blood bank that releases a pre-packed MTP box containing the red cells, the fresh-frozen plasma and the platelets in a fixed ratio (typically 1:1:1 — one unit of red cells, one unit of FFP, one pool of platelets, the "trauma pack"), with the cryoprecipitate and the calcium as the adjuncts. The protocol runs on a continuous cycle — a fresh box is dispatched every 15 to 30 minutes until the team leader stands it down. The fibrinogen is the first clotting factor to fall in the trauma coagulopathy, and the cryoprecipitate (10 to 15 units, or the fibrinogen concentrate) is given when the fibrinogen drops below 1.5 to 2.0 grams per litre. The tranexamic acid 1 gram intravenously over 10 minutes, then 1 gram over 8 hours is given within 3 hours of the injury (the CRASH-2 evidence). The calcium chloride 10 mL of 10 per cent is given after every four units of blood, because the citrate in the stored blood chelates the calcium and the hypocalcaemia produces a cardiomyopathy and a coagulopathy. [1]

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The fixed-ratio versus the goal-directed. The 1:1:1 ratio comes from the PROPPR trial (the Pragmatic Randomised Optimal Platelet and Plasma Ratios), which showed a non-significant trend to the lower 24-hour and 30-day mortality in the 1:1:1 group, and a significant reduction in the death-by-exsanguination at 24 hours. The 1:1:1 is therefore the starting ratio, but the modern practice is the goal-directed, viscoelastic correction — the TEG or the ROTEM run on the ED or the operating-theatre sample, every 30 to 60 minutes, and the products targeted to the trace. The viscoelastic trace gives a real-time picture of the clot initiation, the clot strength and the clot lysis, and it overcomes the limitation of the conventional coagulation screen (the INR and the aPTT), which takes 30 to 60 minutes to return and which does not reflect the whole-clot physiology. [1]

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The FAST and the eFAST — the bedside sonographic screen

The FAST (the focused assessment with sonography in trauma) is the bedside ultrasound performed during or immediately after the primary survey to screen for the free intra-abdominal and the pericardial fluid. It is non-invasive, repeatable, and performed by the treating clinician at the bedside; it has replaced the diagnostic peritoneal lavage in almost every trauma centre. The classic FAST is the four-view examination: the right upper quadrant (the Morrison pouch, the most sensitive view for the intraperitoneal fluid), the left upper quadrant (the perisplenic space), the subxiphoid or the parasternal (the pericardial fluid — the tamponade), and the suprapubic (the pelvis, the most dependent space in the supine patient). [1]

The eFAST (the extended FAST) adds the thoracic windows — the bilateral anterior chest views at the second to fourth intercostal spaces in the midclavicular line (the lung point, the absence of the lung sliding, the M-mode "barcode" or the "seashore" sign) for the pneumothorax, and the bilateral posterior axillary views at the sixth to eighth intercostal spaces for the pleural fluid (the haemothorax). The eFAST is more sensitive than the supine anteroposterior chest radiograph for the anterior pneumothorax — the occult pneumothorax missed on the CXR is picked up by the eFAST in around 20 per cent of the cases — and it has become the standard primary-survey adjunct in the modern trauma bay. [1]

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The CT trauma series — the pan-scan versus the selective

The CT trauma series (the "pan-scan" — the head, the cervical spine, the chest, the abdomen and the pelvis, with the contrast, and the CT angiogram of the neck or the body as indicated) is the definitive imaging for the stable, or the stabilised, major trauma patient. It defines the full extent of the injuries, directs the surgical and the angiographic strategy, and reduces the missed-injury rate. The CT is performed ONLY once the patient is resuscitated to the point of safe transport — the unstable patient belongs in the operating theatre, not in the scanner. [1]

The pan-scan versus the selective CT strategy is the contemporary debate. The pan-scan advocates point to the higher missed-injury rate with the selective approach (the injury outside the index of suspicion, the patient too distracted by the painful injury to report the other, the intoxicated or the brain-injured patient who cannot give a history). The selective advocates point to the radiation dose (the lifetime cancer risk from a single pan-scan), the contrast nephropathy, the incidental findings that generate the cascade of the further testing, and the time on the table. The consensus is that the pan-scan is appropriate for the major-trauma-team-activation patient with the high-energy mechanism and the polytrauma, and the selective approach (the head and the cervical spine, the chest and the abdomen only if the mechanism or the examination suggests the injury) is appropriate for the lower-risk patient. The REACT-2 trial found no overall mortality benefit for the routine immediate total-body CT in the blunt trauma, but the subgroup with the polytrauma and the high-energy mechanism trended towards a benefit. [1]

