Trauma Top-to-Toe

Scene, Safety & First Impression

• Dynamic risk assessment — danger to self, crew, patient, bystanders (traffic, fire, hazmat, hostile persons); don appropriate PPE.
  • Rationale: you are no use as a second casualty.
• Mechanism of injury (MOI) — speed, height, restraints, ejection, entrapment, penetrating vs blunt.
  • Rationale: MOI is not a diagnosis but shapes your index of suspicion and choice of rapid vs focused survey.
• General impression — is the patient talking? colour, posture, obvious external injury.
  • Rationale: a talking patient implies patent airway, adequate breathing and cerebral perfusion in one glance.

Primary Survey — <C>ABCDE

<C> — Catastrophic Haemorrhage

• Look for pooling/spurting blood, soaked clothing.
• Control: direct pressure → wound packing with haemostatic gauze → windlass tourniquet applied proximally for uncontrolled limb bleeding.
• Consider early tranexamic acid (TXA) — 1g IV over 10 min, within 3 hrs of injury.
• Rationale: assessed before airway because exsanguination can kill faster than airway compromise. Remember internal reservoirs — "blood on the floor and four more": chest, abdomen, pelvis, long bones.

A — Airway (with C-spine control)

• Can they talk clearly? Look for blood, vomit, teeth, secretions, facial/neck trauma, airway burns (soot, singed nasal hair, stridor).
• Listen for gurgling/snoring (partial obstruction).
• Manage: manual manoeuvres (jaw thrust if C-spine risk) → suction → adjuncts (OP/NP) → supraglottic/RSI (critical care/HEMS) as indicated.
• Maintain manual in-line stabilisation throughout.
• Rationale: reduced GCS = loss of pharyngeal tone = tongue occludes airway. Airway always takes priority over spinal precautions if the two conflict.

B — Breathing

• Look: rate, depth, symmetry, work of breathing, wounds, bruising (seatbelt sign), flail segment, accessory muscle use.
• Feel: tracheal position, surgical emphysema, chest-wall tenderness/instability.
• Listen/percuss: equal air entry, hyperresonance/dullness.
• Apply SpO₂, titrate oxygen.
• Exclude tension pneumothorax, open pneumothorax, massive haemothorax, flail chest.
• Rationale: tracheal deviation is a late, insensitive sign — decompress on respiratory distress + unilateral absent breath sounds + haemodynamic compromise, don't wait for deviation.

C — Circulation

• Assess pulse rate/quality, skin colour/temp/moisture, cap refill, BP.
• Re-check external haemorrhage control; examine occult reservoirs (chest, abdomen, pelvis, long bones).
• Apply pelvic binder over greater trochanters if suspected pelvic injury.
• Gain IV/IO access; give TXA; consider blood products where available.
• Permissive hypotension in penetrating/uncontrolled haemorrhage — aim for palpable central pulse, not normal BP.
• Rationale: avoid "popping the clot" by over-resuscitating before surgical control is available.

D — Disability

• AVPU rapid screen → full GCS (record E/V/M components).
• Pupils — size, equality, reactivity.
• Limb movement, blood glucose (hypoglycaemia mimics head injury).
• Watch for raised ICP / herniation: falling GCS, unilateral fixed dilated pupil, Cushing's response (hypertension, bradycardia, irregular respiration).
• Rationale: GCS ≤8 = unprotected airway + severe brain injury. Avoid hypoxia/hypotension — they cause secondary brain injury.

E — Exposure & Environment

• Fully expose — check back, axillae, perineum, skin folds for hidden injury.
• Actively warm — blankets, warm vehicle.
• Rationale: hypothermia worsens coagulopathy — part of the lethal triad (hypothermia, acidosis, coagulopathy).

Secondary Survey — Head to Toe

Performed after the primary survey / life threats controlled — often completed en route in major trauma.

Plus TIC over bones (Tenderness, Instability, Crepitus). Take a parallel focused history with AMPLE (Allergies, Medications, Past history, Last oral intake, Events/Environment).

Head & Scalp

• Palpate entire scalp (check gloves for blood); DCAP-BTLS; depressed/boggy skull fractures.
• Basal skull fracture signs: raccoon eyes, Battle's sign (late), CSF/blood from ears or nose, haemotympanum.
• Rationale: signals significant head injury, risk to airway/brain, contraindicates nasal airways/tubes.

Face

• Inspect/palpate orbits, nose, maxilla, mandible — deformity, instability, malocclusion, bleeding into airway.
• Rationale: facial fractures threaten the airway and can signal underlying brain/C-spine injury.

Eyes

• Pupils (size, equality, reactivity), gross visual acuity, foreign bodies, contact lenses, periorbital injury.
• Rationale: check early, before swelling closes the lids.

Neck (maintain C-spine control)

• Second rescuer holds manual in-line stabilisation; open collar to assess.
• Tracheal deviationWoundsEmphysema (surgical) Laryngeal crepitusVenous distensionEmidline tenderness/step
• Rationale: tracheal deviation/JVD → tension pneumothorax/tamponade; midline tenderness/step → C-spine injury; penetrating neck wound = surgical emergency. Re-secure C-spine after.

