Shock, Sepsis & Multisystem · Topic 6 of 14

Multisystem Trauma & the Primary Survey

Multisystem · trauma resuscitation

Multisystem Trauma & the Primary Survey

Find and fix life threats in order — exsanguinating bleeding, airway, breathing, circulation, disability, exposure — before anything else.

Key numbers

Intubate for obstruction, GCS ≤ 8 or hypoxemiaGCS ≤ 8

Permissive hypotension: SBP 80–90 until controlledSBP 80–90 mmHg

01 · FirstPrimary survey order: xABCDE

ATLS 11th edition (2025) runs the primary survey as xABCDE: control exsanguinating external hemorrhage first, then Airway with cervical spine protection, Breathing, Circulation, Disability, Exposure — treating each threat as it is found.

02 · DoStop exsanguinating bleeding first

Control exsanguinating external bleeding immediately: direct pressure, then a tourniquet for extremity bleeding that pressure does not stop; pack wounds and apply a pelvic binder for a suspected unstable pelvic fracture.

03 · DoPermissive hypotension: SBP 80–90 until controlled

Circulation: two large-bore IVs, minimal crystalloid, early blood products, and permissive hypotension — SBP 80–90 mmHg (MAP 50–60) until major bleeding is stopped — except in severe TBI, where MAP is kept ≥ 80 mmHg.

The rules

Know these

Secondary survey only after stabilizationBegin the head-to-toe secondary survey and an AMPLE history (allergies, medications, past history, last meal, events) only after primary-survey threats are controlled; dramatic but non-lethal injuries wait.

Restrict cervical spine motion until clearedRestrict cervical spine motion until injury is excluded. Imaging can be deferred if alert, sober, without midline tenderness, focal deficit or distracting injury; otherwise get CT. ATLS 11 makes spinal restriction selective and criteria-based.

Causes & risk factors

Why it happens

Older trauma: SBP < 110 means high riskOlder trauma patients are often undertriaged. At age 65 or older, ACS/CDC field triage treats SBP < 110 mmHg or shock index > 1 as high risk — triage to the highest-level trauma center.

Presentation

What you'll see

Hidden bleeding: chest, abdomen, retroperitoneum, pelvis, thighExternal bleeding is obvious, but life-threatening internal hemorrhage fits in only a few places — chest, abdomen, retroperitoneum, and the pelvis or thigh (pelvic or femoral fractures).

Head injury does not cause hypovolemic shockDisability: record GCS and pupils. Shock in a patient with an apparently isolated head injury is not from the head — reevaluate for internal bleeding.

Diagnosis & monitoring

Work-up

Massive hemothorax ≥ 1500 mL: thoracotomyMassive hemothorax is a primary-survey circulation threat: chest tube drainage ≥ 1500 mL initially, ongoing output > 200 mL/h for 2–4 hours, or instability calls for thoracotomy.

Lactate or base deficit and serial hemoglobinOrder lactate (or base deficit) to gauge hypoperfusion and repeat hemoglobin serially — a normal first hemoglobin does not exclude major early bleeding. Add type and crossmatch and coagulation studies.

Do right now

In this order

First moves

Stop exsanguinating bleeding first

→

Intubate for obstruction, GCS ≤ 8 or hypoxemiaGCS ≤ 8

→

Decompress tension pneumothorax clinically, then chest tube

→

Permissive hypotension: SBP 80–90 until controlledSBP 80–90 mmHg

→

Head injury does not cause hypovolemic shock

Why each step

Stop exsanguinating bleeding firstControl exsanguinating external bleeding immediately: direct pressure, then a tourniquet for extremity bleeding that pressure does not stop; pack wounds and apply a pelvic binder for a suspected unstable pelvic fracture.

Intubate for obstruction, GCS ≤ 8 or hypoxemiaSecure a definitive airway for airway obstruction, GCS ≤ 8, hypoventilation or hypoxemia, with cervical spine motion restriction; if intubation fails or maxillofacial injury prevents it, perform a cricothyrotomy.

