The trauma primary survey is a sequence that finds and treats what kills first, and NICE guideline NG39 on major trauma, published on 17 February 2016, records it as catastrophic haemorrhage, airway with in-line spinal immobilisation, breathing, circulation, disability and exposure. ATLS, whose provider course in the United Kingdom is run only by the Royal College of Surgeons of England, teaches the same sequence over two days. For a core trainee who is not on a trauma rota, the station tests whether you can hold the structure and call for help at the right moment.

Key takeaways

  • NICE NG39 records the primary survey as catastrophic haemorrhage, airway with in-line spinal immobilisation, breathing, circulation, disability and exposure and environment
  • NG39 recommends intravenous tranexamic acid as soon as possible in major trauma with active or suspected active bleeding, and says not to use it more than 3 hours after injury unless there is evidence of hyperfibrinolysis
  • In hospital, NG39 says not to use crystalloids for patients with active bleeding, and for adults to use a ratio of 1 unit of plasma to 1 unit of red blood cells
  • NG39 asks for chest decompression before imaging only in tension pneumothorax with haemodynamic instability or severe respiratory compromise, and performs it by open thoracostomy followed by a chest drain
  • NG39 says a negative FAST does not exclude intraperitoneal or retroperitoneal haemorrhage, and not to use FAST as a screening test to decide on CT
  • NG39 uses damage control surgery in patients with haemodynamic instability not responding to volume resuscitation, and definitive surgery where haemodynamic status is normal

What is the structure of the trauma primary survey?

The structure of the trauma primary survey is catastrophic haemorrhage first, then airway with in-line spinal immobilisation, breathing, circulation, disability and exposure, which NICE NG39 records as the minimum documentation for the primary survey.

Catastrophic haemorrhage comes before the airway because exsanguination from a limb kills faster than an obstructed airway. NG39 uses simple dressings with direct pressure, and a tourniquet in major limb trauma where direct pressure has failed.

Work through the trauma primary survey by treating each problem as you find it, and by reassessing from the top whenever the patient changes. Say that out loud, because the panel is listening for the loop rather than the list.

How do I manage airway and breathing in the trauma primary survey?

Manage the airway in the trauma primary survey with basic manoeuvres and adjuncts while maintaining in-line spinal immobilisation, and call for an anaesthetist early, because NICE NG39 makes drug-assisted rapid sequence induction the definitive method of securing the airway.

NG39 says that if rapid sequence induction fails, you use basic airway manoeuvres and adjuncts or a supraglottic device until a surgical airway or assisted tracheal placement is performed. A Glasgow Coma Scale of 8 or less is standard ATLS teaching for intubation rather than a numbered NG39 recommendation.

For breathing, NG39 performs chest decompression before imaging only in patients with tension pneumothorax who have either haemodynamic instability or severe respiratory compromise, and performs it by open thoracostomy followed by a chest drain.

NG39 also suggests considering immediate chest radiography and, or, eFAST as part of the primary survey to assess chest trauma in adults with severe respiratory compromise, and immediate CT for those without it who are responding or haemodynamically normal.

How do I manage circulation and bleeding in major trauma?

Manage circulation in major trauma by controlling the bleeding rather than chasing the blood pressure, and NICE NG39 uses a restrictive approach to volume resuscitation until definitive early control of bleeding has been achieved.

NG39 titrates volume resuscitation to maintain a palpable central pulse before hospital, and in hospital moves rapidly to haemorrhage control while titrating volume to maintain central circulation until that control is achieved.

On fluid choice, NG39 says not to use crystalloids in hospital for patients with active bleeding, and for adults to use a ratio of 1 unit of plasma to 1 unit of red blood cells. It starts with a fixed-ratio protocol and moves to laboratory-guided replacement at the earliest opportunity.

NG39 asks you to use physiological criteria, including haemodynamic status and the response to immediate volume resuscitation, to activate the major haemorrhage protocol, and not to rely on a single-time-point haemorrhage risk tool.

When do I give tranexamic acid in major trauma?

Give intravenous tranexamic acid as soon as possible in patients with major trauma and active or suspected active bleeding, which is the NICE NG39 recommendation and the one most likely to be asked for verbatim.

NG39 then sets the limit: do not use intravenous tranexamic acid more than 3 hours after injury in patients with major trauma, unless there is evidence of hyperfibrinolysis.

Say both halves. A candidate who gives tranexamic acid in major trauma but cannot state the three-hour caveat has learned half the recommendation.

How do I reverse anticoagulation in a bleeding trauma patient?

Reverse anticoagulation rapidly in patients who have major trauma with haemorrhage, and NICE NG39 asks hospital trusts to have a protocol for rapidly identifying patients on anticoagulants and reversing them.