The trauma team activation criteria

The trauma team is activated by the pre-hospital notification or by the ED triage on the meeting of one or more of the physiological, the anatomical, the mechanistic or the special-population criteria. The criteria are designed to be sensitive (a low threshold to activate) because the cost of the under-triage (a missed major injury) is far higher than the cost of the over-triage (a team assembled for a patient who turns out to be well). The over-triage rate is accepted at around 25 to 50 per cent, and the under-triage rate at below 5 per cent, as the targets for the mature trauma system. [1]

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The secondary survey — the AMPLE, the head-to-toe, the log-roll and the perineum

The secondary survey is the comprehensive, systematic head-to-toe examination performed AFTER the primary survey has identified and treated the immediately life-threatening conditions and the patient is stable. It begins with the AMPLE history (taken from the patient, the witnesses and the paramedics): the Allergies, the Medications (especially the anticoagulants and the beta-blockers, which alter the bleeding and the heart-rate response), the Past medical history (the comorbidities that change the resuscitation target), the Last meal (the aspiration risk for the anaesthesia), the Environment and the Events (the mechanism, the time, the pre-hospital interventions, the fluids and the drugs given). The paramedic or the pre-hospital team is debriefed at this point — the mechanism, the injuries at the scene, the vital-sign trend, the interventions and the response. [1]

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The transfer to the definitive care — the time-critical retrieval

The major trauma patient is transferred out of the ED once the primary survey is complete, the immediately life-threatening conditions are treated, and the disposition is decided. The transfer is one of three pathways: the operating theatre (for the damage-control surgery — the laparotomy, the thoracotomy, the orthopaedic damage control), the CT scanner (for the full trauma series in the stabilised patient), or the inter-hospital retrieval (to a higher-level trauma centre for the definitive care — the neurosurgery, the cardiac surgery, the burns, the paediatric). The transfer is itself a high-risk event — the patient is moved out of the controlled environment of the resuscitation bay, the monitoring is reduced, the access is limited, and the team is smaller. [1]

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Evidence and regional guidelines [1]

The contemporary framework is the ATLS and the local trauma-team-activation protocol. The resuscitation principles follow the damage-control-resuscitation evidence (the tranexamic acid, the 1:1:1 ratio, the permissive hypotension).[1] The special-populations evidence (the elderly, the anticoagulated) is summarised in the recent reviews.[2] The team roles, the primary survey and the disposition decision are the ATLS-standard global framework; the local protocol governs the activation criteria, the imaging strategy and the theatre pathway.

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Exam pearls

• The trauma team: allocated roles (the leader, the airway, the procedures, the nurse, the scribe); closed-loop communication; no fixation error.
• The primary survey (ABCDE) before the imaging — the CT scanner comes after the life-threatening conditions are treated.
• The resuscitation: permissive hypotension (SBP 80 to 90, not in the TBI); blood products 1:1:1; TXA 1 g within 3 hours; minimise the crystalloid; warm the patient.
• The secondary survey is the head-to-toe AFTER the primary survey stabilises the patient — never before.
• The disposition: the responder → CT → theatre/ward; the non-responder → theatre directly, bypassing the CT.
• The elderly and the anticoagulated: lower threshold for the team activation; higher mortality at every injury severity. [1]

Red flags

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References

1. [1]Mitra B, O'Reilly GM, Schlaphach G, et al. High ratio of plasma to red cells in contemporary resuscitation of haemorrhagic shock after trauma: a secondary analysis of the PATCH-trauma trial Scand J Trauma Resusc Emerg Med, 2025.PMID 41039456
2. [2]Al Ma'ani M, Majeed I, Pandey S, et al. A narrative review: Resuscitation of older adults with hemorrhagic shock Transfusion, 2025.PMID 39985371