Primary secondary and tertiary survey


The strategy of initial assessment and emergent management of severe rauma has come up several times in the past papers. It has not appeared recently, but rather has become split up into sub-specialist injuries (eg. recently the approch to managing life-threatening neck wounds was asked about). ATLS principles generally follow the ABCDE algorithm and the most important component is the resolution of each problem as it is discovered.

Previous questions about the main ATLS algorithm have been as follows:

  • Question 8 from the first paper of 2009 (diaphragmatic rupture; value of the PR in trauma)
  • Question 12 from the second paper of 2005 (primary survey; a repeat)
  • Question 13 from the second paper of 2005 (secondary survey; a repeat)
  • Question 2a from the first paper of 2003 (primary survey)
  • Question 2b from the first paper of 2003 (secondary survey)
  • Question 1a from the first paper of 2002 (primary survey)
  • Question 1b from the first paper of 2002 (secondary survey)

It is hard to recommend any specific publication to help write these answers. The best strategy would be to borrow somebody's ATLS manual (ideally, the recent edition).


  • Primary survey: identify and treat life-threatening injuries
  • Secondary survey: head to toe examination, brief focused history, exclusion of major injuries
  • Tertiary survey:  a patient evaluation that identifies and catalogues all injuries after the initial resuscitation and operative intervention (Grossman et al, 2000)

Primary survey

  • if unable to resolve a problem don’t not leave issue until resolved.
  • at any point if there is deterioration start at airway again.


  • check while leaving the C-spine immobilized
  • generally assume: anyone with blunt injury above the clavicle is probably a C-spine fracture
  • Talk to them to rapidly assess airway patency
  • This is the point where you should look for facial fractures, foreign bodies, vomit and facial burns
  • When their ability to maintain an airway is at all in doubt, intubate them
  • Inline stabilisation of the C-spine throughout
  • Posterior dislocation of the clavicular head can cause an obstruction of the trachea. You need to reduce this, or you wont be able to ventilate. You can either hyper-extend the shoulders, or grab the clavicle with something like a clamp or towel clip, and manually drag it anteriorly, out of the airway. This reduction will usually be stable after you do this.


  • Expose the chest
  • Watch chest excursion: symmetrical?
  • Auscultate: equal air entry?
  • Palpate the midline-ness of the trachea and the rest of the chest, looking for surgical emphysema
  • Percuss the chest looking for hyper-resonance of tension pneumothorax, or dullness of haemothorax.
  • Tension pneumothorax, open pneumothorax, massive haemothorax, flail chest - these should be identified during the primary survey
  • High FiO2 should be administered. One should look for paradoxical respiration pattern due to flail chest, or diaphragmatic breathing due to high spinal cord injury.


  • Circulatory assessment may be clinical at this stage, or a blood pressure may be available.
  • Features of hypovolemia (eg. cool peripheries, pallor) should be sought. Blood should be sampled for crossmatch, and uncrossmatched blood should be transfused if the patient is demonstrating features of anaemia.
  • Wide-bore access is established; bloods should be sent: FBC, EUC, CMP, LFT, coags and crossmatch.
  • Blood products should be preferentially used for resuscitation, with a 1:1:1 ratio of PRBCs, FFP and platelets. The MAP target for fluid resuscitation should be a MAP >50mmHg.
  • Cardiac tamponade may become obvious at this stage; its most striking features at this stage would be a raised JVP and distended neck veins in general. Together with arterial hypotension and


  • GCS level of consciousness
  • Lateralising signs (if the patient is obeying commands)
  • Pupil diameter, reactivity and equality
  • Somebody should probably do the BSL


  • Expose all of the patient
  • At this point, a log roll should happen to examine the back
  • After that, warm blanket and warm fluids to restore temperature

The value of the digital rectal exam

One looks for:

  • Sphincter tone (cord injury)
  • Gross blood (GI tract injury)
  • Swelling (pelvic haematoma)
  • "High riding" prostate - urethral injury
  • Mobile coccyx- sacral or coccygeal fracture
  • Obvious external anal damage
  • Disrupted rectal wall integrity

According to a recent review, the PR changed management in 1.2% of observed cases. LITFL have some choice words about this investigation.

Adjuncts to the primary survey:

After the completion of the primary survey, the following investigations must urgently take place:


  • FBC
  • EUC
  • CMP
  • LFT
  • Coags
  • Crossmatch


  • Chest Xray
  • FAST including pericardium
  • Pelvic Xray
  • Long bone Xrays
  • CT trauma series including aortogram


  • ECG
  • Urine output, IDC
  • Arterial invasive blood pressure
  • ICP monitoring may be indicated if the intracranial pressure cannot be monitored clinically

Secondary survey

This is a head-to-toe examination, including an AMPLE history:

  • Allergies
  • Medications
  • Past history
  • Last meal
  • Events and environment of the injury

Key features:

  • It is more important to identify a problem (e.g. significant abdominal pain) than the exact diagnosis (spleen laceration)
  • A checklist should be used to prevent missed injuries
  • A standardised sequence of examination should be followed, so that the examination can be reproduced if needed

Traumatic diaphragmatic rupture

Why is this here? It's is usually pretty obscure. However, it was a part of Question 8 from the first paper of 2009. Radiological findings are usually all the findings you get. The CXR is usually diagnostic. One can occasionally unearth some of the following (non-specific) clinical features:

  • Hypoxia
  • Decreased air entry on the affected side
  • Decreased chest excursion on the affected side
  • Dull percussion note
  • Bowel sounds in the chest
  • Ileus and bowel obstruction due to volvulus
  • Shoulder pain
  • Stool or bile in the chest drain

Tertiary survey

This is a post-operative repeat of the primary and secondary survey, usually performed in the ICU after all the dust has settled. During this review, a catalogue of remaining injuries and problems is made. Frequently missed injuries are uncovered during this survey (Biffl et al, 2003) - after the implementation of this practice the rate of missed injuries decreased from 5.7% to 3.4% at a busy Rhode Island trauma ICU. In that specific study, the tertiatry survey consisted of a second complete head to toe examination as well as a review of all imaging, within 24 hours of admission.

Key features:

  • A standardised sequence of examination should be followed, so that the examination from the secondary survey can be reproduced and referred to (eg. "were those testes always black? let's see what they found at the secondary survery")
  • The patients in whom this is of greatest importance are patients with a decreased level of consciousness (who cannot report the pain of a lacerated tendon in the  index finger on their dominant hand, or something equally disabling in the long term)
  • Ideally, a person who is not familiar with the patient should be involved gotther with a person who is familair, so as to guard against complacency of the repeat examiner.


Grossman, Michael D., and Christopher Born. "Tertiary survey of the trauma patient in the intensive care unit." Surgical Clinics of North America 80.3 (2000): 805-824.

Biffl, Walter L., David T. Harrington, and William G. Cioffi. "Implementation of a tertiary trauma survey decreases missed injuries." Journal of Trauma and Acute Care Surgery 54.1 (2003): 38-44.