NG39 uses prothrombin complex concentrate immediately in adults with major trauma who have active bleeding and need emergency reversal of a vitamin K antagonist, and says not to use plasma to reverse a vitamin K antagonist.

For any anticoagulant other than a vitamin K antagonist in adults, and for any anticoagulant in children, NG39 asks you to consult a haematologist immediately. It also says not to reverse anticoagulation in patients without active or suspected bleeding.

Which imaging does a major trauma patient need?

A major trauma patient needs imaging matched to their physiology. NICE NG39 uses whole-body CT, a vertex-to-toes scanogram followed by a CT from vertex to mid-thigh, in adults with blunt major trauma and suspected multiple injuries.

NG39 asks that patients are not repositioned during whole-body CT, and says not to use whole-body CT routinely in children, where clinical judgement should limit CT to the areas that need assessment.

On FAST, NG39 is blunt. A negative FAST does not exclude intraperitoneal or retroperitoneal haemorrhage, FAST should not be used before immediate CT in major trauma, and it should not be used as a screening test to determine the need for CT.

For the unstable patient, NG39 limits diagnostic imaging such as chest and pelvis radiographs or FAST to the minimum needed to direct intervention in suspected haemorrhage with haemodynamic instability not responding to volume resuscitation.

When does a trauma patient go to theatre?

A trauma patient goes to theatre for damage control surgery when they have haemodynamic instability and are not responding to volume resuscitation, which is how NICE NG39 words the trigger.

NG39 considers definitive surgery in patients with haemodynamic instability who are responding to volume resuscitation, and uses definitive surgery in patients whose haemodynamic status is normal.

NG39 uses interventional radiology in patients with active arterial pelvic haemorrhage unless immediate open surgery is needed for bleeding elsewhere, and considers it for solid-organ arterial haemorrhage from the spleen, liver or kidney.

Do not forget the simple measures in major trauma. NG39 asks you to minimise ongoing heat loss, applies a purpose-made pelvic binder for suspected active bleeding from a pelvic fracture after blunt high-energy trauma, and uses intravenous morphine as the first-line analgesic.

Who do I escalate a trauma call to, and when?

Escalate a trauma call before the patient arrives. NICE NG39 asks a senior nurse or trauma team leader to receive the pre-alert information and determine the level of trauma team response according to written local guidelines.

As a core trainee who is not on the trauma rota, your role is usually to be a working member of that team, so identify the trauma team leader, state your grade and your skill set, and take the task you are given.

NG39 asks for one member of the trauma team to be designated to record all findings and interventions as they occur, and makes the trauma team leader responsible for checking that the record is complete.

Escalate transfer early too. NG39 says the optimal destination for patients with major trauma is usually a major trauma centre, with intermediate care in a trauma unit in some circumstances under the regional network's agreed practice.

What is the interviewer listening for in a trauma scenario?

The interviewer in a trauma scenario is listening for a candidate who knows their limits, holds the primary survey structure under pressure, and hands over in a structured way.

  • Catastrophic haemorrhage placed before the airway, with a tourniquet named for failed direct pressure
  • Tranexamic acid as soon as possible, with the three-hour limit and the hyperfibrinolysis exception
  • 1 unit of plasma to 1 unit of red blood cells, and no crystalloid in hospital for active bleeding
  • Whole-body CT for the responder, damage control for the non-responder
  • A stated recognition that a non-trauma core trainee is a team member, not the trauma team leader

What are the common mistakes in a trauma primary survey answer?

The commonest mistake in a trauma primary survey answer is starting at A and forgetting catastrophic haemorrhage, which NICE NG39 places first in the documented sequence.

The second is giving large-volume crystalloid to a bleeding trauma patient in hospital, which NG39 tells you not to do, and chasing a normal blood pressure before the bleeding is controlled.

The third is treating a negative FAST as reassurance. NG39 states that a negative FAST does not exclude intraperitoneal or retroperitoneal haemorrhage and that FAST should not decide whether a patient gets a CT.

The fourth is pretending to a competence you do not have. A non-trauma core trainee who says they would call the trauma team leader, the anaesthetist and the blood bank scores better than one who improvises a thoracotomy.

How this comes up at the CST interview

Trauma usually arrives at the CST station as a pre-alert: a young patient from a road traffic collision, hypotensive and tachycardic, arriving in four minutes, with you as the first surgical doctor in the bay.

The panel then pushes on the structure, on the massive haemorrhage protocol, or on what you would do if the patient arrived before the consultant and the anaesthetist.

ATLS is the named course here, run in the United Kingdom only by the Royal College of Surgeons of England as a two-day provider course. The coresurgeryinterview question bank carries scored trauma scenarios among its 299 questions, with AI-marked spoken practice: /Question-Bank/Sample-Questions.