Trauma Primary Survey (MSK Focus)
The trauma primary survey follows ATLS principles with CABCDE approach. Examiners expect you to understand how musculoskeletal injuries fit within the primary survey, particularly life-threatening hemorrhage from pelvic and long bone fractures, and spinal immobilization.
Quick Reference One-Pager
CABCDE Order
- C: Catastrophic hemorrhage control
- A: Airway with C-spine protection
- B: Breathing
- C: Circulation (MSK bleeding)
- D: Disability (neuro)
- E: Exposure and Environment
MSK Priorities
- Stop visible hemorrhage (tourniquet)
- Pelvic binder (suspected pelvic fracture)
- Long bone splinting (femur)
- C-spine immobilization
- Open fracture coverage
Life-Threatening Hemorrhage
- Chest (hemothorax)
- Abdomen
- Pelvis
- Long bones (femur = 1-2L)
- External/Floor
Red Flags
- Unstable pelvis
- Bilateral femur fractures
- Open pelvic fracture
- Traumatic amputation
- Crush injury
CABCDE Approach
Modern Approach
C-ABCDE:
- C: Catastrophic hemorrhage control (added to traditional ABCDE)
- A: Airway with cervical spine protection
- B: Breathing and ventilation
- C: Circulation with hemorrhage control
- D: Disability (neurological status)
- E: Exposure and Environmental control
Key Principle: Treat life-threatening problems as you find them before moving to the next step.
Catastrophic Hemorrhage Control
First Priority
External Hemorrhage:
- Visible arterial bleeding
- Traumatic amputation
- Tourniquet proximal to wound
When to Apply Tourniquet:
- Uncontrollable external hemorrhage
- Traumatic limb amputation
- Mass casualty situations
- Note time of application
Technique:
- 5cm proximal to wound
- Tighten until bleeding stops
- Write time on tourniquet
- Maximum 2 hours before reassessment
Airway with C-Spine Protection
C-Spine Immobilization Required If:
- Mechanism suggestive of injury
- High-speed RTA
- Fall from height (greater than 3m)
- Axial load (diving, ejection)
- Unconscious patient
- Neck pain or tenderness
- Neurological deficit
- Distracting painful injury
Maintain Manual In-Line Stabilization during any airway intervention
Airway Assessment
Can Patient Talk?
- If speaking normally, airway is patent
Look for Obstruction:
- Blood, vomit, debris
- Facial/mandibular fractures
- Swelling (burns, anaphylaxis)
Interventions:
- Jaw thrust (not head tilt in trauma)
- Suction
- Oropharyngeal airway
- Definitive airway if needed
Breathing
Assessment
Inspect:
- Chest wall movement
- Asymmetry
- Open wounds
- Distended neck veins (tension pneumothorax)
Palpate:
- Tracheal position
- Chest wall crepitus
- Tenderness
Percuss:
- Hyper-resonance (pneumothorax)
- Dullness (hemothorax)
Auscultate:
- Breath sounds
- Compare sides
Life-Threatening Chest Injuries
Tension Pneumothorax:
- Respiratory distress
- Tracheal deviation (away)
- Absent breath sounds
- Treatment: Needle decompression then chest drain
Massive Hemothorax:
- Dull percussion
- Absent breath sounds
- Shock
- Treatment: Chest drain
Open Pneumothorax:
- Sucking chest wound
- Treatment: Three-sided dressing, then chest drain
Circulation and Hemorrhage Control
MSK Sources of Major Hemorrhage
Blood Loss by Site:
- Estimated Blood Loss
- 2-4 liters (potentially exsanguinating)
- Estimated Blood Loss
- 1-2 liters per side
- Estimated Blood Loss
- 500mL-1L
- Estimated Blood Loss
- 250-500mL
- Estimated Blood Loss
- 2-3 liters
- Estimated Blood Loss
- Variable (massive possible)
"Blood on the Floor and Four More": Major hemorrhage sources:
- External (on the floor)
- Chest (hemothorax)
- Abdomen (solid organ injury)
- Pelvis (pelvic fracture)
- Long bones (femur fractures)
If hypotensive: Look for these sources!