Decompress tension pneumothorax clinically, then chest tubeTreat suspected tension pneumothorax without waiting for imaging: 14-gauge needle or finger thoracostomy, 4th–5th intercostal space, anterior to midaxillary line, then a chest tube. Seal an open pneumothorax with a 3-sided dressing.

Permissive hypotension: SBP 80–90 until controlledCirculation: two large-bore IVs, minimal crystalloid, early blood products, and permissive hypotension — SBP 80–90 mmHg (MAP 50–60) until major bleeding is stopped — except in severe TBI, where MAP is kept ≥ 80 mmHg.

Head injury does not cause hypovolemic shockDisability: record GCS and pupils. Shock in a patient with an apparently isolated head injury is not from the head — reevaluate for internal bleeding.

Management

Orders

E-FAST positive and unstable: laparotomyE-FAST at the bedside detects hemoperitoneum, hemothorax, pneumothorax and hemopericardium; an unstable patient with intraperitoneal blood goes to laparotomy, a stable patient gets CT. Diagnostic peritoneal lavage is no longer recommended.

Expose fully, then prevent hypothermiaExposure: cut off all clothing, logroll with spinal precautions to inspect the back, then keep the patient warm with heated blankets and warmed IV fluids — hypothermia worsens coagulopathy and mortality.

Tranexamic acid within 3 hours of injuryGive tranexamic acid to the bleeding trauma patient within 3 hours of injury — 1 g IV over 10 minutes, then 1 g over 8 hours — and activate the massive transfusion protocol early.

Resuscitate shock before induction and intubationUnstable trauma patients risk hypotension and arrest at intubation: ATLS 11 emphasizes correcting shock — blood products first — before rapid sequence induction rather than intubating a hypotensive patient immediately.

Ask about anticoagulants; reverse for major bleedingAsk every injured patient — especially older adults — about anticoagulants and antiplatelets: image the head liberally (age > 60, anticoagulant or antiplatelet use) and reverse anticoagulation at once for life-threatening bleeding.

More detail

Reference

Show 5 reference facts

Do not place a urinary catheter when blood is at the urethral meatus or the perineum is ecchymosed — suspect urethral injury and image first.

Pregnancy ≥ 20 weeks: displace the uterus left to relieve caval compression, monitor the fetus 4–6 hours from 22 weeks, give Rh(D) immune globulin if Rh-negative, and begin perimortem cesarean within 4 minutes of arrest.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) can bridge selected patients with intra-abdominal hemorrhage to surgery; massive intrathoracic bleeding may need immediate thoracotomy and autotransfusion.

Consider blunt aortic injury after severe deceleration (widened mediastinum, pulse deficit or arm BP asymmetry) and blunt cerebrovascular injury with a neck seat-belt sign or C1–C3 fracture — get CT angiography.

In older trauma patients, frailty predicts complications better than age; frailty screening with a care pathway (early mobility, delirium prevention, geriatric assessment) lowered delirium and 30-day readmission.

Pearl

Treat the greatest threat to life first: catastrophic bleeding you can see, then airway, breathing and circulation — evaluation and treatment happen together.

Sources · Merck Manual Professional — Approach to the Trauma Patient (Apr 2026) · American College of Surgeons — Trauma Care Gets Major Upgrade with Launch of ATLS 11 (ACS Brief, Sept 16, 2025): ABCDE is now xABCDE · Advanced trauma life support 2025: a brief review of updates. Injury 2026;57(4):113079 (abstract via Europe PMC) · Rossaint R et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023;27:80 · Merck Manual Professional — Hemothorax · JournalFeed — New ATLS update: what you need to know (summary of the Injury 2026 ATLS 11 review) · Geriatric trauma triage: optimizing systems for older adults — AAST publication. Trauma Surg Acute Care Open 2024 (cites ACS COT/CDC field triage: SBP < 110 or shock index > 1 at age ≥ 65) · SGEM Xtra: This One Goes to 11 — ATLS 11th Edition (The Skeptics' Guide to Emergency Medicine, Mar 2026) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).