Chest

• Re-inspect, palpate every rib + clavicles/sternum, re-auscultate/percuss.
• Bruising patterns, paradoxical movement, tenderness/crepitus.
• Rationale: multiple/first-second rib fractures = high energy transfer + underlying lung/vascular injury; sternal injury raises suspicion of cardiac contusion.

Abdomen

• Look: bruising (seatbelt sign, Grey-Turner's/Cullen's — late), distension, wounds, evisceration.
• Feel: all four quadrants — tenderness, guarding, rigidity.
• Rationale: major site of concealed haemorrhage. A soft abdomen in an obtunded patient is not reassuring.

Pelvis

• Inspect — deformity, wounds, scrotal/perineal bruising, PV/PR blood, leg-length/rotation discrepancy.
• Palpate gently, once for tenderness.
• Never "spring" the pelvis (repeated compression/distraction).
• If any suspicion — apply pelvic binder over greater trochanters; do not re-examine further.
• Rationale: springing is a poor predictor (sensitivity ~59%, specificity ~71%) and can dislodge clot, worsening haemorrhage. The binder is a haemorrhage-control treatment — "if unsure, apply it."

Back & Spine

• Controlled log roll (or scoop/orderly lift) to inspect/palpate whole spine, posterior chest, flanks.
• DCAP-BTLS + midline tenderness/step.
• Rationale: posterior wounds, spinal injury and occult bleeding are easily missed if the back is never seen. In time-critical major haemorrhage, formal log roll may be deferred.

Limbs (all four)

• DCAP-BTLS + TIC on each limb; active/passive movement where appropriate.
• Neurovascular status distal to every injury — pulses, cap refill, colour, temperature, sensation, motor — compare left vs right.
• Recheck after any splinting/realignment.
• PainPallorParaesthesia PulselessnessParalysisPoikilothermia
• Rationale: the 6 Ps flag compartment syndrome / vascular injury — pain out of proportion is often the earliest sign.

Skin / Full Body

• Overall pallor, cyanosis, mottling, rashes, medical-alert jewellery.
• Complete picture of burns, entry/exit wounds, injection sites.

Scoring & Decision Tools

Glasgow Coma Scale

• Eye (1–4) + Verbal (1–5) + Motor (1–6) = 3–15. Record components (e.g. E3V4M5), not just total.
• GCS ≤8 → severe brain injury, airway at risk. Fall of ≥2 = significant deterioration.

Canadian C-Spine Rule (NICE NG41)

For alert (GCS 15), stable trauma patients:

1. Any high-risk factor (age ≥65, dangerous mechanism, paraesthesiae in extremities) → immobilise/image.
2. If none — any low-risk factor allowing safe ROM assessment (simple rear-end RTC, sitting position, ambulatory at any time, delayed neck pain, no midline tenderness)? If none present → immobilise.
3. If a low-risk factor present — patient actively rotates neck 45° left/right. If able → can clear clinically without immobilisation.

Validated for paramedic use: Ottawa study recommended "no immobilisation" in 66% of patients with no missed cord injury.

Major Trauma Triage (NWAS Paramedic Pathfinder)

Supported 24/7 by the Complex Incident Hub (CIH) for destination decisions.

Frailty (Older Trauma Patients)

• Low mechanism (fall <2m) accounts for the large majority of major trauma in older adults — occult injury and blunted physiology are common.
• Rockwood Clinical Frailty Scale used within some triage tools.
• FrIP pathway (Frail Injured Patient) — for "Pathfinder-negative" but concerning frail/elderly patients: discuss with CIH, issue FrIP pre-alert for senior review + early imaging.
• Older patients are markedly under-pre-alerted (~9%) — have a low threshold to escalate.

Pain Scoring

• Verbal Numerical Rating Scale (0–10): pain-free (0), mild (1–3), moderate (4–6), severe (≥7).
• Wong-Baker FACES / behavioural scales for children or those unable to self-report.
• Score at first contact, reassess after analgesia.

Rapid vs Focused Survey — How to Choose

Handover — ATMIST / ATMISTER

Structured hands-off handover to the assembled trauma team, ~30–60 seconds.

AMPLE (Allergies, Medications, Past history, Last oral intake, Events) — background history, usually given after ATMIST once patient is on the trolley.

Delivery Best Practice

• Pre-alert early via control/red phone so the team can assemble and prepare blood, imaging, theatre.
• One clinician (usually lead paramedic) delivers a single, structured, hands-off handover.
• No simultaneous patient transfer or task distraction during handover.
• Team leader identifies self, ensures whole team is listening, takes questions after ATMIST and again after AMPLE — not during.
• Capture contemporaneously (ATMIST slate/card); leave written copy/PCR.
• Only an immediate uncorrected life threat (e.g. need for CPR) should interrupt the structured handover.

Governance

• JRCALC — UK ambulance clinical guidelines (<C>ABCDE, prehospital TXA, ATMIST)
• NICE NG39 — Major trauma assessment & management
• NICE NG40 — Major trauma service delivery
• NICE NG41 — Spinal injury assessment (Canadian C-Spine Rule)
• TARN — Trauma Audit and Research Network (outcome data)
• Faculty of Prehospital Care (RCS Edinburgh) — position statements (traumatic cardiac arrest, pelvic fracture management)