Pelvic Assessment
Special test
Pelvic Stability Assessment
Identify potentially unstable pelvic fracture
Technique
- 1ONLY compress pelvis ONCE (gentle AP and lateral compression)
- 2Look for clinical instability
- 3If unstable: Apply pelvic binder immediately
Positive Sign
Pain, instability, or crepitus with gentle compression
Indicates
Potentially unstable pelvic fracture - apply pelvic binder
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Pelvic Binder Application
Indications:
- Mechanism suggesting pelvic injury
- Clinical instability on examination
- Hemodynamic instability with suspected pelvic source
- High-energy trauma
Correct Position:
- Over greater trochanters (NOT over iliac crests)
- Reduces pelvic volume
- Tamponade effect on venous bleeding
Types:
- Commercial binder (SAM Pelvic Sling)
- Sheet wrapped tightly
- Apply before log roll
Long Bone Assessment
Long Bone Fractures
Rapid Assessment:
- Obvious deformity
- Swelling
- Shortening
- Rotation
Femur Fractures:
- 1-2 liters blood loss per fracture
- Bilateral = massive hemorrhage potential
- Traction splint (Thomas or similar)
Open Fractures:
- Photograph wound
- Saline-soaked sterile dressing
- Splint
- Antibiotics within 1 hour
- Tetanus status
Disability
Rapid Neurological Assessment
AVPU Scale:
- A: Alert
- V: Responds to Voice
- P: Responds to Pain
- U: Unresponsive
GCS (Glasgow Coma Scale):
- Eye opening (1-4)
- Verbal response (1-5)
- Motor response (1-6)
- Total: 3-15
Pupils:
- Size, equality, reactivity
- Unequal = herniation until proven otherwise
Spinal Cord Injury
Rapid Assessment:
- Can move arms and legs?
- Sensation to light touch?
- Rectal tone (in complete assessment)
Neurogenic Shock:
- Hypotension + bradycardia
- Warm, dry extremities
- High spinal cord injury (T6 or above)
Spinal Shock:
- Areflexia below level of injury
- May last days to weeks
- Does not cause hypotension
Exposure and Environment
Complete Examination
Log Roll:
- Minimum 4 people
- Manual in-line stabilization maintained
- Inspect entire back
- Palpate spine
- Rectal exam if indicated
Environmental Control:
- Remove wet clothes
- Warm blankets
- Warm IV fluids
- Avoid hypothermia (trauma triad of death)
Trauma Triad of Death:
- Hypothermia
- Acidosis
- Coagulopathy
These are self-perpetuating and lead to physiological exhaustion. Prevention is key - damage control surgery principles.
Secondary Survey
Head-to-Toe Examination
After Primary Survey and Resuscitation:
- Complete head-to-toe examination
- AMPLE history
- Detailed neurological exam
- All imaging
AMPLE History:
- A: Allergies
- B: Medications
- C: Past medical history
- L: Last meal
- E: Events leading to injury
MSK Secondary Survey
Each Limb:
- Look: Deformity, swelling, wounds
- Feel: Tenderness, crepitus
- Move: ROM (if appropriate)
- Neurovascular: Pulses, sensation, motor
Document:
- All injuries
- Neurovascular status
- Open vs closed
- Photographs of wounds
Special Situations
High Mortality Injury:
- Massive hemorrhage potential
- Associated injuries common (bladder, urethra, bowel)
Management:
- Pelvic binder (over trochanters)
- Massive transfusion protocol
- CT angiography
- May need: External fixation, preperitoneal packing, angioembolization
- Definitive fixation when stable
Summary Presentation
“32-year-old motorcyclist brought to ED after high-speed collision. GCS 14, heart rate 120, blood pressure 85/60.”
Examination Sequence
Systematic Approach
- Scene safety and PPE
- C: Control catastrophic external hemorrhage
- A: Airway with C-spine immobilization
- B: Breathing - chest examination
- C: Circulation - access, fluids, hemorrhage source
- Pelvic assessment (once only) and binder
- Long bone splinting
- D: Disability - GCS, pupils, limb movement
- E: Exposure - log roll, environment
- Secondary survey when stable
Examiner Tips
Do
- Follow CABCDE order systematically
- Know pelvic binder positioning (trochanters)
- State blood loss estimates for long bone fractures
- Mention massive transfusion protocol
- Consider damage control principles
Don't
- Repeatedly test pelvic stability (once only)
- Delay hemorrhage control for imaging
- Forget C-spine immobilization with high-speed mechanism
- Miss external hemorrhage sources
- Allow hypothermia (part of trauma triad)